Glaucoma

topc for glaucoma

1. GLAUCOMA PRESENTED BY:- EMDADUL ISLAM B.OPTOM 7 TH SEM NHSHM KNOWLEDGE CAMPUS DURGAPUR

2. INTRODUCTION Usually with a charecteristics loss of visual function. Damage to a optic nerve is irreversible prosses Usually caused by raised IOP acting on the nerve head Normal IOP is - 15-21 mnn of hg It is a heterogenous group of diseases in whitch optic nerve is damage. IOP is the most common risk factor for development of glaucoma Vission loss is irreversible It is the secound leading causes of BLINDNESS. In its early stages it affects peripheral visual field only but as it advances it affects central vision and results in loss of visual acuity,

3. Intraocular pressure is not the only factor responsible for glaucoma! 95% of people with elevated IOP will never have the damage associated with glaucoma. One-third of patients with glaucoma do not have elevated IOP. Most of the ocular findings that occur in people with glaucoma also occur in people without glaucoma.

4. EPIDEMIOLOGY Globally estimated 8.4 million people who are blind on the result of glaucoma These number are set to increases to 11.2 million by 2020 It is the secound leading causes of BLINDNESS globally The highest prevelance of open angle glaucoma occures in AFRICA.( WWW.SCIENCEDIRECT.COM ) Global prevelance of glaucoma -2%of those over the age of 40 years and 10% of those over 80 years of age Glaucoma blindness- - global 8.0% - india 12.8%

5. Primary open-angle glaucoma (POAG) is the most common type of glaucoma, accounting for over 70% of cases. Ocular hypertension affects 3-5% of the population over 40 years of age .

6. from google

7. Population distribution of IOP

8. AQUEOUS PRODUCTION AND DRAINAGE SECRATION OF AQUEOUS HUMOR:- cilliary body ROUTE OF DRAINAGES- -TRABECULAR OUTFLOW(90%) -UVEAL-SCLERAL OUTFLOW(10%)

9. TRABECULAR OUTFLOW :- CILLIARY BODY POSTERIOR CHAMBER ANTERIOR CHAMBER TRABECULAR MESHWORK SCLEMNS CANEL COLLECTOR CHANELS EPISCLERAL VEIN

10. UVEOLSCLERAL OUTFLOW CILLIARY BODY POST. CHAMBER ANT. CHAMBER CILLIARY BODY SUPRA CHOROIDAL SPACE VENOUS CIRCULATION OF CILLIARY BODY ( The normal level of IOP is essentially maintained bye the formation and outflow of the aqueous humour )

11. CLASSIFICATION of glaucoma ( A)Congenital/Developmental glaucoma 1)primary congenital glaucoma (without associated anomalies ) 2)developmental glaucoma (with associated anomalies )

12. ( B)PRIMARY GLAUCOMA 1)POAG 2)PACG 3)Primary mixed mechanism glaucoma (C) SECONDARY GLAUCOMA P hacomorphic glaucoma Phacolytic glaucoma Pigmentary glaucoma Traumatic glaucoma Cilliary block glaucoma Neovascular glaucoma Glaucoma in aphakia

13. Absolute glaucoma The end stage of glaucoma is referred to as absolute glaucoma. There is no functioning vision, the pupillary reflex is lost and the eye has a stony appearance. The condition is very painful and is treated by destructive processes.

14. CONGENITAL/DEVELOPMENTAL GLAUCOMA A rare condition Manifest without associated anomalies Bupthalmhos and cloudy cornea

15. Congenital Glaucoma Buphthalmos , glaucomatous cupping, and cloudy cornea OD Normal OS Haa’s bstriae

16. PATHOGENESIS Maldevelopmental of the angle structures Impaired aqueous outflow Raised IOP Damage optic nerve

17. CLASSIFICATION Primary developmental/congenital glaucoma Developmental glaucoma with associated congenital ocular anomalies Developmental glaucoma with associated systemic anomalies ISOLATED CONGENITAL GLAUCOMA:- ISOLATED CONGENITAL GLAUCOMA

18. V. INFANTILE CONGENITAL GLAUCOMA:- - synonymous with congenital glaucoma -1 months to 3 years JUVENILE GLAUCOMA :- -Primary glaucoma occuring latter in childhood -3years to 18years

19. EPIDEMIOLOGY -1 in 10,000 births -65% of patients are boys

20. CLINICAL FEATURES SYMPTOMS:- -Photophobia - Lacrimation - Blepharspasm -Irritation -Cloudy cornea -Red eye -Poor vission and pain

