gluacoma clinical evaluation
TRANSCRIPT
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Myopia- pigment dispersion, open angle glaucoma (?)
Hyperopia- small disc, angle closure glaucoma
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• Tuberous sclerosis• Neurofibromatosis• Sturge weber syndrome• TAO
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• Juvenile xanthogranuloma• Oculodermal melanocytosis• Axenfeld rieger syndrome• Orbital varices• CCF
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RAPDCorectopia, ectropion uveae
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• Black adrenochrome deposits• Conjunctival injection• Dec tear production• Foreshortening of the conjunctival
fornices and scarring• Bleb• Episcleral vessel dilation• staphyloma
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• Haab striae• PED• Microcystic epithelial edema• Krukenberg spindle• Exfoliation material• KP• Guttae• “ beaten bronze” appearance
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• Van Herick method• Iris bombé• Heterochromia• Iris atrophy• Transillumination defects• Neovascularization• LENS– Phacodonesis– PSC
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1. diagnostic- identify abnormal angle structures and estimate the width of the AC
2. Surgical- LTP, goniotomyVisualize the anterior chamberEliminates tear- air interfacePrevents total internal reflection
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DIRECT GONIOSCOPY
Koeppe, Barkan-Hoskins, Swan Jacob
done under EUA (supine)
may examine eye simultaneously
needs handheld biomicroscope, light
source direct image
INDIRECT GONIOSCOPY
Goldmann, Zeiss, Susman, Possner
clinic setting (sitting) one eye at a time needs slit lamp confusing mirror
image
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Goldmann- needs coupling agent Stabilizes the globe Clearest visualization of the AC Useful for LTP
Zeiss, Posner, Sussman- Four- mirror goniolens No need for coupling agent Useful for indentation gonioscopy
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Koeppe Useful for fundus exam Useful in patients with nystagmus or
irregular cornea
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Angular width of the angle recess peripheral iris contour Insertion of the iris root
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Pressure is applied to the cornea aqueous humor forced into AC Appositional closure- (+) force opening Synechial closure- remain closed Partial synechial closure- partially open/
closed
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Scleral spur and schwalbe’s line- most consistent
Superior quadrant- narrowest Inferior quadrant- widestPigmentation- most marked in the
inferior angle
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Faint red line in the posterior TMEpiscleral venous pressure > IOPHypotonyElevated episcleral venous pressure
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IRIS PROCESS
Open and lacy Follows the normal
curve of the angle Structures visible
in the open space b/n processes
PAS
More solid or sheet-like
Composed of iris stroma
Obliterate the angle recess
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Increases with ageDarkly pigmented irisPDSPESMalignant melanoma traumaUveitis/inflammationSurgery hyphema
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PDS
Uniform pigmentation
Finer pigment
PES
Patchy pigmentation
(+) sampaolesi line
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Wide ciliary body band
Increased prominence of the scleral spur
Torn iris process Variation of ciliary
face width and angle depth in different quadrants
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Early glaucomatous changes Loss of axons,blood vessels and glial
cells
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MECHANICAL THEORY
Direct compression of axonal fibers
Distortion of the LC plates
Interruption of axoplasmic flow
Death of RGC
ISCHEMIC THEORY
Decresed optic nerve perfusion
Intraneural ischemia
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DIRECT OPHTHALMOSCOPE
Small pupil Detection of NFL No stereosopic detail
INDIRECT OPHTHALMOSCOPE
Uncooperative patients, media opacity, high myope
Can detect ON cupping but less pronounced with slit lamp method
Magnification- is inadequate
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Hruby lens, 60, 78 or 90 D lens Can detect subtle changes in ONH High magnification, excellent
illumination, stereoscopic view Quantitative measurement of the
diameter of the disc▪ 60D= x 1▪ 78D= x 1.1▪ 90D= x 1.3
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1. Generalized enlargement of the cup2. Focal enlargement of the cup3. Superficial splinter hemorrhage4. Loss of NFL5. Translucency of the neuroretinal rim6. Developmenmt of vessel overpass7. Asymmetry of cupping b/n patient’s
eyes8. Peripapillary atrophy ( beta zone)
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Cup disc ratio Measure vertical and horizontal diameter Large disc- large cup▪ Eg myopia, aging, blacks
N- < 0.3 5% - 0.6 Asymmetry of >0.2 -?
