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AQUEOUS HUMOUR
PRODUCTION
ACTIVE SECRETION FROM NON-PIGMENTED EPITHELLIUM OF
THE CILIARY BODY AS RESULT OF A METABOLIC PROCESS
( Na+/K+ ATPase PUMP, CARBONIC ANHYDRASE)
OUTFLOW
TRABECULAR MESHWORK :
- UVEAL MESHWORK
- CORNEOSCLERAL MESHWORK
- ENDOTHELIAL (JUXTACANALICULAR) MESHWORK
.
DEFINITION
GLAUCOMA IS AN OPTIC NEUROPATHY
WITH CHARACTERISTIC APPEARANCE OF
OPTIC DISC AND SPECIFIC PATTERN OF
VISUAL FIELD DEFECTS THAT IS
ASSOCIATED FREQUENTLY BUT NOT
INVARIABLY WITH RAISED IOP
VISUAL FIELD
MEASSUREMENT BY HUMPHREY PERIMETRY
CHARACTERISTIC PATTERN OF THE GLAUCOMATOUS FIELD
DEFECT:
- PARACENTRAL SCOTOMA
- A NASAL (ROENNE) STEP SCOTOMA
- ARCUATE-SHAPED DEFECTS
- PERIPHERAL SCOTOMA
- END STAGE CHANGES
CLASSIFICATION
1. PRIMARY GLAUCOMA
= PRIMARY OPEN ANGLE GLAUCOMA
= PRIMARY ANGLE-CLOSURE GLAUCOMA, 6 CLINICAL
STAGES:
A. LATENT ANGLE-CLOSURE GLAUCOMA
B. SUBACUTE (INTERMITTEN) ANGLE-CLOSURE
GLAUCOMA
C. ACUTE CONGESTIVE ANGLE-CLOSURE GLAUCOMA
D. POSTCONGESTIVE ANGLE-CLOSURE GLAUCOMA
E. CHRONIC ANGLE-CLOSURE GLAUCOMA
F. ABSOLUTE ANGLE-CLOSURE GLAUCOMA
2. SECONDARY GLAUCOMA
= SECONDARY OPEN ANGLE GLAUCOMA
A. PRETRABECULAR GLAUCOMA, WHICH AQUEOUS
OUTFLOW
IS OBSTRUCTED BY A MEMBRANE COVERING THE TRABECULUM
+ FIBROVASCULAR TISSUE (NEOVASCULAR GLAUCOMA)
+ ENDOTHELIAL CELLS (IRIDOCORNEAL ENDOTHELIAL
= ICE SYNDROME)
+ EPITHELIAL CELLS (EPITHELIAL INGROWTH)
B. TRABECULAR GLAUCOMA, WHICH THE OBSTRUCTION
OCCURS
AS A RESULT OF CLOGGING UP OF THE MESHWORK BY:
+ PIGMENT PARTICLES (PIGMENTARY GLAUCOMA)
+ RED BLOOD CELLS ( RED CELL GLAUCOMA)
+ DEGENERATED RED CELLS (GHOST CELL GLAUCOMA)
+ MACROPHAGES AND LENS PROTEINS ( PHACOLYTIC GLAU
+ PROTEINS ( HYPERTENSIVE UVEITIS)
+ PSEUDOEXFOLIATIVE MATERIAL
(PEX GLAUC)
.
+ OEDEMA (HERPES-ZOSTER IRITIS)
+ SCARRING (POST-TRAUMA ANGLE RECESSION GLAUC)
C. POST TRABECULAR GLAUCOMA, WHICH AQUEOUS
OUTFLOW
IS IMPAIRED AS ARESULT OF ELEVATED EPISCLERAL VENOUS
PRESSURE
+ CAROTID-CAVERNOUS FISTULAE
+ STURGER-WEBER SYNDROME
+ OBSTRUCTION OF THE SUPERIOR VENA CAVA
= SECONDARY ANGLE CLOSURE GLAUCOMA
A. POSTERIOR FORCED PUSH THE PERIPHERAL IRIS AGAINST
THE TRABECULUM (IRIS BOMBESECLUSIO PUPILLAE)
B. ANTERIOR FORCED PULL THE IRIS OVER THE TRABECULUM
BY CONTRACTION OF INFLAMMATORY (LATE NEOVASC GL)
3. CONGENITAL GLAUCOMA
A. TRUE PRIMARY CONGENITAL GLAUCOMA, WHICH IOP ELEVATED
DURING INTRAUTERINE LIFE
B. INFANTILE GLAUCOMA, WHICH MANIFESTS PRIOR TO THE 3TH
BIRTHDAY
C. JUVENILE GLAUCOMA, IOP RISED AFTER 3TH BIRTHDAY BUT
BEFORE
THE AGE OF 16 YEARS.
