Download MBBS Ophthalmology PPT 53 Secondary Glaucoma 1 Lecture Notes

Secondary Glaucoma

Learning Objectives

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

to :

? Define secondary glaucoma.

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? Classify secondary glaucoma.

? Understand the aetiopathogenesis and clinical

features of secondary glaucoma's.

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? Understand the fundamentals of managing

secondary glaucoma's.

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Question

? A 12 year old boy is diagnosed as having an

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angle recession glaucoma. It is a type of

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

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? secondary angle closure glaucoma

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Definition

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

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systemic disease.

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Classification of secondary glaucoma's

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? Based on mechanism of IOP rise

Secondary open angle glaucoma

Secondary angle closure glaucoma

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Classification of secondary glaucoma's

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? Depending on causative primary disease

? Phacogenic (Lens induced) glaucoma

? Pigmentary glaucoma

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? Neovascular glaucoma

? Inflammatory glaucoma (Uveitic)

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? Traumatic glaucoma

? Steroid induced glaucoma

? Pseudoexfoliative glaucoma

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? Glaucomas associated with intraocular tumours

(Malignant melanoma, retinoblastoma)

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Lens induced glaucoma

? Raised IOP secondary to a disorder of crystalline lens

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? Secondary angle closure Secondary open angle

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Phacomorphic glaucoma Phacolytic glaucoma
Phacotopic glaucoma Lens particle glaucoma

Phacoanaphylactic

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glaucoma

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Phacomorphic glaucoma

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

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

forwards, obliterating the angle

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? Presentation ? Acute congestive glaucoma

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Phacomorphic glaucoma

? Treatment ?

? Medical treatment ?

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Control of IOP by

iv mannitol, systemic

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acetazolamide and

topical beta blockers

? Surgical

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Cataract extraction

with implantation of

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PCIOL

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Phacolytic glaucoma

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? Trabecular meshwork is clogged

by lens proteins and

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macrophages which
phagocytose the lens
proteins and inflammatory
debris
? Treatment

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? Medical therapy to lower IOP

fol owed by extraction of
cataractous lens with PCIOL
implantation.

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Lens particle glaucoma

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? Trabecular meshwork is

blocked by lens

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particles floating in

aqueous humour.

? Management

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? Medical therapy to lower

IOP and

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irrigation ? aspiration of

lens particles from

anterior chamber

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Phacoanaphylactic glaucoma

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? Fulminating acute inflammatory

reaction due to antigen ? antibody

reaction

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? Granulomatous inflammation in

involved eye

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? Preceding disruption of lens capsule

and leakage of proteins from capsule

? IOP is raised due to inflammatory

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reaction of uveal tissue excited by lens

matter.

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Phacoanaphylactic glaucoma

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? Management includes

medical therapy to

lower IOP.

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Treatment of iridocyclitis

with steroids and

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cycloplegics .

Irrigation ? aspiration

of lens matter from

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anterior chamber ( if

required).

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Pigmentary glaucoma

? Clogging up of trabecular

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meshwork by pigment particles

in patients with Pigment

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Dispersion Syndrome(PDS)

? Pigment released by mechanical

rubbing of posterior pigment

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layer of iris with zonular fibrils

? Clinical features ?

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Pigment deposition on lens zonules and

equatorial region. The deposits are clearly

? Young myopic males

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visible in full mydriasis.

? Features similar to POAG

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? Deposition of pigment granules

in anterior segment

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REVERSE PUPILLARY BLOCK IN

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PIGMENTARY GLAUCOMA

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CLASSIC DIAGNOSTIC TRIAD

? Krukenberg spindle (Pigment deposition on

the endothelium, in a vertical spindle-shaped

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distribution).

? Midperipheral iris transillumination defects
? Dense trabecular meshwork pigmentation

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Pigmentary glaucoma

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? Gonioscopy ? pigment

accumulation along

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the Schwalbe's line

especial y inferiorly

(Sampaolesi's line)

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? Iris transil umination ?

radial slit ? like

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defects in the periphery

? Treatment is similar to

that of POAG

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Neovascular glaucoma

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? Intractable glaucoma due to neovascularisation

of iris and angle of anterior chamber.

? Due to retinal ischaemia

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Diabetic retinopathy

CRVO

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Sickle cell retinopathy

Eales' disease

Chronic intraocular inflammation

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PATHOGENESIS

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? CHRONIC RETINAL ISCHAEMIA

? ANGIOGENIC FACTORS RELEASED

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? NEOVASCULARISATION ON IRIS AND ANGLE

? NEOVASCULAR GLAUCOMA

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Stages of neovascular glaucoma

? Pre-glaucomatous stage
? Open angle glaucoma

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stage

? Secondary angle closure

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glaucoma

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TREATMENT

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

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? Filtering surgeries
? Glaucoma drainage devices
? Cyclodestructive procedures

