Secondary open-angle glaucoma Kathy Hondeghem ZNA Middelheim MaNaMa 12/10/13 Definition Open anterior chamber angle (at least 270 ) Trabecular meshwork (and thus aqueous humor outflow) is occluded by a variety of cells and debris, e.g. blood, pigment A form of glaucoma that develops in individuals with an underlying ocular disease Often unilateral/asymmetric Definition 1
Classification Pigment Dispersion Pseudoexfoliation Corticosteroid-induced glaucoma Angle-recession glaucoma (post-traumatic) Inflammatory glaucoma * Fuch s iridocyclitis * Posner-Schlossman Lens-related glaucoma (phacolytic) Classification Pigment Dispersion Pseudoexfoliation Corticosteroid-induced glaucoma Angle-recession glaucoma (post-traumatic) Inflammatory glaucoma * Fuch s iridocyclitis * Posner-Schlossman Lens-related glaucoma (phacolytic) 2
Pigment Dispersion Triad 1. Krukenberg Spindel 3
2. Iris Transillumination 4
5
3. Trabecular Hyperpigmentation Don t leave home without your gonioscope! 6
NB : syndrome vs. glaucoma Pigm entdispersion SYNDROME Pigm entdispersion GLAUCOMA Who? Mechanism 7
Often quick progression! Can we stop it?? Preventive YAG laser iridotomy 8
How does it work? To do or not to do?? 9
10
Now what??? YES: iridotomy (if concave iris) Especia ly if< 40 yrs old Especia ly ifonly syndrom e and notyet glaucom a!! 2008 11
YES: iridotomy 2009 NB : iridotomy perforated?? Do NOT look for pigm entflush forw ard!! Treatment PDG: 1. collyria Pilo All others 12
Treatment PDG: 2. LTP Treatment PDG: 3. Surgery Trabeculectom y 13
Classification Pigment Dispersion Pseudoexfoliation Corticosteroid-induced glaucoma Angle-recession glaucoma (post-traumatic) Inflammatory glaucoma * Fuch s iridocyclitis * Posner-Schlossman Lens-related glaucoma (phacolytic) Pseudoexfoliation Clinical features Exfoliation material on the lens capsule Dandruffs at pupillary border Moth-eaten iris transillumination Trabecular hyperpigmentation (Sampaolesi) Zonular weakness Often nuclear cataract Poor pupillary dilatation Decreased endothelial count Increased risk of central venous occlusion Many possible complications in cataract surgery 14
a. Exfoliation target b. Dandruffs 15
c. transillumination 16
d. Hyperpigmentation (Sampaolesi) e. Cataract and complications Weak zonules: due to lysosomal enzymes in exfoliative deposits ( often narrow angle) Poor dilatation Post-operative intraocular lens dislocation Capsular bag phimosis 17
f. Decreased endothelial count Often keratopathy: endothelial decompensation Decreased number of endothelial cells Exfoliative flakes on endothelium Beware: cataract surgery! g. Venous occlusion 18
NB : Pseudoexfoliation SYNDROME Pseudoexfoliation GLAUCOMA Some facts PXF = the most common identifiable cause of open angle glaucoma worldwide 70 million people worldwide have PXF Syndrome 6 million have PXF Glaucoma PXF gives 6-fold increase in risk of glaucoma PXF syndrome PXF glaucoma 38% in 10 years Book: Exfoliation Syndrome and Exfoliative Glaucoma, G. Hollo and G.P. Konstas, EGS, 2008 Who? 19
Where? Where? Unilateral? NO! Clinically often unilateral presentation Actually never unilateral, rather asymmetrical! Electron microscopy: often fibrils found in clinically uninvolved fellow eye 38% of clinically unilateral convert to clinically bilateral during a decade. THUS: be careful during cataract operation of the seemingly uninvolved fellow eye of a patient with clinically unilateral PXF!! 20
Systemic disease? YES! Exfoliation fibers also found in: skin, muscles, heart, kidneys, lungs, blood vessels, gall bladder, cerebral meninges.. Elevated plasma homocystein level PXF more common with Alzheimer No increased mortality NB : Pigm dispersion vs. PXF pigm entdispersion pseudoexfoliation 21
Classification Pigment Dispersion Pseudoexfoliation Corticosteroid-induced glaucoma Angle-recession glaucoma (post-traumatic) Inflammatory glaucoma * Fuch s iridocyclitis * Posner-Schlossman Lens-related glaucoma (phacolytic) Corticosteroid-induced glaucoma Mechanism Decreased outflow through trabecular meshwork (due to accumulation of glycosaminoglycans in TM) Increased production Reduced phagocytosis 22
Risk factors History of POAG / POAG-suspect Age Connective tissue disease (eg Rh A) Diabetes First-degree relative with POAG High myopia IOP elevation typically manifests 2-6 weeks after initiation of steroids. Administration Risk: Topical > Systemic IOP elevating risk 23
