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169 Cards in this Set
- Front
- Back
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What's the major difference between primary angle closure and primary angle closure glaucoma?
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PACglaucoma has glaucomatous neuropathy and field loss present
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T or F: In a primary angle closure suspect, there is no PAS, no disc damage, and IOP is normal.
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T
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What races is 'primary angle closure with pupil block' more present in?
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Asian and Eskimo (eskimo=highest incidence of angle closure)
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Who would you most likely see 'primary angle closure with pupil block' in:
1. small or large corneal diameter? 2. small or large axial length? 3. moderate myope or hyperope? 4. thicker or thinner lens? 5. shallow or deep A/C? |
1. small
2. small 3. hyperope 4. thicker 5. shallow |
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What A/C depth do you never see 'primary angle closure glaucoma with pupil block' in?
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>2.5mm
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CP: What condition is easily mistaken for acute closure glaucoma and vice versa? How do you tell the difference between the two?
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acute anterior uveitic glaucoma; there will be a very active A/C rxn in uveitic (DO NOT USE PILOCARPINE WITH UVEITIC GLAUCOMA)
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CP: What's the typical profile of an angle closure glaucoma patient?
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older, hyperopic female. asian descent increases the risk greatly
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What 4 topical drops and 1 oral med should you use in acute angle closure glaucoma?
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Topicals:
1. beta blocker 2. miotic (Pilocarpine) 3. alpha agonist 4. Steroid (for inflamm.) Oral: 1. CAI (topical can be used if oral not available, but will be less effective) |
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What surgical therapy is the definitive tx and must be done in any case of primary angle closure with pupil block? What is another successful way to break angle closure attacks?
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Laser peripheral iridotomy (LPI); Argon laser iridoplasty
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CP: What do you do if the cornea is too cloudy to visualize the angle with gonio and won't clear with glycerin? (and you suspect acute angle closure)
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Do gonio on the other eye...if you don't find a small, occludable angle then it isn't acute angle closure!
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T or F: the symptoms for subacute angle closure are worse than acute angle closure (glaucoma)
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F!!
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What are the 3 types of angle closure WITH pupil block?
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acute, intermittent, chronic
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What are the type(s) of angle closure without pupil block?
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plateau iris syndrome (configuration)
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What medications do you give your patient who has acute angle closure with a pressure of 50? (with corneal edema)
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Since IOP is >40, don't give Pilocarpine 2%! (won't work due to ischemia...)
Topical glycerin 1. beta blocker 2. alpha agonist 3. diamox 500mg 4. pred forte Eventually they will have LPI |
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What's the goal of treating angle closure glaucoma?
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to change the angle anatomy (NOT lower the pressure!)
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T or F: every case of primary angle closure with pupil block needs LPI as part of management
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T
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what's the most common type of primary angle closure?
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chronic angle closure glaucoma with pupil block
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where do PAS especially form in subacute/chronic angle closure glaucoma with pupil block?
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superiorly
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do we give medications after doing an LPI in chronic angle closure glaucoma? if so, what would we give?
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yes...prostaglandins work exceptionally well in chronic angle closure (compared to acute)
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what's the only way that plateau iris syndrome is diagnosed?
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with an LPI (this DOESN'T cure it!)
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what's the primary procedure to do for plateau iris syndrome? are there any topicals the patient would benefit from?
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ARGON LASER IRIDOPLASTY; pilocarpine!
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T or F: the presence of a patent LPI tells you that the patient is safe to dilate
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F! don't forget about plateau iris syndrome
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what drug was bolded in the notes that can cause drug-induced choroidal effusions? how do we manage these patients?
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Topiramate (Topamax)
1. d/c topamax 2. add Pred Forte q1h 3. Scopolamine BID 4. Beta blocker BID 5. (alpha agonist mentioned) 6. NO LPI! |
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What drug might be better than pilocarpine in patients with angle closure due to choroidal expansion? why?
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Atropine; increases the forward diffusional area for fluid
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the secondary angle closures with pupil block involve either ______ or a list of conditions involving the _____
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uveitis; lens
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the secondary angle closures without pupil block include ____ _____ and _____ ______.
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ICE syndromes and ciliary block
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what are the 3 ICE syndromes? what is the underlying mechanism that causes these?
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essential iris atrophy, chandler's syndrome, iris nevus (cogan-reese); corneal endothelial cells oversecrete leading to Descemet's membrane migrating and extending over the TM. As the membrane contracts, PAS form
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The ICE syndromes are typically unilateral/bilateral?
