1. Dr. Sharmila Glaucoma clinic
Basics in Glaucoma
Dr. Sharmila
Glaucoma clinic

2. Glaucoma
Glaucoma is an optic neuropathy with characteristic appearance of the optic disc and specific pattern of visual field defects that is associated frequently but not invariably with raised IOP

5. POAG Adult onset IOP > 21mm Hg Open Angles
Glaucomatous nerve damage
Visual field loss

6. Risk factors
Age > 65
Black race
Positive family history
Myopia
Thin Corneas

7. Pathogenesis Increased resistance to aqueous outflow Ischaemic Theory
Mechanical theory

8. pathogenesis
Pathogenesis

9. Symptoms
Usually asymtomatic
Rarely decreased visual fields

10. Diagnosis of glaucoma History taking
Visual acuity and refractive state
Tonometry
Gonioscopy
Ophthalmoscopy
Perimetry

11. Tonometry Indentation tonometry-schiotz tonometer
Applanation tonometry
variable force-goldmann Tonopen
variable area- maklakov
Non contact tonometer

12. Schiotz indentation Tonometry
Body –footplate-rests on the cornea
Plunger
Weights-
5.5gm –permanently fixed.
additional weights-7.5g.10g,15g

13. Technique of schiotz tonometry
Anaesthetise cornea
Patient in supine position
Fixes on the target
Eyelids gently separated
Plunger rests on cornea.
Look for movement of the needle
Additional weights –if reading is <4
IOP derived from conversion table

14. Sources of error Ocular rigidity
High ocular rigidity-high hyperopia,long standing glaucoma,ARMD
Low ocular rigidity –high myopia,osteogenesis imperfecta,miotic therapy,retinal surgeries
Thick cornea-high value

15. Other tonometers
GOLDMAN APPLANATION
TONOPEN

16. PNEUMOTONOMETER
PERKINS TONOMETER

17. Gonioscopy Goniolens[direct] Koeppe, layden, barken Gonioprism
Goldman single mirror, two mirror, three mirror
Zeiss four mirror
Posner four mirror

18. Normal angle structures
Ciliary body band
Scleral spur
Trabecular meshwork
Schwalbe’s line

19. Ophthalmoscopy Disc Focal atropy Concentric atrophy
Deepening of the cup Advanced glaucomatous cupping
Vascular changes
Haemorrhage,baring of vessels, bayonetting
Retinal nerve fiber layer changes
Peripapillary atrophy

21. Perimetry Kinetic Static Visual fied defects Paracentral scotoma
Seidel scotoma
Arcuate scotoma
Double arcuate scotoma
Nasal step

22. Angle Closure Glaucoma
With pupillary block
Without pupillary block
Diagnosis depends on :
Anterior segment examination
Gonioscopy

23. Risk factors Age Gender Asians, Chinese, Eskimos Family history
Hypermetropia

24. Pathogenesis
Increased opposition between iris and lens enhance the degree of pupillary block
Increased pressure in posterior chamber
Increased peripheral iris bowing
Iris Bombe
High IOP

25. Types Latent Subacute Acute congestive Post congestive Chronic
Absolute

26. Acute Congestive Glaucoma
Symptoms
Severe pain and vomiting
Unilateral visual loss
coloured haloes
Headache and vomiting

27. Signs Shallow AC Corneal edema Semi dilated pupil High IOP
Closed angles

28. Treatment Immediately 2% Pilocarpine Steroid eye drops Β blockers
Analgesics and antiemetics
Lie in supine position
I.V. Mannitol + Oral T. Diamox

29. Treatment MEDICAL LASER PI IF NOT POSSIBLE TRABECULECTOMY
AFTER CORNEA CLEARS
LASER PI
IF NOT POSSIBLE
TRABECULECTOMY

30. Cont.d… After 1 hr: After 11/2 hr: Pilocarpine 2% Yag PI
If IOP is still high
50% oral glycerol
20% Mannitol (1-2g/kg) I.V. over 45minutes

31. Laser Iridotomy Clear corneas Less than 1800 of angle by PAS
Surgery: Trabeculectomy

32. Congenital Glaucoma 1:10,000 births 65% are boys Pathogenesis:
Maldevelopment
of the angle of anterior chamber

33. Classification Congenital Glaucoma Infantile Glaucoma
Juvenile Glaucoma

34. Clinical Features Corneal edema Buphthalmos Breaks in DM
Optic disc cupping

35. Diagnosis Increased IOP Increased Corneal diameter > 11mm at 1yr
Treatment:
Goniotomy
Trabeculotomy
trabeculectomy

36. Lens related Glaucomas
Phacolytic:
Hyper mature cataract
Corneal edema
AC reaction – psuedo hypopyon
Open angles

37. Treatment
Anti glaucoma drugs
Topical antibiotic steroids
surgery

38. Phacomorphic Galucoma
Intumscent cataractous lens
Shallow anterior chamber
Treatment:
Antiglaucoma drugs
Laser iridotomy
surgery

