Secondary glaucoma

This presentation describes the secondary glaucoma and its different types .....you can find the illustrated video presentation in the following link:
https://www.youtube.com/watch?v=G1wkThV_za8

1. Secondary Glaucoma Subtitle By Dr. Amr Mounir Lecturer of Ophthalmology Sohag University

2. Background - Glaucoma is a group of irreversible, progressive optic neuropathies that can lead to severe visual field loss and blindness . - May be primary or secondary

3. Background In primary glaucoma , the elevation of IOP is not associated with any other ocular disorder In secondary glaucoma a recognizable ocular or non-ocular disorder alters aqueous outflow which , in turn, results in elevation of IOP.

4. Secondary glaucoma

5. Classification

6. 2ry Angle Closure With pupillary block - Miotic induced. - Swollen lens induced glaucoma ( Phacomorphic glaucoma). - Mobile lens induced glaucoma ( ectopia lentis , microspherophakia ). - Posterior synechiae (to lens, vitreous, or IOL) . Without pupillary block a) Anterior pulling mechanism : pulling the iris forward by contraction of a membrane e.g. late neovascular glaucoma and inflammatory membrane . b) Posterior pushing mechanism : pushing the iris forward by a condition in the posterior segment e.g. Malignant glaucoma and intraocular tumors.

7. 2ry Open Angle Subdivided on the basis of the site of aqueous outflow obstruction . Pre-trabecular glaucoma Trabecular Post-trabecular

8. 1) Pre-trabecular glaucoma: in which aqueous outflow is obstructed by a membrane covering the trabeculum , which may consist of: Fibrovascular tissue (e.g. early neovascular glaucoma ) . - Endothelial cells (e.g. iridocorneal endothelial syn ­ drome ).

9. 2) Trabecular glaucoma: in which the obstruction occurs as a result of: a) Clogging up of the meshwork by : - Pigment particles (e.g. pigmentary glaucoma ). - Red blood cells (e.g. red cell glaucoma ). - Degenerated red cells (e.g. ghost cell glaucoma ). - Macrophages and lens proteins (e.g. phacolytic glau­coma ). - Proteins (e.g. hypertensive uveitis ). - Pseudoexfoliative material. b) Alteration of the trabecular fibers themselves by: - Edema (e.g. herpes zoster iritis ). - Scarring (e.g. post-traumatic angle recession glau­coma ).

10. 3) Post-trabecular glaucoma Aqueous outflow is impaired as a result of elevated episcleral venous pressure due to: - Carotid-cavernous fistula . - Obstruction of the superior vena cava .

11. Important types of Secondary Glaucoma

12. Pseudoexofoliation Glaucoma Pseudoexofoliation (PEX) syndrome : characterized by deposition of grey-white, fibrillogranular material in the anterior lens capsule, zonules , ciliary body , iris , trabeculum , anterior vitreous face and conjunctiva. Pseudoexofoliation glaucoma occurs when trabecular block occur by clogging up of the trabeculum by Pseudoexofoliation material

13. Pseudoexofoliation Glaucoma Clinical picture: 1) Cornea: PEX materials on the posterior surface. 2) Iris: Atrophy – PEX material. 3) Lens: PEX materials forming central disc and peripheral band – cataract – subluxation. 4) Gonioscopy : Trabecular hyperpigmentation and PEX materials. Treatment: as POAG.

14. Neovascular Glaucoma Retinal ischemia  vasoproliferative growth factor  retinal neovascularization, rubeosis iridis & neovascularization at the angle of AC. Causes: 1) Ischemic CRVO and CRAO. 2) PDR. 3) OLD RD. 4) IO Tumors.

15. Neovascular Glaucoma: 3 stages 1 ) Rubeosis iridis : iris new vessles . Treatment : Argon laser photocoagulation of the ischemic retina. 2 ) 2ry open angle glaucoma: due to neovascular membrane in front of the trabeculum . Treatment: 1 ) Medical: antiglaucoma – steroids – atropine. 2) Argon laser photocoagulation of the ischemic retina. 3 ) 2ry angle closure glaucoma : due to contraction of the membrane. Treatment: 1) Argon laser photocoagulation of the ischemic retina. 2) Surgery: trabeculectomy with adjunctive Mitomycin C OR artificial shunt. 3) Cyclodestruction : destruction of the ciliary processes by laser.

16. Lens induced Glaucoma

17. A) Phacolytic Glaucma : Hypermature cataract  lens proteins leak through intact capsule  blockage of the trabeculum with proteins and macrophages filled with proteins. Clinical picture: - Corneal edema. - Deep AC with floating white particles ( pseudohypopyon ). - Gonioscopy : open angle. Treatment: - 1st : Control IOP medically. - Then: cataract surgery .

18. B) Phacoanphylactic glaucoma: Rupture of lens capsule  autoimmune reaction to lens proteins  uveitis and glaucoma.

19. C) Phacomorphic glaucoma : Intumescent cataract (Swollen lens)  pupillary block  iris bombe  angle closure. Treatment: 1) Control of IOP. 2) Cataract surgery .

20. Thank You Hussein Bicar (1913-2002)