Recommended Books for Ophthalmology

1.

Vaughan & Asburys General Ophthalmology 16th Edition 2004 a LANGE medical book
Parsons Diseases of the Eye 19th Edition 2003 Butterworth publication

3.

Clinical Ophthalmology by Jack J. Kanski 5th Edition 2003 Butterworth publication

GLAUCOMA
Patho-physiology & Detection
Dr. Nasir Saeed

Epidemiology of Glaucoma
Glaucoma is not a single disease entity,but the result of a group of different mechanisms which cause a loss of retinal ganglion cells. This loss may be acute or episodic, or slowly and relentlessly progressive. Some authors therefore refer to the glaucomas. The common, connecting feature used to be

regarded as the height of the intraocular pressure (IOP), which

dominated the understanding of the clinical manifestations to a greater or lesser extent. Although intraocular pressure is frequently raised, it is now regarded as a risk factor, and no longer considered a defining characteristic.

Glaucoma prevalence surveys, by racial groups

Location European Origin Baltimore, Md. Beaver Dam, Wisc. Blue Mountains, Australia African Origin Asian Origin Jamaica Baltimore, Md. Umanaq area, Greenland Age 40+ 43-84 49+ 35-74 40+ >40 PACG (%) 0.31 0.04 0.27 Nil 0.67 4.8 POAG (%) 1.29 2.1 3.0 1.4 4.74 1.26 Secondary glaucoma 0.68 Not stated 0.15 0.35 1.42 1.00 Congenital/ Developmental No available Not stated Nil Nil Not available Nil

NW Alaska
Beijing, China Hvsgl, Mongolia

40+
40+ 40+

2.65
1.4 1.4

0.24
0.03 0.5

Nil
Not stated 0.3

Nil
Not stated Nil

World estimates of glaucoma prevalence

Affected Congenital 300 000 POAG 13.5 million PACG 6 million Secondary 2.7 million Glaucoma suspects 105 million (IOP>21 mmHg)

Blind 200 000 3 million 2 million ?

RISK FACTORS
Age:
The prevalence and incidence of PACG increase with age. Although a peak has been claimed, the best evidence suggests that incidence rises continually with age. Attacks

of ACG are rare before age 45.

 GENDER POAG PACG Equal Females > Males

Race
Chinese European Africans Japanese Asians Refraction ACG POAG ACG POAG POAG<ACG NTG ACG<=POAG

Hypermetopes Myopes

Genetics

 Intra-ocular Pressure

Diabetes
Family History Hypertension Vascular Spasm

ANATOMY OF THE ANGLE STRUCTURES

Aqueous Humour
Produced by the ciliary processes into the posterior chamber Through the pupil it circulates into the anterior chamber 90% of it is drained through the trabecular meshwork into the Schlemms canal and the epi-scleral venous system (conventional pathway) 10% of it leave the eye through the uveo-scleral route (un-conventional pathway) into the suprachoroidal space and chained by venous circulation of the ciliary body and sclera

Functions of Aqueous humour

It maintains the shape and internal structure of the eye by

sustaining an intraocular pressure higher then atmospheric pressure and helps in maintaining the optical structure. It carries oxygen and nutrients to the lens and cornea It carries waste products away from the lens and cornea

Aqueous humour production

Produced by the ciliary processes of the ciliary body. Two Mechanisms I- Active secretion

80% of aqueous is produced by the non pigmented ciliary epithelium as a result of active metabolic process
Involves several enzymatic systems i.e. Na+ - K + ATPase / Carbonic Anhydrase

Na+, K+, Ascrobate, HCO3

Transported into the posterior chamber Secretion diminishes by factors which will inhibit active metabolism like drugs, hypoxia, hypothermia Independent of IOP

Aqueous humour production

II- Passive Secretions 20% Diffusion to maintain equilibrium between the osmotic pressure and electrical balance on the two sides of the ciliary processes Ultra-filtration When the diffusion of water and salt is accelerated by blood pressure (hydrostatic pressure) in the ciliary body The passive secretion is dependent on level of blood pressure in the ciliary body, plasma oncotic pressure and intraocular pressure Blood Aqueous Barrier

