Download MBBS Ophthalmology PPT 53 Secondary Glaucoma 1 Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Ophthalmology PPT 53 Secondary Glaucoma 1 Lecture Notes


Secondary Glaucoma

Learning Objectives

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

to :

? Define secondary glaucoma.
? Classify secondary glaucoma.

? Understand the aetiopathogenesis and clinical

features of secondary glaucoma's.

? Understand the fundamentals of managing

secondary glaucoma's.

2
Question

? A 12 year old boy is diagnosed as having an

angle recession glaucoma. It is a type of

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

3

Definition

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

4
Classification of secondary glaucoma's

? Based on mechanism of IOP rise

Secondary open angle glaucoma

Secondary angle closure glaucoma

5

Classification of secondary glaucoma's

? Depending on causative primary disease

? Phacogenic (Lens induced) glaucoma

? Pigmentary glaucoma

? Neovascular glaucoma

? Inflammatory glaucoma (Uveitic)

? Traumatic glaucoma

? Steroid induced glaucoma

? Pseudoexfoliative glaucoma

? Glaucomas associated with intraocular tumours

(Malignant melanoma, retinoblastoma)

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7

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Lens induced glaucoma

? Raised IOP secondary to a disorder of crystalline lens

? Secondary angle closure Secondary open angle





Phacomorphic glaucoma Phacolytic glaucoma
Phacotopic glaucoma Lens particle glaucoma

Phacoanaphylactic

glaucoma

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Phacomorphic glaucoma

? Causes -
? Intumescent lens
? Anterior subluxation or dislocation of the lens
and spherophakia (Phacotopic variant)
? Pathogenesis ? Swollen lens pushes iris

forwards, obliterating the angle

? Presentation ? Acute congestive glaucoma

10


Phacomorphic glaucoma

? Treatment ?

? Medical treatment ?

Control of IOP by

iv mannitol, systemic

acetazolamide and

topical beta blockers

? Surgical

Cataract extraction

with implantation of

PCIOL

11

Phacolytic glaucoma

? Trabecular meshwork is clogged

by lens proteins and

macrophages which
phagocytose the lens
proteins and inflammatory
debris
? Treatment
? Medical therapy to lower IOP

fol owed by extraction of
cataractous lens with PCIOL
implantation.

12


Lens particle glaucoma

? Trabecular meshwork is

blocked by lens

particles floating in

aqueous humour.

? Management

? Medical therapy to lower

IOP and

irrigation ? aspiration of

lens particles from

anterior chamber

13

Phacoanaphylactic glaucoma

? Fulminating acute inflammatory

reaction due to antigen ? antibody

reaction

? Granulomatous inflammation in

involved eye

? Preceding disruption of lens capsule

and leakage of proteins from capsule

? IOP is raised due to inflammatory

reaction of uveal tissue excited by lens

matter.

14


Phacoanaphylactic glaucoma

? Management includes

medical therapy to

lower IOP.

Treatment of iridocyclitis

with steroids and

cycloplegics .

Irrigation ? aspiration

of lens matter from

anterior chamber ( if

required).

15

Pigmentary glaucoma

? Clogging up of trabecular

meshwork by pigment particles

in patients with Pigment

Dispersion Syndrome(PDS)

? Pigment released by mechanical

rubbing of posterior pigment

layer of iris with zonular fibrils

? Clinical features ?

Pigment deposition on lens zonules and

equatorial region. The deposits are clearly

? Young myopic males

visible in full mydriasis.

? Features similar to POAG

? Deposition of pigment granules

in anterior segment

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REVERSE PUPILLARY BLOCK IN

PIGMENTARY GLAUCOMA

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CLASSIC DIAGNOSTIC TRIAD

? Krukenberg spindle (Pigment deposition on

the endothelium, in a vertical spindle-shaped

distribution).

? Midperipheral iris transillumination defects
? Dense trabecular meshwork pigmentation

18


Pigmentary glaucoma

? Gonioscopy ? pigment

accumulation along

the Schwalbe's line

especial y inferiorly

(Sampaolesi's line)

? Iris transil umination ?

radial slit ? like

defects in the periphery

? Treatment is similar to

that of POAG

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Neovascular glaucoma

? Intractable glaucoma due to neovascularisation

of iris and angle of anterior chamber.