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unilateral
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Women/men usually get ICE syndromes
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women
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What surgery is needed for ICE syndrome's secondary glaucoma?
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filtering Sx and often penetrating keratectomy
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When does ciliary block glaucoma most typically occur?
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after ocular Sx for angle closure glaucoma
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In ciliary block glaucoma, an abnormally impermeable ____ ____ ____ may play a role by preventing aqueous from diffusing thru the vitreous into the AC.
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anterior hyaloid face
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What's the classic sign of ciliary block?
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anterior chamber shallowing with IOP slowly rising following trabeculectomy
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In ciliary block, what drug will aggravate or even cause this condition?
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miotics
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How are patients with ciliary block best managed?
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1. Atropine 1% BID
2. topical Steroids 3. Aqueous suppressants 4. probably acetazolamide 1 gm PO QD eventually everything BUT Atropine is tapered |
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T or F: patients with secondary glaucomas are typically younger than POAG patients
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T
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What is the mechanism of IOP rise in a person with pigmentary glaucoma?
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breakdown of TM secondary to pigment processing occurs
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What condition do you see Krukenberg Spindle in?
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pigmentary glaucoma
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What is the patient profile for someone with pigmentary glaucoma?
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young, myopic white males 20-45
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Is the angle open or closed in pigmentary glaucoma?
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open
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What condition has high diurnal IOP fluctuations (and therefore can be easily missed on an exam?)
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Pigmentary glaucoma
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T or F: Pigmentary glaucoma declines with age
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T (relative pupil block raises iris off zonules)
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Where are the transillumination defects in pts with pigmentary glaucoma?
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mid-peripheral iris
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T or F: the pigment accumulation in pigmentary glaucoma is directly related to IOP
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F!!
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What does it mean if you see more pigment superiorly in pigmentary glaucoma?
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"Pigment reversal sign"; the TM processing is returning to better activity
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What's a scheie line?
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found in pigmentary glaucoma...pigment on the lens equator
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If you diagnose someone with pigment dispersion syndrome, when is the next follow up and what tests need to be performed?
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On that visit you do field, disc, and RNFL analysis...f/u 3-6mos. and do DFE and fields
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Should you do an LPI on a person with pigmentary glaucoma?
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NO..since GLAUCOMA has already occured, any potential benefit from the LPI is lost
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When pigmentary glaucoma develops from pigment dispersion syndrome, how do you tx?
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Like POAG! (use aqueous suppressants...doesn't mention cycloplegics...DON'T USE pilocarpine for risk of retinal detachment!)
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T or F: pseudoexfoliation glaucoma has a 50% likelihood in getting glaucoma in 10 years
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T (and pigmentary also has a 50% conversion rate over a lifetime)
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T or F: pseudoexfoliation glaucoma is an age-related disorder and is rare under 40 y.o.
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T!
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What's the most common identifiable cause of open angle glaucoma worldwide?
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pseudoexfoliation glaucoma
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Your pt comes in with high IOP. You examine the pt and they have an open angle. Upon further inspection, you see that they have peripupillary TIDs. You suspect pseudoexfoliation but do not see any of the characteristic material. What is it?
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Probably pseudoexfoliative glaucoma! (a pt originally diagnosed with POAG with peripupillary TIDs that eventually develops exfoliative material probably always had pseudoexfoliative glaucoma)
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In what populations does pseudoexfoliative:
1) have high prevalence (1)? 2) low prevalence (2) |
1). northern europeans (scandinavian, ireland, USA)
2) Africans and Eskimos |
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IOP rise after dilation due to pigment liberation is very diagnostic of what?
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pseudoexfoliative glaucoma
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How do you treat pseudoexfoliative glaucoma?
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as POAG! (pilocarpine works here)
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T or F: ALT/SLT can be used to Tx pigmentary and pseudoexfoliative glaucomas
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T
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_________ glaucoma is one of the worst types of glaucoma to be encountered regularly in clinical practice
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pseudoexfoliative
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What must you do on a pseudoexfoliative glaucoma patient or you run the risk of not catching it?
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a dilated lens evaluation
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What should be your first thought when encountering unilateral glaucoma?
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Angle recession
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T or F: the severity of glaucoma in angle recession is related to the extent of the recession
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TTTTT!!!!
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What's the etiology of glaucoma in angle recession?