21. CLINICAL FEATURES SIGNS:- Corneal oedema Corneal enlargement Haab’s straie Sclera thin and blue A.chamber deep Iridodonesis Optic disc-variable cupping & atrophy

22. INVESTIGATION IOP measurement Corneal diameter measurement Slit lamp examination Ophthalmoscopy Gonioscopy

23. TREATMENT MEDICAL TREATMENT :- -Not very effective. -It is a surgical diseases . - Acetazolamide & beta-blockers use till surgery is taken

24. TREATMENT B .SURGICAL TRATMENT:- - Goniotomy - Trabeculectomy - Filteration surgery -Glaucoma drainage devices tr T T RABECULECTOMY

25. Images of surgical treatment GONIOTOMY

26. POAG ( PRIMARY OPEN ANGLE GLAUCOMA ) POAG is a commonly disease of a adult onset It is a charecterized by -IOP >21 mm of hg -open anterior chamber angle -optic dics cupping -optic dics damages -specific visual field damages

27. POAG is a bilateral disease IOP is the major risk factor Also known as chronic simple glaucoma Most prevalence of all glaucoma Most common glaucoma

28. PREDISPOSING & RISK FACTORS IOP –most common risk factors Age -most case >40 years BP -Diastolic pressure <55 mm of hg Retinal diseases -CRVO,RD,RP Diabetes melitus Central corneal thickness

29. PATHOGENESIS OF RISE IN IOP Certain rise of IOP that occures due to decrease of aqueous outflow . Aqueous outflow reduce due to -thickening of trabecular meshwork -sclerosis of trabecular meshwork -narrowing of intertrabecular spaces - trabecular meshwork stiffening

30. EPIDEMIOLOGY POAG affects about 1 in 100 of general population Forms about one third cases of all glaucoma

31. CLINICAL FEATURES - SYMPTOMS -Asymptomatic diseases -Gradual painless loss of vision -Mild headache -Visual field defect -Changes in presbyopic glasses -Delayed dark adaptation

32. SIGNS Ant.segment signs:- -normal -corneal haze -lazy pupil reflex Iop changes:- -Initial stages IOP normal -Doing DIURNAL variation test -In later stages,IOP is permanently raised -Range of IOP between 30 to 45 mm of hg

33. ONH evaluation:- Early glaucomatouas changes -Large cup - Asymetry of >0.2 between two eyes -Cup ratio 0.6 or more -pallor disc -vertical oval cup -splinter haemmorages Advavce glaucomatous chamges :- -Cup size 0.7 to 0.9 - Neuroretinal rim thinning -Nasal siftting of retinal vessels -Lamellar dot signs

34. Visual field deffects :- In glaucoma ,visual field defects observed in BJERRUM’S area .... -Retinal paracentral scotoma - Roenn’s nasal steep -Seidel scotoma - Arcuate scotoma

35. INVESTIGATION OF POAG 1)GONIOSCOPY:- -Wide open angle of ant.chamber -structure seen ROI,SS,SL,CBB,TM TONOMETRY :- - Tonometry shoul be preferred over Schitze tonometry -IOP <21 mm of hg PROGRESSIVE CUPPING:- CD= 0.3 to 0.4 normal fundus

36. CD=0.5 CD=0.5 to 0.7 optic dics margine NRR CD=0.9 CD=1.0 0.9 CD=1.0

37. Cup-to-disk ratio

38. MANAGEMENT Aim of treatment to prevent impairment of vision Require careful & regular periodic supervision by ophthalmologist Theraputic choices:- -Medical therapy:- - Parasympathomimetic drugs - Prostaglandine -Topical beta blockers -Carbonic anhydrase inhibitors Argon or diode laser trabeculoplasty :- Action:- outflow by causing shrinkage of TM Technique:-40-50 spots on the anterior half of TM over 180 using a Goniolens

39. SURGERY FOR POAG Fileration surgery Trabeculectomy Trabeculectomy

40. PACG PRIMARY ANGLE CLOSURE GLAUCOMA It refers to occlusion of the TM by the peripheral iris abstructing aqueous outflow Narrow angle/acute glaucoma Much more rare IOP is ries very queckly It is caused by a rapid or sudden increase in eye pressure

