GLAUCOMA Part 1: glaucoma essentials • GLAUCOMA ESSENTIALS •Glaucoma ≠ elevated IOP!! •BUT, glaucoma is usually associated with high IOP (x normal tension glaucoma) •Late symptoms onset •Affects 60.5 million people worldwide • GLAUCOMA ESSENTIALS •accounts for 8% of all cases of blindness and is the leading cause of irreversible blindness worldwide •Early detection is essential • • GLAUCOMA ESSENTIALS (OS) GLAUCOMA ESSENTIALS •Optic nerve damage. GLAUCOMA ESSENTIALS Part 2: definition, anatomy, patophysilogy • Definition •a group of diseases defined by a characteristic irreversible optic neuropathy •remodeling of the connective tissue elements of the optic nerve head •loss of neural tissue (ganglion cells) •associated with the eventual development of visual dysfunction. •intraocular pressure (IOP) level is one of the primary risk factors for development of glaucoma, BUT does not have a role in the definition of the disease •Glaucoma ≠ elevated IOP!! Glaucoma is not fully understood •Susceptibility to glaucoma •determined by the resilience of the optic nerve to the multiple pathogenic mechanisms involved in the neuropathy •progressive injury may occur at low IOP levels whereas in other cases with higher pressures, injury never occurs. •the optic nerve may continue to be damaged despite decreasing the IOP Aqueous Humor Dynamics •aqueous humor composition: •is protein free (optical clarity) •production: ciliary body - 80 ciliary processes, rich supply of fenestrated capillaries •3.6 ml per day • Uveitis - Eye Disorders - MSD Manual Consumer Version Aqueous Humor Dynamics •Trabecular Outflow •pressure-sensitive outflow and functions as a one-way valve •Uveoscleral Outflow •up to 45% of total aqueous outflow. •pressure-insensitive outflow •aqueous passage from the anterior chamber into the ciliary muscle and then into the supraciliary and suprachoroidal spaces •decreases with age and is reduced in patients with glaucoma •increased by cycloplegia, adrenergic agents, and prostaglandin analogues but decreased by miotics Trabecular outflow Uveoscleral outflow Part 3: Classification • Glaucoma classification •Main classification •Open angle glaucoma •Angle closure gl. •Childhood gl. •By cause •Primary, secondary •By time •Acute •Chronic •Intermitent • Open angle gl. •Primary (more common) •POAG – primary open angle gl. •NTG – normal-tension gl. •JOAG – juvenile open angle gl. •OHT – ocular hypertension •Glaucoma suspect •Secondary •Pigmentary, pseudoexfoliation, uveitic… • • Angle closure gl. •Primary •PACS – primary angle closure suspect - narrow angle no nerve damage •PAC – primary angle closure - narrow angle, elevated IOP, no nerve damage •PACG – primary angle closure glaucoma - elevated IOP, nerve damage •Primary angle closure without pupilary block (plateau iris) •Chronic angle closure (angle permanently closed by PAS) •Secondary •With pupillary block •Other mechanism than anatomical configuration (intumescent lens, secluded pupil..) •Without pupillary block •Pushing forward (choroideal tumor) •Pulling forward (NV glaucoma) Childhood gl. •PCG •presents within the first few years of life •Glaucoma associated with congenital anomalies •Associated with local (aniridia) or systemic (neurofibromatosis..) disorders •Secondary glaucoma in infants and children •Inflamation, retinoblastoma, trauma.. Dětský glaukom, vrozený zelený zákal Terminology: absolute glaucoma •Any type of glaucoma at its terminal phase – practical or total blindness •Main goal of therapy = pain elimination •Cyclocryo/photocoagulation •Retrobulbar alcohol application – sensitive inervation block •Enucleation • absolute glaucoma, failed iridencleisis, and tattooed cornea. EyeRounds.org: Online Ophthalmic Atlas Part 4: Emergency cases: acute angle closure + malignant glaucoma • ACUTE ANGLE CLOSURE Pupillary block •the most common mechanism leading to acute angle-closure (glaucoma) •the flow of aqueous humor from the posterior chamber to the anterior chamber is. obstructed by a functional block between the pupillary portion of the iris and the lens •Iris root is then pushed against trabecular meshwork •Risk factors: •Narrow angle, hypermetropia, age related lens swelling (cataract) •Mydriasis •Nighttime (less light) •Emotions Pupillary block • Pupillary block Acute angle closure - signs •Unilateral (usually) •IOP (usually) over • 60 mmHg • Acute angle closure – primary care •Miotics •Other local antiglaucomatics •Systemic therapy: •Osmotics •Carbonanhydrase inhibitors •Analgetics •Antiemetics • • Pilocarpine - Wikipedia Acute angle closure – secondary care •Laser iridotomy (Nd:YAG laser) •(neodymium-doped yttrium aluminum garnet) •Little hole in the iris periphery •Help to equal the pressures between posterior and anterior eye segment •Cataract extraction • • iridotom iriditomie Laser iridotomy video •https://www.youtube.com/watch?v=pNpzdYA3TqI Special case: Malignant glaucoma Part 5: Examination • Examination in glaucoma •History •Slit lamp examination •gonioscopy •IOP measurement •Perimetry •Imaging •OCT RNFL •Ganglion cells •HRT • Medical history in glaucoma •Typically no symptoms for chronic glaucoma in early stages •Risk factors: •age, family history, high IOP, hyperopia, DM, previous eye injury, thin cornea, race •Important in medical history •Past ocular surgery •Refractive error •General medical history (corticosteroid use – steroid induced gl.) •Past medical history (DM, AB, AI, heart diseases, raynauds phenomenon) •Glaucoma in family Slit lamp examination •External adnexae (lashes) •Pupils – may differ in size •Conjunctiva – hyperaemia, scarring due to decreased tear production.. •Cornea – epithelopathy (mediacal toxicity), microcystic oedema (IOP), Kruckenbergs spindle (pigmentary gl.), precipitates (uveitic gl.) •AC – van Herick method (width) •Iris – translumination defects (pigmentary gl), ectropion uveae, rubeosis iridis.. •Lens – intumescent cataract, pseudoexfoliation, subluxation… •Fundus – optic nerve head, retinal haemorrhages, masses… • Side effects associated with prostaglandin analog therapy. | Semantic Scholar • Krukenberg spindle, causes, symptoms, diagnosis, treatment & prognosis Pigmentary glaucoma (secondary open angle) PEX glaucoma (secondary open angle) Neovascular gl. (secondary angle closure) • rubeooooza Van Herick grading Obsah obrázku stůl Popis se vygeneroval automaticky. Obsah obrázku text, tmavé Popis se vygeneroval automaticky. Under ¼ = high risk of angle closure Obsah obrázku text Popis se vygeneroval automaticky. Slit lamp examination • Gonioscopy •Visualisation of the anterior • chamber angle Gonioscopy: What Is It And Why Is It Needed? | glaucoma.org Obsah obrázku text, kniha, snímek obrazovky Popis se vygeneroval automaticky. Obsah obrázku text, ruka Popis se vygeneroval automaticky. • Obsah obrázku stůl Popis se vygeneroval automaticky. Spaeth grading system Pigmentary glaucoma: E60c 4+ ptm CB IOP MEASUREMENT - „NORMAL“ IOP? •in the general population of Europe: approximately 15.5 mm Hg, with a standard deviation of 2.6 mm Hg •Circadian variation: IOP varies by 2–6 mm Hg over a 24-hour period, peak is indvidual, often in the morning •High IOP is often first sign of glaucoma •factors that may increase intraocular pressure: •Playing a wind instrument, Valsalva maneuver, Blepharospasm, Corticosteroids… •Factors that may decrease intraocular pressure •Pregnancy, alcohol, cannabis, aerobic exercise… • IOP measurement •Goldmann applanation tonometer •the most widely used method •Imbert-Fick principle: pressure inside an ideal dry, thin-walled sphere equals the force necessary to flatten its surface divided by the area of the flattening •Circular menisus is converted into 2 semicircles by the prism Aplanation tonometry - video •https://www.youtube.com/watch?v=KOHe9wzM4ns&embeds_euri=https%3A%2F%2Fhubblecontent.osi.office.net %2F&source_ve_path=MjM4NTE&feature=emb_title&ab_channel=EyeDoc IOP measurement •Noncontact (air-puff) tonometers •measuring the force of air required to indent the cornea to a fixed point •Pachymetry •Corneal hysteresis •Advantage: no risk of infection, no need of local anesthaesia •Disadvantage: less accurate •Schiøtz tonometry •The amount of indentation is read on a linear scale on the instrument and converted to mm Hg by a calibration table •Due to a number of practical and theoretical problems, Schiøtz tonometry is now rarely used in the developed world. Perimetry •Kinetic perimetry •Older method, still used in terminal cases •Static (computer) perimetry •More accurare •Absolute/relative scotomas •Usually takes several tries to learn •Indicates false positive, false negative