Large molecules such as plasma proteins and cells do not get into the aqueous chambers even when the plasma concentration is very high
Sites of the barrier is tight junctions between the non-pigment ciliary epithelium and their basement membrane

Intra-ocular pressure (IOP)

The circulation of aqueous humour in the eye maintains the IOP The equilibrium of aqueous formation and outflow rate is of crucial importance

Normally aqueous humour is secreted at a rate of 0.02l / minute and

same amount is drained The distribution of IOP in general population : 11-21 mm of Hg Average = 15 mm of Hg Diurnal variation High in morning Low in evening No sex difference by 5 mm of Hg

Determinants of Intraocular Pressure

Rate of aqueous humour formation Resistance encountered in out flow channels Level of epi-scleral venous pressure

Factors influencing Intra-Ocular Pressure

I- Rate of Aqueous Humour formation Increased by a. Inflammation b. Blood Pressure c. Hypo-osmolarity of plasma

Decreased by a. Retinal / Choroidal / Ciliary body detachments b. Drugs c. Anaesthesia

B-Blocker Carbonic Anhydrase hulibitors

II- Out flow Resistance Increased by Age

Membrane
Pupillary Block Synechia Lens Vitreous Trabecular Meshwork block Inflammation Cellular debris Steroids Inflammatory exudates Peripheral Iris bowing Peripheral Anterior Synechia Idiopathic

 Outflow Resistance Decreased by

Accommodation Drugs Miotics Prostaglandins Adrenaline

III- Episcleral Venous Pressure

Increased by Increased CVP Valsalva Carotid Cavernous fistula

Hypercarbia
Dysthyroid eye disease Succinyl choline Co-contraction of extra-ocular muscles Decreased by Hypotension Decreased carotid blood flow

Decrease CVP

Applied Anatomy of the optic n. head

Retinal Nerve fibre layers

Relative positions of nerve fibre layer

Cross Section of the Optic N. Head

Optic Cup & Neuro-retinal rim

Physiological Cup & Neuro-retinal rim

Glaucomatous Damage Retinal Nerve fibre layers Normal

Glaucomatous Damage Abnormal Nerve fibre layers

Abnormal nerve fibre layers

Glaucomatous Damage Optic disc cupping

Bilateral glaucomatous cupping with inferior notching and bayonetting

Bilateral advanced glaucomatous cupping with nasal displacement of the blood vessels

End Stage glaucomatous cupping

Clinical Methods for detection and evaluation of glaucoma

IOP Measurements Gonioscopy

Perimetry Techniques
Advanced Techniques

Measurement of Intraocular Pressure Tonometry

Principal The pressure inside a sphere may be measured directly by canulating it and connecting it to a measuring device. This is called manometry. It is the most accurate method but not practical for routine clinical measurement. It can also be measured by the Imbert Fick Law Pressure = Force /Area.

The pressure can be measured by measuring the force necessary to flatten a fixed area or by measuring the area flattened by a fixed force.
Also a known force will indent a sphere. In low pressure the indentation will be more and in high pressure the indentation will be less.

Goldmann Applanation Tonometer

Applanation tonometry measures the force applied per unit area. The Goldmann tonometry is a variable force tonometer consisting of a double prism with a diameter of 3.06 mm. It is the most popular and accurate tonometer.

Goldmann applanation tonometer

Fluorescein-stained semicircles seen during tonometry

A- Schiotz tonometer

B- Principles of indentation tonometry

Checking for diurnal changes= phasing

Demonstrating elevation of IOP after pupillary

dilation, water drinking

IOP checking in different direction of gaze Checking for steroid responsiveness IOP-measurement digitally

Gonioscopy
Visualization of the anterior chamber angle is called Gonioscopy

Purposes 1. Diagnostic: to identify abnormal angle structures and to

estimate the width of the anterior chamber angle. This is

particularly important to classify the open angle and angle closer glaucoma 2. Surgical: to visualize the angle during the procedures

such as laser trabeculopasty and goniotomy

Optical Principal
In normal circumstances the angle of anterior chamber can not be visualized because of the total internal reflection

a b c

Lighter Medium

Denser Medium
d c b a Critical Angle d

Optical Principal of Gonioscopy

Single Mirror goniolens & Zeiss four mirror goniolens

Swan-Jacob surgical goniolens & Koeppe goniolenses

Normal Anatomy of Angle structure

Schaffers Grading System

Abnormal Anterior Chamber Angle

Perimetry Visual fields ;

An island of vision surrounded by a sea of darkness

 Isopter.
Scotoma.

