Secondary open angle glaucoma

Secondary open angle glaucoma

1. SECONDARY OPEN ANGLE GLAUCOMA Dr. Samarth Mishra

2. introduction Characterized by- Raised IOP Open angles A/w underlying disorder leading to alteration in aq. humor dynamics A/w OD & VF changes

3. classification

4. pretrabecular Aq. Flow obstructed by a membrane covering TM Consists of – Fibrovascular memb .-- neovascular glaucoma Descement like memb .—IEC, trauma Epithelial downgrowth Fibrous downgrowth Inflammatory memb – Fuch,s cyclitis

5. Neovascular glaucoma Neovacular tissue arbourise in the angle F orm a fibrovascular memb . Blocks TM SOAG

6. Stages of neovascular glaucoma. Pre-glaucoma stage with new vessels appearing at pupillary margin and in angle . ( B) Open-angle glaucoma stage with new vessels spreading and fibrovascular tissue covering angle . ( C) Heavy neovascularization and extensive peripheral anterior synechiae . (D) Regression stage with angle sealed and vessels less visible.

7. Treatment options of neovascular glaucoma Atropine and steroids to decrease inflammation Beta- bockers intravitreal VEGF inhibitor injection Panretinal photocoagulation - in early cases Artificial filtering devices - in very advanced cases Cyclodestructive procedures - to relieve pain Retrobulbar alcohol injection to relieve pain Topical

8. Membrane forms in one area of angle . ( B) Additional areas of angle are involved , and contraction of membrane displaces pupil.

9. Trabecular causes CLOGGING Erythrocytes: haeme , ghost cell Macrophages: phacolytic , hemolytic, melanolytic Neoplastic : melanoma, NF, naevus of Ota, JXG Pigment: PDS, Uveitis , melanoma Proteins: PXF, uveitis , lens particle Mucopolysaccharides : vitreous, viscoelastic Gas & oil: C3F8, SF6, Air, silicone oil Retinal photoreceptors : Swartz’s syn TM ALTERATION Edema/ inflammation Chemical burn Blunt trauma, angle recession Fe IOFB, siderosis of TM Steroid induced

10. Pigmentary glaucoma B/L condition due to pigment dispersion in AC Risk factors is young adolescent male, whites, high myopic, AD located at 7q35-36 Pathogenesis is rubbing of pig. Epi . Of iris against zonules -> liberation of pig -> deposited in angle by convection current in aq. Signs are:- cornea – krukenberg’s spindle AC – deep, homogeneous fine hyperpig . over post. Trabeculum Iris – radial, spoke like, mid peripheral transillumination defect, concave iris Lens – Scheie’s line/ Zentmayer’s ring Zonules - pigmentation

11. Contd … Management -> medical—beta blockers, adrenaline, dipivefin , CA inhibitor, miotic Laser – ALT, PI, Peri . Iridoplasty Surg - trabeculectomy

12. Exfoliation glaucoma TM clogging up by PXF material &/or pig. From iris Risk factors are –fem, in Scandinavia, mutation in LOXL1 gene at 15q22 locus Patho ---grey-white fibrillary extracellular material composed of protein core surrounded by GAGs produced by abnormal BM of ageing epi . Cells of TM, equatorial lens capsule & CB. Signs –cornea -> dandruff like deposi , in endo . AC -> Sampolesi’s line iris -> absence of pupi . Ruff, moth-eaten trans illumination defect lens -> cataract, exfo . Deposi . As central disk with peri . Band & a clear zone in middle

13. Pseudoexfoliation glaucoma Pseudoexfoliative material Iris sphincter atrophy Gonioscopy Central disc with peripheral band Trabecular hyperpigmentation - may extend anteriorly (Sampaolesi line) O n retroillumination

14. Contd.. T/T --- Medical - beta blockers, epinephrine, miotics Laser – ALT Surg – trabeculectomy Trabecular aspiration

15. Lens induced glaucoma PHACOLYTIC :- . Due to protein leakage from mat./ hypermat . cat . mechanism is –a) high molecular wt. soluble protein directly block b)macrophages engulf the proteins & block . c/f – seen in elderly with h/o poor vision for mons - acute onset of uniocular pain, redness & watering - grossly decres . Vision & raised IOP - signs of uveitis - hypermat / morgagnian cat - AC shows heavy flare a/w hyper refringent crystals which are ca++ oxalate / cholesterol crystals . t/t – medical ( hyperosmotic , CA inhi.,topical b-blockers & steroids - surg ( ECCE with PCIOL)

16. Phacolytic glaucoma Pathogenesis Signs Deep anterior chamber Control IOP medically Remove cataract Floating white particles Treatment

17. Calcium oxalate crystal in the lens of a patient with glaucoma associated with hypermature cataract. ( Hematoxylin and eosin stain.) Phacolytic glaucoma with bloated macrophages and lens material obstructing the trabecular meshwork.