responses and fixation loss •Special glucoma indexes and evaluation (GHT, MD..) to map the progression • OD full field 120p OD threshold 24-2 Perimetry Printout BLIND SPOT RELATIVE SCOTOMA ABSOLUTE SCOTOMA NORMAL SENSITIVITY Imaging RNFL measurement and analysis printed out of the Spectralis OCT in the... | Download Scientific Diagram Part 6: Therapy • Therapy = lowering IOP •Pharmacotherapy •Antiglaucomatics •Neuroprotectin (Citikolin) •Surgery •Laser therapy • •Therapy selection depends on glaucoma type: •Open angle •Pharmacotherapy •Surgery •Angle closure •Surgery •Pharmacotherapy (pilocarpine) • Antiglaucomatics •For local use •Monotherapy/combined therapy (up to 4) •For systemic use •Carbonanhydrase inhibitors •decrease of aqueous humor production •CI: kidney/liver failure, gravidity • •Osmotics •Vitreuous dehydratation – leads to retraction of iridocorneal diaphragma backwards – anterior chambre deepening) •CI: heart/kidney failure • Antiglaucomatics •Prostaglandins •Drug of first choice •Used once a day (evening), long effect, best compliance, 30% IOP decrease •Mechanism – higher outflow through uveoscleral pathway •Contraindication: inflamation, surgery… Antiglaucomatics •Beta-blockers (nonselective) •Mechanism: decrease of aqueous humor production (vasoconstriction – beta 1 and 2 rcp) •Contraindications: arrhythmia, COPD, AB •1-0-1 • •Beta-1 selective betablockers Antiglaucomatics •Alpha-2 selective agonists •decrease of aqueous humor production (vasoconstriction in ciliary body), increase of uveoscleral outflow •CI: IMAO use, children Antiglaucomatics •Parasymphatomimetics (pilokarpine) •Increase of a.h. outflow by contracting ciliary body •Increase of a.h. outflow by „angle opening“ (miosis) •CI: uveitis, bradycardia, hypotension, recent heart attack, gastrintestinal ulcers, epilepsy, parkinson disease • Antiglaucomatics •Carboanhydrase inhibitors •decrease of aqueous humor production (CA is an enzyme in ciliary body processes) •CI: cornea diseases (endothelial cells decrease) Antiglaucomatics •RHO kinase inhibitors •New drugs, targeting TM •Unavailable in CZ LASER THERAPY iridotom LASER IRIDOTOMY Laser trabeculoplasty •Argon laser •50-100 strikes into the trabeculum in order to make it more permeable for a.h. •A space between the strikes is left intact so it opens a little Cyclophotocoagulation •a laser procedure that helps lower the eye pressure by targeting the part of the eye that produces fluid (ciliary processes) •Destroying part of the ciliary body by laser coagulation •Transscleral apliccation of laser beam •Indicated in most advanced cases with poor prognosis of vision • •Cyclocryocoagulation •Even stronger • •Retrobulbar alcohol application •Terminal cases Advances in cyclophotocoagulation: Good, better, best options outlined Glaucoma: Cyclodestruction - American Academy of Ophthalmology Cyklocryocoagulation - video •https://www.youtube.com/watch?v=D5CRcJO3U9M Surgery •Classical filtration surgery •Trabeculectomy •Filtration implants •Deep sclerectomy (non penetrating) •MIGS •High safety profile •Minimal disruption of normal anatomy •Ab interno approach • • Five Pointers on Choroidal Effusion and Suprachoroidal Hemorrhage - Glaucoma Today Endophthalmitis | Concise Medical Knowledge Trabeculectomy •Main goal is to make arteficial pathway for the a.h. outside of the eye implant Express implant Long term effect on IOP of a stainless steel glaucoma drainage implant (Ex-PRESS) in combined surgery with phacoemulsification | British Journal of Ophthalmology Long-Term Data on Ex-Press Shunt for Uncontrolled Glaucoma Are Very Promising - MDalert.com Express implant - video •https://www.youtube.com/watch?v=Eay9oxuCosM&ab_channel=Dr.Adri%C3%A1nHern%C3%A1ndezMart%C3%ADnez MIGS – Xen implant • XEN | Premium Vision Surgical Centres MIGS – Preserflo implant More Industry News & Trends | Market Scope Part 7: glaucoma essentials • GLAUCOMA ESSENTIALS •Glaucoma ≠ elevated IOP!! •BUT, glaucoma is usually associated with high IOP (x normal tension glaucoma) •Late symptoms onset •Affects 60.5 million people worldwide • GLAUCOMA ESSENTIALS •accounts for 8% of all cases of blindness and is the leading cause of irreversible blindness worldwide •Early detection is essential •Educate patients with positive • family history • • GLAUCOMA ESSENTIALS Thank you •