Glaucoma Exam 2

Front 1

what is angle closure glaucoma

Back 1

A type of glaucoma caused by the APPOSITION OF THE IRIS TO THE TM, obstructing the outflow of aqueous.

Front 2

1. what is considered PRIMARY ANGLE CLOSURE SUSPECT?
2. PAS?
3. Status of Disc and IOP?
4. Medical Therapy?

Back 2

1. pigmented TM blocked by iris
2. NO PAS
3. disc and IOP NORMAL
4. no clear medical therapy (probe of symptoms)

Front 3

1. what is considered PRIMARY ANGLE CLOSURE?
2. PAS?
3. Status of Disc and IOP?
4. Medical Therapy?

Back 3

1. pigmented TM blocked by iris 180 degrees
2. either PAS or high IOP present
3. NO DISC DAMAGE nor FIELD LOSS
4. pathological
5. LPI recommended

Front 4

what is considered PRIMARY ANGLE CLOSURE GLAUCOMA?
PAS?
Status of Disc and IOP?
Medical Therapy?

Back 4

1. Pigmented TM is blocked by iris for 180 degrees
2. Have either PAS or elevated IOP
3. Glaucomatous neuropathy and field loss
4. LPI recommended

Front 5

what is primary angle closure attack?
what are the classic signs?
medical therapy?

Back 5

1. near complete apposition of iris to pigmented TM
2. injection, vision loss, nausea, emesis, halos, corneal edema, high IOP, inflammation, mid dilated fixed pupil
3. iridotomy, iridoplasty, trabeculectomy

Front 6

what is the classic profile of an angle closure glaucoma patient

Back 6

OLD, HYPEROPIC ASIAN FEMALE

1. white>black
2. asian: ACG>POAG
3. females>males
4. older>younger
5. hyperopes>myopes
6. ESKIMOS
7. sulfa medications

Front 7

what is iris bombe?

Back 7

bowing forward of iris due to posterior pressure buildup

Front 8

what is the mechanism for primary angle closure with pupil block

Back 8

1. mid dilated state causes most problems
2. IRIS BOMBE
3. irido corneal apposition causing angle closure via PAS
4. irido lenticular apposition causing posterior synechiae
5. dramatic IOP elevation (40+ mmHg)

Front 9

medical therapy for posterior synechiae

Back 9

dilation or miosis
1. miosis has long been standard of care
2. dilation will also work (atropine)
3. basically anything that will get that sucker loose

Front 10

what are the anatomical features of primary angle closure with pupil block

Back 10

1. small corneal diameter
2. small axial length
3. moderate hyperope
4. thick lens
5. shallower AC depth (75% ACG with AC depth < 1.5mm)

Front 11

DO NOT mistake acute angle closure glaucoma with...

Back 11

UVEITIC GLAUCOMA
1. uveitic glaucoma will have a very active anterior chamber reaction
2. acute angle closure will have a quiet anterior chamber

Front 12

what are the symptoms of acute primary angle closure GLAUCOMA

Back 12

1. entire angle closed
2. vision loss in days
3. NFL damage by 48 hours
4. profound signs and symptoms
5. may result in chronic IOP elevation after breaking attack and alleviating angle closure due to TM damage

Front 13

What is the treatment for Primary Angle Closure Attack?

Back 13

1) Medical therapy
2) LPI
3) Iridoplasty
4) Trabeculectomy

Front 14

What is the treatment for Acute Primary Angle Closure?

What is the goal of this treatment?

Back 14

To relieve Corneal Edema:
1) Glycerin
2) Corneal Indentation

AQS
- Beta Blocker (1 DROP)
- Iopidine or Alphagan (x2)
- CAI - Diamox 500 mg

Pilocarpine 2% (if <40mmHg)
Prostaglandin (may not work fast enough in an acute situation)

Pred Forte Q15min-Q30min

Osmoglyn

Surgical therapy:
LPI
Iridectomy with Trabeculectomy
Argon Laser Iridoplasty

Goal is not to reduce the IOP, but to change the Angle Anatomy. Pressure reduction is merely part of the process.

