A complicated groups of disorders characterized by optic disc and v. field changes related to a high or a statically normal IOP. It involves a study
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2 THE GLAUCOMAS
3 A complicated groups of disorders characterized by optic disc and v. field changes related to a high or a statically normal IOP. It involves a study of (1) IOP(2) ON head changes (3) V.field Loss (4) Drainage angles.
4 IOP = Aqueous +Vit. Body. Production by non pigmented cilary epith. 80% by active secretion (many enzyme systems Na + / K + ATP ase. 20% by ultrafiltration and diffusion. Production Rate: 2.00micro Litre/min. Secreted in posterior chamber, through the pupil, fills anterior chamber and egress through TM.
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7 Trabecular Meshwork is small fibroelastic structure about 0.6mm present in the A.A.C. at limbus in deeper part of sclera. 90% of drainage. Uveal + corneoscleral and juxta canalicular schlemm s canal collector channels subepiscleral meshwork episcleral veins. About 10% through ciliary body and iris to suprachoroidal venous system.
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9 CLASSIFICATION 1) Congenital or developemental 2) Acquired
10 Classification Congenital Development Aquired Primary Associated Secondary Open Angle Angle Closure Primary Secondary NTG Ocular Hypertension Pupillary Block Without P. Block Primary Secondary Primary Secondary
11 PRIMARY ISOLATED CONGENITAL GLAUCOMA : (TRABECULODYSGENESIS) ASSOCIATED : (with Ocular or Systemic Disease) e.g. [Anterior Segment dysgenesis, Aniridia, Iris Hypoplasia, Micro Cornea, Micro Spherophakia]. e.g. [Marfan s Synd, Homocystinuria, Neuro fibro matosis, Sturge Weber synde]. SECONDARY : e.g PHPV, ROP, Uveitis, Retinoblastoma, Trauma.
12 OPEN ANGLE : Primary Open Glaucoma (Meshwork Sclerosis) SECONDARY OPEN ANGLE : 1. Pseudoexfoliative Glaucoma 2. Pigmentary Glaucoma 3. Lens Induced Glaucoma 4. Inflammatory Glaucoma 5. Traumatic Glaucoma 6. Intra Ocular Hemorrhage 7. Glaucoma After Cataract Surgery
13 ANGLE CLOSURE GLAUCOMA WITH PUPILLARY BLOCK: 1. Primary Angle Closure Glaucoma 2. Secondary Angle Closure Glacoma Examples: 1. Miotic Induced 2. Swollen Lens 3. Ectopia Lentis 4. Posterior Synechiae (360 degree)
14 ANGLE CLOSURE GLAUCOMA WITHOUT PUPILLARY BLOCK: 1. PRIMARY ANGLE CLOSURE WITHOUT PUPILLARY BLOCK : (Plateau Iris) 2. SECONDARY : New Vascular Glaucoma, Epithelial ingrowth, Uveitis, Ciliary Block Glaucoma (Malignant Glaucoma) Cyst of Iris and Ciliary Body, Scleral buckle, Intravitreal air injection
15 MANAGEMENT 1. Symptoms 2. Signs 3. Instrumental Investigations SYMPTOMS: May remain asymptomatic till late when Visual Loss is appreciable due to Central Retinal Involvement.(POAG) May Precipitate presbyopia early or aggravate it rapidly. Severe Pain, Red Eye, Watering, Nausea & Vomiting indicate acute rise of IOP.(Acute congestive glaucoma : (ACG)
16 History of Eye Pains with dusk, Winter nights and prolonged work in head down position are signs of Transient rise of IOP(ACG). Halos around light is classical of acute congestive Glaucoma with corneal oedema (ACG). Watering, bigger cornea, cloudy cornea (PCG)
17 SIGNS C:D asymmetry> 0.2, bayoneting of disc vessels. Best Corrected visual Acuity IOP: Normal (16.0 mmhg ) or Raised IOP (22.0 mm or above). Disc Findings: Increased cup disc ratio (Thinning neural rim), notching of the rim, splinter hemorrhage, nasal shift of b.vessels, Baring of Retinal Blood Vessels,
18 SIGNS CONTINUED---- Ant. Segment, Gonioscopy and IOP : OA or AC, primary / Secondary. Fundoscopy. Visual fields: Others : OCT
19 Torch exam and SLE IOP measurement Gonioscopy Fundoscopy
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32 OPTIC NERVE HEAD EXAMINATION 1: Retinal nerve fiber layer. 2: Scleral canal and lamina cribrosa. 3: Optic cup. 4: Cup Disc Ratio.
