1. GLAUCOMA Dr. D.Chandrakanth

3. Chronic progressive Optic neuropathy by group of Ocular conditions( IOP ) Visual loss

4. Pathogenesis Mechanical -- IOP Vascular Perfussion

5. Considerations IOP Angle of Anterior Chamber Optic Disc Visual Fields

6. Production and drainage of aqueous

7. Modes of IOP rise Open angle E:\DR PUNEET (J)\Photos\glaucoma\DSC02805.JPG E:\DR PUNEET (J)\Photos\glaucoma\DSC02805.JPG – Pre trabecular – Trabecular – Post trabecular Closed angle E:\DR PUNEET (J)\Photos\glaucoma\DSC02806.JPG E:\DR PUNEET (J)\Photos\glaucoma\DSC02806.JPG – With pupillary block – Without pupillary block Anterior pull/Posterior push

8. Measurement of IOP- Tonometry Indentation (Schieotz) Applanation ( Contact – Goldmann; Non-contact) >21mm of Hg

9. Angle of Anterior Chamber- Gonioscopy Goldmann 3- mirror Angle Structures 1.Shcwalbes line 2.Trabecular meshwork 3.Scleral spur 4.Cilliary body band

10. Open AngleClosed angle

11. Evaluation of Optic disc - Slit lamp biomicroscopy (78D / 90D) Cup :Disc Ratio- >0.5 NRR- Notch/Thinning Vessels Parapapillary Area

12. Disc changes Lamellar dot sign Bayoneting sign splinter haemorrhage BARRING OF THE VESSELS

13. Visual field analysis- Perimetry – Manual (Bjerrum’s) – Automated (Humphrey’s)

14. Classification of Glaucomas (Age, Etiology, Angle) Congenital and developmental Glaucomas Without ass. anomalies - Primary congenital With ass. anomalies - ICE syndromes Primary glaucomas POAG PACG Secondary glaucomas Open angle (Pxf / pigment / Inflamm. Cells / Blood) Closed angle (Pupillary block)

15. Management plan Decreased aqueous production Increased aqueous outflow Vascular perfusion Medical Beta blockers ( Eg: timolol) Parasympathomimetics (Eg: pilocarpine) CA inhibitors (Eg: dorzolamide) Prostaglandins (Eg: latanoprost) Sympathomimetics (Eg: apraclonidine) Calcium channel blockers ( Eg: verapamil) Surgical Peripheral iridectomy Filtering surgeries - trabeculectomy

16. Angle closure Glaucomas Primary Secondary –Phacomorphic G /Late NVG /Malignant G

17. Primary Angle Closure Glaucoma Def. – Primary (no obvious cause) G Raised IOP–Narrow angles–Blocked Aqueous drainage Predisposing Factors – Asians / Females / First degree relatives Small Eyes (hyperopes) / Narrow angles

18. Pathogenesis Precipitating Factors:- 1.Dim light 2.Emotional stress 3.Mydriatics Mech. Of Raised IOP :-

19. Narrow Angles Assessment- 1.Torch light 2.Slit-lamp – C. thickness with Peripheral AC Depth (Van herick’s grading) 3. Gonioscopy – visualisation of angle structures a)Schaffer’s – Angles b)Scheie’s – Structures c) Spaeth’s

20. Clinical Staging 1.PACG Suspect 2.Sub Acute / Intermittent PACG 3.Acute PACG 4.Chronic PACG 5.Absolute G

21. 1. PACG suspect Symptoms – Asymptomatic Signs – Normal IOP Shallow AC Occludable Angles– Pigmented TM Not Visible 3 / 4 Q Provocative test- Prone Dark Room Test Mydriatic test Management – Prophylactic YAG:Peripheral Iridotomy

22. 2. Sub Acute / Intermittent PACG Symptoms – Recurrent attacks of (Unilateral Headache, Browache / episodes of blurring of Vision / Color Halos) Symptom free period in between Signs – Raised IOP, Shallow AC, Occludable narrow angles Management - YAG:Peripheral Iridotomy

23. 3. Acute PACG Symptoms – Severe Unilateral Headache Red Eye Sudden Diminution of vision / Color Halos Signs – Lid Edema Diffuse + Cilliary Congestion Corneal edema Shallow AC / Iris bombe Vertically oval mid-dilated pupil sluggish- absent reaction IOP markedly Raised Gonioscopy – Closed angles

24. D/D – acute conjunctivitis / acute iridocyclytis Management – Plan –Decrease IOP Peripheral iridotomy/iridectomy Decrease IOP – Pilocarpine 2% 15mins for 1 hour / ½ hourly 2 hour Timolol 0.5% BD (+/-combinations) Tab. Acetazolamide 500mg stat IV Mannitol YAG Peripheral iridotomy No result/not possible – Surgical Peripheral Iridectomy

25. 4. Chronic PACG Symptoms – Dull ocular pain Field Defects Signs – Raised IOP Gonioscopy–angles Synechial closure (PAS) 180` Field defects – similar to POAG Management – Same as POAG Medical + Surgical (Trabeculectomy)

26. 5. Absolute Glaucoma Symptoms – Painful, irritable, blind eye Signs – VA = no PL Cilliary Congestion Corneal Bullous Keratopathy Shallow AC Atrophic Patches on Iris Mid-dilated fixed pupil Optic Disc – Glaucomatous Atrophy IOP very High Complications – C. Ulcer / Ant. Staphyloma/ Atrophic Bulbi Management – Temporary retrobulbar alcohol injection Cyclodestructive procedures (cyclo-cryo) Enucleation

27. Questions Angle closure Glaucoma Primary Angle closure glaucoma Acute angle closure glaucoma Differential diagnosis of Red eye 1) acute conjunctivitis 2) acute iridocyclitis 3) acute angle closure glaucoma Absolute glaucoma Atrophic bulbi – phthysical bulbi

28. IOP - tonometer Gonioscopy Angle structures Visual fields Primary open angle glaucoma Buphthalmos Peripheral iridotomy / iridectomy Trabeculectomy Anti- glaucoma drugs