Glaucoma Exam 1

Front 1

characteristic of POAG

Back 1

1. progressive
2. chronic optic neuropathy
3. open anterior chamber angle
4. atrophy of optic nerve
5. loss of retinal ganglion cells
6. visual field damage
7. IOP involvment

Front 2

what are the FOUR theories of how glaucoma causes damage

Back 2

1. mechanical compression
2. ischemic vascular
3. excitotoxicity of neural cells
4. genetically pre-programmed cellular suicide

Front 3

what are the main characteristics of MECHANICAL COMPRESSION IN POAG

Back 3

1. fiber distortion due to pressure resulting in vertical cupping
2. increased IOP causes stretching of lamina connective tissue (only bad in POAG)
3. connective tissue collapses on itself

Front 4

what are the main characteristics of ISCHEMIA in POAG

Back 4

1. vascular stasis to the short posterior ciliary arteries which supplies the anterior ONH
2.disrupts axonal transport
3. increased IOP compresses vessels with lower interluminal pressure
4. causes decreased metabolic activity (increases exotoxins, glutamate)
5. deprivation of neutrophins and RGC death due to low axonal transport

Front 5

what are the main characteristics of EXCITOTOXICITY in POAG

Back 5

1. low glutamate= neurotransmitter
2. high glutamate= neurotoxin
3. due to neutrophin deprivation due to ischemia
4. when cells die they release glutamate which kills healthy adjacent cells

Front 6

what is the mechanism of glutamate in the eye

Back 6

1. acts on sodium channels
2. increases calcium levels
3. activates nitric oxide synthase
4. increases nitric oxide
5. form free radicals
6. result in retinal cell death

Front 7

what is the current pathophysiology of glaucoma

Back 7

1. deforms lamina cribosa
2. impairs blood flow to the optic nerve
3. decreases ocular perfusion pressure
4. block axonal transport
5. deprives the ganglion cells of nerve growth
6. APOPTOSIS occurs
7. dead cells release glutamate to adjacent cells
8. pressure and ischemia also plays a contributing factor

Front 8

what is preperimetric glaucoma

Back 8

1. glaucomatous damage to the optic nerve with noticeable visual field loss
2. glaucoma can be diagnosed based upon disc appearance in the absence of visual field loss

Front 9

uveitis in relation to glaucoma

Back 9

1. uveitis can cause IOP elevation (uveitic glaucoma)
2. not TRUE glaucoma, but if the condition is not treated, glaucoma pathology will develop.

Front 10

what is ocular hypertension

Back 10

IOP of 21+ mmHg in the absence of structural and functional change

Front 11

what are SEVEN characteristics to SUSPECT glaucoma

Back 11

1. elevated IOP/OHTN
2. suspicious disc appearance
3. family history of glaucoma
4. increase age
5. race
6. suspicious VF loss
7. suspicious NFL

Front 12

what are the characteristics of POAG (7)

Back 12

1. most prevalent type of glaucoma
2. DECREASED OUTFLOW (not increased inflow)
3. elevated IOP
4. Rim Notching
5. NFL defects
6. OPEN ANGLE
7. MUST RULE OUT SECONDARY CAUSES

Front 13

what is the main problem in the ANTERIOR SEGMENT in relation to POAG

Back 13

DECREASED OUTFLOW
increased resistance to outflow at the level of the juxtacanalicular tissues in the trabecular meshwork

Front 14

what is the main problem in the POSTERIOR SEGMENT in relation to POAG

Back 14

1. compression of laminar sheets
2. distortion of laminar pores
3. blockage of axonal transport
4. death of ganglion cells
5. deepening and enlargement of optic cup
6. posterior and lateral displacement of laminar sheet

Front 15

where does the visual field loss occur in glaucoma?

what is the earliest detectable visual field loss

Back 15

1. 90-93% of all field loss in glaucoma occurs within the central 30 degrees
2. not a disease where the patient loses peripheral vision
3. earliest detectable field defect is SMALL FLUCTUATING SCOTOMA

Front 16

how should you consider IOP in glaucoma

Back 16

1. MOST significant risk factor OVERALL
2. however IOP is different between individuals and should not be made a prerequisite for glaucoma
3. half of all glaucoma patients have IOP <21mmHg
4. increase with age
5. decrease with exercise (transiently)
6. increased blood osmolarity decreases IOP

Front 17

Diurnal Variuation of IOP
normal?
when is IOP is highest?

