Download MBBS Ophthalmology PPT 53 Secondary Glaucoma 1 Lecture Notes

--- Content provided by​ FirstRanker.com ---

? At the end of this class the students shal be able

to :

? Define secondary glaucoma.

--- Content provided by​ FirstRanker.com ---

? Classify secondary glaucoma.

? Understand the aetiopathogenesis and clinical

features of secondary glaucoma's.

--- Content provided by‌ FirstRanker.com ---

? Understand the fundamentals of managing

secondary glaucoma's.

--- Content provided by‌ FirstRanker.com ---

2
Question

? A 12 year old boy is diagnosed as having an

--- Content provided by‌ FirstRanker.com ---

angle recession glaucoma. It is a type of

? primary open angle glaucoma
? secondary open angle glaucoma
? primary angle closure glaucoma

--- Content provided by​ FirstRanker.com ---

? secondary angle closure glaucoma

3

Definition

--- Content provided by⁠ FirstRanker.com ---

? Secondary Glaucoma
A group of disorders in which rise in
intraocular pressure(leading to glaucoma) is
associated with some primary ocular or

--- Content provided by‍ FirstRanker.com ---

systemic disease.

4
Classification of secondary glaucoma's

--- Content provided by‍ FirstRanker.com ---

? Based on mechanism of IOP rise

Secondary open angle glaucoma

Secondary angle closure glaucoma

--- Content provided by​ FirstRanker.com ---

5

Classification of secondary glaucoma's

--- Content provided by​ FirstRanker.com ---

? Depending on causative primary disease

? Phacogenic (Lens induced) glaucoma

? Pigmentary glaucoma

--- Content provided by‌ FirstRanker.com ---

? Neovascular glaucoma

? Inflammatory glaucoma (Uveitic)

--- Content provided by⁠ FirstRanker.com ---

? Traumatic glaucoma

? Steroid induced glaucoma

? Pseudoexfoliative glaucoma

--- Content provided by⁠ FirstRanker.com ---

? Glaucomas associated with intraocular tumours

(Malignant melanoma, retinoblastoma)

--- Content provided by‍ FirstRanker.com ---

6


7

--- Content provided by​ FirstRanker.com ---

8
Lens induced glaucoma

? Raised IOP secondary to a disorder of crystalline lens

--- Content provided by‌ FirstRanker.com ---

? Secondary angle closure Secondary open angle

--- Content provided by‍ FirstRanker.com ---

Phacomorphic glaucoma Phacolytic glaucoma
Phacotopic glaucoma Lens particle glaucoma

Phacoanaphylactic

--- Content provided by‌ FirstRanker.com ---

glaucoma

9

--- Content provided by‍ FirstRanker.com ---

Phacomorphic glaucoma

? Causes -
? Intumescent lens
? Anterior subluxation or dislocation of the lens

--- Content provided by⁠ FirstRanker.com ---

and spherophakia (Phacotopic variant)
? Pathogenesis ? Swollen lens pushes iris

forwards, obliterating the angle

--- Content provided by​ FirstRanker.com ---

? Presentation ? Acute congestive glaucoma

10

--- Content provided by‌ FirstRanker.com ---

Phacomorphic glaucoma

? Treatment ?

? Medical treatment ?

--- Content provided by​ FirstRanker.com ---

Control of IOP by

iv mannitol, systemic

--- Content provided by‌ FirstRanker.com ---

acetazolamide and

topical beta blockers

? Surgical

--- Content provided by⁠ FirstRanker.com ---

Cataract extraction

with implantation of

--- Content provided by​ FirstRanker.com ---

PCIOL

11

Phacolytic glaucoma

--- Content provided by‍ FirstRanker.com ---

? Trabecular meshwork is clogged

by lens proteins and

--- Content provided by⁠ FirstRanker.com ---

macrophages which
phagocytose the lens
proteins and inflammatory
debris
? Treatment

--- Content provided by​ FirstRanker.com ---

? Medical therapy to lower IOP

fol owed by extraction of
cataractous lens with PCIOL
implantation.

--- Content provided by‌ FirstRanker.com ---

12


Lens particle glaucoma

--- Content provided by‌ FirstRanker.com ---

? Trabecular meshwork is

blocked by lens

--- Content provided by‍ FirstRanker.com ---

particles floating in

aqueous humour.

? Management

--- Content provided by⁠ FirstRanker.com ---

? Medical therapy to lower

IOP and

--- Content provided by FirstRanker.com ---

irrigation ? aspiration of

lens particles from

anterior chamber

--- Content provided by FirstRanker.com ---

13

Phacoanaphylactic glaucoma

--- Content provided by FirstRanker.com ---

? Fulminating acute inflammatory

reaction due to antigen ? antibody

reaction

--- Content provided by⁠ FirstRanker.com ---

? Granulomatous inflammation in

involved eye

--- Content provided by‍ FirstRanker.com ---

? Preceding disruption of lens capsule

and leakage of proteins from capsule

? IOP is raised due to inflammatory

--- Content provided by‍ FirstRanker.com ---

reaction of uveal tissue excited by lens

matter.