18. Contd … 2) LENS PARTICLE :- . k/a phacotoxic uveitis . Mechanism is – due to trauma/ surg.retained lens material disruption of lens capsule lens material liberation raised IOP inflammatory response raised IOP . c/f – features of uveitis , rai IOP, chunky white particles in AC, hypopyon . Diag. by paracentesis . t/t – medical as phacolytic - surg. ( removal of lens material)

19. Contd … 3) PHACOANAPHYLAXIS :- . occur when patients become sensitized to their own lens protein k/a endophthalmitis anaphylactica . typically develops after penetrating trauma or extracapsular cataract extraction . granulomatous inflammation of the lens with polymorphonuclear leukocytes, lymphocytes, epithelioid cells, and giantcells . . t/t is surg. Removal of residual lens material

20. Glaucoma after trauma CHEMICAL :- . Alkali>acid . caused by scleral shrinkage and release of active substances, including prostaglandins . IOP measured more accurately with the pneumatic or MacKay- Marg tonometers .managed by – medical ( topical and systemic medications) 2) ELECTRIC :- . pressure rise to venous dilation, contraction of the extraocular muscles, and pigment dispersion . No therapy due to transient rise of IOP

21. Contd … 3) RADIATION :- . Mechanism are neovascularization / ghost-cell glaucoma associated with radiation retinopathy and vitreous hemorrhage. 4) PENETRATING :- . Due to retained organic material / FB / severe inflammation / TM damage 5) CONTUSION :- . can cause hyphema , iridocyclitis , iris sphincter tears, iridodialysis , cyclodialysis , lens subluxation , retinal tear or dialysis, retinal detachment, vitreous hemorrhage, choroidal rupture, and glaucoma.

22. Contd …

23. Glaucoma a/w intraocular haemorrhage GHOST CELL :- . mecha . - retinal disease/ trauma/surgery /snake poisoning vitreous haem . degenerated RBC’s travel thr . Disruped ant hyaloid face obstructs TM . Diag. by paracentesis & cyto . Exam. which shows HEINZ bodies i.e. RBCs in the vitreous degenerate to tan-colored spheres (ghost cells), which appear empty except for clumps of denatured hemoglobin . t/t is AC wash / pars plana vitrectomy to remove remaining ghost cells

24. Contd … 2) HEMOLYTIC :- . Due to macrophages laden with pigments, RBC’s & debris 3) HEMOSIDEROSIS :- . Due to iron liberted from Hb causing siderosis of TM 4) HYPHEMA :- . Due to blood & blood products . Total hyphema changing color from red to black ( black-ball or eightball hyphema ) . t/t – topical anti glaucoma - surgical removal of hyphema

25. Glaucoma a/w uveitis . Mechanism are- (1) increased viscosity of aqueous humor; (2) obstruction of the trabecular meshwork by inflammatory cells and debris (3) swelling and dysfunction of the trabecular meshwork; (4) liberation of active substances such as prostaglandins; (5)scarring of the outflow channels; (6) development of a cuticular endothelial membrane over the angle; (7) neovascularization ; (8) elevation of episcleral venous pressure;

26. Contd … Causes are:- FUCH’S HETEROCHROMIC IRIDOCYCLITIS . Mild form of anterior uveitis associated with cataract and glaucoma. .c/f – mild uveitis , fine filaments on the endothelium between the keratic precipitates, a patchy loss of the iris pigment epithelium, hypochromia , grey-white nodules on the anterior iris, a few opacities in the anterior vitreous, and chorioretinal scars . Gonioscopy reveals fine vessels that bridge the angle

27. Contd … 2) GLAUCOMATOCYCLITIC CRISIS :- . k/a POSNER – SCHLOSSMAN SYNDROME . young to middle-aged adults and consists of recurrent episodes of mild anterior uveitis and marked elevations of IOP . mild ciliary flush, a dilated or sluggishly reactive pupil, corneal epithelial edema, IOP in the range of 40–60 mmHg, decreased outflow facility, open angles, faint flare, and 1–20 fine keratic precipitates