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angle scarring/sclerosis
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What do you diagnose when you see "2 scleral spurs"?
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angle recession
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What's the #1 cause of unilateral glaucoma?
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angle recession
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What class of topical meds seem to work well in pts with angle recession glaucoma?
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PGAs (uveoscleral pathway doesn't seem to be damaged)
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Would you do ALT/SLT on a pt with angle recession glaucoma?
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nah...very questionable and poor response if recession is >180
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When diagnosing angle recession, what must you do to make sure it's angle recession?
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look at the other eye!
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What is the prognosis based on in hyphema patients?
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size of initial hemorrhage (1/3=good, 2/3=fair, >2/3=poor)
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(Usually) Where is the tear in the ciliary body in hyphema patients?
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longitudinal muscle
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What is ghost cell glaucoma?
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when RBCs lose their biconcavity due to loss of hemoglobin after 120 days, they can no longer fit thru the angle...secondary open angle mechanism
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What's the tx for hyphema? What do you need to avoid?
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1. bed rest
2. atropine 1% BID 3. pred forte q1h 4. aqueous suppressants AVOID MIOTICS AND PGAs! and aspirin! |
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What's the 24/24 rule?
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In sickle cell patients with hyphema, if IOP>24 for 24 hours, they need paracentesis
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About ___ of the population are steroid responders.
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2/3 (this does NOT MEAN they will get glaucoma! less than 10% of the population ever has this become a significant problem)
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Response to steroids is dependent on: frequency of _____ and ____
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application; dose
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What's the mechanism of glaucoma secondary to steroid use?
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Outflow difficulty...GAG accumulation is thought to be the underlying difficulty (TM endothelium decreases phagocytic ability)
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What patients are at risk for getting glaucoma secondary to steroid use?
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(myopes), PTS WITH POAG, CHILDREN
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What's the tx for steroid-induced glaucoma?
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1. d/c meds
2. aqueous suppressants (trabeculectomy) |
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What type of glaucoma is caused by uveitis and elevated IOP in association with hypermature cataract?
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phacolytic
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What glaucoma has the same pathophysiology as phacolytic glaucoma except that there is antecedent trauma rupturing the capsule rather than lens hypermaturity
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lens particle glaucoma
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What is glaucoma caused by uveitis following cataract sx?
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phacoanaphylactic (uveitis) (autoimmunity to lens antigens following sx)
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What lens-induced uveitis is described as "acute onset of pain and redness in an eye that is non-seeing"?
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phacolytic
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What's the tx for phacolytic glaucoma?
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1. lensectomy and vitrectomy
2. corticosteroids (q15mins - q2h) 3. cycloplegia (unless there's zonular damage) 4. aqueous suppressants avoid PGAs and miotics! |
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Consider phacomorphic gluacoma in cases with glaucoma, ____, ___, and _____.
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angle closure, shallow chamber, asymmetric advanced cataract
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How do you differentiate primary angle closure from phacomorphic glaucoma?
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phacomorphic has a SHALLOW anterior chamber
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How do you tx phacomorphic glaucoma?
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address acute nature of angle closure (aq. suppressants, corticosteroids, pgas, pilo...)
secondary management: LPI cataract sx with LPI before |
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What are two conditions that can cause secondary angle closure without pupil block?
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1. neovascular glaucoma
2. uveitic glaucoma (inflammatory) |
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How do you tx neovascular glaucoma?
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1. cycloplegia
2. pred forte 2. aqueous suppressants temporarily but generally its not treated this way.... PRP!! or anti-VEGF injections (Avastin and Lucentis) |
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Always obtain an ___ and ____ on pts over 60 who have anterior seg neovasc. What are you looking for?
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ESR and c-reactive protein; giant cell arteritis
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What glaucoma do you see with blood in schlemm's canal?
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glaucoma assoc with elevated EVP
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What medication family can you use in pts with glaucoma due to elevated EVP?
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PGAs!
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When a pt comes in with unilateral red eye and ipsilateral IOP elevation, what 3 things should you consider?
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1. acute angle closure
2. uveitic glaucoma 3. low-flow carotid cavernous sinus fistula |
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Whats the systemic dz that Dr. Sowka has found most associated with uveitic glaucoma?
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herpes zoster
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There is something unique about herpes virus that causes a profound _____
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trabeculitis
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Most cases of uveitic glaucoma have a ___ angle
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OPEN
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How do you tx acute anterior uveitis? (what do you avoid?)
