glaucoma & inflammation. - school of medicine · epidemiology of glaucoma & keratitis....
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Glaucoma & Inflammation.
Jorge L. Fernandez Bahamonde, MD.
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Definition.Inflammatory ocular conditions compromise outflow of aqueous humor.
KeratitisEpiscleritis.Scleritis.Uveitis
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Glaucoma & Keratitis.Anterior uveitis often accompanies it.
Open angle mechanism.Inflammatory cells & debris occludes the TM.
Angle closure.Pupillary block.
Posterior synechiae. (bombe).
PAS.Acute.Chronic.
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Epidemiology of Glaucoma & Keratitis.
Keratitis and elevated IOP is uncommon.But occurs in 33% of patients with HSV keratitis associated with uveitis and/or endothelial disease.
10% develop glaucoma.Peripupillary iris atrophy.
H. Zoster ophthalmicus.40% have uveitis.10% secondary glaucoma. 25-30% chance of glaucoma if h. zoster keratouveitis is present.Sector iris atrophy.
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Epidemiology of Glaucoma & Keratitis.
Other infections causes.Treponema pallidum.Leprosy.Bacterial, Fungal keratitis.Adenovirus type 10.
keratoconjunctivitis/pharingitis/fever.
Chemical burns.Alkali.
Initial raise due to shrink of outer coats of the eye.Followed by slow late increase in IOP, prostaglandins mediated.
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Differential diagnosis.Hx, SLE. Gonio, DFE.
Corneal abrasion, recurrent erosion syndrome.HSV, HZO.Leprosy.Infectious causes.Chemical.
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Rx: Glaucoma & Keratitis.Treat underlying condition.
Antivirals, steroids.Aqueous supressants.
Beta-blockers.Alpha-2 agonists.CAIs, topical vs systemic
Surgery.Restasis for HSV keratitis in steroid responders?
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Glaucoma & Episcleritis.Rare.
9% in patients without past history of glaucoma.50% were using steroids.More common in recurrent cases.Less common in bilateral cases.
Mechanism, open angle but cause still not clear.DD.
Scleritis.Decrease in VA, uveitis, glaucoma.
Rx: oral NSAIA, soft steroids, or topical NSAIA, local support.
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Glaucoma & Scleritis.Scleritis.
Severe ocular pain, orbital radiation.Photophobia, decrease VA.Ciliary injection.
Vessels not movable.50% association with systemic disease.Anterior vs Posterior.Sector (Nodular) vs Diffuse.
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Gl. & Scleritis, Epidemiology.Anterior.
12-13% glaucoma.20% of those have also keratitis.18.7% glaucoma in rheumatoid scleritis.Damage to TM.PAS.Other: Steroid response.
Herpes zoster.Episcleritis then 3 months later scleritis.
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Gl. & Anterior Scleritis. Mechanism.
Open angle.Inflammation of TM.Pre-existent pathology of TM aggravated by perilimbal inflammation and edema.Elevated episcleral venous pressure.Steroid response.
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Gl. & Anterior Scleritis.Closed angle.
Less common, needs uveitis.Pupillary block (posterior synechiae).PAS
Neovascular glaucoma.Posterior uveitis:
Choroidal effusion, secondary angle closure.
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Dx & Rx.R/O Necrotizing scleritis.Recognize association with systemic vasculitis.Steroids, inmunosupressives.IOP.
Aqueous supressants.Mydriatics.LPI, iridoplasty, pupilloplasty, filtering sx.
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Glaucoma & Uveitis.Elevated IOP is common.
All possible mechanisms present.Secondary Open angle. e.g.: HSV uveitis.
Most common. Clogging of TM by inflammatory cells & debris.
Ocassional “KP” at the TM.Swelling of the corneal stroma.Inflammation of the endothelial cells of the TM.
Primary Angle closure.Occurrence in those with previous relative pupillary block component.
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Glaucoma & Uveitis.Secondary Angle Closure.
PAS.Adherence of inflammatory cells and material to TM & iris drawing them together.
Forward CB rotation.Pupillary block
Posterior synechiae.Seclussio, occlussio pupillae.
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Glaucoma & Uveitis, Dx & DD.Hx, SLE, gonio.
Flare & cells aq. Humor/vitreous.Gonioscopy.
“KP”s.PAS.Rubeosis.
DD.Adenoma of the non-pigmented CB.UGH.Lens induced glaucoma-uveitis.
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Glaucoma & Uveitis. Rx.Balancing act.
Topical “strong” steroids.To improve TM function but it may also normalize inflow or lead to an steroid response.NSAIA & soft steroids?
Periocular injections.Glaucoma meds.
Aqueous supressants.Diamox? (avoid it with Trusopt/Azopt).Cartelol (best beta-blocker in uveitis?)Avoid miotics & PGF
(when desperate some try: Acular + Xalatan?)
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Glaucoma & Uveitis. Rx.Mydriatics & Cycloplegics.
Avoid posterior synechiae.Always gonio first.Homoatropine 5%.
Shorter than atropine but good mydriasis & cycloplegia.
Inmunosupression.Cyclophosphamide.Methotrexate.Azathioprine.Restasis, CsA (systemic).
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Glaucoma & Uveitis. Rx.Surgery.
