ACUTE CONGESTIVE GLAUCOMA.pptx

bilateral potentially blinding condition in which obstruction to aqueous outflow is brought about solely by closure of angle by peripheral iris  One eye is usually affected before the other

1. ACUTE CONGESTIVE GLAUCOMA BY DR,B,UGANDHAR REDDY MS PROFESSOR REH,KNL .

2. An attack of acute primary angle closure glaucoma occurs due to a sudden total angle closure leading to severe rise in IOP. May occur due to pupillary block. This is sight threatening emergency.

3. CLINICAL FEATURES SYMPTOMS Pain: Typically acute attack is characterised by sudden onset of very severe pain in the eye which radiates along the branches of 5th nerve. Nausea, vomiting and prostrations are frequently associated with pain. Severe unilateral headache

4. Rapidly progressive impairment of vision, redness , photophobia and lacrimation develop in all cases. Past history: About 5 percent patients give history of typical previous intermittent attacks of subacute angle-closure glaucoma .

5. SIGNS Lids may be oedematous . Conjunctiva is chemosed , and congested , (both conjunctival and ciliary vessels are congested). Cornea becomes oedematous and insensitive . Anterior chamber is very shallow . Aqueous flare or cells may be seen in anterior chamber.

6. Shallow anterior chamber

7. Angle of anterior chamber is completely closed as seen on gonioscopy ( shaffer grade 0 ). Iris may be discoloured . Pupil is semi-dilated, vertically oval and fixed . It is non-reactive to both light and accommodation

8. Angle structures from anterior to posterior S chwalbe’s line T rabecular meshwork S cleral spur C iliary body band R oot of iris

9. IOP is markedly elevated , usually between 40 and 70 mm of Hg. Optic disc is oedematous and hyperaemic . Fellow eye shows shallow anterior chamber and a narrow angle (latent angle closure glaucoma).

10. DIFFERENTIAL DIAGNOSIS Acute conjunctivitis Acute iridocyclitis Phacomorphic glaucoma Acute neovascular glaucoma Glaucomatocyclitic crisis

11. MANAGEMENT It is a serious ocular emergency and needs to be managed aggressively. Immediate medical therapy to lower IOP. Definitive treatment. Prophylaxis of fellow eye. Long term glaucoma surveillance and IOP management in both eyes.

12. immediate medical therapy to lower IOP : Systemic hyperosmotic agents if IOP is more than 40 mmHg intravenous mannitol 20%(1-2gm/kg body weight) Oral hyperosmotics eg : 50% glycerol (1gm/kg body weight) in lemon juice may be given. C/I in diabetes mellitus

13. Systemic carbonic anhydrase inhibitors: Eg : acetazolamide 500 mg IV stat followed by 250mg tablet 3 times a day. Topical antiglaucoma drugs: Beta-blockers eg : 0.5% timolol or 0.5% betaxolol . Alpha adrenergic agonists eg : brimonidine 0.1-0.2% Prostaglandin analogue eg : latanoprost 0.005%

14. Pilocarpine eyedrops should be started after the IOP is bit lowered by hyperosomtic agents. At higher pressure iris sphincter is ischaemic and unresponsive to pilocarpine. Initially 2 percent pilocarpine should be administered every 30 minutes for 1-2 hours and then 6 hourly

15. Central corneal indentation with a squint hook or indentation goniolens to force aqueous into the angle. Epithelial oedema can be cleared first with topical 50% glycerol to improve visualization and to avoid abrasion

16. Analgesics and antiemetics may be required. Topical steroids like 1% prednisolone acetate or dexamethasone eye drops administered 3 – 4 times a day reduces inflammation.

17. Definitive therapy Laser peripheral iriotomy : goniscopy should be performed as soon as cornea becomes clear. Laser PI should be performed if PAS are seen in <270 angle. LPI re-establishes communication between posterior and anterior chamber so it bypasses pupillary block and immediately relieves the crowding of the angle.

18. Filtration surgery: It should be performed in cases where IOP is not controlled with the best medical therapy following an attack of acute congestive glaucoma and also when peripheral anterior synechiae are formed in more than 270 degrees of the angle of the anterior chamber. Mechanism: Filtration surgery provides an alternative to the angle for drainage of aqueous from anterior chamber into subconjunctival space .

19. Clear lens extraction by phacoemulsification with intraocular lens implantation by has recent been recommended by some workers .

20. Prophylactic treatment in the normal fellow eye Prophylactic laser iridotomy (preferably) or surgical peripheral iridectomy should be performed on the fellow asymptomatic eye. It should be done as early as possible as chances of acute attack are 50% in such eyes.

21. Long term glaucoma surveillance and IOP management in both eyes . It is must to ultimately prevent glaucomatous blindness. Eyes treated with PI may develop PACG at any time, so it should be treated as when required. Filtration surgery may fail anytime during course and hence need to be repeated with antimetabolites.

22. Sequelae of acute PAC Postsurgical acute PAC Spontaneous angle reopening Ciliary body shut down Vogt’s triad

23. Postsurgical acute PAC: This refers to the clinical status of the eye after laser peripheral iridotomy (PI) for an attack of acute PAC. It may occur in two clinical settings : i . With normalized IOP after successful laser PI, the eye usually quitens after some time with or without marks of an acute attack. ii. With raised IOP after unsuccessful laser PI, there occurs a state of chronic congestive glaucoma. It needs to be treated by trabeculectomy operation

24. Spontaneous angle opening: It may very rarely occur in some cases and the attack of acute PACG may subside itself without treatment. Treatment of such cases is laser peripheral iridotomy .

25. Ciliary body shut down : It refers to temporary cessation of aqueous humour secretion due to ischaemic damage to the ciliary epithelium after an attack of acute PACG . Clinical features in this stage are similar to acute congestive glaucoma except that the IOP is low and pain is markedly reduced

26. Treatment includes: Topical steroid drops to reduce inflammation. Laser iridotomy should be performed when the cornea becomes clear and IOP should be monitored. Trabeculectomy is required when IOP rises constantly .

27. Vogt’s triad It may be seen in patients with any type of postcongesive glaucoma and in treated cases of acute congestive glaucoma. It is characterized by: Glaucomflecken (anterior subcapsular lenticular opacity), Patches of iris atrophy, and Slightly dilated non-reacting pupil (due to sphincter atrophy).

28. A patient presents with sudden onset of severe unilateral eye pain, headache associated with blurred vision, rainbow colored haloes around bright light, nausea and vomiting. Examination revealed a fixed midpoint pupil and a hazy, cloudy cornea with marked conjunctival congestion. What could be the diagnosis? Discuss the pathophysiology and treatment of the above condition.

29. Differential diagnosis of acute red eye. Describe clinical features and management of acute congestive glaucoma.