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1. reduce inflamm: pred forte 1% q15mins x 6h, then q1h while awake, or Durazol .05% QID
2. cyclopledge (if atropine/scopolamine/homatropine dont work, use 10% phenylephrine in office) 3. lower IOP (aq suppressants) AVOID PGAS AND MIOTICS |
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In causes of uveitic glaucoma, _____ tend to be less effective and _____ tend to be more effective than in POAG.
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beta blockers; CAIs
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Whats the mechanism for the IOP elevation in chronic iridocyclitis?
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likely due to trabeculitis and increased aqueous viscosity due to flare and NOT angle closure or inflammatory cell accumulation within meshwork
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T or F: glaucoma is more likely to occur in pts with acute uveitis than chronic uveitis.
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F!
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Whats the tx of uveitic glaucoma?
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aggressive use of steroids, cycloplegics (regardless of angle status), mydriatic agents, and aqueous suppressants...avoid PGAs and miotics
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What's the causative mechanism of glaucomatocyclitic crisis?
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decreased outflow suggests a TRABECULITIS as the causative mechanism
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what is found in high concetrations in pts with GCC?
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prostaglandin E
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What's Posner-Schlossman syndrome?
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GCC
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T or F: GCC is more common in those b/w 20-60
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T
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What condition is unilateral, recurrent, and self-limiting? (hint: keratic precipitates)
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GCC
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What's the tx of choice in GCC?
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corticosteroids; aq. suppressants can also be used to lower TM (but this condition is self-limiting....just don't use miotics or PGAs!)
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The highest pressures Dr. Sowka has encountered is with what condition? Are patients in pain?
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GCC; NO! IOP level is disproportionate to the amount of inflamm and the pt is barely bothered...blurred vision is the most common complaint)
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What's the mechanism of glaucoma development in pts with Fuch's heterochromic iridocyclitis?
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chronic trabecular inflamm leading to sclerosis
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What condition has chorioretinal lesions reminiscent of toxoplasmosis?
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Fuch's heterochromic....
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How do you tx Fuch's?
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Tx as POAG if glaucoma develops
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T or F: Fuch's responds well to steroids.
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F!
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T or F: Fuch's is associated with cataract
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T
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An IOP over ____ in children in concerning.
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20
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Primary congenital glaucoma and primary infantil glaucoma occur secondary to ________.
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trabeculodysgenesis
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Whats the main different b/w primary congenital and primary infantil glaucomas?
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when they occur: congenital= birth-2months, infantile=2months-2years
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What's the classic triad of congenital glaucoma?
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1. epiphora
2. photophobia 3. blepharospasm |
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T or F: congenital, infantile, and JOAG pts need to have surgery to be treated
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T (meds only adjunctive)
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What medication class is the best option in pediatric glaucoma cases (as adjuctive tx)?
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CAIs (beta blockers OK...PGAs not effective in younger children)
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T or F: aphakic and pseudophakic children must be followed for the rest of their lives for the development of glaucoma
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T
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Which laser-tissue interaction is non-pigment dependent?
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photodisruption
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The only time photovaporization is desiarble is in what?
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thermal iridotomies
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T or F: coagulation occurs in photodisruption
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F!!!
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Photodisruption is the basis for _____ capsulotomies and iridotomies.
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Nd:YAG
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Photocoagulation warms ____, stimulating it to contract....changes the microanatomy of the tissue.
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collagen
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Complication rate with lasers is a factor of the ____ _____ ____ ____ delivered into the eye.
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total cumulative LASER ENERGY
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What are the 5 things that ALT is indicated for?
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1. pseudoexfoliative
2. pigmentary 3. POAG 4. non-compliance with meds 5. inadequate medical control |
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Which trabeculoplasty can be repeated more than once?
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SLT
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How does SLT work?
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it stimulated the cells in the TM that haven't been cleaning out the debris and dividing into new cells (which are better at cleaning)....ALT has 3 possible ways it works....
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T or F: SLT causes tissue alteration
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F...ALT does (SLT is non-thermal...just stimulates macrophages)
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ALT and SLT are used to Tx closed/open angle glaucoma
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OPEN
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What are the two procedures to tx closed angle glaucoma?
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argon laser iridoplasty and LPI
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What are the two indications for LPI?
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angle closure with pupil block and prophylaxis in narrow, occludable angles
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T or F: you cannot perform Nd:YAG laser in a blue iris
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F! ARGON LASER!!!!!!!!!!!!
