increased pigmentation of angle
- PDS (uniform)
- PXF (patchy, sampaolesi)
- surgery
- trauma
- inflammation
- hyphema
- angle closure
causes of arcuate defect
glaucoma
AION / NAION
disc drusen
BRVO / BRAO
optic nerve pit w/ serous detachment
optic nerve coloboma
myelinated nerve fibers
optic neuritis / C-R’itis
retinoschisis
retinitis pigmentosa
papilledema
laser
high myopia
shock optic neuropathy
melanocytoma
visual field defect with clear cut edge
Hyperope Rx (+6.00D on 30-2)
Brain surgery removed
Absolute defect in retinoschisis
RP
enlarged blind spot
Structural causes
- Large disc/megalopapilla
- ONH drusen
- High myope
Eye disease
- Early papilledema
- Chronic papilledema
- Early glaucoma
- AIBSE (acute idiopathic B.S. enlargement)
- MEWDS
- diabetic or hypertensive papillitis
large disc > 4.09 mm2
physiologic
megalopapilla
high myopia
morning glory/pits
congenital glaucoma
small disc < 1.29 mm2
physiologic
high hyperopia
hypoplasia
drusen
thickest rim and most susceptible to glaucoma
thickest: I>S>N>T
most susceptible: I>S>T>N
K spindle
Age
PXF
PDS
Trauma
Surgery
Hyphema
Uveitis
Melanoma
Nevus of Ota
hyphema in an adult
Systemic causes
- Bleeding diathesis – anemia – sickle cell
- Anticoagulation
- Leukemia / lymphoma
- Behcet’s / HLA-B27
Local causes
- Iris tumour
- NVI
- HSV / VZV
- Fuchs
- ocular surgery
- UGH
- trauma
causes of ectropion uvea
ICE
AR
uveitis
PPMD
NF-1
NVG
epi downgrowth
isolated congenital anomaly
causes of epi down growth
ECCE #1
PK
Glaucoma sx
Penetrating trauma
risk factors for OAG
IOP
Age
Race
FHx
thin CCT
(C:D, VF severity)
Soft: DM / myope / CRVO/ HTN/CVD
ass systemic diseases: sleep apnea, myopia, DM, BP, CRVO, migraine, thyroid, raynauds, hyperlipid
Risk factors for NTG
Female
Migraine
Disc H
Vasospasm / Raynauds
Smoking
risk factors for ACG
I Age
Race
Sex (F > M)
Hyperope
FHx
ocular biometrics
blacks vs white disease
3 – 6x white OAG
earlier onset (1 decade)
HIGHER IOP
Larger c:d ratios / ONH
More BLIND (8x increased risk)
Thinner cornea (CCT thin = underestimate)
causes of increased EVP
- AVM - SWS, AV fistula- carotid or dural cavernous sinus, orbital varix
- Venous obstruction -
- local - thyroid, retrobulbar tumour, CS thrombosis, orbital vein thrombosis
- systemic - CHF, SVC syndrome
- idiopathic
blood in schlemms
artifact of goniolens occluding episcleral veins
high episcleral venous pressure
- idiopathic uveal effusion syndrome
- Sturge-Weber
- carotid-cavernous fistula
- dural-cavernous fistula
- orbital AV fistula
- retrobulbar tumor
- mediastinal tumor
- superior vena cava obstruction
low IOP
- inflammation
- hypotony
- following trabeculectomy
normal eye
unilateral IOP rise with uveitis
Trabeculitis (stellate KP – HSV / VSV / FHI / Posner / toxo / sarcoid / syphilis)
Lens-related (lytic / anaphylactic /particle)
UGH
Other: JRA (20%)
HLA-B27 (Reiter’s)
Lyme
TB
VKH
Behcet’s
Causes of NVI NVA
DDx - NVI/NVA - 97% d/t ischemia – 3% d/t inflammation d/o
ocular vascular dz
- DR (30%)
- CRVO (30%) – 90 day glaucoma
- CRAO / BRVO
- ROP / FEVR / Eales
- sickle cell
- Coats disease
- PHPV
- syphilitic vasculitis
- sarcoid
- anterior segment ischemia
other ocular dz
- ocular ischemic syndrome
- chronic uveitis
- chronic RD
- endophthalmitis
- Stickler syndrome
- retinoschisis
Intraocular tumors
- uveal melanoma
- metastatic carcinoma
- RB
- reticulum cell sarcoma
ocular therapy
- radiation therapy
- postvitrectomy in DR
systemic vascular dz
- carotid occlusive dz
- carotid artery ligation
- CCF
- GCA
- Takayasu (pulseless) disease
Trauma
Rare causes FHI, Uveitis, Iris melanomas, PXF
ONH analyzers
HRT (Heidelberg Retinal Tomogram)
– confocal scanning laser- tomographic slices are manipulated to form a 3D construct, can calculate NFL measurements
GDx (Glaucoma Diagnostix)
– scanning laser polarimeter- takes advantage of hte birefringent properties of hte rNFL arising from parallel microtubules - as light passes through NFL polarization state changes, deeper layers of retinal tissue reflect light back to the detector where the degree to which polarization has changed can be recorded.
– polarized lite shift measures relative NFL thickness
OCT (Optical Coherence Tomography)
– interferometer; low coherence lite
– high resolution (10 um)
– measures absolute NFL thickness
when to treat with cycloplegic
Pseudophake /aphake
ACIOL pupil block
Microspherophakia (pulls lens back – LIE on BACK!)
Malignant glaucoma
Post-SB (band too tight!) – pushes L-I back
Uveitis (posterior synechiae)
Cyclodialysis cleft (low IOP) – it closes it
congenital glaucoma problems
whole eye:
- anterior segment dysgenesis (A-Reigers / Peters)
- nanophthalmos / microphthalmia
- high hyperopia
cornea
- sclerocornea
- cornea plana
- megalocornea
- microcornea (closed angle)
- aniridia: 50% get glaucoma
lens:
- microspherophakia
- dislocation DDX
retina / vitreous:
- PHPV / ROP
nerve:
- morning glory
blind painful eye
Make sure correct dx – r/o malignancy! (B-scan)
Atropine / Pred Forte
Cauterize cornea
Retrobulbar EtOH / chlorpromazine (lasts 6 mos – 1 year & immediate results)
Cycloablation
! Laser (diode / trans-scleral YAG)
! Cryo
Enucleate / eviscerate (DEFINITIVE!)
How do you define progression
- need at least two confirmatory tests
- in CNTGS used thresold testing - If two or more points within or adjacent to an existing scotoma worsened by at least 10 dB or three times the average of the short-term fluctuations= progression if seen on two further fields… may not apply to Swedish Interactive Threshold Algorithm (SITA) visual fields for two reasons. First, the short-term fluctuation is not measured in the SITA program. Second, a 10-dB change in full threshold may not be equivalent to a 10-dB change in a SITA field.
- In EMGTS for the indication of likely progression, used the Glaucoma Progression Analysis software requires that three consecutive visual field tests contain three or more identical points that have changed at a statistically significant level
- total dev plot two spots that are less than 5 % suspicious for defect…or one spot that is less than 1% repeat
