Glaucoma disease

Question 1

What is the most common type of open angle glaucoma?

Answer 1

POAG

NOTE: asymptomatic until later stages (periph/central VA loss)

Question 2

Signs of POAG?

Answer 2

1. ONH damage
2. Large C/D
3. Asymmetry > 0.2
4. Focal vergical thinning/notching
5. NFL bundle defects
6. Vascular signs (baring, hemes)
7. Doesn’y follow ISNT
8. IOP >21 mmHg

Question 3

What is the most common VF defect in POAG?

Answer 3

Nasal step

Question 4

Which open angle glaucoma are DH more likely to be seen in?

Answer 4

NTG

Question 5

What are you thinking about systemically in NTG? What do you need to R/O?

Answer 5

Raynaud’s, migraines, low BP, sleep apnea, hypercoagulability

R/O hemorrhagic shock, MI, syphilis, vasculitis, especially if unilateral

Question 6

What VF defect are you expecting in NTG?

Answer 6

More focal/dense+close to fixation

Inferotemporal rim is MORE commonly affected first compared to POAG

Question 7

What are some RF for POAG?

Answer 7

1. Thin corneas <555 um
2. AA
3. Family Hx
4. Older age

Question 8

What are RF for NTG?

Answer 8

1. Japanese
2. Female
3. IOP <21 mmHg
4. Drance Hemes

Question 9

Old age, Scandinavian, Caucasian, & bull’s eye on the lens capsule –> what should you think?

Answer 9

Pseudoexfoliation (PXE) Glaucoma

Question 10

What are common findings in PXE glaucoma?

Answer 10

1. Abnormal white flaky deposits on pupil margin
2. Lens capsule (bull’s eye)
3. Zonules
4. +TM
5. Poor pupil dilation
6. INC risk of lens subluxation
7. Cataract Sx complications
8. Sampaolesi’s line

Question 11

What is the risk of developing glaucoma in PXE?

Answer 11

15% in 10 years

Question 12

You see a young, myopic male who is caucasian with posterior bowing of the iris. What glaucoma should you be thinking about?

Answer 12

Pigmentary Dispersion Syndrome

Question 13

Common signs of PDS?

Answer 13

1. Bilateral
2. Bowing of iris posteriorly = contact bw iris/lens zonules
3. Asymptomatic but may have blur/halos after exercising/pupil dilation
4. TID, Krukenberg’s spindle, TM hyperpigmentation, Sampolesi’s line****

Question 14

Risk of developing glaucoma in PXE and PDS in 10-15 years?

Answer 14

15%!

Question 15

Name the types of primary angle closures?

Answer 15

1. Acute
2. Sub-acute (chronic)
3. Pupillary block (iris bombe)
4. Plateau iris syndrome

Question 16

Common signs in Acute Angle Closure?

Answer 16

1. > 50 mmHg (acute)
2. Halos
3. Vomiting
4. Intense ocular pain
5. Hazy cornea
6. Mid dilated pupil
7. Ciliary flush
8. Glaukomflecken (anterior subcapsular opacities)

Question 17

What is the biggest threat to vision in an acute angle closure?

Answer 17

Acute CRAO (IOP > perfusion pressure of CRA)

Question 18

What are some signs of sub-acute (chronic) angle closure?

Answer 18

1. PAS/pigment clumps on TM
2. Progressive optic nerve damage w corresponding VF loss

NOTE: in pts w occludable angles

Question 19

When is pupillary block (iris bombe) most likely to occur?

Answer 19

With anatomically narrow angles (hyperopes)

MOST risk = mid-dilated (greatest iris-lens contact)

Question 20

What are the risk factors for pupillary block?

Answer 20

1. Hyperopia
2. Advanced cataracts
3. Asian/inuit
4. Subluxation of the lens

Question 21

When is neovascular glaucoma most commonly seen?

Answer 21

As a result of retinal ischemia

1. CRVO (MOST COMMONLY)
2. Proliferative retinopathy (2nd)

NEXT: ocular ischemic syndrome, CRAO, retinal detachments = much less common

Question 22

Most important sign of neovascular glaucoma?

Answer 22

Rubeosis of the iris!!!!

Progression can cause 2nd angle closure –> 360 degrees of PS causes pupillary block, resulting in angle closure. PAS causes varying changes in IOP (greater the degree of PAS, greater the elevation of IOP)

Question 23

What causes uveitic glaucoma?

Answer 23

Due to PAS + PS**

Uveitis causes iris to becomes inflamed + sticky can cause stick to the lens or TM

PS and cause of pupillary block if 360 of attachment btwn iris/lens, PAS cause varying changes in IOP

Question 24

Which migraine medication can cause acute angle closure?

Answer 24

Topamax (Topiramate)

Causes supraciliary effusion (moves lens/iris forward), occurs w/in 1st month of use OR if dosage INC

Question 25

Congenital glaucoma is a developmental abnormality in AC impeding aqueous outflow. Describe the patient profile.

Answer 25

1. Birth to 3 months 2. Males 3. Bilateral 4. Bupthalmos: enlarge HVID >12mm that occurs by 1 year old in pts w congenital glaucoma as a result of high IOP

Question 26

What syndrome that causes glaucoma is characterized by endothelium that takes on epithelial characteristics?

Answer 26

Iridocorneal endothelial (ICE) syndromes

Question 27

What are 3 things that can occur in ICE syndromes?

Answer 27

1. Essential iris atrophy: iris thinning=heterochromia, polycoria, corectopia, ectropion uveae 2. Chandler's syndrome: corneal endothelium has "beaten metal" appearance + corneal edema + corectopia 3. Cogan-Reese (Iris nevus) Syndrome: nodules present on anterior iris surface

Question 28

Which Axenfeld Rieger Syndrome has Schwalbe's Line anteriorly displaced?

Answer 28

Posterior Embryotoxin

Question 29

Which Axenfeld Rieger Syndrome has Schwalbe's Line + Angle abnormalities?

Answer 29

Axenfeld anomaly

Question 30

Which Axenfeld anomaly Schwalbe's Line + Angle abnormalities + Iris stromal hypoplasia?

Answer 30

Rieger's anomaly

Question 31

Which Axenfeld anomaly Schwalbe's Line + Angle abnormalities + Iris stromal hypoplasia + SYSTEMIC DEFORMITIES?

Answer 31

Rieger's syndrome