• Circular shape • Enlarged cup, NRR pink • Cup-disc ratio = approx. 0.7 • Diagnosis: Glaucomatous cupping "POS" Dr Sabin Sahu 51
• Shape oval • Pale color of disc • Cup as well as neuroretinal rim is pale • Margin – distinct • Blood vessels normal Diagnosis: Optic atrophy "POS" Dr Sabin Sahu 52
4. Visual field examination • Perimetry – Kinetic : Goldmann perimeter – Static : Automated perimeters like Humphrey field analyzer "POS" Dr Sabin Sahu 53
Humphrey field analyzer • Uses static white on white stimuli standard automated perimetry • Testing patterns: ▪ 24-2 : central 24o /54 points ▪ 30-2 : central 30o /76 points • Testing strategies : SITA (Swedish Interactive Threshold Algorithm) – most commonly used "POS" Dr Sabin Sahu 54
Clinical types of glaucoma and its management "POS" Dr Sabin Sahu 55
Primary Congenital glaucoma • Presentation: from birth to early childhood • Pathogenesis: trabeculodysgenesis or goniodysgenesis, iris and cornea are not involved • Clinical features: Symptoms: • Triad of 1. Epiphora 2. Photophobia 3. Blepharospasm "POS" Dr Sabin Sahu 56
"POS" Dr Sabin Sahu Signs: – Axial myopia – Buphthalmos - Enlarged eyeball – Cloudiness of cornea – Descemet’s membrane breaks (Haab’s striae) – Disc cupping – Raised intraocular pressure 57
Management • Examination under anesthesia (EUA) – measurement of IOP, corneal thickness, gonioscopy, ophthalmoscopy • Medical – Beta blockers, prostaglandins, acetazolamide – Brimonidine is contraindicated below 10 yrs • Surgical – Main treatment modality – Trabeculotomy + Trabeculectomy – treatment of choice – Trabeculotomy – Goniotomy – treatment of choice if cornea is clear – Combination of these procedures "POS" Dr Sabin Sahu 58
Primary open angle glaucoma • Primary open-angle glaucoma (POAG) is a commonly bilateral disease of adult onset (age >40 years). • It is characterized by: • IOP >21 mmHg at some stage. • Glaucomatous optic nerve damage. • An open anterior chamber angle. • Characteristic visual field loss as damage progresses. • Absence of signs of secondary glaucoma or a nonglaucomatous cause for the optic neuropathy. "POS" Dr Sabin Sahu 59
• Risk factors for POAG: – Age more than 40 yrs – Family history of POAG – Myopic eyes – Diabetes mellitus – Hypertension – Cardiovascular diseases "POS" Dr Sabin Sahu 60
Spectrum of Open angle glaucoma IOP Optic disc Visual field Diagnosis Increased Abnormal Abnormal Glaucoma (POAG) Normal Normal Normal Normal Increased Normal Normal Ocular hypertension "POS" Dr Sabin Sahu 61
Spectrum of Open angle glaucoma IOP Optic disc Visual field Diagnosis Normal Abnormal Abnormal Normal tension glaucoma Normal Abnormal Normal Disc suspect Normal Normal Abnormal Glaucoma suspect "POS" Dr Sabin Sahu 62
Diagnosis Symptoms: • Visual acuity is likely to be normal except in advanced glaucoma. • Frequent change in presbyopic glasses • Difficulty in dark adaptation • Eyeache, headache Examinations: • Tonometry – check intraocular pressures • Optic disc examination for glaucomatous changes • Gonioscopy – open angles • Pachymetry- for CCT, Corrected IOP • Visual fields – to look for any visual field defects "POS" Dr Sabin Sahu 63
Management • Aim of treatment: prevent functional impairment of vision within the patient’s lifetime by slowing the progression of disease. • Currently the only proven method of achieving this is the lowering of IOP. • Treatment modalities: I. Medical treatment - prostaglandin analogue / beta blocker / alpha agonists / combinations II. Laser procedures – laser trabeculoplasty III. Surgical treatment – trabeculectomy / glaucoma drainage device "POS" Dr Sabin Sahu 64
Primary Angle closure glaucoma • Primary angle closure glaucoma is a specific type of glaucoma where aqueous outflow is blocked as a result of closure of the angles. "POS" Dr Sabin Sahu 65