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Notching or narrowing of the rim Inferior and superior temporal poles
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Linear red streak on or near the discUsually located inferotemporallyMay clear over weeks to months–
localized notching of rim and VF lossNTG more likely to have hgesPrognostic sign for development or
progression of VF loss
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Red- free illumination N- plush, refractile appearanceThinning, less visibleDiffuse > focal
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• Tissue between the cup and border• Orange or pink• ISNT rule• More translucent in glaucoma
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Alpha zone- irregular hyper and hypopigmentation of
the RPE Temporal crescent seen in myopia Seen in normal subjects
Beta zone Choriocapillaries and RPE loss Choroidal vesels and sclera visible- white appearance More common in glaucoma patients
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Nasalization of vesselsLaminar dot signBayonetingBaring of circumlinear vesselsNarrowing of peripapillary retinal
veseelsPale and excavated cup in advanced
stages
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Confocal scanning laser ophthalmoscopy
Scanning laser polarimetryOptical coherence tomography
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Measures differential light sensitivity or the ability of the subject to distinguish a stimulus light from background illumination
Assess the visual field1. Identify abnormal visual field2. Quantitative assessment of normal or
abnormal fields to guide follow- up care
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1. short wavelength automated perimetry- blue- yellow perimetry
2. Frequency- doubling technology- uses a low spatial frequency sinusoidal grating undergoing rapid phase reversal flicker Simulates M cells
3. Visually evoked cortical potentials and electroretinography- assess RGC function
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KINETIC
Moving stimulus of fixed intensity and size
Simple confrontation, tangent screen, Lister perimeter, Goldmann perimeter
manual
STATIC
Non moving stimuli of varying intensity
Henson, Octopus, Humphrey
automated
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Traquair’s Island of vision Island of sight surrounded by sea of
darkness
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Nasal= 60Superior= 60 Inferior= 70Temporal= 90Blind spot= 10- 20 temporally
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Almost always localizedRespects the horizontal meridianBegins nasal to the blind spot almost always detectable within the
central 30Structural loss precedes VF loss50% RNFL loss before VF defect
develops
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Generalized depressionParacentral scotomaarcuate-/Bjerrum scotomaNasal stepAltitudinal defectTemporal wedge
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Relative or absolute visual loss within 10 of fixation
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10- 20 from fixation
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Relative depression of one horizontal hemifield compared with the other
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Near complete loss of the superior or inferior VF
Advanced GON
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1. Fixation2. Stimulus luminance3. Size of stimulus4. Presentation time5. Patient refraction6. Pupil size7. Wavelength of background and
stimulus
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Numerical- threshold for all points checked
Grey scale- decreasing sensitivity is represented by
darker tones Each change in grey scale tone is
equivalent to 5 dBTotal deviation-
deviation of the patient’s result from age matched controls
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Pattern deviation Adjusted for any generalized depression
in the overall fieldProbability values
P indicates the significance of the defects
< 5%, < 2%, < 1%, and < 0.5% The lower the P- greater clinical
significance
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Fixation losses- indicate steadiness of gaze during the
testFalse positives-
detected when a stimulus is accompanied by a sound
Trigger happy patients Grey scale print out appears pale > 33%- unreliable
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False negatives- detected by presenting a stimulus much
brighter than threshold at a location where sensitivity has already been recorded
Indicates inattention or tiredness May also be an indicator of disease severity Grey scale print out has a clover- leaf shape > 33% unreliable
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Mean deviation- measure of overall field loss
Pattern standard deviation- measure of focal loss or variability within the field taking into account any generalized depression in the hill of vision
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Miosis- decreases threshold sensitivity in the peripheral field and increases variability in the central field
Lens opacitiesUncorrected refractive errorLens rimPtosis Inadequate retinal adaptation
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1. Optic disc less cupped than expected for the degree of VF loss
2. Pallor> cupping3. Progression of VF loss is excessive4. Pattern of VF loss is uncharacteristic
for glaucoma5. Location of VF loss does not
correspond to the location of cupping or thinning of neural rim
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