28. Contd … 3) JRA :- . most common in young girls with iridocyclitis and monoarticular or pauciarticular involvement . Due to inflammation of the trabecular meshwork 4) HERPES :- . Due to trabeculitis , inflamm . Of TM . Commonly in disciform & necrotising sromal type 5) SYPHILIS :- . Due to acute interstitial keratitis

29. Contd … 6) SARCOIDOSIS :- . swelling and dysfunction of the trabecular meshwork, obstruction of the trabecular meshwork by inflammatory cells and debris 7) PRECIPITATES IN THE TM Diag. by lab. & imaging technique t/t- medical ( topical, sys. & periocular steroids, cycloplegics , NSAIDS, immunomodulators , anti glaucoma) - surg (ALT, filtering procedure, tube shunts, cycloablative , Nd:YAG laser cyclophotocoag .)

30. Glaucoma a/w intraocular tumors Mechanisms are:- direct extension of the tumor into the trabecular meshwork seeding of tumor cells into the outflow channels pigment dispersion inflammation Hemorrhage , inducing hemolytic glaucoma, and suprachoroidal hemorrhage neovascularization of the angle obstruction of the trabecular meshwork by macrophages containing melanin released by a necrotic tumor ( melanomalytic glaucoma)

31. Contd … Tumors causing rai . IOP:- Iris- neavus , melanocytoma , malignent melanoma, metastatic CB- medullocytoma , melanocytoma , malignent melanoma Choroid- malignent melanoma, metastatic ON- melanocytoma , metastatic Retina – retinoblastoma Metastatic CA Others- leukemia, lymphoma, multiple myeloma, juvenile xanthogranuloma

32. Contd … Diag. by- gonio ., indirect & direct ophthalmoscope, USG, MRI, FNAC, Aq. Aspiration, excisional biopsy t/t –medical (anti glaucoma with surg./radiation/ chemo/a combination) - surg — . smaller tumor ( observation till growth) . Iridectomy / iridocyclectomy for smaller tumor . Ant. Tumor ( argon laser trabeculopexy ) . Post. Tumor ( local resection/ photocoagulation/ episceral radiopaque therapy / enucleation / exenteration )

33. Corticosteroid glaucoma Seen in steroid responders who use topical, creams, oientment on eyelids, systemic, periocular , inhaled steroids Steroid responders are those who showed rai . IOP to topical steroids in 4-6 wks as compared to general population 3 groups- low (manifest with no change in IOP) intermediate ( mod. Elevation of IOP to 22-30) high ( marked rise to >30) Patho .:- stabilize lysosomal memb . Prevents polymerization of GAG GAG accumulation in TM t/t :- dicontinuation of drug - anti glaucoma medication - trabeculectomy / seton implantation in uncontrolled

34. Glaucoma after cataract surgery Mechanism are:- 1. Inflammation with the release of active substances, including prostaglandins and the formation of secondary aqueous humor. 2. A watertight wound closure with multiple fine sutures limiting the ‘safety valve’ leak of aqueous humor. 3. Deformation of the limbal area, reducing trabecular outflow. 4. Obstruction of the trabecular meshwork by pigment, blood,lens particles, inflammatory cells, and viscoelastic substances.

35. Contd … A. Early onset (within first postoperative week) 1. Pre-existing chronic open-angle glaucoma 2. alpha- Chymotrypsin -induced glaucoma 3. Hyphema /debris 4. Viscoelastic material 5. Idiopathic pressure elevation B. Intermediate onset (after first postoperative week) 1. Pre-existing chronic open-angle glaucoma 2. Vitreous in the anterior chamber 3. Hyphema 4. Inflammation 5. Lens particle glaucoma 6. Corticosteroid-induced glaucoma 7. Ghost-cell glaucoma C. Late onset (more than 2 months postoperatively) 1. Pre-existing chronic open-angle glaucoma 2. Ghost-cell glaucoma 3. Neodymium:yttrium -aluminum-garnet ( Nd:YAG ) laser capsulotomy 4. Vitreous in the anterior chamber 5. Late-occurring hemorrhage 6. Chronic inflammation

36. 1.alpha-Chymotrypsin Glaucoma used widely to facilitate intracapsular cataract extraction. mechanism for alpha- chymotrypsin glaucoma is that zonular fragments obstruct the outflow channels t/t by using a lesser concentration of the drug (1:10 000 instead of 1:5000) in a lower volume(0.25–0.5 ml instead of 2 ml) anterior chamber should be irrigated before lens extraction to remove zonular fragments

