Approach to glaucoma by Dr.fajri mohammed

1. Approach to glaucoma
by: Fejiri Mohammed,MD.
Ophthalmology R. R2
Moderator: Dr.Guteta G/Mechael,MD,
Cataract and glaucoma surgeon)
1

2. Out line
• Introduction
• Classification
• Clinical evaluation
• Investigation
• Principle of management
2

3. Introduction
• The term glaucoma refers to a group of progressive optic neuropathies
characterized by
– An excavated appearance of the optic disc, often described as cupped, together with
– loss of retinal ganglion cells and their axons and
– corresponding vision loss.
• The primary site of injury is thought to be the lamina cribrosa, which has been
shown to be structurally damaged in eyes with glaucomatous optic neuropathy,
leading to the appearance of optic disc excavation.
3

4. Cont…
• The causes are multifactorial and include genetic and environmental factors.
• IOP is a continuous risk factor for the development of glaucoma over its entire
range;
• However, it is not elevated above the statistically normal range in a substantial
proportion of patients with primary open- angle glaucoma (POAG) and
• Is not a defining characteristic of the disease.
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5. Cont…
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6. Cont…
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7. Epidemiology
• As the leading cause of irreversible blindness in the world, glaucoma poses a
significant public health problem.
• It has been estimated that by 2020, approximately 80 million people
worldwide will have glaucoma, with 11.2 million bilaterally blind as a result.
• A meta- analysis estimated that the global prevalence is about 3.5% in the
population aged 40–80 years.
• Because older age is a major risk factor for glaucoma and because
• Life expectancies are increasing in most populations, the prevalence of
glaucoma is expected to increase sharply in the coming de cades.
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8. Classifications
• Glaucomas are classified by
– age of onset (childhood vs adult onset),
– Etiology (primary vs secondary), and
– Gonioscopic assessment of the iridocorneal angle (open vs closed).
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9. 9

10. Cont….
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11. Clinical evaluation
• History
– Demographics
- Age.
-Race and ethnicity.
-Symptoms
-Ocular history
Refractive error.
Trauma
Ocular surgery.
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12. Cont.…
• General medical
– diabetes mellitus,
– cardiac and pulmonary disease
– systemic hypertension,
– sleep apnea, Raynaud phenomenon
– migraine and other neurologic diseases
– renal stones, and pregnancy.
• Drug: Systemic or local
– Corticosteroid
• Quality of Life
12

13. Cont…
Refractive Error
• Correcting any significant refractive error is necessary for accurate perimetry;
and
• Different refractive states can be associated with various types of glaucoma.
Especially high myopia, is a risk factor for primary open- angle glaucoma.
pigment dispersion syndrome is more common in moderately myopic eyes.
 optic disc and peripapillary anomalies associated with myopia can confound the
evaluation of the optic disc and RNFL both clinically and OCT imaging
13

14. General examination
 External Adnexae
• Tuberous Sclerosis (Bourneville Syndrome)
• the “ash-leaf sign” & adenoma sebaceum
• Neurofibromatosis
– Subcutaneous plexiform neuromas
• Juvenile Xanthogranuloma,
• yellow and/or orange papules
• Oculodermal melanocytosis (nevus of Ota).
• skin pigmentation
14