Front 15

what must be a part of every treatment plan for primary angle closure with pupil block

Back 15

laser peripheral iridotomy is the definitive treatment

Front 16

What is the mechanism for Subacute or Intermittent Angle Closure?

Back 16

1. A partial angle closure that can seen in dim lighting which leads to pupil dilation and block
2. ONH cupping and field loss are often first indications

*not narrow angle glaucoma, angle chronically narrow and occludable

Front 17

What is the correct treatment for Subacute Angle Closure?

Back 17

1. LPI followed by iridoplasty if necessary
2. filtering surgery

*long term medical management not appropriate (allows PAS to form)

Front 18

what is the most common type of primary angle closure

Back 18

CHRONIC (80%)

Front 19

what is the mechanism of CHRONIC primary angle angle closure glaucoma?

Back 19

less pupil block and more creeping angle closure

PAS in superior angle

Front 20

what is the medical therapy for CHRONIC primary angle angle closure glaucoma

Back 20

1. DO GONIO!!
2. iridotomy then filtering surgery if necessary
3. topical medication following iridotomy to control IOP due to chronic trabecular damage
4. prostaglandin analogs work well!!!

Front 21

what is the role of the choroid in angle closure glaucoma

Back 21

1. likely to contribute heavily to ACG
2. choroidal expansion takes up volume
3. leads to forward movement of lens and iris, and AC flattening with ACG
4. change in choroidal vessel permeability leads to choroidal expansion (SCLERITIS)

Front 22

what is the main highlighted drug that causes angle closure glaucoma

Back 22

sulfa based drugs:
TOPIRAMATE (TOPAMAX)

and viagra haha...

Front 23

what is the difference between pupil block and choroidal expansion in acute angle closure

Back 23

PUPIL BLOCK:
1. IRIS BOMBE PRESENT
2. treat with BB, PILOCARPINE, AA, CAI, PGA, tp steroids
3. LPI

CHOROIDAL EXPANSION:
1. flat AC, NO IRIS BOMBE
2. treat with tp steroids, ATROPINE, BB, AA, d/c adverse medication
3. NO LPI

Front 24

what is the difference between iris plateau configuration and syndrome

Back 24

Gonioscopy: (CONFIGURATION)
1. any eye with deep AC and narrow angle due to large last roll of the iris draping forward.
2. displaced ciliary processes, forward rotation

SYNDROME:
the angle remains either closed or potentially closed following LPI

*treat with pilocarpine

Front 25

what are the 7 SECONDARY ANGLE CLOSURE WITH PUPIL BLOCK

Back 25

1. uveitic
2. phacomorphic
3. aphakia
4. vitreous prolapse
5. pseudophakia
6. reverse pupil block with AC lens
7. subluxated lens

Front 26

What is the treatment for Plateau Iris Syndrome?

Back 26

1. Argon Laser Iridoplasty
2. Pilocarpine.

Front 27

What is the mechanism for Ciliary Block Glaucoma?

Back 27

Anterior displacement of the iris and ciliary body which causes misdirection of aqueous into the vitreous and the posterior chamber with anterior displacement of the structure of the eye.

This is most typically occurs following ocular surgery for angle closure glaucoma (Trabecuectomy)

1. disparity in AC depth between eyes
2. MIOTIC will aggravate or cause condition
3. NO LPI

Front 28

What are the two names given for CBG?

Back 28

1. Malignant Glaucoma
2. Aqueous Misdirection Syndrome

Front 29

What is the treatment for Ciliary Block Glaucoma?

Back 29

Best managed with Cycloplege and Steroids:
- Atropine 1% BID
- Topical Steroids
- AQS --> Possible Diamox 1 gram PO QD (dehydrates and shrinks the vitreous
(Eventually everything is tapered but Atropine.)