41. CLASSIFICATION ( 1)Primary angle closure suspect:- -Normal IOP,optic disc & visual field -No peripheral anterior synechiae ( 2)Primary angle closure:- -Optic nerve damage from an episode of severe IOP elevation -ITC in three or more quadrants ( 3)Primary angle closure glaucoma:- -Shows three or more quadrents of ITC with rised IOP. -Normal disc & field

42. RISK FACTORS Age:- -60 years- pupillary block -young non pupillary block Gender:- Female > Male Family history :-Genetic factors Race:- Asians Refraction:- Typically hypermetropic

43. CAUSES Angle beteween iris and cornea is closed Increase IOP suddenly Completely block the canals,which stops fluid flowing Some health condition can also cause ACG:- -Cataract -Ectopic lens -Diabetic retinopathy - Tumors

44. MECHANISM OF ACG 1)Relative pupil block:- 70% of case -Iris hase large arc of contact with anterior surface of lens 2)Iris bombe formation:- Responsible for few atypical case 3)Appositional angle closure:- mechanism along with pupillary block with iris bombe. Relative pupilary blok :-

45. IRIS BOMB

46. Iris bombe

47. CLINICAL FEATURES Symptoms:- -Rapidly progressive impairement of vision -Painful eye -Red eye -Nausea - Vomitting -photophobia -Haloes

48. Signs:- -Reduce visual acuity -Cornea cloudy,& oedemotous -Pupil oval,fixed,modaretly dilated -Eye feels hard on palpation -Elevated IOP 50-100 mm of Hg -Aqueous flare & cells -Optic disc oedema & hyperaema

49. MANAGEMENT 1)Medicine:- - Acetazolamide -Topical steroids -Topical beta blockers 2)Surgical management:- -Peripheral laser iridotomy -Peripheral iridotomy INITIAL MANAGEMENT :- - Immediately on attack: - Pilocarpine -beta blockers -Topical corticosteroid

50. -If patient in pain:- -Topical ketorolac -Systemic pain medication -If patient in vomitting :- - Intramascular metoclopromide -If patient in comfortable:- -Laser iridoctomy in fellow eye

51. SECONDARY GLAUCOA Group of disorder in which the raised IOP is assosiated with a primary ocular or systemic diseases.

52. CLASSIFICATION ( A)Depending on the mechanism of rise in IOP:- i )Secondary open angle glaucoma:- -In which aqueous outflow may be blocked by pretrabucular membrane or trabecular closing. ii)Secondary angle closure:- which may be or may not be assosiated with pupil block

53. ( B)Depending on the cavsative primary diseases:- -Lens induced glaucoma - Inflamatory glaucoma - Neuvascular glaucoma - Cilliary block glaucoma -Traumatic glaucoma -Glaucoma in aphakia -glaucoma with assosiated with intra ocular haemorrhage

54. LENS INDUCED ( phacogenic ) Pacomorphic –(due to swollen lens) Phacotopic -(anterior lens displacement) Phacolytic Lens partical glacucoma Phacoanaphylactic glaucoma

55. Figure 1: (a) Traumatic anterior dislocation of lens with pupillary block glaucoma; (b) lens particle glaucoma; (c) phacomorphic glaucoma; (d) phacolytic

56. PHACOMORPHIC GLAUCOMA Causes:- - Intumesent lens - ant.subluxation of lens & spherophakia Pathogenosis :- -swollen lens pushes iris forward Treatment:- -Medical:-control of IOP by- - iv mannitol - acetazolamide -topical beta blockers -LASER iridotomy

57. PHACOLYTIC GLAOCOMA Pathogenesis:- - T.M is clogged by the lens proteins,macrophages . -Deep anterior chamber and aqueous may contain fine white protein particles. Clinical features:- - Symptoms:- - pain,nausea,vomitting -rapidly progressive impairement of vision

58. Signs:- -Lid oedematous - Congunctiva-chemosed & congested - Cilliary vessel congested -A.C very shallow -Iris may be discolored -Optic disc oedematous & hyperaemic Management:- -Medical therapy to lower the IOP -Extraction of the hypermature catarctous lens with PCIOL implantation

59. Phacolytic glaucoma

60. NEUVASCULAR GLAUCOMA Result due to formation of neuvascular membrane involving the angle of anterior chamber Etiology:- Neuvascularization of iris following retina isvhaemia features of – -PDR -CRVO -Sickle-cell retinoparhy

61. Clinical Profile:- - Pre- glaucomotous stage -Open angle glaucoma stage -Secondary angle closure glaucoma Treatment:- - Panretinal photocoagulation -Medical therapy not affective - Arteficial filtration shunt.