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INFLAMMATORY GLAUCOMA

? Non specific inflammatory glaucoma

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? Open angle

? Angle closure

? Specific hypertensive uveitis syndromes

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? Fuchs' uveitis syndrome

? Glaucomatocyclitic crisis (Posner Schlossman

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syndrome)

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Open angle inflammatory glaucoma

Acute open ? angle

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Chronic open ? angle

inflammatory glaucoma inflammatory glaucoma

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Mechanism of rise in

Trabecular clogging ,

Chronic trabeculitis and

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IOP

trabecular oedema and

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trabecular scarring

prostaglandin ? induced

rise in IOP

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Clinical features

Features of acute

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Raised IOP, open angle, no

iridocyclitis associated with active inflammation but

raised IOP with open-angle signs of previous episode

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of anterior chamber

of uveitis present

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Management

Treatment of iridocyclitis

Medical therapy

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Medical therapy to

Trabeculectomy

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lower IOP by use of

Cyclodestructive

hyperosmotic agents,

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procedures

acetazolamide and beta ?

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blockers eye drops

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Angle closure inflammatory glaucoma

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? 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

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

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Specific hypertensive uveitis

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syndromes

? Glaucomatocyclitic crisis

? Fuchs' uveitis syndrome

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(Posner Schlossman

syndrome)

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? Chronic low grade anterior

? Recurrent attacks of

uveitis.

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unilateral, acute mild

? Occurs unilateral y in middle

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uveitis with secondary

aged persons

open angle glaucoma.

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? Glaucoma is out of

? Heterochromia of iris

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proportion to

? No posterior synechia.

inflammation.

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? Associated with cataract

? Due to accompanying

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acute trabeculitis.

and secondary glaucoma

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Blunt Trauma

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Causes of glaucoma after trauma

? Inflammatory glaucoma
? Glaucoma due to hyphema

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

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Angle recession glaucoma

? Rupture in ciliary body

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face

? Bimodal onset at 1 year

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and 10 year post

trauma

Gonioscopic view of angle recession,

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demonstrated by a widened ciliary body band.

? 270 degree recession-

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risk of glaucoma- 5%

? 360 degree recession-

risk of glaucoma- 24%

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There is a disruption in the ciliary body

between the external longitudinal muscle

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fibers and the internal oblique and circular

muscle fibers.

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Traumatic glaucoma

? Management
? Medical therapy with topical 0.5% timolol and

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oral acetazolamide

? Surgical intervention needs to be

individualized according to nature and site of

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trauma

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Steroid induced glaucoma

? Secondary open angle glaucoma following steroid therapy

? In the general population:

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? High steroid responders ? 5%

? Moderate steroid responders ? 35%

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? Non steroid responders ? 60%

(IOP rise after six weeks of steroid therapy)

Precise mechanism of IOP rise not known

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Prevented by judicious use of steroids and regular IOP

monitoring

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Treated by stopping steroids gradually and anti glaucoma

medications

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Pseudoexfoliative glaucoma

? Pseudo exfoliation

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syndrome(PES)/Glaucoma

capsulare is associated

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with Secondary OAG in

50% of the cases.

? Deposition of an

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amorphous grey dandruff

? like material on the

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pupil ary border,

posterior surface of iris

and ciliary processes

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? Trabecular blockage by

exfoliative material

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? Managed on the same

lines as POAG

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Causes of elevated IOP post cataract surgery

? Early phase

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? Inflammation

? Haemorrhage

? Retained viscoelastic/lens matter

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? Late phase

? Tight suture

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? Excessive cautery

? Pupil ary block(IOL/Vitreous)

? Aqueous misdirection

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? Epithelial/Fibrous down growth

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Glaucoma associated with iridocorneal endothelial

syndromes

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? Three clinical entities:

? Progressive iris atrophy

? Chandler's syndrome

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? Cogan-Reese syndrome/Iris

nevus syndrome

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? Pathogenesis: Abnormal

corneal endothelial cells

proliferate to form a

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membrane in angle of AC.

Contraction of membrane

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leads to secondary angle

closure

? Treatment: Difficult and

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usually surgical

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Other causes of secondary glaucoma

? Glaucoma in aphakia/pseudophakia

? Ciliary block glaucoma

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? Glaucoma associated with intraocular

haemorrhage

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Red cell glaucoma

Haemolytic glaucoma

Ghost cell glaucoma

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Hemosiderotic glaucoma

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Question

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? A 50 year old lady with uncontrol ed diabetes

presented with painful red eye and decreased

visual acuity in her right eye. On examination

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there was raised Intraocular Pressure and new

blood vessels on the iris. The treatment includes

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al except?

? atropine

? beta blockers

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? steroids

? pilocarpine

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Question

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? The laser procedure, most often used for

treating neovascular glaucoma:

a) Goniophotocoagulation

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b) Laser trabeculoplasty

c) Panretinal photocoagulation (PRP)

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d) Laser iridoplasty

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Question

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? What is the most likely type of glaucoma in

this patient ?

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

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