4. OCULAR HYPERTENSION
IOP MORE THAN 21 MMHG & ABSENCES OF DETACTABLE
GLAUCOMATOUS DAMAGE
5. NORMAL TENSION GLAUCOMA IS A VARIANT OF POAG,
CHARACTERIZED BY :
- IOP EQUAL TO OR LESS THAN 21 MMHG (DIURNAL TESTING)
- GLAUCOMATOUS OPTIC DISC DAMAGE & VISUAL FIELD LOSS
- OPEN ANGLE ON GONIOSKOPY
- ABSENCES OF SECONDARY CAUSES
Cont.. POAG
AETIOLOGIES
1. The ischaemic theory, postulates that compromise of the microvasculature with resultant ischaemia in the optic nerve head
2. The direct mechanical theory, raised IOP directly damages the
retinal nerve fiber
RISK FACTORS
1. AGE . After the age of 65 years
2. RACE. More earlier & severe in black people than in white
3. FAMILY HISTORY with POAG
4. MYOPIA
5. RETINAL DISASES , central retinal vein occlusion, rhegmatogenous
retinal detachment, retinitis pigmentosa
CONT..POAG
.
CLINICAL FEATURES
SYMPTOMS. Asymptomatic until significant loss of visual field has
occurred
SIGN : - Raised IOP (> 21 mmHg ) & diurnal fluctuation in IOP (> 5
mmHg)
- Optic disc changes
- Typical visual field changes
- Gonioscopy shows a normal open angle
MANAGEMENT
- Medical therapy ( timolol maleat, prostaglandine analough )
- Laser trabeculoplasty
- Trabeculectomy
Cont.PACG
PATHOGENESIS
is incompletely understood.
1. The dilatator muscle theory postulates that contraction of
the dilator pupillae exerts a posterior vector.
2. The sphincter muscle theory postulates that the sphincter
pupillae is the prime culprit in precipating angle closure.
Cont PACG
CLASSIFICATION
1. LATENT ANGLE-CLOSURE GLAUCOMA
Clinical features
-Symptoms are absent
-Slit lamp biomicroscopy
+ Axial anterior chamber depth is less than normal.
+ Convex-shaped iris-lens diaphragm
+ Close proximity of the iris to the cornea
-Gonioscopy : Shaffer grade 1 or 0
Treatment
- Prophylactic peripheral laser iridotomy
Cont.PACG
CLINICAL FEATURES :
- BLURRING OF VISION ASSOCIATED WITH HALOES AROUND LIGHTS
- CORNEAL EPITHELIAL OEDEMA
- OCULAR DISCOMFORT
- FRONTAL HEADACHE
- THE ANGLE IS NARROW
TREATMENT
- PROPHYLACTIC PERIPHERAL LASER IRIDOTOMY
Cont.PACG
Cont ..PACG
Cont..PACG
Cont.PACG
Cont .PCG
.
CLINICAL FEATURES
- Corneal haze ( epithelial & stromal oedema) lacrimation,
photopho
bia, blepharospasm
- Buphthalmos, large eye as result of stretching due to elevated IOP
Scleral thinner ( blue appearance), AC deep, lens subluxasion (zonular fibres stretch), axial myopia (increase axial length)
- Breaks in Descemet membrane (Haab striae)
- Optic disc cupping
SURGERY
- Goniotomy
- Trabeculotomy
- Trabeculectomy
ContOH
Cont.. NTG
.
TREATMENT
- progressive VF loss
- IOP to reduce by at least 30 %