62. Neuvascular glaucoma

63. TRAUMATIC GLAUCOMA Mechanism:- -Inflammatory glaucoma due to iridocyclitis -Due to intra ocular haemorrhage -Lens-induced glaucoma due to shollen lens -Epithelial grouth -Angle recession glaucoma -Angle-closure glaucoma due to anterior synechia

64. Management:- Medical therapy with topical 0.5% timolol and oral acetazolamide and surgical intervention according to situation. Image of traumatic glaucoma:-

65. GLAUCOMA INVESTIGATION Instrument which are use in glaucoma investigation are:- - OCT (Disc profile): -To measure the thickness of RNFL - VFA :- for visual field test - Perimetry :-visual field test - Tonometry :- measure the inner eye pressur - Opthalmoscopy :-for shape & color of optic nerve - Gonioscopy :-to see the iridocorneal angler - Pachymetry :- to measure thickness of cornea

66. Tonometry Applanation Schiotz Gonioscopy

67. THE VISUAL FIELD Humphrey automated perimetry

68. PATIENTS RECORDS

69. CASE:-01 PT’S NAME :- Vishwanath thakur DATE:- 09/10/2018 REG NO .:- 1819-011510 AGE:- 55 year OCCUPATION:- farmer SEX:- Male ADRESS :- west bengal C/O :- RE-Trauma by hand FINDING :- Fundus -RE- T otal cup ,LE -c/d=0:5 V/A:- RE-6/60p ,LE:-6/24p IOP:- RE-54,LE:-15

70. INVESTIGATION:- VFA APLANATION TONOMETRY INDIRECT OPHTHALMOSCOPY REPORTS:-VFA:- RE- Trabeular vision LE-generalized depression A.T:- RE-55,LE-14 I.O:- RE-Total cupping,LE :-c/d=0:5 CONCLUSIONS:-

71. CASE:- 02 PT’S NAME :- Hiralal manjhi DATE:-12/10/2018 REG NO .:-1718-017579 AGE:-52y OCCUPATION:- bussinessman SEX:-male ADRESS :- P urulia,W.B C/O :-low vision,headache , FINDING :- Fundus -LE-cupping undialated V/A:-RE-NOPL ,LE:-6/18P CORNEA:-RE-Total corneal opacity

72. INVESTIGATION:- VFA OCT (DISC PROFILE) APLANATION TONOMETRY INDIRECT OPHTHALMOSCOPY REPORTS:-VFA:-LE- advanced field loss A.T:- RE-18,LE-27 OCT:-LE significant development seen of inferior quadrent (LE-vertical C/D=1.00) CONCLUSIONS :-

73. CASE:- 03 PT’S NAME :- DATE:- ID NO .:- AGE:- OCCUPATION:- SEX:- ADRESS :- C/O :- FINDING :- Fundus V/A:-RE- ,LE:-

74. INVESTIGATION:- VFA OCT (DISC PROFILE) APLANATION TONOMETRY INDIRECT OPHTHALMOSCOPY REPORTS:- CONCLUSIONS:-

75. CASE:- 04 PT’S NAME :- DATE:- ID NO .:- AGE:- OCCUPATION:- SEX:- ADRESS :- C/O :- FINDING :- Fundus V/A:-RE- ,LE:-

76. INVESTIGATION:- VFA OCT (DISC PROFILE) APLANATION TONOMETRY INDIRECT OPHTHALMOSCOPY REPORTS:- CONCLUSIONS:-

77. CASE:-05 PT’S NAME :-REENA DEVI DATE:- 04/09/2018 REG NO.:- Reg1819-011281 AGE :-30 years SEX:- female OCCUPATION:- House wife ADRESS :-Ranchi C/O :- -painless loss of vision,-Mild headache -Changes in presbyopic glasses FINDING:- Fudus -Cupping V/A-RE-6/6P,LE-6/6P NCT-RE-22,LE-10

78. INVESTIGATION :- -VFA -OCT (DISC PROFILE) -INDIRECT OPHTHALMOSCOPY -APLANATION TONOMETRY REPORTS:- VFA :-Normal OCT :-Vertical C/D=RE-0.71,LE-0.72 I.O :-Cupping A.T:- RE-23,LE-13 (mm of Hg) CONCLUSIONS:-