37. Scanning electron micrograph of the zonular fragments obstructing the trabecular meshwork after alpha- chymotrypsin administration

38. 2. Glaucoma From Viscoelastic Substances Sodium hyaluronate blocks TM tiny ruby-like globs of hemorrhage on the iris surface or suspended in the anterior chamber

39. 3. Glaucoma with Pigment Dispersion from Intraocular Lenses Mechanism:- Decentered , tilted, excessively mobile, too small, or reversed in position excess friction between the optic or haptic and the iris pigment epithelium Pigment particles block TM c/f :- geographical loss of iris pigment

40. 4. Uveitis -Glaucoma- Hyphema Syndrome Seen in iris supported ACIOL / PCIOL c/f:- rai.IOP, iridocyclitis & recurrent hyphema for wks to mons after surg. Due to excessive chafing of the iris by the pseudophakics because the lenses are too mobile

41. 5.Glaucoma After nD : yag Laser Posterior Capsulotomy occurs within 2–4 hours of the laser treatment and then abates spontaneously over the next 24 hours usually associated with particulate debris clogging the trabecular meshwork Pretreatment with apraclonidine 1% 1 hour prior to surgery and one drop 1 hour after surgery has been shown to decrease the number and severity of postoperative pressure spikes

42. 6. Glaucoma from Vitreous in the Anterior Chamber Common in aphakic eyes after a spontaneous rupture of the hyaloid face or after an extensive posterior vitreous detachment.

43. Retinal detachment and glaucoma Due to vitreous loss Schwartz Syndrome- RD + Rai . IOP + decrea . Outflow + open angles + cells & flare in AC Mechanism:- a)angle recession,inflammation , pigment granules released by the retinal pigment epithelium, and glycosaminoglycans synthesized by the photoreceptors blocks TM - b) photoreceptor outer segments migrate through the retinal hole and obstruct the trabecular meshwork

44. Glaucoma after vitrectomy Pre-existing glaucoma Angle recession Ghost cell Primary open-angle glaucoma Pigmentary glaucoma Associated with intraocular hemorrhage Hyphema Ghost cell Hemolytic Hemosiderosis Related to lens material Phacolytic Lens particle Phacoanaphylactic Neovascular Inflammatory Corticosteroid induced Intraocular gas or liquid Air Viscoelastic substances Perfluorocarbons Silicone

45. Post- trabecular causes TM is normal but aq. Flow is impaired due to elevated episcleral venous pressure For every 1mm rise in EVP-> 0-8 mm rise in IOP Causes are :- I . Obstruction of venous drainage A. Episcleral-1. Chemical burns 2. Radiation B. Orbital -1. Retrobulbar tumors 2. Thyroid eye disease 3. Pseudotumor 4. Phlebitis C. Cavernous sinus thrombosis D. Jugular vein obstruction E. Superior vena cava obstruction F. Pulmonary venous obstruction II. Arteriovenous fistulas A. Orbital B. Intracranial-1. Carotid-cavernous fistula 2. Dural fistula 3. Venous varix 4. Sturge -Weber syndrome III. Idiopathic

46. Superior Vena Cava Obstructions Mainly due to tumors, aortic aneurysms, mediastinal masses, hilar adenopathy , and intrathoracic goiter produces edema and cyanosis of the face and neck ( pumpkinhead appearance) as well as dilated vessels in the head, neck, chest, and upper extremities ocular findings include exophthalmos , papilledema , and prominent blood vessels in the conjunctiva, episclera , and retina IOP is elevated mainly in supine position

47. Arteriovenous Fistulas Carotid-cavernous fistulas- It provide a free communication between the internal carotid artery and the surrounding cavernous sinus  in high blood flow and high mean pressure in the shunt reversal of blood flow in the vessels leads to congestion of the orbital veins and soft tissues - c/f--- pulsating exophthalmos , chemosis , lid edema, vascular engorgement, and restriction of ocular motility

48. Carotid-cavernous fistula.

49. Contd … Sturge -Weber Syndrome k/a enchephalotrigeminal angiomatosis Congenital, sporadic oculocutaneous disorder Glaucoma is seen in 30% of pt’s having ipsilateral facial hemangiomata during first 2yrs of life Patho  isolated trabeculogenesis -> raised episcleral venous pressure t/t medical (topical PG’s)  goniotomy  combined trabeculotomy & trabeculectomy

50. THE END