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39 VISUAL FIELDS DEFECTS 1: Paracentral scotoma (Bjerrum s area) 2: Seidel scotoma. 3: Nasal step(roenne) or a temporal wedge. 4: Arcuate scotoma.
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50 TREATMENT OPTIONS FOR GLAUCOMA 1. Medical treatment 2. Laser treatment 3. Surgical treatment 4. Treatment of end stage glaucoma
51 Medical treatment of glaucoma.. Sr no. Name of drug Group Mode of action Side effects 1 Timolol E/ Dps ( % BD) B-Blocker aqueous secretion. Ocular: Allergy, PEE, Dry eye 2 Betaxolol (betoptic) E/dps (.5 % BD) B-Blocker Cardio selective. aqueous secretion. Systemic : bronchospasm (ex. Betaxolol). Bradycardia, hypotension, 3 Levobunolol (betagan) (.5% BD) B-Blocker aqueous secretion. Sleep disorder, hallucinations, confusion, depression, fatigue, headache.
52 Medical treatment of glaucoma.. Sr no. Name of drug Group Mode of action Side effects 4 Brimonidine (alphagan) (0.2 % BD) Alpha-2 agonist aqueous secretion and u.s outflow. Ocular: Allergic conjunctivitis, G. uveitis. Systemic : xerostomia, drowziness, fatigue. 5 Apraclonidine (1% BD) Alpha-2 agonist aqueous secretion and u.s outflow. Tachyphylaxis + more than brimonidine. 6 Pilocarpine E/Dps (.5 %, 1 %, 2% or 4 % BD) Miotics Parasympathomi metic. stimulation of ciliary and sphincter muscles. Miosis, visual drop, headache, myopic shift, V.F constriction, RD and uveitis.
53 Sr no Name of drug Group Mode of action Side effects 7 Dorzolamide (trusopt) E/Dps (2% TDS or BD) 8 Brinzolamide (azopt) 1 % TDS or BD CA Is Alpha- 2 agonist Inhibits aqueous secretion. Inhibits aqueous secretion. Allergic blepharo conjunctivitis, endothelial dysfunction, bitter taste. Lesser incidence of side effects. Lesser than dorzolomide. 9 Latanoprost (xalatan) E/Dps (0.005 % once daily) Travoprost (0.004 %), bimatoprost (0.03 %), tafluprost ( %) PGF2 alpha analogu es. U.S outflow. Conj. hyperaemia, conj. Pigmantation, iris pigmentation, lengthening, thickening, pig. and number of eye lashes, pig. Periocular skin, CMO, ant. Uveitis and rec. herpetic caratitis. Migraine, URTI and teratogenesis
54 Medical treatment of glaucoma.. Name of drug Combination Cosopt (timolol + dorzolamide )( BD) Xalacom (timolol + latanoprost) ( OD) Timpilo (timolol + pilocarpine) (BD) Combigan (timolol + brimonidine) (BD)
55 Sr no. Medical treatment of glaucoma.. Name of drug Group Mode of action Side effects 1 Acetazolamide(tab 250 mg (1-4tabs / day) and inj. 500 mg) 2 Dichlorphenamide (tab 50 mg BD/TDS) CAI CAI Inhibits aqueous secretion. Inhibits aqueous secretion. Paraesthesia, malaise complex, GI complex, renal stone, S-J synd, blood dyscrasias and hypokalaemia. 3 Methazolamide (tab 50 mg BD/TDS) CAI Inhibits aqueous secretion.
56 Medical treatment of glaucoma.. Sr no. Name of drug Group Mode of action Side effects 1 Inf. Mannitol (20 % 5ml/ kg body weight I/V mins) Osmotic agent Osmotic gradient b/w blood and vitreous. Cardiovascular overload, urinary retention, headache, nausea and confusion. 2 Oral glycerol (50 % with lemon juice 2 ml /kg body weight ) Osmotic agent Osmotic gradient b/w blood and vitreous. Sweet and sickly taste, hyperglycaemia. 3 Oral isosorbide (same as glycerol) Osmotic agent Osmotic gradient b/w blood and vitreous. Minty taste.
57 LASER THERAPY ARGON LASER TRABECULOPLASTY (ALT) SELECTIVE LASER TRABECULOPLASTY (SLT) DIODE LASER CYCLOABLATION (CYCLODIODE) LASER IRIDOPLASTY
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