DEVELOPMENTAL GLAUCOMA

PRIMARY OPEN ANGLE GLAUCOMA

chronic, slowly progressive optic neuropathy with - atrophy & cupping of optic nerve head - visual field defect - IOP

1ry ANGLE CLOSURE WITH PUPILLARY BLOCK

Predisposed eye : - shallow AC + sort axial length - in hypermetropes - mydriasis + mydriatics - dim light + prone position pupil dilatation lens-iris apposition (pupillary block) forward bowing of peripheral iris ( iris bombe) in predisposed eye AC angle closure IOP *acute attack: - severe pain - rapid VA Hand motion - nausea , vomiting, sweating *acute attack: - edema of eyelids + chemosis - marked ciliary injection - corneal edema (VA) - very shallow AC - mid-dilated, oval pupil + sluggish reaction - stony hard IOP

1ry ANGLE CLOSURE W/OUT PUPILLARY BLOCK

SECONDARY GLAUCOMA
open angle glaucoma 1. Phakolytic glaucoma (hypermature cataract) 2. Phakoanaphylactic glaucoma 3. Steroid-induced glaucoma 4. Pseudoexfoliation syndrome (glaucoma capsulare) 5. Pigmentary glaucoma 6. Intraocular hemorrhage 7. Trauma (angle recession glaucoma) 8. Acute iridocyclitis 9. Chronic iridocyclitis + PAS angle closure + pupillary block 1. Intumescent cataract (phakomorphic glaucoma) 2. Sublaxated lens 3. Chronic iridocyclitis + posterior synechia angle closure without pup.block 1. Rubeosis Iridis in DM/CRVO (neovascular glaucoma) 2. Inflammation 3. Intraocular tumor

pathogenesis

symptoms

1. Persistent mesodermal membrane in AC angle 2. Impermeable TM 3. Stenosis/Absent COS - photophobia, tearing, blepharospasm, eye rubbing - progressive enlargement of the globe - corneal diameter >12mm - axial length, myopic error - corneal edema (Haabs striae) - IOP - cupping of optic nerve

resistance to aqueous outflow of TM, dt: - obstruction by FB - loss of trabecular endothelial cells usually Asymptomatic! - gradual painless VA - vague headache - frequent change of presbyopic glasses (weak ciliary muscle dt IOP) 1. IOP - IOP > 21 mmHg - exaggeration of normal diurnal variation > 5 mmHg 2. Optic changes - deeper, wider, oval optic cup - notching of cup edge - Asymmetric size of rt & lt cup - overhanging edge hooking of Vs under cup edges - arterial pulsations - cup/disc ratio + depth & erosion of neural rim + visibility of lamina cribrosa complete optic atrophy + NO PL 3. visual field defect - multipleisolated scotomata in Bjerrum zone arcuate scotoma nasal steps baring of blind spot loss of peripheral field tubular field 1. MEDICAL i) Aq. Outflow - B-blocker : timolol, levobunolol - CAI : acetazolamide tabs, dorzolamide ED ii) drainage - PGs : xalatan, travatan - a-adrenergic : alphagan - cholinergics/miotics : pilocarpine 2. LASER : Argon-laser trabeculoplasty 3. SURGICAL i) Filtering procedure - Trabeculectomy - Seton valves ii) Cyclo-destructive - Cyclocryotherapy/ cyclo photocoagulation

angle closure occurs despite patent iridectomy

signs

- normal AC depth - flat iris plane - pupil dilatation iris crowding covers TM

Rx

SURGICAL! 1. Goniotomy 2. Trabeculotomy 3. Trabeculectomy 4. Synthetic valve surgery

*acute attack: 1. Hospitalization! st 2. Treat corneal edema 1 - hyperosmolar therapy (mannitol 20% IV / oral glycerine) - pilocarpine + CAIs - topical steroids 3. Operation: - PAS not extensive laser/surgical iridectomy - extensive synechia trabeculectomy (filtering) * other eye prophylactic laser peripheral iridectomy *absolute glaucoma cyclo-destruction (YAG laser)

peripheral iridectomy - laser (argon/YAG) - surgical