Clinical features of glaucoma

clinical features of glaucoma

1. Clinical Features of glaucoma Dr.Sidesh Hendavitharana (Registrar-ophthalmology)

2. Etiological classification of glaucoma primary Children True congenital glaucoma Infantile glaucoma Juvenile glaucoma Adults Primary open angle glaucoma Primary angle closure glaucoma

3. secondary Children Aniridia Iridocorneal dysgenesis Ectopia lentis syndrome Lowe’s syndrome Rubella Adults Phacogenic glaucoma Pigmentary glaucoma Pseudoexfoliative glaucoma Inflammatory glaucoma Neovascular glaucoma Ghost cell glaucoma

4. Clinical features of congenital glaucoma Symptoms Photophobia,blepharospasm and eye rubbing due to irritation of corneal nerves because of elevated IOP. Lacrimation due to corneal edema and erosion. Defective vision due to corneal edema leading to hazy cornea , enlarment of cornea and eye as a whole. Irritable child.

5. signs Corneal edema(Hazy frosted glass cornea) 1 st sign to arouse suspicion At first,epithelial,lateral stromal Results in permanent opacities Corneal enlargement Along with enlargement of eyeball Cornea more than 13mm(normal 10.5mm in infants) Tears and breaks in Descemet’s membrane( haab striae ) Because of less elasticity Appear as horizontal curvilinear lines representing healed breaks of descemet membrane

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9. . Thin and blue sclera(due to stretching of corneoscleral junction) Flattening of lens and backward displacement (due to stretching of zonules of zinn ) and even subluxation of lens. Cupping and atrophy of optic disc especially after 3 rd yr Raised IOP Axial myopia(due to increased in axial length) anisometropic amblyopia

10. Clinical features of primary open angle glaucoma Symptoms Painless,progressive loss of vision Mild headache and eyeache Defects in visual fields Difficulty in reading and close work(due to failure in accomodation because of constant pressure on cilliary muscles and its nerve supply)thus frequent changes in presbyopic glasses Delayed dark adaptation

11. signs Anterior segment Normal depth and angle of anterior chamber Slightly hazy cornea(late stage)sluggish pupillary reflex(late stages) IOP changes In initial stages ,rhythmic swing in diurnal variation of IOP(morning rise 20%,afternoon rise 25%) Variation of >5mm of Hg of IOP is suspicious and >8mm of Hg is diagnostic In late stages , IOP raised permenently above 21 mmHg , usually between 30-45mmHg

12. Optic disc changes Typically progressive and asymetric . Pathophysiology Mechanical effect Raised IOP , forces lamina cribrosa backward squeezes nerve fibres within its meshes disturbance in axoplasmic flow Vascular factors Contribute in ischemic atrophy of nerve fibres resulting in large caverns or lacunae(cavernous optic atrophy)

13. Early changes Vertically oval cup(due to selective loss of neural rim tissue in inferior and superior poles) Asymetry of cups in both eye(difference more than 0.2) Large cup,0.6 or more due to concentric expansion Splinter haemorrhage on or near optic disc margin Pallor areas on disc Atrophy of retinal nerve fiber layer(seen with red free light) Barring of curcumlinear vessels at disc margin

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19. Advanced changes Marked cupping(cup size 0.7-0.9)-bean pot cupping Excavation reaching disc margin,steep and no shelving Thinning of neuroretinal rim seen as cresentic shadow adjecent to disc margin on temporal side Nasal shifting of retinal vessels with broken off appearance at margin(bayonetting sign) Pulsation of retinal arteries at disc margin Pores in lamina cribrosa slit-shaped and visible up to disc margin(laminar dot sign) Glaucomatous optic atrophy Destructon of all neural tissue of disc Optic nerve head appears white and deeply excavated.

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24. Clinical features of ACG Symptoms Asymptomatic but during attack transient blurring of vision,coloured halos and mild headache Signs Eclipse sign Shadow on nasal side elicited by shining penlight across anterior chamber from temporal side Indicates decreased axial anterior chamber depth

25. Slit lamp examination Congested episcleral and conjunctival blood vessels Corneal epithelial edema Shallow anterior chamber Mild amount of aqeous flare and cells Mid dilated,sluggish and irregularly shaped pupil Convex lens-iris diaphragm Glaukomflecken -characteristic small anterior subcapsular lens opacities

26. Secondary glaucoma Clinical features of neovascular glaucoma Symptoms Severe pain Markedly reduced vision Signs Ciliary and episcleral congestion Corneal edema High IOP Rubeosis iridis

27. Causes for NVG CREDITS…… C -CRVO R -RD E - eale’s disease D -diabetic retinopathy I -intraocular inflammations T -Tumors(intraocular) S -sickle cell retinopathy

28. Pseudoexfoliation syndrome Clinical features Effects elderly Presents like primary open angle glucoma Diposition of amorphous grey dandruff like material on pupillary border,anterior lens surface,posterior surface of iris,zonules and cilliary processes Arrangement of pigments anterior to schwalbe’s line- sampaolesi line. Subluxation of lens due to looseness of zonules

29. Clinical features of pigmentary glaucoma Pigment diposition on the corneal endothelium in a vertical spindle pattern- krukenberg spindle(absolutely necessary to make the diagnosis) Peripheral iris transillumination -characteristic spokelike loss of the iris pigment epithelium When the pupil is dilated,pigment deposits can be seen on the zonular fibres,anterior to hyaloid and the lens capsule near the equator of the lens( zentmayer line)

30. THANK YOU .