Back 17

1. normal: <5mmHg
2. highest IOP occurs when the patient is sleeping in the supine position

Front 18

READ OVER THE STUDIES ON PAGE 9 OF THE POAG PACKET

Back 18

READ OVER THE STUDIES ON PAGE 9 OF THE POAG PACKET

Front 19

what are the most significant risk factors for glaucoma today (5)

Back 19

1. elevated IOP
2. thin central cornea
3. old age
4. race (blacks and older hispanics)
5. lower OPP

Front 20

gonioscopy and glaucoma??

Back 20

CANNOT accurately diagnose or categorize any glaucoma unless you do GONIOSCOPY

Front 21

what where the results of the advanced glaucoma intervention study (AGIS)

Back 21

1. black pts. with advanced glaucoma should receive LASER FIRST
2. white pts. with advanced glaucoma should receive SURGERY FIRST
3. Low IOP is associated with reduced progression of visual field defects

Front 22

what were the key features in the Ocular Hypertensions Treatment Study

Back 22

1. determines if lowering IOP in OHTN pt will reduce glaucoma
2. OHTS is the first and only NEI funded study that used an optometrist and an optometry college as a principal investigator
3. lowering IOP in patients with OHTN reduced the risk of developing glaucoma in five years
4. central corneal thickness appears to be a powerful predictor of the progression from OHTN to POAG
5. Blacks in the study had twice the risk of developing POAG

Front 23

gonioscopy in relation to anterior angles (5)

Back 23

1. artificially opens closed angles by creating suction
2. false impression of angle (more open than it truely is)
3. excess light or near fixation may make an angle appear more open than it typically is
4. best performed in light and dark
5. TONO BEFORE GONIO

Front 24

what are the anterior structures seen in gonioscopy from posterior to anterior

Back 24

1. iris
2. angle recess
3. ciliary body
4. scleral spur
5. trabecular meshwork
6. schwalbes line

Front 25

what is the best anatomical landmark to find in gonioscopy?
why?

Back 25

SCLERAL SPUR
1. anterior to it is TM
2. posterior to it is ciliary body

massive angle recession can cause TWO scleral spurs

Front 26

what type of pigmentation is most important to notice?

Back 26

degree of pigmentation of the TRABECULAR MESHWORK is more important than ciliary body

Front 27

what structure is highly indicative of pigment dispersion syndrome

Back 27

SAMPAOLESI'S LINE

Front 28

what is the difference between angle recess and angle recession

Back 28

1. angle recess: area between iris and cornea
2. angle recession: traumatic dialysis of the iris from the ciliary body

Front 29

what is peripheral anterior synchiae?
what causes it

Back 29

permanent adhesion between the iris and TM caused by:
1. inflammation
2. angle closure
3. neovascularization
4. trauma/hyphema/surgery
5. congenital

Front 30

characteristics of angle recession

Back 30

1. blunt trauma
2. CB tear
3. TM scarring
4. angle appears very open
5. need contralateral comparison
6. antecedent trauma usually included hyphema

Front 31

what is diagnostic for chronic angle closure glaucoma

Back 31

SUPERIOR ANGLE PERIPHERAL ANTERIOR SYNCHIAE (PAS)

Front 32

what helps to differentiate between PAS and appositional closure

Back 32

indentation gonioscopy

Front 33

what type of notching do you usually see with glaucoma

Back 33

1. vertical elongation via inferior and superior notching
2. occurs only from inside cup to inner rim (not outside)
3. hemorrhages and visual defects usually accompanies notching

Front 34

what are disc hemorrhages usually located?