? Due to retinal ischaemia

Diabetic retinopathy

CRVO

Sickle cell retinopathy

Eales' disease

Chronic intraocular inflammation

20


PATHOGENESIS

? CHRONIC RETINAL ISCHAEMIA

? ANGIOGENIC FACTORS RELEASED

? NEOVASCULARISATION ON IRIS AND ANGLE

? NEOVASCULAR GLAUCOMA

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Stages of neovascular glaucoma

? Pre-glaucomatous stage
? Open angle glaucoma

stage

? Secondary angle closure

glaucoma

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TREATMENT

? Panretinal photocoagulation
? Intra- vitreal Anti -VEGF
? Mydriatics and Corticosteroids
? Filtering surgeries
? Glaucoma drainage devices
? Cyclodestructive procedures

23

INFLAMMATORY GLAUCOMA

? Non specific inflammatory glaucoma

? Open angle

? Angle closure

? Specific hypertensive uveitis syndromes

? Fuchs' uveitis syndrome

? Glaucomatocyclitic crisis (Posner Schlossman

syndrome)

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Open angle inflammatory glaucoma

Acute open ? angle

Chronic open ? angle

inflammatory glaucoma inflammatory glaucoma

Mechanism of rise in

Trabecular clogging ,

Chronic trabeculitis and

IOP

trabecular oedema and

trabecular scarring

prostaglandin ? induced

rise in IOP

Clinical features

Features of acute

Raised IOP, open angle, no

iridocyclitis associated with active inflammation but

raised IOP with open-angle signs of previous episode

of anterior chamber

of uveitis present

Management

Treatment of iridocyclitis

Medical therapy

Medical therapy to

Trabeculectomy

lower IOP by use of

Cyclodestructive

hyperosmotic agents,

procedures

acetazolamide and beta ?

blockers eye drops

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Angle closure inflammatory glaucoma

? 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
? 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

syndromes

? Glaucomatocyclitic crisis

? Fuchs' uveitis syndrome

(Posner Schlossman

syndrome)

? Chronic low grade anterior

? Recurrent attacks of

uveitis.

unilateral, acute mild

? Occurs unilateral y in middle

uveitis with secondary

aged persons

open angle glaucoma.

? Glaucoma is out of

? Heterochromia of iris

proportion to

? No posterior synechia.

inflammation.

? Associated with cataract

? Due to accompanying

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

31

Angle recession glaucoma

? Rupture in ciliary body

face

? Bimodal onset at 1 year

and 10 year post

trauma

Gonioscopic view of angle recession,

demonstrated by a widened ciliary body band.

? 270 degree recession-

risk of glaucoma- 5%

? 360 degree recession-

risk of glaucoma- 24%

There is a disruption in the ciliary body

between the external longitudinal muscle

fibers and the internal oblique and circular

muscle fibers.

32
Traumatic glaucoma

? Management
? Medical therapy with topical 0.5% timolol and

oral acetazolamide

? Surgical intervention needs to be

individualized according to nature and site of

trauma

33

Steroid induced glaucoma

? Secondary open angle glaucoma following steroid therapy

? In the general population:

? High steroid responders ? 5%

? Moderate steroid responders ? 35%

? Non steroid responders ? 60%

(IOP rise after six weeks of steroid therapy)

Precise mechanism of IOP rise not known

Prevented by judicious use of steroids and regular IOP

monitoring

Treated by stopping steroids gradually and anti glaucoma

medications

34


Pseudoexfoliative glaucoma

? Pseudo exfoliation

syndrome(PES)/Glaucoma

capsulare is associated

with Secondary OAG in

50% of the cases.

? Deposition of an

amorphous grey dandruff

? like material on the

pupil ary border,

posterior surface of iris

and ciliary processes

? Trabecular blockage by

exfoliative material

? Managed on the same

lines as POAG

35

Causes of elevated IOP post cataract surgery

? Early phase

? Inflammation

? Haemorrhage

? Retained viscoelastic/lens matter

? Late phase

? Tight suture

? Excessive cautery

? Pupil ary block(IOL/Vitreous)

? Aqueous misdirection

? Epithelial/Fibrous down growth

36


Glaucoma associated with iridocorneal endothelial

syndromes

? Three clinical entities:

? Progressive iris atrophy

? Chandler's syndrome

? Cogan-Reese syndrome/Iris

nevus syndrome

? Pathogenesis: Abnormal

corneal endothelial cells

proliferate to form a

membrane in angle of AC.

Contraction of membrane

leads to secondary angle

closure

? Treatment: Difficult and

usually surgical

37

Other causes of secondary glaucoma

? Glaucoma in aphakia/pseudophakia

? Ciliary block glaucoma

? Glaucoma associated with intraocular

haemorrhage

Red cell glaucoma

Haemolytic glaucoma

Ghost cell glaucoma

Hemosiderotic glaucoma

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41

Question

? A 50 year old lady with uncontrol ed diabetes

presented with painful red eye and decreased

visual acuity in her right eye. On examination

there was raised Intraocular Pressure and new

blood vessels on the iris. The treatment includes

al except?

? atropine

? beta blockers

? steroids

? pilocarpine

42


Question

? The laser procedure, most often used for

treating neovascular glaucoma:

a) Goniophotocoagulation

b) Laser trabeculoplasty

c) Panretinal photocoagulation (PRP)

d) Laser iridoplasty

43

Question

? What is the most likely type of glaucoma in

this patient ?

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

44

This post was last modified on 07 April 2022