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2. Examination under General
Jahangir sadeghi md
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3. Anesthesia in childhood patient with Glaucoma.
The mechanisms of glaucoma in childhood is often different from those seen in older patients. Clincian must be familiar with additional information for the evaluation and care of childhood glaucoma patients.
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4. When enlargement of the cornea is associated with a deep anterior chamber glaucoma should be strongly suspected. The baby may be noticed to shy away from light or bury his head against his parent to prevent exposure to light . Clouding of the cornea is the most frequent physical abnormality. After age 4 years, glaucoma is most frequently detacted for decreased uncorrected visual acuity related to myopia.
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6. The Office Evaluation
Before E.U.A the Office Evaluation of infants with suspected glaucoma is an important step in their evaluation.
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7. E.U.A for childhood glaucoma
1- Antiglaucoma medication either locally or systemically should be stopped 12h. Before general anesthesia. 2- Barbiturates & Narcotics should be given before examination those lower IOP. 3- Atropine in the usual dosage is not contra indicated. 4- In the past ethyl ether with nitrous oxide was routine. 5- Halothane decrease IOP IOP measurements should be made unly after the patient is relaxed. Never when moving the eyes struggling.
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8. 5 steps in E.U.A External examination Pressure measurements
Corneal diameter measurements
Gonioscopy
Ophthalmoscopy
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10. External examination Evaluation of the corneal luster and clarity
Evaluation of the corneal epithelium
Evaluation of the Descemet’s m. not all leteaks in Descemet’s m. are caused by infantile glaucoma. (forceps injury at birth)
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11. Breaks due to glaucoma are:
Multiple
Curved
Horizontal
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12. Pressure measurements
Tonometry is performed before Gonioscopy- IOP remain undisturbed
Methods of tonometry
Schiotz- indentation
Applanation – flatten the cornea
Goldman
Perkins applanation
The eye should be still and in the primary position.
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14. Schiotz tonometry – older method
Advantages
Portability
Ease of use
Low cost
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15. Accuracy of measurement is limited by
Variation in corneal curvature
Rigidity and volume of the eye
Rarally used in clinical practice
Applanation tonometry
Gold standard for measuring IOP
Perkins applination in infants under general anesthesia
Pneumatic tonometry
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16. PneumatiC toNOMETER Valuable for measuring IOP after
Corneal transplantation
Corneal scaring
Corneal edema
Corneal irregularity
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17. Tonopen is a hand-held device in accordance with the principle of Mackay-Mary tonometry To measure the pressure applied via a plunger to flatten a small area of cornea “1.5mm” Diameter. A variation of Glaucoma tonometer is the noncontact or air-puff tonometer.
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19. Corneal diameter measurement
To measure the diametric distance from nasal limbus to temporal limbus.
Evaluating the severity and control of glaucoma in infants and children less than 2 years of age.
Normal range of corneal diameter in infants is between mm increasing to mm at one year of age and as much as in the first 3 years.
Under one year of age diameters of mm are suggestive of abnormal enlargement.
13 mm or more at any time in childhood is strongly suggestive of abnormality
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20. Gonioscopy
If the cornea is clear, Gonioscopy is performed by using koeppe Gonioscopy lenses of proper size and a hand- held binocular microscope Gonioscopy findings in infants and young children differ significantly from those of adults.
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21. Ophthalmoscopy Direct ophthalmoscopy is the best
For infants & children
Optic nerve head evaluation is crucial in ophthalmoscopy
Cupping of the nerve head from glaucoma in infants and children appears similar to that in adults.
Myopia is a common accompaniment of enlargement of the eye in infantile glaucoma.
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22. THE END
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