Back 34

1. superior and inferior
2. nasal and temporal hemorrhages tend to not be associated with glaucoma
3. typically where notching occurs
4. resides in the retinal nerve fiber layer, NOT IN CUP

*resolves in 6 weeks

Front 35

what are two criterias of NFL defect

Back 35

1. they are at least the same caliber as an arteriole
2. they must extend to the disc

*anything that doesnt meet these criteria are pseudodefects

Front 36

what is parapapillary atrophy?
what are the zones

Back 36

1. atrophic peripapillary retina shoud suspect glaucoma
2. ZONE BETA: adj to nerve, scleral tissue and more associated with glaucoma
3. ZONE ALPHA: pigment adj to zone beta

Front 37

what is the SAME in tumors and glaucomas

Back 37

1. isolated
2. painless
3. progressive
4. visual dysfunction
5. cupped disc

Front 38

what is DIFFERENT about tumor and glaucoma

Back 38

1. visual acuity
2. color vision
3. RAPD
4. visual field defect
5. disc appearance (pallor is not glaucoma, obliteration of rim IS glaucoma)

Front 39

other than glaucoma, what notches a cup?

Back 39

1. AION
2. Compression
3. Inflammation
4. Trauma
5. Hereditary

*rim pallor is NOT glaucoma
*remember the ISNT rule of THICKNESS

Front 40

what are the visual field changes in glaucoma (scotoma) (7)

Back 40

types of scotomas:
1. relative
2. fluctuating
3. absolute
4. paracentral (5-15 degrees)
5. nasal step
6. arcuate (Bjerrum)
7. altitudinal defect

Front 41

what is the earliest visual defect?
what is the earliest DETECTABLE defect?

Back 41

1. earliest: increased short term fluctuations
2. earliest detectable: shallow fluctuating scotoma

Front 42

what are the visual field testing that can be done to diagnose glaucoma

Back 42

FT, SITA, SITA FAST
1. 30-2 (30 deg)
2. 24-2 (24 deg)
3. 10-2 (10 deg)

*24-2 most used and accurate for glaucoma
*cannot compare results from different test strategies and testing algorithms

Front 43

how does fixation loss occur in visual field testing

Back 43

1. pt gaze often drifts from fixation
2. presumed location of blind spot is incorrect
3. pt readjusted head position after the blind spot had been plotted

Front 44

what function in the visual field machine helps manage fixation loss

Back 44

eye tracking system (gaze monitor)
1. deviation up: pt gaze was not on the fixation target
2. deviation down: indicates a blink

Front 45

what is indicative of a high false NEGATIVE value

Back 45

1. fatigue
2. changed personal criteria for response
3. true indicator of actual field loss where sensitivities are variable

Front 46

what is indicative of a high false POSITIVE value

Back 46

1. suprathreshold levels
2. MD has a high positive value
3. fixation loss high
4. patchy loss on grayscale
5. PD is worse than TD

*unreliable field
*most devasting to interpretation (10+% should be discarded)

Front 47

what is the best representation of the TRUE retro-lenticular visual field defect

Back 47

PATTERN DEVIATION

Front 48

what is mean deviation in the visual field testing

Back 48

weighted average of the numbers on the total deviation plot each value weighted according to the magnitude of the normal range at that point

Front 49

what can the mean deviation signify

Back 49

1. overall severity of the field loss
2. interpret the severity of the field loss at individual locations and the area of the field involved

Front 50

what can a POSITIVE mean deviation signify?
NEGATIVE?

Back 50

1. positive: average sensitivity is above the normal for age
2. negative: average sensitivity is below the average age matched normal

Front 51

abnormalities in mean deviation can indicate:

Back 51

1. widespread damage
2. general depression
3. many small depressions

Front 52

what is the relationship between MD and PSD

Back 52

1. MD worsen and PSD relatively the same is WORSENING CATARACT
2. MD remains stable, PSD worsens, PROGRESSING GLAUCOMA
3. Both worsening, both glaucoma and cataract is getting worse

Front 53

what should be measured when giving a beta blocker

Back 53

pulse rate
blood pressure

Front 54

what is the biggest failure of treatment

Back 54

NONCOMPLIANCE

Front 55

monocular trials?
what are the misconceptions?