Surgical options include:
1. Vitrectomy
2. Lensectomy
3. Chandler's Procedure

Front 30

after successful treatment for angle closure glaucoma, the IOP is still high...whats wrong?

Back 30

cause by compromise to the angle structures (TM) from the angle closure

"residual stage of angle closure glaucoma"

Front 31

how would you PROPHYLAX for primary angle closure glaucoma

Back 31

1. LPI for AC < 2.0mm
2. Gonio to identify areas of reversible closure
3. provocative tests

Front 32

what is the mechanism for ICE syndrome

Back 32

1. corneal endothelial cells over-secrete leading to Descemet's membrane migrating and extending over the TM.
2. membrane contraction forms PAS
3. UNILATERAL seen more in WOMEN

Front 33

ICE syndrome: essential iris atrophy

Back 33

1. gonioscopy shows progressive angle closure by PAS
2. pupil displaced towards PAS
3. ectropion uveae, stromal atrophy, and full thickness iris hole formation opposite PAS

Front 34

ICE syndrome: chandlers

Back 34

1. iris normal to mild change
2. corneal edema
3. normal IOP

Front 35

ICE syndrome: Cogan-Reese

Back 35

gonioscopy shows progressive angle closure by PAS except that an iris nevus covers the anterior iris

Front 36

what are THREE secondary glaucomas that are ALWAYS or ALMOST ALWAYS OPEN ANGLED

Back 36

1. Pigmentary
2. Pseudo-exfoliative
3. Steroid induced

Front 37

what is the ONLY secondary glaucoma that is ALWAYS CLOSED ANGLED

Back 37

NEOVASCULAR

Front 38

what are the FOUR secondary glaucomas that has equal prevalence of being open or closed angled

Back 38

1. traumatic
2. lens induced
3. inflammatory
4. miscellaneous causes

Front 39

pigmentary glaucoma is typically seen in what type of patient?

what is a precursor to this disease?

Back 39

OPEN ANGLE:
1. young myopic white male (20-45)
2. can be seen in BLACK FEMALES too (distinctly different appearance)
3. BILATERAL, asymmetric
4. high diurnal fluctuations

pigment dispersion syndrome is a precursor

Front 40

what is the difference between the presentation of pigmentary glaucoma in whites and blacks

Back 40

WHITES:
1. endothelial pigments
2. transillumination defects
3. TM pigments
4. backwards bowing of iris

BLACKS:
1. rare endothelial pigment
2. no transillumination defects
3. HEAVY TM pigment

Front 41

what is SCHEIE LIINE

Back 41

1. pigment on the lens equator
2. was considered diagnostic for PDS/PG
3. certain patterns are more indicative of exfoliation syndrome
4. more common in BLACKS

Front 42

what type of secondary glaucoma will present with IOP spike after exercise and dilation

Back 42

PIGMENTARY GLAUCOMA

Front 43

what are legitimate treatments for pigmentary glaucoma

Back 43

1. BB, AA, CAI, PGA
2. Pilocarpine (not a real option because of the risk for ret detach)
3. argon laser trabeculoplasty (or selective laser)
4. trabeculectomy
5. for PDS f/u Q3-6 months for IOP check due to diurnal fluctuations (DFE and VF also)

Front 44

what is the primary indicator for pseudoexfoliative glaucoma

Back 44

presence of development of peripupillary transilluminations defects (TIDs)

Front 45

what is the mechanism for pseudoexfoliative glaucoma

Back 45

1. and age related abnormal basement membrane deposition from the lens epithelium and other tissues on the anterior lens capsule, and clogging TM.
2. posterior synechiae
3. #1 notable cause of OPEN ANGLE GLAUCOMA

Front 46

PXE glaucoma in comparison to POAG

Back 46

1. PXEG MORE SEVERE!!
2. more medication and surgery required for PXEG
3. PXEG one of the worse glaucomas to encounter regularly in clinic
4. PXEG easily missed w/o a dilation