Avoid it if possible, specially in an inflamed eye.Filtering surgery has a low success rate.
75% ≤ 21 with MMC.Fibroblast proliferation.Subconjuctival fibrosis.
Uveitis eyes have an elevated number of T Lymph.
Setons, indicated in active stage.CPC.
Increase post-op inflammation.Further angle closure.
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Specific syndromes.Fuchs’ Iridocyclitis.
Chronic anterior uveitis.Stellate KP’s.
Auto-antibodies to corneal endothelium 90%No PAS.Iris nodules (Koeppe’s like).Vessels in TM (no typical rubeosis).
Some cases of true rubeosis seen in ant.segment ischemia.
Heterochromia.Cataract.
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Specific syndromes.Fuchs’
Open angle glaucoma.Prevalence: 6.3%-59%.Risk 0.5%/year.Failure rate of trab: 56%.
Other causes.Lens-induced.Rubeosis.Recurrent spontaneous hyphema.
Rx: Aq. Suppressants.Glaucoma non-responsive to Rx for uveitis.
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Specific syndromes.Posner-Schlossman.
Usually unilateral, rare cases OU.20-50 yrs old.40% hypochromia of the iris.Most cases self-limited, 2.8 x risk of OAG after 10 yrs of active disease.
Open Angle.Severe episodic elevation of IOP.Corneal edema.Mild A/C reaction.
Sentinel KP.
PUD, GIT disorders, HSV?Rx. Aq suppressants, steroids.
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Specific syndromes.JRA.
Secondary glaucoma. 14-27%.Pauciarticular.Pupillary block.Progressive closure by PAS.Less often: decrease outflow with open angle.Steroid response.
Rx. Aq suppressants.Regular filters not very successful.Setons, trabeculodialysis.
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Specific syndromes.Intermediate Uveitis (Pars Planitis).
Inflammation peripheral retina OU.Snow banking.Vitritis.
MS, Sarcoid, Lyme’s disease, TB, idiop.Glaucoma in 7-8% of adults, 15% children.
PAS, rubeosis, steroid response.Rx. Aq suppressants.
Sx: Setons, CPC.
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Specific syndromes.Behçet’s.
Acute hypopion, iritis.Oral & Genital Ulcers.Erythema nodosum in young adults.Male:Female almost 2:1, males have greater incidence of ocular disease 90%.
Mediterranean, turks.Glaucoma:
Clogging of TM by cells and debris.PAS.Rubeosis.
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Specific syndromes.Behçet’s.
Poor prognosis for VA.Resistence to steroids.
Use Chlorambucil or Cytoxan.IOP.
Aq. Suppressants.Setons.
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Specific syndromes.VKH.
Attack to Ag ofmelanocytes
OU:Panuveitis.Serous R/D.Choroidal infiltrates.Perilimbal vitiligo.
Headaches, nausea, vomits, vitiligo, hearing loss, poliosis, alopecia, madarosis.
20-50 yrs. Old, Asian or Native-Americans.
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Specific syndromes.VKH.
Glaucoma.Secondary open-angle.Pupillary block.Secondary angle closure.
Rotation of CB.
Rx. Aq. Suppressants, Mydriatics.LPI.Setons.
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Specific syndromes.Sympathetic ophthalmia.
Bilateral granulomatous panuveitis after injury to one eye.
Uveitic glaucoma almost 50%.Pupillary block, bombe.PAS, thickening of iris and CB, cell infiltration.
Filtering procedure in a blind-painful eye is often the origin.
Rx: Rx. Aq. Suppressants, Mydriatics, Inmunesupression.
Sx: Setons.
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Specific syndromes.Sarcoidosis. 38% ocular involvement.
Bilateral chronic granulomatous uveitis.20-40 yrs, blacks & women.
Systemic, lungs, liver, spleen, joints.52-74 % occurrence with ocular involvement.Mutton fat KP’s.Iris nodules.PAS.Glaucoma.
11-26% in patients with sarcoid uveitis.Higher risk in blacks.
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Specific syndromes.Glaucoma in sarcoidosis.
Pupillary block (posterior synechiae).PAS.Clogging of the TM.Steroid response.Rubeosis.
Rx: Aq. Suppressants,LPI, filters, setons. Direct damage to optic nerve, similar to glaucomatous optic neuropathy.
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Specific syndromes.HSV.
Superficial Keratitis.Disciform.*Stromal keratitis.Neurotrophic ulcer.*Uveitis. 5% of all uveitis in adults.Retinitis.
* Keratitis with greater incidence of elevated IOP.
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Specific syndromes.Increase IOP in 28-40% of HSV infection.
10% of HSV will have secondary glaucoma.Clogging of the TM, trabeculitis.PAS.
Rx: Control the HSV, aq. Suppressants.Oral acyclovir.Sx. Filters, combined sx.
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Specific syndromes.HZV.
Ocular involvement in 2/3 of patients with HZ ophthalmicus.
Areas, like HSV plus: Scleritis.Choroiditis.Optic nerve neuritis.
Glaucoma. 16-50%. (uveitis, keratitis).Trabeculitis.
Rx: Oral acyclovir. Aq. Suppressants, steroids, mydriatics.