Back 55

DO NOT GIVE VALUABLE INFO

MISCONCEPTIONS:
1. diurnal IOP is identical between eyes
2. diurnal IOP is similiar between days, weeks, months
3. response of medication is identical between eyes

Front 56

how would you initiate a combo

Back 56

1. CAI and BB effective, discontinue both and ADD COSOPT
2. A2 Agonist and BB effective, discontinue both and ADD COMBIGAN
3. Pilocarpine and CAI (po) are NOT great choices and NOT typically used

each medication added has diminishing returns

Front 57

how is adherence often measured

Back 57

1. self reporting (greatly overestimated)
2. electronic monitoring (theoretically ideal, not practical)
3. pharmacy records (still pretty useless)

Front 58

what drugs have the highest degree of adherence and persistence?
why?

Back 58

1. prostaglandins analogs
2. lowest prevalence of adverse effects

Front 59

how do you improve patient adherence and persistance

Back 59

1. easy dosing
2. ask open ended questions
3. acknowledge that dosages are going to be missed
4. provide printed information and internet sources
5. glaucoma social groups
6. preset next appointment or send reminders to schedule

Front 60

what are the characteristics of the Scanning Laser Polarimetry

Back 60

1. double pass laser along the NFL, records retardation times to measure thickness.
2. near infra red wavelength
3. <3min for both eyes
4. completely objective
5. clear corneal surface required
6. undilated pupil works best

Front 61

when it comes to imaging, what is the greatest indicator of glaucoma vs. normalcy

Back 61

SYMMETRY between the two eyes

Front 62

what is the mechanism for PROSTAGLANDIN ANALOGS?

dosing?

Back 62

enhance uveoscelral outflow

QD (NEVER INCREASE)

Front 63

what is the mechanism for MIOTICS?

dosing?

Back 63

Increases outflow of aqueous through trabecular meshwork

QID

Front 64

what is the mechanism for ALPHA AGONIST?

dosing?

Back 64

aqueous suppressors

TID

Front 65

what is the mechanism for BETA BLOCKER?

dosing?

Back 65

aqueous suppressors

BID

Front 66

what is the mechanism for CARBONIC ANHYDRASE INHIBITORS?

dosing?

Back 66

aqueous suppressors

TID

Front 67

contraindication of prostaglandins analogs

Back 67

1. secondary inflammatory glaucoma
2. uveitis
3. anterior segment inflammation

Front 68

contraindication for miotics?

Back 68

1. NEVER use miotics with inflammation
2. NEVER let the person fet up after taking medication (vasovagal response)
3. uveitic glaucoma
4. neovascular glaucoma
5. aphakia
6. retinal detachment
7. cataracts
8. pre-presbyopes

Front 69

what are the most significant effect of alpha 2 agonist

Back 69

1. drowsiness
2. fatigue
3. dry mouth
4. headache

DO NOT USE ON KIDS

Front 70

what drugs is most likely to cause systemic side effects

Back 70

beta blockers

Front 71

what type of medication do you use for atheletes

Back 71

OCUPRESS (beta blocker)
1. has intrinsic sympathetic activity
2. least likely to cause bradycardia even though its NON SELECTIVE

Front 72

characteristics of OSMOTICS

Back 72

1. osmotic dehydrations (sucks fluid out of patients, TWSS)
2. serve this with cracked ice (like a COCKtail, haha)
3. EMESIS
4. NOT for use in chronic care (USE ONLY ONCE!!!)

Front 73

what are the contraindications for carbonic anhydrase inhibitors

Back 73

1. sulfa allergies (SJ syndrome)
2. sickle cell
3. hypokalemia
4. renal/liver diseases
5. COMPROMISED CORNEA!!

Front 74

what is the best companion for a prostaglandin analog

Back 74

CARBONIC ANHYDRASE INHIBITOR!!!

Front 75

what are the combo medications?

dosing

Back 75

1. COSOPT (BB+CAI)
dosing: BID

2. COMBIGAN (BB+AA)
dosing: BID

Front 76

what are the criteria for neuroprotection?

what glaucoma drug class has this?

Back 76

1. must reach target
2. must have receptors on the target organ
3. has to confer some resistance to stress
4. has to be proven effective in humans

*alpha agonist has been said to have neuro-protective effects