Front 47

management of PXEG

Back 47

1. BB, AA, CAI, PGA
2. ALT/SLT
3. trabeculectomy

Front 48

what is very diagnostic for PXEG

Back 48

1. IOP rise after dilation due to pigment liberation

*highest IOP typically outside office hours

Front 49

transillumination defects for pigmentary glaucoma vs. PXEG

Back 49

pigmentary glaucoma:
1. mid periphery

PXEG:
1. peri-pupillary
2. pt. with radial oriented pigment on the anterior lens, pigment liberation with dilation (with or w/o IOP spike) and peripupillary TIDs can be considered exfoliation suspects

Front 50

what is the #1 cause of unilateral glaucoma

Back 50

ANGLE RECESSION

gonioscopy must be done on both eyes to compare

Front 51

hyphema management

Back 51

1. bed rest at 30 deg incline (with bathroom privileges only)
2. atropine
3. pred forte q1h
4. aq. suppressers

AVOID:
1. PGA
2. MIOTICS
3. ASPIRIN (blood thinners)

Front 52

angle recession management

Back 52

1. monitor IOP and disc, glaucoma can develop years after trauma
2. BB, CAI, AA, PGA
3. trabeculectomy
4. POAG more common in fellow uninjured eye

DOESNT WORK WELL:
1. miotics due to TM change
2. ALT/SLT, poor response if recession > 180

Front 53

steroid induced glaucoma management

Back 53

1. d/c steroids (after prolonged use, IOP may not lower with medication cessation)
2. BB, AA, CAI, PGA
3. trabeculoplasty (poor)
4. trabeculectomy (better)

Front 54

what percentage of the population will respond to steroids with IOP spike

what demographic is most significant

Back 54

1. 66%
2. 2-5 week for IOP spike to become apparent
3. <10% of population ever become a significant problem
4. MOST SIGNIFICANT IN KIDS, ELDERLY and POAG PTS.

Front 55

what is photocoagulation

Back 55

1. laser is focused on pigmented tissue (melanin dependent) and absorbed, converted to heat
2. photocoagulatin occurs when tissue is warmed by 10-20 degrees.
3. blood coagulation and inflammation serves to create desired scarring and adhesions
4. warms collagen stimulating it to contract
5. tissue atrophy arises surrounding each photocoagulation scar

Front 56

what is photovaporization

Back 56

1. dependent upon light absorption by pigment
2. heated by 60-100 degrees
3. more powerful and short burst of light
4. ONLY desirable in thermal iridotomies
5. UNDESIRABLE in thermal laser photocoagulations

Front 57

what is photodisruption

Back 57

1. non pigment dependent
2. CONSIDERED NON THERMAL
3. infrared spectrum
4. highly localized instantaneous temperature rise (15000C)
5. ionization of tissue occurs
6. coagulation DOES NOT OCCUR
7. Nd:YAG capsulotomies and iridotomies

Front 58

complications associated with anterior segment laser procedures

Back 58

1. elevation of IOP from intraocular inflammation (pre and post op. glaucoma medication)
2. corneal burns (edematous or shallow corneals)
3. ret. detach and intraocular hemorrhage (mostly cold lasers)

Front 59

what is argon laser trabeculoplasty?

what are the indications?

Back 59

thermal laser alteration of the TM to increase aq outflow

1. PXEG
2. pigmentary glaucoma
3. POAG
4. non-compliance with meds
5. inadequate medical controls

Front 60

what are the theories for the pressure lowering mechanism of ALT

Back 60

1. laser burns causes stretching of TM causing pores
2. burns attract phagocytes that clean up debris in TM improving flow
3. destroys endothelial cells stimulating the production of new, more viable cells