15. cont…
Pupillary Function
• RAPD is often seen in the presence of asymmetric glaucoma damage;
• However if an RAPD cannot be reconciled with the overall clinical picture of glaucoma, the
presence of a non glaucomatous optic neuropathy must be ruled out.
• In some clinical situations, it is not possible to assess the pupils objectively for the presence
of an RAPD, and
• a subjective comparison between the eyes of the perceived brightness of a test light may
be helpful.
• Color vision test
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16. Slit lamp examination
 Anterior segment
 Conjunctiva
• hyperemia.
acutely elevated IOP
sympathomimetics and prostaglandin analogues
• Black adrenochrome deposits
• epinephrine derivatives
• filtering surgery Scar
• filtering bleb present, size, height, degree of
vascularization, and integrity
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17. Cont.…
 Episclera and sclera
• Dilation of the episcleral vessels
Sturge-Weber syndrome
arteriovenous fistulae,
 thyroid eye disease.
• Sentinel vessels intraocular
tumor
• Oculodermal melanocytosis
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18. Cont…
Cornea
• Irregular and vesicular lesions in posterior polymorphous
dystrophy
• a “beaten bronze” appearance in the iridocorneal
endothelial syndrome
• large posterior embryotoxon in Axenfeld-Rieger syndrome
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19. Cont..
• Haab stria
• Kp”s
• Kruken berg spindle
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20. Cont…
Anterior chamber
• uniformity of depth of the chamber & estimate the
width of the angle.
• Iris bombé and plateau iris syndrome
• malignant (aqueous misdirection) glaucoma
• Inflammatory cells/ debris RBC, floating pigment.
Van Herick classification system
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21. Central Anterior Chamber
(Ghorbani-Smith Method)
•
21

22. Cont.…
Iris
• The iris should be examined before pupillary
dilation.
• The clinician should note
 heterochromia,
 iris atrophy,
ectropion uveae (the presence of pigmented iris
epithelial cells on the anterior iris surface)
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23. Cont.…
• corectopia (displacement of the pupil),
• nevi, nodules,
• exfoliative material
• Transillumination defects, the presence and
patency of an iridotomy or iridectomy, and any
surgically induced iris abnormalities.
• Iris color should be noted, especially in patients
being considered for treatment with a
prostaglandin analogue
23

24. Cont…
• Early stages of neovascularization of the anterior segment may appear as
– Either fine tufts at the pupillary margin or
– A fine network of vessels on the surface of the iris adjacent to the iris root.
• ocular trauma, such as
– Iris sphincter tears,
– Iridodialysis (tear in the iris root), or
– Iridodonesis
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25. Cont.…
• contour of the iris
– clues about the under lying mechanism of angle closure.
– choroidal effusion or hemorrhage
– iris or ciliary body cyst or, rarely, uveal melanoma;
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26. Cont…
• Lens
• The clinician should examine the lens both before and after pupillary dilation,
evaluatingits size, shape, clarity, and stability.
• Examination of the lens may help the clinician to determine the etiology and
guide the management of lens- related glaucomas
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27. Vitreous and Fundus
• Dilated examination of the posterior segment allows the clinician to evaluate
 the vitreousfor signs of inflammation,
hemorrhage, or
ghost cells.
Careful stereoscopic evaluation of the optic nerve head
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28. Gonioscopy
• It is the clinical technique that
allows the structures in the
anterior chamber angle to be
visualized.
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29. Cont…
Indirect Method
• In this method, the problem of total internal reflection is overcome by a prism/mirror
system and a viscous coupling solution or tears between the lens
• The image of the anterior chamber angle is reflected in a mirror at a tilt of 59°–64°
(62° most common).
• Therefore, the portion of the angle viewed is that opposite the mirror, 180° away.
• However, the up/down and left/right orientations remain the same.
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30. Cont.…
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31. cont…
Direct Method
• Direct gonioscopy is performed with a steeply convex lens, which permits
light from the angle to exit the eye closure to the perpendicular at the
interface between the lens and the air .
 Eg. Koeppe lens, Hoskin-Barkan, and Swan-Jacob.
 The Koeppe lens that is 50 D lens is placed on the eye in patient on supine position.
 Saline is used to bridge the gap between lens and cornea.
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32. Cont…
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33. Cont…..
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34. Cont…
 Indentation goneoscopy
• Indent the central cornea, thereby displacing aqueous into the peripheral
anterior chamber (PAC) where it bows the iris posteriorly and widens the
chamber angle.
• The commonly used indentation lenses (Zeiss, Posner, and Sussman)
have four mirrors with 64° tilt, spaced at 90° intervals.
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35. Structure of AC angle visible on goneoscopy
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36. 36

37. Grading system
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38. Cont….
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39. Cont…
• The Spaeth gonioscopic grading
system
• expands on this schema to include a
description of
– the peripheral iris contour,
– the insertion of the iris root, and
– the effects of dynamic gonioscopy
on the angle configuration
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40. Cont…
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41. Cont…
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42. 42