--- Content provided by‌ FirstRanker.com ---

14


Phacoanaphylactic glaucoma

--- Content provided by​ FirstRanker.com ---

? Management includes

medical therapy to

lower IOP.

--- Content provided by FirstRanker.com ---

Treatment of iridocyclitis

with steroids and

--- Content provided by​ FirstRanker.com ---

cycloplegics .

Irrigation ? aspiration

of lens matter from

--- Content provided by‌ FirstRanker.com ---

anterior chamber ( if

required).

--- Content provided by​ FirstRanker.com ---

15

Pigmentary glaucoma

? Clogging up of trabecular

--- Content provided by​ FirstRanker.com ---

meshwork by pigment particles

in patients with Pigment

--- Content provided by⁠ FirstRanker.com ---

Dispersion Syndrome(PDS)

? Pigment released by mechanical

rubbing of posterior pigment

--- Content provided by⁠ FirstRanker.com ---

layer of iris with zonular fibrils

? Clinical features ?

--- Content provided by⁠ FirstRanker.com ---

Pigment deposition on lens zonules and

equatorial region. The deposits are clearly

? Young myopic males

--- Content provided by⁠ FirstRanker.com ---

visible in full mydriasis.

? Features similar to POAG

--- Content provided by‌ FirstRanker.com ---

? Deposition of pigment granules

in anterior segment

16

--- Content provided by​ FirstRanker.com ---

REVERSE PUPILLARY BLOCK IN

--- Content provided by‍ FirstRanker.com ---

PIGMENTARY GLAUCOMA

17

--- Content provided by​ FirstRanker.com ---

CLASSIC DIAGNOSTIC TRIAD

? Krukenberg spindle (Pigment deposition on

the endothelium, in a vertical spindle-shaped

--- Content provided by FirstRanker.com ---

distribution).

? Midperipheral iris transillumination defects
? Dense trabecular meshwork pigmentation

--- Content provided by⁠ FirstRanker.com ---

18


Pigmentary glaucoma

--- Content provided by⁠ FirstRanker.com ---

? Gonioscopy ? pigment

accumulation along

--- Content provided by‍ FirstRanker.com ---

the Schwalbe's line

especial y inferiorly

(Sampaolesi's line)

--- Content provided by FirstRanker.com ---

? Iris transil umination ?

radial slit ? like

--- Content provided by‍ FirstRanker.com ---

defects in the periphery

? Treatment is similar to

that of POAG

--- Content provided by FirstRanker.com ---

19

Neovascular glaucoma

--- Content provided by​ FirstRanker.com ---

? Intractable glaucoma due to neovascularisation

of iris and angle of anterior chamber.

? Due to retinal ischaemia

--- Content provided by‍ FirstRanker.com ---

Diabetic retinopathy

CRVO

--- Content provided by FirstRanker.com ---

Sickle cell retinopathy

Eales' disease

Chronic intraocular inflammation

--- Content provided by⁠ FirstRanker.com ---

20


PATHOGENESIS

--- Content provided by​ FirstRanker.com ---

? CHRONIC RETINAL ISCHAEMIA

? ANGIOGENIC FACTORS RELEASED

--- Content provided by⁠ FirstRanker.com ---

? NEOVASCULARISATION ON IRIS AND ANGLE

? NEOVASCULAR GLAUCOMA

21

--- Content provided by FirstRanker.com ---

Stages of neovascular glaucoma

? Pre-glaucomatous stage
? Open angle glaucoma

--- Content provided by⁠ FirstRanker.com ---

stage

? Secondary angle closure

--- Content provided by‌ FirstRanker.com ---

glaucoma

22

--- Content provided by⁠ FirstRanker.com ---

TREATMENT

? Panretinal photocoagulation
? Intra- vitreal Anti -VEGF
? Mydriatics and Corticosteroids

--- Content provided by​ FirstRanker.com ---

? Filtering surgeries
? Glaucoma drainage devices
? Cyclodestructive procedures

23

--- Content provided by‌ FirstRanker.com ---

INFLAMMATORY GLAUCOMA

? Non specific inflammatory glaucoma

--- Content provided by‌ FirstRanker.com ---

? Open angle

? Angle closure

? Specific hypertensive uveitis syndromes

--- Content provided by​ FirstRanker.com ---

? Fuchs' uveitis syndrome

? Glaucomatocyclitic crisis (Posner Schlossman

--- Content provided by​ FirstRanker.com ---

syndrome)