ALT will fail over time and retreatment generally not beneficial

Front 61

whats the difference between SLT and ALT

Back 61

ALT:
1. mechanical alterations, due to collateral thermal effects

SLT:
1. no apparent tissue alterations, due to lack of such thermal effects
2. can be performed more than once (most of the time only once)
3. obliterated macrophages leaves the non-pigmented lining TM cells intact

Front 62

what are the laser therapies for closed angle glaucoma

Back 62

1. argon laser iridoplasty
2. laser peripheral iridotomy
3. argon laser LPI
4. Nd:YAG laser LPI
5. trabeculectomy
6. antimetabolites

Front 63

what are the indications for LPI

Back 63

1. angle closure with pupil block
2. prophylaxis in narrow, occluded angles

*allowing flow between the anterior and posterior chamber, relieving pupil block

Front 64

indication for ALT

Back 64

1. irido-retraction procedure
2. breaking attack of acute angle closure (phacomorphic glaucoma and plateau iris syndrome)

Front 65

what is the difference between argon LPI and Nd:YAG

Back 65

Argon Laser LPI:
1. photocoagulation leading to photovaporization
2. unlikely to bleed
3. less likely to disrupt lens and vitreous
4. difficult to penetrate iris
5. pigment dependent (CONTRAINDICATED IN BLUE IRIS)
6. morely like to close in time

Nd:YAG
1. photodisruption
2. more likely to bleed
3. more likely to disrupt lens and vitreous
4. much easier to penetrate iris
5. less likely to close in time
6. pigment INDEPENDENT (CAN BE USED IN BLUE IRIS)

Front 66

comparison between post surgical trabeculectomy vs. malignant glaucoma

Back 66

post trabeculectomy:
1. shallow chamber
2. low IOP
3. indicates overfiltration or bleb leakage

malignant glaucoma:
1. shallowing chamber
2. rising IOP

Front 67

what are considerations for surgery

Back 67

1. maximal medical and progression
2. poor patient compliance with medications
3. failure or contraindication of LT
4. need for very low IOP

Front 68

what are signs of surgical failures

Back 68

1. hypotony from wound leaks and over secretions
2. shallow anterior chamber with low IOP
3. residual elevated IOP
4. bleb encapsulation
5. overfiltrations
6. ciliochoroidal detachment
7. cyclodialysis

Front 69

what are antimetabolites used for in trabeculectomy

Back 69

1. inhibits fibroblasts preventing scarring after surgery
2. mitomycin and 5-fluorouracil

Front 70

procedure of trabeculectomy

Back 70

1. creates fistula through the TM and creates a communication between the anterior chamber and subconjunctival space
2. creates anther channel for aqueous to exit the chamber
3. iridectomy is also performed so that the iris doesnt block and adhere to the surgical filter

Front 71

what are the characteristics of CONGENITAL/INFANTILE glaucoma

Back 71

1. ABNORMAL angle
2. LARGE globe
3. corneal EDEMA
4. onset near birth
5. MEGALOCORNEA
6. symptomatic (blepharospasm, photophobia, lacrimation)

Front 72

what are the characteristics of Juvenile Open Angle/Secondary glaucoma

Back 72

1. NORMAL angle
2. NORMAL axial length
3. CLEAR cornea
4. onset LATER
5. NORMAL corneal size
6. ASYMPTOMATIC

Front 73

what is important in detection of glaucoma in children

Back 73

1. IOP does not have to be high in a child for glaucoma to develop.
2. 20+ mmHg IOP in a child in concerning
3. ALWAYS DO TONOMETRY

Front 74

medical therapy for kids with glaucoma?

what is good to use?
what shouldnt be used?

Back 74

GOOD TO USE:
1. CAI (drug of choice)
2. beta blockers

NOT SO GREAT:
1. PGA (not effective, BEST in JOAG >15yrs old)
2. DONT USE BRIMONIDINE!!!