43. Cont….
43
• Posttraumatic angle recession
– may be associated with monocular open- angle
glaucoma.
– The gonioscopic criteria for diagnosing angle
recession include
 an abnormally wide ciliary body band
increased prominence of the scleral spur
 torn iris processes
 marked variation of ciliary face width
and angle depth in different quadrants of
the same eye

44. Recording the finding
44

45. Examination of the Optic Nerve Head
• indirect / direct ophthalmoscope
• slit-lamp bio microscope with posterior pole lens
– diameter of the optic nerve head in millimeters.
• 60.00 D lens the same
• 78.00 D lens multiply by 1.1
• 90.00 D lens multiply by 1.3
• Normal 1.5 to 2.2 mm in diameter.
– Size
• Small: <1.5 mm
• Medium: 1.5–2.0 mm
• Large: >2.0 mm
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46. Cont…
• Five basic rules (“the 5 Rs”)5 for the assessment of a normal optic disc:
1.Observe the scleral Ring to identify the limits of the optic disc and its size.
2. Identify the size of the Rim.
3. Examine the Retinal nerve fiber layer.
4. Examine the Region outside the disc for parapapillary atrophy.
5. Watch for Retinal and optic disc hemorrhage.
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47. Cont.…
• The vertical cup–disc ratio
– normally between 0.1 and 0.4
– 5% of individuals without glaucoma will have cup–disc
ratios larger than 0.6.
– Asymmetry of the cup–disc ratio of more than 0.2 occurs
in less than 1% of individuals without glaucoma.
– Less than 10% of normal eyes have a smaller horizontal
cup-disc ratio than their vertical cup-disc ratio
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48. Cont….
• ISNT rule
• rim widths
• not highly specific
• acquired optic disc pit.
– high risk for progression
– 20% or more of normal eyes may not follow the ISNT rule.
– that 25% of glaucomatous eyes may follow the ISNT rule.
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49. Cont…
49

50. Cont….
• Deep localized notching, in which the lamina cribrosa is vis i ble at the disc
margin, is sometimes termed an acquired optic disc pit
• Patients with acquired pits are at especially high risk for progression.
• Even in the healthy eye, laminar trabeculations or pores may be visible as
grayish dots in the base of the physiologic cup
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51. Cont….
• Retinal nerve fiber layer hemorrhages can be a sign of glaucoma and
usually appear as a linear red streak on or near the disc surface
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52. Cont…
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53. • Recording of optic nerve findings
– Diagram
– Photography
• monoscopic photographs
• stereophotography
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54. Establishing Diagnosis Of Glaucoma
• Glaucoma suspect
• Anatomic changes –
– Optic disc examination
– OCT
• Functional changes
– Visual field
• We should correlate the above two points for
the diagnosis of glaucoma in order to avoid
misdiagnosis
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55. 55

56. From Glaucoma Suspect to Manifest Glaucoma
• A confirmed new defect in a previously normal visual field consistent with
glaucomatous damage
• A confirmed deepening or expansion of a previously ambiguous visual field
defect
• Progressive thinning of the circumpapillary RNFL consistent with a
glaucomatous process
• Progressive optic disc cupping, notching or rim thinning documented by serial
stereoscopic disc photographs.
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57. Imaging
• CCT
– Pachymetry
• ACD measurement
– UBM
– ASC -OCT
• Imaging of the ONH & RNFL
– optical coherence tomography (OCT)
– confocal scanning laser ophthalmoscopy (CSLO)
– scanning laser polarimetry (SLP).
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58. • Oct
– Normal thickness and contour.
– Abnormal thickness, normal
contour.
– Normal thickness, abnormal
contour.
– Abnormal thickness and
contour.
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59. Cont…
• Any focal thinning in the superior or inferior pole, especially if the thickness is at or
below the 5th percentile (yellow or red regions of nomogram);
• Any significant asymmetry between the right and left eye contour, especially if the departure
is located superiorly or inferiorly
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60. GPA
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61. The Visual Field
• Perimetry serves 2 major purposes in the management of glaucoma:
1. Identification and quantification of abnormal fields
2. to detect glaucomatous progression and measure rates of change
• Baring of blind spot ,Arcuate or Bjerrum scotoma
• Nasal step
• Paracentral scotoma
• Altitudinal defect
• generalized depression (rare in glaucoma in the absence of localized loss)
• Temporal wedge (rare)
• Isopter contraction.
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62. 62