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In Trabeculectomy, the bleb should be ___ and ____.
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elevated (not flat) and avascular
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Why are antimetabolites used in filtering sx?
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they inhibit fibroblast proliferation and reduce scarring so that the filter functions (but they may work too well...hypotony and flat AC)
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What are the antimetabolites?
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Mitomycin C and 5-fluorouracil
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After trabeculectomy, if the patient exhibits a shallow AC and high IOP, what does this indicate?
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malignant glaucoma
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What is Tenon's cyst?
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a opalescent thick-walled bleb that develops from proliferation of noncontractil collagen-producing fibroblasts (anti-metab have no effect)
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What 3 things are glaucoma drainage devices indicated for?
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HIGH RISK CASES
1. uveitis 2. youth 3. previous trabeculectomy failure |
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What progression analysis compares baseline to most recent data?
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Event analysis
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What the most important determinant of therapy and future visual impairment in glaucoma patients?
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glaucoma progression rate
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What's the most influential determiner of future progression rate?
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past progression rate
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What's the most significant modifiable risk factor for glaucoma development and progression?
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IOP level
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T or F: thin central corneal thickness is a risk factor for progression
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T
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When are disc hemorrhages a strong risk factor for progression?
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when the pt ALREADY has glaucoma/OHTN
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Ocular perfusion pressure is a difference b.w what two things?
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blood pressure and IOP
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Regarding patient compliance, nearly ____% of patients show non-continuous use by 6 months after start of therapy
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50
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The CNTGstudy says those at risk of progression include what 3 things? What one thing is associated with tx benefit here?
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female gender, history of migraines, those manifesting disc hemorrhages; female gender
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T or F: in glaucoma, the field can be better than the nerve but not worse
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T
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In these studies, what came first: VF changes (functional) or disc changes (structural)
1) OHTS 2) EMGT 3) SAFE |
1) disc changes
2) VF changes 3) disc changes |
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T or F: for the most accurate diagnosis, you need at least one structural measurement and one functional test
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T
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T or F: with imaging, we can only diagnose and not determine progression
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F! both
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What are the biggest limiting factors of functional measurement?
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reliability and reproducibility
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According to OHTS, a VF endpoint of ___ consecutive abnormal, reliable VF test results appears to have greater specificity and sensitivity than a lower # of test results.
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3
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T or F: according to AGIS, pts with advanced glaucoma only need one test 6 months after a VF worsening (with at least 2 decibels of MD) to indicate a persistent defect
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T
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What are the three limitations of structural measurement?
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artifact in acquisition, anatomy not consistent with normative database to which patient is being compared (including very little and too much damage), and subjective interpretation of results
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When is it appropriate to do visual fields and imaging when monitoring a patient with glaucoma?
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VF: if stable, annually (if not, more freq)
Imaging: at time of diagnosis and annually thereafter |
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The Humphrey HFA 2-i perimeter uses what technology to measure progression?
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Visual Field Guided Progression Analysis (GPA)
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Is GPA an example of event analysis or trend analysis?
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EVENT (highlights changes from baseline exam)
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Is Guided Progression Analysis compared to norms in the population?
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yes....highlights changes in baseline exams that are larger than typical clinical variability in pts with similar degrees of glaucoma
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When do these occur after the TWO baseline exams:
1) open triangles 2) half-filled triangles 3) filled triangle |
1) first follow up (3 exams)
2) two consecutive follow ups (4 exams minimum) 3) three consecutive follow ups (5 exams minimum) |
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How many exams (minimum) does:
1) Possible progression occur? 2) Likely progression occur? How many points must these exams show degradation on? |
1) 4
2) 5 3 or more! |
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T or F: VFI is optmized for progression analysis
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T
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In VFI, the rate of progression is plotted relative to what?
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the patient age
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Does VFI calculate functional or structural loss?
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functional (perimetry!)
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A minimum of ___ exams over ___ years is required to have VFI plot
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5; 3
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Is VFI event or trend analysis?
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TREND
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What is one thing that VFI ignores?
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progression isn't necessarily linear
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T or F: it is difficult to differentiate error in aquisition and true biological change when comparing photographs for progression analysis
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T
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What is the only structural test that has a GPA? (the other 2 don't have FDA approval)
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HRT Topographic change program (Spectral OCT GPA and GDx GPA don't have the approval....the Stratus OCT GPA has problems with image registration)
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