24

--- Content provided by​ FirstRanker.com ---

25

Open angle inflammatory glaucoma

Acute open ? angle

--- Content provided by‍ FirstRanker.com ---

Chronic open ? angle

inflammatory glaucoma inflammatory glaucoma

--- Content provided by⁠ FirstRanker.com ---

Mechanism of rise in

Trabecular clogging ,

Chronic trabeculitis and

--- Content provided by‌ FirstRanker.com ---

IOP

trabecular oedema and

--- Content provided by⁠ FirstRanker.com ---

trabecular scarring

prostaglandin ? induced

rise in IOP

--- Content provided by⁠ FirstRanker.com ---

Clinical features

Features of acute

--- Content provided by⁠ FirstRanker.com ---

Raised IOP, open angle, no

iridocyclitis associated with active inflammation but

raised IOP with open-angle signs of previous episode

--- Content provided by FirstRanker.com ---

of anterior chamber

of uveitis present

--- Content provided by⁠ FirstRanker.com ---

Management

Treatment of iridocyclitis

Medical therapy

--- Content provided by⁠ FirstRanker.com ---

Medical therapy to

Trabeculectomy

--- Content provided by‍ FirstRanker.com ---

lower IOP by use of

Cyclodestructive

hyperosmotic agents,

--- Content provided by​ FirstRanker.com ---

procedures

acetazolamide and beta ?

--- Content provided by‌ FirstRanker.com ---

blockers eye drops

26
Angle closure inflammatory glaucoma

--- Content provided by⁠ FirstRanker.com ---

? Mechanism of rise in IOP ?
? Secondary angle ? closure with pupillary block
? Secondary angle ? closure without pupillary block
? Clinical features ? Raised IOP, seclusio papillae,
shallow anterior chamber

--- Content provided by​ FirstRanker.com ---

? Management ?
? Prophylaxis ? Local steroids and atropine to
prevent formation of synechiae
? Curative treatment ? Medical therapy, surgical or
laser iridotomy and filtration surgery

--- Content provided by‌ FirstRanker.com ---

27

Specific hypertensive uveitis

--- Content provided by‌ FirstRanker.com ---

syndromes

? Glaucomatocyclitic crisis

? Fuchs' uveitis syndrome

--- Content provided by⁠ FirstRanker.com ---

(Posner Schlossman

syndrome)

--- Content provided by‌ FirstRanker.com ---

? Chronic low grade anterior

? Recurrent attacks of

uveitis.

--- Content provided by⁠ FirstRanker.com ---

unilateral, acute mild

? Occurs unilateral y in middle

--- Content provided by‌ FirstRanker.com ---

uveitis with secondary

aged persons

open angle glaucoma.

--- Content provided by FirstRanker.com ---

? Glaucoma is out of

? Heterochromia of iris

--- Content provided by‍ FirstRanker.com ---

proportion to

? No posterior synechia.

inflammation.

--- Content provided by FirstRanker.com ---

? Associated with cataract

? Due to accompanying

--- Content provided by⁠ FirstRanker.com ---

acute trabeculitis.

and secondary glaucoma

28

--- Content provided by‌ FirstRanker.com ---

Blunt Trauma

29

--- Content provided by​ FirstRanker.com ---

30

--- Content provided by‍ FirstRanker.com ---

Causes of glaucoma after trauma

? Inflammatory glaucoma
? Glaucoma due to hyphema

--- Content provided by FirstRanker.com ---

? Lens induced glaucoma
? Angle recession glaucoma
? Epithelial or fibrous ingrowth
? Angle closure due to PAS

--- Content provided by‌ FirstRanker.com ---

31

Angle recession glaucoma

? Rupture in ciliary body

--- Content provided by⁠ FirstRanker.com ---

face

? Bimodal onset at 1 year

--- Content provided by⁠ FirstRanker.com ---

and 10 year post

trauma

Gonioscopic view of angle recession,

--- Content provided by‍ FirstRanker.com ---

demonstrated by a widened ciliary body band.

? 270 degree recession-

--- Content provided by‍ FirstRanker.com ---

risk of glaucoma- 5%

? 360 degree recession-

risk of glaucoma- 24%

--- Content provided by‌ FirstRanker.com ---

There is a disruption in the ciliary body

between the external longitudinal muscle

--- Content provided by FirstRanker.com ---

fibers and the internal oblique and circular

muscle fibers.