24
Resolution of IOP rise Usually within 1-4 weeks after cessation ±3% of cases: raised IOP is irreversible, especially if family history of POAG chronic use of steroid (>4yrs) Treatment: beta-blockers, CAI s, excision of depot, trabeculectomy Beware: Beware: 25
NB: Diff. Diagnosis: NTG!! Classification Pigment Dispersion Pseudoexfoliation Corticosteroid-induced glaucoma Angle-recession glaucoma (post-traumatic) Inflammatory glaucoma * Fuch s iridocyclitis * Posner-Schlossman Lens-related glaucoma (phacolytic) Angle-recession glaucoma 26
Angle recession A sequel of blunt eye trauma A tear in the ciliary muscle Men>women; ¾ younger than 30 yrs. old 5.5% develop glaucoma (8% glaucoma if 360 of angle recession) Glaucoma often 10-20 yrs. after trauma How? Blunt trauma with hyphema Traumatic hyphema 60-94% of eyes have angle recession! 27
Definitions Angle recession: a tear between longitudinal and circular muscles of the ciliary body Cyclodialysis: separation of ciliary body from scleral spur Iridodialysis: a tear in the root of the iris Diff. diagnosis Gonioscopy: angle recession 28
Gonioscopy: angle recession Gonioscopy ofangle recession (left) and norm alsubject(right). TM = trabecular meshwork SC = scleralspur CM = ciliary muscle Diagnosis Look for other signs of previous trauma: cataract, pupil sphincter tears Compare gonioscopy of both eyes! Important! Fellow eye at increased risk for POAG!! Lifelong yearly follow-up 29
Classification Pigment Dispersion Pseudoexfoliation Corticosteroid-induced glaucoma Angle-recession glaucoma (post-traumatic) Inflammatory glaucoma * Fuch s iridocyclitis * Posner-Schlossman Lens-related glaucoma (phacolytic) Fuchs Heterochromic Iridocyclitis Fuchs Mostly 20-40 yr old patients Often diffuse iris atrophy hypochromia Uncertain etiology (toxoplasmosis, rubella??) 30
Fuchs Chronic nongranulomatous iridocyclitis TRIAD: Heterochromia Uveitis (asymptomatic) Cataract Fine stellate KPs over ENTIRE endothelium (pathognomonic) Never posterior synechiae Poor response to topical steroids Fuchs 2 take-home messages Prof Kestelyn: Can be bilateral!! (13%) Often floaters in vitreous!! Fuchs and glaucoma Chronic glaucoma in 13-59% of cases Trabeculitis reduced outflow R/ IOP lowering drops or trabeculectomy 31
Classification Pigment Dispersion Pseudoexfoliation Corticosteroid-induced glaucoma Angle-recession glaucoma (post-traumatic) Inflammatory glaucoma * Fuch s iridocyclitis * Posner-Schlossman Lens-related glaucoma (phacolytic) Posner-Schlossman Posner-Schlossman = Recurrent Glaucomatocyclitic Crisis Acute attack of unilateral IOP rise (>40mmHg), disproportionate to inflammation Etiology?? (trabeculitis due to herpes/cmv??) Inflammation of trabecular meshwork reduced outflow strong IOP rise 32
Clinical features Unilateral Mild pain Colored halos/blurred vision Minimal conjunctival injection (white eye) Corneal epithelial edema IOP 40-60mmHg Cells+/-, flare+/-, few fine keratic precipitates No posterior synechiae Who? Young adults (20-50 years) Recurring episodes with varying frequency Months to years between episodes Decreasing frequency with age No ethnic predilection Men>women Treatment Self-limiting!!Short course of topical steroids!! Topical IOP-lowering drops during attack (PG) No cycloplegics No treatment between attacks Many patients (25-50%?) later develop POAG! 33
NB: Posner-Schlossman vs. Fuchs Posner-Schlossm an Fuchs Classification Pigment Dispersion Pseudoexfoliation Corticosteroid-induced glaucoma Angle-recession glaucoma (post-traumatic) Inflammatory glaucoma * Fuch s iridocyclitis * Posner-Schlossman Lens-related glaucoma (phacolytic) Lens-related glaucoma 34
Phacolytic glaucoma Hypermature cataract Lens proteins leak into the aqueous and obstruct the outflow pathway Treatment Emergency removal of the lens First lower IOP with eye drops, Diamox Lessen inflammation with topical steroids Thoroughly irrigate anterior chamber! The IOP usually returns to normal after lens removal. 35
A few last words of advice... ALWAYS do gonioscopy for secondary glaucoma!!! Angle open? Hyperpigmentation? Angle recession? Rubeiosis? Uveitis: PAS? No prostaglandines or Pilo if eye is inflamed! No LTP if damaged or inflamed trabeculum! Thank you for your attention!! 36