Front 75

what is the classic triad of congenital glaucoma

Back 75

1. epiphora
2. photophobia
3. blepharospasm

Front 76

what are surgical options for congenital glaucoma

Back 76

1. goniotomy
2. trabeculotomy
3. viscocanalostomy
4. filtering surgery
5. cyclocryotherapy
6. YAG cyclophotocoagulation
7. diode laser photoablation

Front 77

NOTE:
any childhood glaucoma caused by TRABECULODYSGENESIS is considered PRIMARY CONGENITAL GLAUCOMA

a child with glaucoma but WITHOUT angle abnormalities has JOAG

Back 77

NOTE:
any childhood glaucoma caused by TRABECULODYSGENESIS is considered PRIMARY CONGENITAL GLAUCOMA

a child with glaucoma but WITHOUT angle abnormalities has JOAG

Front 78

trend analysis

Back 78

1. looks at significance of rate of change over time
2. identifies progression by looking at patient behavior over time
3. uses all data points and a linear regression formula

weakness: progressioni is not necessarily linear

Front 79

event analysis

Back 79

1. compares baseline to most recent data
2. change as dictated by criteria has occurred or not

Front 80

mechanism for steroid responders

Back 80

accumulation of GAGs in the TM

Front 81

what are the TWO anti VEGF drugs?

Back 81

Avastin
Lucentis

Front 82

phacolytic mechanism?

Back 82

1. hypermature cataract leaks proteins into AC
2. bloated macrophages with lens material in TM
3. outflow blockage

Front 83

phacolytic management

Back 83

1. pred forte
2. atropine
3. BB, AA, CAI

AVOID PGA and PILOCARPINE!!!

Front 84

phacomorphic mechanism?

Back 84

1. unilateral
2. increasing lens thickness causes irido-lenticular apposition
3. pupil block and posterior chamber pressure increase
4. iris bombe
5. ANGLE CLOSURE/PAS

Front 85

neovascular mechanism?
mostly likely caused by...

Back 85

most likely caused by...
1. central retinal vein occlusion
2. diabetic retinopathy
3. carotid artery disease

1. hypoxia
2. rubeosis
3. angle neovascularization
4. SECONDARY ANGLE CLOSURE W/O PUPIL BLOCK

Front 86

neovascular manangement

Back 86

1. atropine
2. pred forte
3. Avastin/Lucentis

overal poor prognosis

Front 87

a person 60+ yrs old comes in with rubeosis and neovascularization...what must you get on the patient

Back 87

1. ESR
2. C-reactive protein

Front 88

DIAGNOSIS and TREATMENT of glaucoma associated with elevated episcleral venous pressure

Back 88

Dx: BLOOD in Schlemm's Canal in gonio

Tx: PGA!!!

Front 89

pt comes in with unilateral and ipsolateral IOP elevation, you should think THREE causes

Back 89

1. acute angle closure
2. uveitic glaucoma
3. low-flow carotid cavernous fistula

Front 90

how do you break a stubborn posterior synchiae

best treatment for uveitic glaucoma

Back 90

10% phenylephrine

1. steroids
2. cycloplegia
3. CAI's

Front 91

what medications should you avoid in uveitic glaucoma

Back 91

1. MIOTICS
2. PGA

Front 92

what are the FOUR unilateral glaucomas

Back 92

1. glaucomatocyclitic crisis (GCC)
2. phacomorphic
3. angle recession
4. increased episcleral venous pressure

Front 93

cloudy cornea...cant look through it to do gonio.

what do you do?

Back 93

1. Osmoglyn
2. Isosorbide FOR DIABETICS!!
3. Glycerin

LOOK AT OTHER EYE!!

Front 94

what FOUR conditions do you use MIOTICS

Back 94

1. phacomorphic
2. acute primary angle closure
3. acute angle closure with pupil block
4. Plateau Iris Syndrome (primary angle closure w/o pupil block)

Front 95

what are the SIX conditions do you DILATE

Back 95

1. hyphema
2. phacolytic
3. neovascular
4. uveitic
5. acute angle closure secondary to choroidal expansion
6. ciliary block glaucoma