39. Neo vascular Glaucoma Retinal ischaemia NVI NVA OPEN ANGLE
ANGLE CLOSURE

40. Causes Ischeamic CRVO Diabetes Mellitus Miscellaneous Carotid disease
Intra ocular tumor
Long standing RD

41. Symptoms & Signs Decreased visual acuity Congestion of Globe
Very high IOP and corneal edema
Severe pain
Aqueous flare
NVI
Gonioscopy - NVA

42. Treatment Medical – topical Atropine & steroids
Retinal ablation / - DIODE CPC
Surgery:
Trab with MMC
Aqueous drainage shunts
Retrobulbar alcohol injection
Enucleation

43. Treatment Modalities in glaucoma
Medical
Laser
Surgery – Trabeculectomy
combined surgery

44. Anti Glaucoma Drugs Β blockers Contra indications:
Decreases IOP by decreasing aqueous secretion
Contra indications:
Congestive cardiac failure
Heart block
Bradycardia
Bronchial asthma

45. Side effects Iotim, Nyolol, Glucomol 0.5% bd Ocular Systemic
allergy Bradycardia, Hypotention
SPK’s Broncho spasm
tear secretion Hallucination, head ache
nausea, dizziness

46. Alpha 2 Agonists Mechanism: Side Effects: Brimonidine, apraclonidine
Decreases aqueous secretion
Increases uveo scleral outflow
Side Effects:
Allergic conjunctiviti s
Xerostomia
Drowsiness and headache

47. PROSTAGLANDIN ANALOGUES
Mechanism
Decreases IOP by increasing uveoscleral outflow
Latanoprost F2 α analogue.005%
Travoprost 0.004%
Bimatorpost 0.3%
Unoprostone 0.15% BD

48. Side Effects Conjunctival hypereamia
Eye lash growth and hyperpigmentation of periorbital skin
Anterior uveitis
Cystoid macular edema

49. MIOTICS Pilocarpine 1% 2% 3% 4% QID
Parasympathomimetic stimulates muscarinic receptors in sphincter pupillae & ciliary body
In POAG – increases aqueous outflow
In PACG – opens the angles

50. Side Effects
Miosis
Browache
Myopic shift
Visual field defect

51. Carbonic Anhydrase Inhibitors
Inhibits aqueous secretion
Topical CAI
Dorzolamide (Trusopt)
Brinzolamide (Azopt)
Systemic CAI
Acetazolamide 250mg BD

52. Side Effect
Parasthesia
Malaise
GI upset
Renal Stone
Blood dyscrasias

53. Hyper Osmotic Agents Glycerol 1g / kg in 50% solution
Mannitol 1-2g/kg in 20% solution
Side Effects:
Cardiac or renal failure
Urinary retention
Head ache, nausea

54. Lasers in Glaucoma Laser Iridotomy: Indications: PACG
Occludable angles
SACG with pupillary block
Combined mechanism glaucoma

55. Laser PI prerequisites Instil 1% Apraclonidine Miotic pupil
Laser settings 4-8 mJ
Post laser steroid eye drops
Abraham lens

56. Complications
Bleeding
Iritis
Corneal burn
Glare
Diplopia

57. Surgery Trabeculectomy:
A conventional filtering procedure creates a new channel for aqueous outflow between the anterior chamber and subtenons space without the use of an artificial device
Partial thickness
Full thickness

58. Management of coexistent cataract and glaucoma

59. Complications
Wound leak
Excessive filteration
Pupillary block
Malignant glaucoma
Hypotony
Choroidal detachment

60. Failing bleb Initial few weeks critical SIGNS Injection
Vascularisation
Thickening
Localization
High domed Bleb
Normal / High IOP
Low IOP
Initial few weeks critical

61. Failing filtration
Frame work for Classification
IOP
Bleb

62. Failing filter – High IOP
Low localized Bleb
External Subconjunctival fibrosis
- Tight scleral flap sutures
Internal - Sclerectomy obstruction

63. Failing filter – High IOP
High domed bleb – encapsulated bleb or Tenon’s cyst

64. Failing filter - Low IOP
Elevated diffuse bleb - Over Filtration hypotony
Low bleb - Bleb leak

65. Bleb Failure Argon laser suturolysis 0.2sec 50µ 500-700mw
Digital massage
Topical steroids
5FU injection
DF Nd yag laser
Needling of tenons cyst

66. REFRACTORY GLAUCOMA
AQUEOUS DRAINAGE IMPLANTS

67. Refractory glaucomas
Cyclo destructive procedures

68. New diagnostic and surgical procedures
Central corneal thickness assessment

69. OPTICAL COHERENCE TOMOGRAPHY

70. ULTRASOUND BIOMICROSCOPY

71. Thank you