• Risk factors for angle closure glaucoma: – Females more commonly affected than males – Hypermetropic eyes – Eyes with shorter axial length – Relatively large size of crystalline lens – Shallow anterior chamber "POS" Dr Sabin Sahu 66
• Symptoms – Transient blurring of vision – Colored haloes around light • These symptoms occur more often at night, due to precipitating factors like dim light, mydriasis In acute angle closure: – Sudden and severe pain in the eye, blurring of vision – Associated nausea, vomiting – Redness, photophobia, watering "POS" Dr Sabin Sahu 67
Spectrum of Angle Closure Glaucoma Clinical stages of primary angle closure glaucoma: – Primary angle closure suspect (PACS) – Primary angle closure (PAC) – Primary angle closure glaucoma (PACG) – Absolute glaucoma "POS" Dr Sabin Sahu 68
Acute Angle Closure Glaucoma • Ocular emergency • Needs rapid diagnosis and immediate intervention • Symptoms – Pain – sudden onset, severe pain in the eye – Headache, Nausea, vomiting – Rapidly progressive decreased vision – Redness – Photophobia – Watering "POS" Dr Sabin Sahu 69
Signs of Acute angle closure glaucoma • Lids – edema • Conjunctiva – circumcorneal congestion, chemosis • Cornea – hazy due to epithelial and stromal edema • Anterior chamber – shallow, cells and flare • Pupil – mid-dilated, vertically oval and fixed • Iris – patchy stromal atrophy with posterior synechiae • Lens – glaukomflecken (anterior capsular opacities due to lens epithelial ischemia or necrosis) • IOP – markedly elevated in range of 40 – 70 mmHg • Optic disc – normal or edematous "POS" Dr Sabin Sahu 70
Treatment I. Immediate medical treatment - to control pain and lower IOP 1. Analgesic to relieve the severe pain 2. Acetazolamide 500 mg stat and then 250 mg QID orally. 3. Hyperosmotic agents – if IOP is more than 40 mmHg e.g. IV mannitol (1 – 2 gm/kg, 25% solution over 30 minutes) 4. Pilocarpine (2 %) every 15 minutes for one hour and then QID 5. Timolol maleate (0.5%) eyedrops BD 6. Topical steroid 3 to 4 times a day to control the inflammation "POS" Dr Sabin Sahu 71
II. Surgical treatment 1. Peripheral iridectomy/laser iridotomy - is sufficient when peripheral anterior synechiae (PAS) are formed in <50 percent of the angle. 2. Filtration surgery (e.g., trabeculectomy) - is performed when PAS are formed in more than 50 percent of the angle 3. Prophylactic Peripheral iridectomy/laser iridotomy should also be considered for the fellow eye. "POS" Dr Sabin Sahu 72
Management options of glaucoma 1. Medical therapy 2. Laser therapy 3. Surgical therapy "POS" Dr Sabin Sahu 73
1. Medical therapy • Adrenergic agonists – Brimonidine • Beta-blockers – – Timolol, Betaxolol • Carbonic anhydrase inhibitors – Acetazolamide, Dorzolamide • Miotics: – Pilocarpine • Prostaglandin analogues – Latanoprost, Bimatoprost • Hyperosmotic agents – Mannitol, Glycerol Increased Uveoscleral outflow Decreased aqueous production Increases trabecular outflow "POS" Dr Sabin Sahu 74
2. Laser therapy 1. Laser Trabeculoplasty (SLT / ALT) 2. Peripheral iridotomy (PI) 3. Cyclophotocoagulation (TSCPC) "POS" Dr Sabin Sahu 75
3. Surgical therapy 1. Goniotomy 2. Trabeculotomy 3. Trabeculectomy (± MMC) 4. Glaucoma drainage implants 5. Non-penetrating surgeries: Deep sclerectomy, viscocanalostomy, canaloplasty "POS" Dr Sabin Sahu 76
Glaucoma evaluation approach • History: – Family history of glaucoma – Systemic history of asthma, heart disease • IOP: Increased or Normal in NTG • Optic disc evaluation: CDR, NRR, RNFL defects • Gonioscopy: Open angle or Angle closure glaucoma • CCT (central corneal thickness): Corrected IOP • HVF (visual field): confirm visual field defects • OCT–ONH and RNFL: when patient can’t do HVF "POS" Dr Sabin Sahu 77
