ESSAM OSMAN,FRCS ASSISTANT PROFESSOR,CONSULTANT DEPATMENT OF OPHTHALMOLOGY K.S.U.

GLAUCOMA EGS definition: progressive optic neuropathies, progressive optic neuropathies, that have in common characteristic morphological changes at the optic nerve head and retinal fiber layer in the absence of other ocular disease or congenital anomalies. Progressive retinal ganglion cell death and visual field loss are associated with these changes.” —EGS, Terminology and Guidelines for Glaucoma, 2nd Edition, 2003

GLAUCOMA *A major cause of blindness. *Often A symptomatic; in early stage. *Damage is irreversible. *Effective treatment is available.

The Visual PathwayCornea Anterior Chamber LensVitreousRetinaIris

The Visual Pathway *Phototransduction:By photoreceptors (rods and cones) *Image processing: By horizontal, bipolar, amacrine and RGCs *Output to optic nerve: Via RGCs and nerve fiber layer RGCs Nerve Fibers

The Visual Pathway Retina Optic Nerve Optic Chiasm Visual Pathway Lateral Geniculate Nucleus Primary Visual Cortex

TYPES OF GLAUCOMA

ACUTE GLAUCOMA

Etiology *PRIMARY *SECONDARY ACUTE GLAUCOMA

Primary angle closure glaucoma ANATOMIC FEATURES:  SMALL CORNEAL DIAMETER  SHALLOW ANTERIOR CHAMBER  THICKER LENS  SMALL RADIUS OF THE ANTERIOR LENS CURVATURE  ANTERIOR LENS POSITION  SHORT AXIAL LENGTH  HYPEROPIC EYES

Anatomical predispositions Convex iris-lens diaphragm Shallow anterior chamber Narrow entrance to chamber angle

Pupil block Increase in physiological pupil block Dilatation of pupil renders peripheral iris more flaccid Increased pressure in posterior chamber causes iris bombe Angle obstructed by peripheral iris and rise in IOP

1. Latent - asymptomatic 3. Acute 2. Sub acute - intermittent angle closure 4. Chronic IOP may remain normal Congestive - sudden total angle closure Follows intermittent angle closure 5. Absolute CLASSIFICATION No PL following acute attack

ACUTE CONGESTIVE ANGLE-CLOSURE GLAUCOMA Severe corneal oedema Complete angle closure (Shaffer grade 0) Dilated, nonreactive, vertically oval pupil Shallow anterior chamber Ciliary injection Signs

SIGNS OF POSTCONGESTIVE ANGLE-CLOSURE GLAUCOMA Folds in Descemet membrane Stromal iris atrophy with spiral-like configuration Posterior synechiae Fixed dilated pupil Fine pigment on iris Glaukomflecken

CHRONIC ANGLE-CLOSURE GLAUCOMA Similar to POAG with cupping and field loss Easily missed unless routine gonioscopy performed Variable amount of angle closure Signs

Treatment of Acute Congestive Angle-Closure Glaucoma 2. Hyperosmotic agents - if appropriate Oral glycerol g/kg of 50% solution in lemon juice Intravenous mannitol 2g/kg of 20% solution 3. Topical therapy Pilocarpine 2% to both eyes Beta-blockers Steroids 1. Acetazolamide 500 mg iv or oral 4. YAG laser iridotomy To both eyes when cornea is clear

ANGLE-CLOSURE GLAUCOMA Treatment - bilateral YAG laser iridotomy Epithelial oedema and closed angle during attack Signs Treatment

Secondary Angle Closure Glaucomas Mechanism Pulling & Pushing

Pushing Mechanism  Pupillary block  Tumors or cysts “Cil. Bod, chr.”  Posterior swelling The angle will be closed and obscured by a rounded forward bulging of the iris.

Pushing Mechanism

Pulling Mechanism  Membrane  Inflammation  Abnormal tissue On gonioscopy the peripheral iris will appear to hang like a drape tacked to the mesh work.

NVG Neovascular membrane developed in the surface of the iris and angle causes: Diabetic retinopathy Central retinal vein occlusion Carotid occlusive disease Ocular ischemic syndrome Central retinal artery occlusion Radiotherapy, RD surgery, uveal melanoma

NVG  Management  Admission to hospital  Anti-glaucoma medication  Full PRP  When NVI&NVA disappear trabeculectomy

Importance of gonioscopy

Video gonioscopy

conclusion  Acute glaucoma is not always primary  Gonioscopy is necessary in all patient  Laser iridotomy prophylactic can prevent any attack. Thank you