Glaucoma

Prof. Dr. Tehseen Sahi Chairman Department of Ophhalmology: KEMU

Aqueous flow

Ciliary epithelium

Posterior chamber through pupil Anterior chamber

Trabecular meshwork

Canal of schlemn Aqueous veins venous circulation

Aqueous flow

Angle of anterior chamber

Ir is process

Scleral spur

Schlemn canal

Trabeculum

Schwalbe l ine

Sites of Obstruction

Primary glaucoma Pupil block (angle closure) Open angle

Primary glaucomas Pupil block Person

Young Female Idealistic High strung

Open angle Person

ordinary

Primary glaucomas Pupil block Eye

Small Hypermetropic Shallow AC Angle narrow

Open angle Eye

Average

Presentation Pupil block

ACUTE SUDDEN, MARKED

PAIN LOSS OF VISION CONGESTION GENERAL EFFECTS

Open angle SLOW GRADUAL

TREATMENT Pupil block

SURGICAL

Open angle

MEDICAL

PROGNOSIS Pupil block

VERY GOOD

Open angle

RELATIVELY POOR

Pupil Block GlaucomaMECHANISM OF ATTACK(Mid-Dilated Pupil)

Increase in physiological pupil blockIncrease in physiological pupil block

Pupil Block GlaucomaMECHANISM OF ATTACK(Mid-Dilated Pupil)

Dilatation of pupil renders peripheral iris more flaccid

Increased pressure in posterior chamber causes iris bombe

Pupil Block GlaucomaMECHANISM OF ATTACK(Mid-Dilated Pupil)

Angle obstructed by peripheral iris and rise in IOP

Pupil block glaucoma

Pupil block glaucoma Stages

Prodromal stage Stage of constant instability Acute congestive glaucoma Ch. Congestive glaucoma Absolute glaucoma

Constricted Pupil

Area of contact ……. More Force of contact …… Less

Dilated

No Contact No Force

Mid Dilated Pupil

Area of Contact …….. Less Force of Contact …….. More

Pupil block glaucoma(Mid Dilated Pupil) Prodromal stage (mechanism)

Tense person sitting in dark area

Pupil mid-dilated

Firm Contact between Loose Iris iris and lens.

Pupil Block

Iris bombe

Angle closure

Increased I.O.P

Mid Dilated Pupil

Area of Contact …….. Less Force of Contact …….. More

Pupil Block GlaucomaMECHANISM OF ATTACK(Mid-Dilated Pupil)

Increase in physiological pupil blockIncrease in physiological pupil block

Pupil Block GlaucomaMECHANISM OF ATTACK(Mid-Dilated Pupil)

Dilatation of pupil renders peripheral iris more flaccid

Increased pressure in posterior chamber causes iris bombe

Pupil Block GlaucomaMECHANISM OF ATTACK(Mid-Dilated Pupil)

Angle obstructed by peripheral iris and rise in IOP

Pupil block glaucoma Prodromal stage

Features Mild headache Colored haloes

Pupil block glaucoma Prodromal stage

Patient comes to bright light or goes to sleep

Pupil constricts

Attack finished

Pupil block glaucoma Stage of constant Instability

Prodromal attacks

More frequent More prolonged

Mechanism same.

Mid Dilated Pupil

Area of Contact …….. Less Force of Contact …….. More

Pupil Block GlaucomaMECHANISM OF ATTACK(Mid-Dilated Pupil)

Increase in physiological pupil blockIncrease in physiological pupil block

Pupil Block GlaucomaMECHANISM OF ATTACK(Mid-Dilated Pupil)

Dilatation of pupil renders peripheral iris more flaccid

Increased pressure in posterior chamber causes iris bombe

Pupil Block GlaucomaMECHANISM OF ATTACK(Mid-Dilated Pupil)

Angle obstructed by peripheral iris and rise in IOP

Pupil block glaucoma Acute congestive glaucoma

Mechanism same Attack cannot be abolished spontaneously Features

Acute ,marked pain Redness Loss of vision

Mid Dilated Pupil

Area of Contact …….. Less Force of Contact …….. More

Pupil Block GlaucomaMECHANISM OF ATTACK(Mid-Dilated Pupil)

Increase in physiological pupil blockIncrease in physiological pupil block

Pupil Block GlaucomaMECHANISM OF ATTACK(Mid-Dilated Pupil)

Dilatation of pupil renders peripheral iris more flaccid

Increased pressure in posterior chamber causes iris bombe

Pupil Block GlaucomaMECHANISM OF ATTACK(Mid-Dilated Pupil)

Angle obstructed by peripheral iris and rise in IOP

Pupil block glaucoma Acute congestive glaucoma

Signs Lid swelling Ciliary congestion Corneal edema Shallow AC Angle closed Very high I.O.P Pupil dilated and oval

Pupil block glaucoma

Severe corneal edema

Dilated, un-reactive, vertically oval pupil

Pupil block glaucoma Ch. Congestive glaucoma

Angle …peripheral anterior Synechiae Symptoms and signs Dec. severity

Pupil block glaucoma Absolute glaucoma

Management Stage I (prodromal attacks)

Surgical Iridotomy (laser) Iridectomy

laser iridotomy

Management prodromal attack Medical

PILOCARPINE eyedrops

Mangement Stage of constant Instability

Same as prodromal attack

Managemant Acute congestive stage

(a) Early Control of I.O.P by medical means Then perform iridectomy/iridotomy

(b) similar to stage 4

Management Acute congestive glaucoma

Medical control of I.O.P1. pilocarpine constrict pupil mid-dilated position changes

Force of contact b/w iris tightsPupil and lens decrease

pupil block finished

control of I.O.P

Management Acute congestive glaucoma 2)Carbonic anhydrase inhibitors

(acetazolamide) CO2 + H2O H2CO3

H + HCO3

Inhibition HCO3 ions Aq.production

Management Acute congestive glaucoma 3) Osmotic Agents I.S Intravascular H2O I.S

Osmotic pressure Hydrostatic pressure Osmotic pressure

I.S pressure osmotic Pressure I.S pressure

Management Acute congestive glaucoma Agents

Oral Pure glycerine Alcohol

Intravenous Mannitol 20% urea

Management Ch. Congestive glaucoma

Control of I.O.P by medical means Perform filtration operations