32

--- Content provided by FirstRanker.com ---

Traumatic glaucoma

? Management
? Medical therapy with topical 0.5% timolol and

--- Content provided by​ FirstRanker.com ---

oral acetazolamide

? Surgical intervention needs to be

individualized according to nature and site of

--- Content provided by‍ FirstRanker.com ---

trauma

33

--- Content provided by​ FirstRanker.com ---

Steroid induced glaucoma

? Secondary open angle glaucoma following steroid therapy

? In the general population:

--- Content provided by FirstRanker.com ---

? High steroid responders ? 5%

? Moderate steroid responders ? 35%

--- Content provided by FirstRanker.com ---

? Non steroid responders ? 60%

(IOP rise after six weeks of steroid therapy)

Precise mechanism of IOP rise not known

--- Content provided by‌ FirstRanker.com ---

Prevented by judicious use of steroids and regular IOP

monitoring

--- Content provided by FirstRanker.com ---

Treated by stopping steroids gradually and anti glaucoma

medications

34

--- Content provided by FirstRanker.com ---

Pseudoexfoliative glaucoma

? Pseudo exfoliation

--- Content provided by‌ FirstRanker.com ---

syndrome(PES)/Glaucoma

capsulare is associated

--- Content provided by⁠ FirstRanker.com ---

with Secondary OAG in

50% of the cases.

? Deposition of an

--- Content provided by‍ FirstRanker.com ---

amorphous grey dandruff

? like material on the

--- Content provided by‌ FirstRanker.com ---

pupil ary border,

posterior surface of iris

and ciliary processes

--- Content provided by‍ FirstRanker.com ---

? Trabecular blockage by

exfoliative material

--- Content provided by‌ FirstRanker.com ---

? Managed on the same

lines as POAG

35

--- Content provided by‌ FirstRanker.com ---

Causes of elevated IOP post cataract surgery

? Early phase

--- Content provided by​ FirstRanker.com ---

? Inflammation

? Haemorrhage

? Retained viscoelastic/lens matter

--- Content provided by​ FirstRanker.com ---

? Late phase

? Tight suture

--- Content provided by‍ FirstRanker.com ---

? Excessive cautery

? Pupil ary block(IOL/Vitreous)

? Aqueous misdirection

--- Content provided by⁠ FirstRanker.com ---

? Epithelial/Fibrous down growth

36

--- Content provided by‍ FirstRanker.com ---

Glaucoma associated with iridocorneal endothelial

syndromes

--- Content provided by​ FirstRanker.com ---

? Three clinical entities:

? Progressive iris atrophy

? Chandler's syndrome

--- Content provided by‌ FirstRanker.com ---

? Cogan-Reese syndrome/Iris

nevus syndrome

--- Content provided by FirstRanker.com ---

? Pathogenesis: Abnormal

corneal endothelial cells

proliferate to form a

--- Content provided by FirstRanker.com ---

membrane in angle of AC.

Contraction of membrane

--- Content provided by⁠ FirstRanker.com ---

leads to secondary angle

closure

? Treatment: Difficult and

--- Content provided by‍ FirstRanker.com ---

usually surgical

37

--- Content provided by‌ FirstRanker.com ---

Other causes of secondary glaucoma

? Glaucoma in aphakia/pseudophakia

? Ciliary block glaucoma

--- Content provided by‌ FirstRanker.com ---

? Glaucoma associated with intraocular

haemorrhage

--- Content provided by⁠ FirstRanker.com ---

Red cell glaucoma

Haemolytic glaucoma

Ghost cell glaucoma

--- Content provided by‌ FirstRanker.com ---

Hemosiderotic glaucoma

38

--- Content provided by‌ FirstRanker.com ---

39

40

--- Content provided by‍ FirstRanker.com ---

41

Question

--- Content provided by​ FirstRanker.com ---

? A 50 year old lady with uncontrol ed diabetes

presented with painful red eye and decreased

visual acuity in her right eye. On examination

--- Content provided by​ FirstRanker.com ---

there was raised Intraocular Pressure and new

blood vessels on the iris. The treatment includes

--- Content provided by⁠ FirstRanker.com ---

al except?

? atropine

? beta blockers

--- Content provided by⁠ FirstRanker.com ---

? steroids

? pilocarpine

--- Content provided by​ FirstRanker.com ---

42


Question

--- Content provided by FirstRanker.com ---

? The laser procedure, most often used for

treating neovascular glaucoma:

a) Goniophotocoagulation

--- Content provided by⁠ FirstRanker.com ---

b) Laser trabeculoplasty

c) Panretinal photocoagulation (PRP)

--- Content provided by​ FirstRanker.com ---

d) Laser iridoplasty

43

Question

--- Content provided by FirstRanker.com ---

? What is the most likely type of glaucoma in

this patient ?

--- Content provided by‌ FirstRanker.com ---

a) Phacolytic glaucoma
b) Phacoanaphylactic glaucoma
c) Phacotopic glaucoma
d) Lens particle glaucoma

--- Content provided by‍ FirstRanker.com ---

44