63. Cont.….
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64. Minimum Criteria for Diagnosing Acquired Glaucomatous Damage
in a 24-2Examination
• Any of the following must be reproducible on two consecutive fields –
• A Glaucoma Hemifield Test “Outside normal limits.”
• A cluster of three or more points in a location typical for glaucoma, all of
which are depressed on the pattern deviation plot at a p < 5% level and one
of which is depressed at a p < 1 % level.
• A pattern standard deviation that occurs in less than 5% of normal fields
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65. Staging
1. Mild or early-stage glaucoma – pre-perimetric glaucoma (with a normal visual
field).
2. Moderate-stage glaucoma – optic nerve abnormalities consistent with glaucoma
and glaucomatous visual field abnormalities in one hemifield, and not within 5° of
fixation.
3. Severe-stage glaucoma – optic nerve abnormalities consistent with glaucoma and
glaucomatous visual field abnormalities in both hemifields and/or loss within 5° of
fixation in at least one hemifield.
4. Indeterminate – optic nerve abnormalities consistent with glaucoma are present
without available visual field data. 65

66. Principles of glaucoma management
• Establishing diagnosis
• Establish base line IOP
• Target IOP
• Patient counseling
• Settle type of management
– Medical management
– Surgical management
• Follow up
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67. Baseline IOP
• Ideally, a 24-hour IOP curve should be obtained before starting
treatment.
• Best compromise is the mean of 4–6 IOP readings at different times of
the day over 2–3 visits
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68. Target IOP
• The term target pressure refers to an IOP below which the clinician
estimates the rate of disease progression to be sufficiently slow as to
minimize the patient’s risk of experiencing further symptomatic vision loss
in his or her lifetime.
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69. Cont…
• 20% for mild
• 30 % for moderate
• 40 % for severe
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70. Cont…
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71. Cont…
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72. 72

73. Cont…
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74. • Medical Management of Glaucoma
– prostaglandin analogues
– adrenergic drugs
• β-adrenergic antagonists
• adrenergic agonists
– carbonic anhydrase inhibitors (topical and systemic)
– parasympathomimetic (miotic) agents
• direct-acting cholinergic agonists
• indirect-acting anticholinesterase agents
– combination medications
– hyperosmotic agent
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75. •
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76. • Surgical Therapy for Glaucoma
– Laser surgery
• laser iridotomy and laser iridoplasty
• laser trabeculoplasty and cyclodestruction
– Incisional surgery
• Trabeculectomy
• implantation of tube shunts
• MIGS
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77. Follow up
• Establish a good baseline.
• Set a reasonable initial target pressure
• Lower the pressure.
• Continue to observe the patient to determine if the target pressure is met
and if the glaucomatous damage progresses.
• Modify the target pressure and treat as indicated by the patient’s course
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78. Cont…
• Three major questions arise in relation to follow-up:
– How frequently should the patient be examined?
– What should be tested at follow-up examinations?
– Is the patient's condition stable or worsening?
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79. Content of Follow-Up Examinations
• History.
• Vision.
• Intraocular pressure.
• Gonioscopy.
• Fundus examination.
• Retinal nerve fiber layer and optic disc imaging.
• Visual fields.
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80. Cont…
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81. 81

82. Recognition of Progressive Damage
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83. 83

84. Reference
• BCSC sect 10 glaucoma 2021–2022
• Shields Textbook of Glaucoma, 6th Edition
• Manual of Glaucoma First Edition: 2016
• GLAUCOMA Medical Diagnosis & Therapy 2nd ed
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85. Thank you
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