An Isopter is a line in the field of vision exhibiting similar visual acuity Is a defect in the visual field Absolute Relative Positive

Negative
Visible threshold. Is the luminance of the stimulus measured in dB at which it is perceived 50% of times when it is

presented statically

Perimetric Principals

Perimetry is a method of evaluating the visual fields

Qualitative Perimetry is a method of detecting a visual field defect

and is the first screening phases of glaucoma suspects

Quantitative Perimetry

Visual Fields defects in glaucoma

1. Arcuate scotomas : develop between 100 and 200 of fixation in areas that constitute downward or more commonly, upward extensions from the blind spot (Bjeerrum area) 2. Isolated paracentral scotomas: superior or inferior scotomas may also be found in early glaucoma. 3. A nasal (Roenne) step

4. Ring scotomas
5. Temporal Wedge 6. End Stage fields defects

1. Arcuate scotomas : develop between 100 and 200 of fixation in

areas that constitute downward or more commonly, upward

extensions from the blind spot (Bjeerrum area)

Isolated paracentral scotomas: superior or inferior scotomas may also be found in early glaucoma

A nasal (Roenne) step

Temporal Wedge

End Stage fields defects

Advanced Techniques

Quantitative Measurements Digitalized photogrammetry Confocal scanning laser ophthalmoscope (HRT) Measurements of ocular blood flow

Digitalized photogrammetry

Confocal scanning laser ophthalmoscope (HRT)

Glaucoma is the second leading cause of

worldwide blindness.
Early detection and early onset of treatment are

the most important factors for preventing

progressive glaucoma damage.

A comprehensive evaluation of a glaucoma suspect

is the key to diagnosis and management.

The aims of assessment are:

To assess the risk factors to determine whether glaucoma is present or likely to develop To exclude or confirm the alternative diagnosis To identify the underlying mechanism of damage; so as to select best choice for management To plan a strategy for management

ASSESSMENT

Presenting

Social

HISTORY

Past

Family

VA Gonio OM

IOP

Exoph

EXAMINATION
Fundus Ocu surf

Lens Pupils AC

Cornea

Ocular Examination

Record visual functions Ocular motility Exclude any proptosis/exophthalmos Ocular surface for episcleral blood vessels Conjunctiva for papillae and follicles Cornea for size, shape and transparency

Check for corneal thickness

Ocular Examination

Anterior chamber for inflammation, blood, pigment Check for AC depth, central and peripheral

Convex iris-lens diaphragm

Shallow anterior chamber

Narrow entrance to chamber angle

Ocular Examination
Iris for atrophy , rubeosis, trans-illumination defects and pseudoexfoliation

Stromal iris atrophy with spiral-like configuration

Mid-peripheral iris atrophy

Central disc with peripheral band

Ocular Examination

Pupil for size, shape and reaction Lens for presence, transparency, thickness, position and shape

Ocular Examination

Record intraocular pressure, look for diurnal variations Evaluate IOP for 24 hours if in doubt Use a Goldmann-style applanation tonometer

Ocular Examination
Gonioscopy: look for width of the angle, configuration of the iris and chamber, PAS, vessels and iris processes

Open angle of normal appearance

Schaffers grading of angle

Synechial angle closure

Trabecular hyperpigmentation - may extend anteriorly (Sampaolesi line)

Irregular widening of ciliary body band

Ocular Examination
Fundoscopy: evaluate optic nerve head and retinal nerve fibre layer use slit lamp indirect lenses and a dilated pupil Look for optic disc size, colour, neuro-retinal rim, disc haemorrhage, vascular pattern, peri-papillary atrophy and cup disc ratio

Small dimple central cup

Larger and deeper punched-out central cup

Cup with sloping temporal wall

Optic disc evaluation

Retinal nerve fibre layer analysis

Investigations
Order for a visual field examination with a standard automated perimeter

Investigations
HRT OCT GDx

Systemic investigation include

Imaging of CNS Evaluation of CVS Haematological profile