Guideline for glaucoma management • First line therapy 1. Beta blockers (Betoxolol, Timolol) 2. Alfa agonist (Brimonidine) • If asthma/heart ds present 3. Prostaglandin analogue (Latanoprost, Bimatoprost) • For affordable patients • Review: Check compliance and whether target IOP achieved or not • Combined therapy / Addition of anti-glaucoma drugs: if target IOP is not achieved or progressive visual field or optic nerve damage "POS" Dr Sabin Sahu 78
• Surgical management ( Trabeculectomy / Combined surgery) if: ▪ Failure of medical therapy (Uncontrolled IOP despite maximum medication) ▪ Noncompliance with medical therapy ▪ Intolerable side effects of medical therapy ▪ Cost issues or other considerations ▪ Poor follow up "POS" Dr Sabin Sahu 79
Normal tension glaucoma • Do Diurnal variation test (DVT) /phasing to determine baseline and target IOP • CCT- rule out thin cornea • Close follow up of patients – Serial IOP monitoring – Serial optic disc examination (look for disc hemorrhage) – Serial visual field assessment – 6 monthly – Disc photography • If progression or damage seen then start treatment • Target 25 - 30% reduction of initial IOP • Refer to neurologist if poor disc / field correlation or if pallor exceeds cupping. "POS" Dr Sabin Sahu 80
Lens induced glaucoma • Tab. Diamox 250mg TDS/QID • Drop Timolol 0.5% BD • Drop Antibiotic+steroid /Predacetate 1 hourly • Consider Mannitol 20% 1-2g/kg body weight IV over 30- 45 minutes after BP check. (in case of very high IOP or insufficient response to Diamox) • LENS EXTRACTION is the definite management "POS" Dr Sabin Sahu 81
Neovascular glaucoma • History – determine the underlying cause • Complete ocular examination including dilated fundus examination to look for retinal pathology – Causes: DR (most common) > CRVO (NVG in CRVO = 100-day glaucoma!) • IOP measurement and gonioscopy • Investigate for secondary causes- B-scan ; FFA as needed to identify underlying retinal abnormality or in preparation for PRP "POS" Dr Sabin Sahu 82
• Medical therapy: – Topical Predacetate 1-6 hrly – Atropine TDS – Timolol BD – Tab Diamox TDS - QID • Treatment of choice: Pan retinal photocoagulation • Cyclophotocoagulation (TSCPC): in painful blind eyes and medically uncontrolled IOP • Filtration surgery: in eye with inactive neovascularization and medically uncontrolled IOP • In eyes without useful vision topical steroid and cycloplegics are adequate "POS" Dr Sabin Sahu 83
How to read Visual field? "POS" Dr Sabin Sahu • Patient data • Reliability indices • Gray scale • Actual threshold value • Total deviation plots • Pattern deviation plots • Global indices 84
"POS" Dr Sabin Sahu Let’s read this ! 85
Step 1: Is this the correct test? • Confirm patient name, date of test and eye (RE /LE) • Check test strategy used (24-2/30-2/10-2) Step 2: Is this field reliable? Reliability indices: – Check whether the field is reliable or not. – Fixation loss, false positive, false negative should be less than 15-20% "POS" Dr Sabin Sahu 86
"POS" Dr Sabin Sahu Reliable! 87
Step 2: Is there a significant VF defect? • Look for Anderson’s criteria. • Pattern deviation plot – Leave the outermost edge points – Check if 3 consecutive points are more than half black (<5%)! – At least one should be full black (<1%), rest two can be full black or half black! – Look for a superior or inferior arcuate defect pattern • Glaucoma hemifield test (GHT): Abnormal • Pattern standard deviation (PSD): Abnormal with P <5% "POS" Dr Sabin Sahu 88
"POS" Dr Sabin Sahu Significant VF defect! Superior arcuate pattern! 89
"POS" Dr Sabin Sahu Fullfill’s Anderson’s criteria! 90
"POS" Dr Sabin Sahu Report of HVF: Right eye superior arcuate defect suggestive of right eye glaucoma. 91