2 - Caudill Flashcards
LPI
-main indication
Any form of angle-closure glaucoma that has a pupillary block component
LPI
-iris bombe
-pupillary block
—2 classifications
Bowing forward of iris -> closed angle
-iris has not moved, but is bulged forward (compared to malignant glaucoma)
Restriction of aqueous flow from PC to AC
PB classifications
- relative = functional/partial restriction, most common
- absolute = post synechia completely binds iris
LPI
-conditions that are indications (5)
Acute angle closure glaucoma (AACG)
Malignant glaucoma
PDS and PDG
-G if nerve damage/optic neuropathy
Phacomorphic glaucoma = change in the shape of the lens - concavity incr -> iris bombe, etc.
Eyes with occludable angles
- “occludable” = narrow enough that it’s most likely occludable -> LPI
- “narrow” = not necessarily enough for LPI to be needed
Acute angle closure glaucoma (AACG)
-describe
Urgent, uncommon, dramatic symptomatic event
Blurring of vision, painful red eye, HA, nausea, vomiting
High IOP, corneal edema, shallow AC, closed angle on gonio
Acute angle closure glaucoma (AACG)
-hx and exam
HA, nausea, vomiting, reduced VA, red eye, extreme IOP, corneal edema
Risk factors (hyperopia, thick cataractous lens, etc.) Halos Aching eye/brow pain Engorged conj vessels Fixed dilated pupils
Occludable angles
- describe narrow angle
- probable vs likely
May watch and consider other risk factors for development of glaucoma
- intermittent IOP spikes -> HA/brow ache
- intermittent eye pain
Probable <20 degrees
Likely <10 degrees
Malignant glaucoma
-describe
After ANY type of surgery
AC becomes shallow/flattened and IOP elevated
AH is forced backward into vitrous by CB apposition to lens and/or vitreous
Malignant glaucoma
-treatment
Vitrectomy
- LPI is unsuccessful
- ant seg OCT is very valuable
Plateau iris configuration/syndrome
-difference
IOP
- C = anatomical
- S = incr IOP
Plateau iris
-sign to look for during exam
Double hump pattern on indentation gonio
-anteriorly displaced CB
-use 4 mirror = small contact surface
—do not use 3 mirror
Plateau iris
-PDS and PDG are indicative of what tx
LPI - if iris bowing is present
-iris is bowed backwards (opposite of bombe) and rubbing against the lens, but LPI will still equalize the pressure in AC/PC
Gonio angle grading systems
-describe Shaffer
Degrees
-e.g. 20 degrees is narrow, 45 is wide open
Gonio angle grading systems
-Spaeth includes (4)
Location of insertion of iris (A thru E)
Angle formed with Schwalbe’s (cornea)
Iris configuration (e.g. F = flat, B = bowed forward, etc.)
Pigment level (1 thru 4)
LPI procedure
- work-up (3)
- pre-op (7)
Comprehensive exam, dx, DFE
VA, IOP, med/allergy check, vitals Alphagan (Brimonidine) -iopidine is an older, more expensive drug Pilocarpine 1% Informed consent
LPI procedure
- vitals (4)
- laser lens options
BP, temp, pulse, oximetry
Abraham 66D most common
Wise 103D also used, easy to get lost
LPI procedure
-why use a lens (6)
Magnifies with good depth of field
Concentrates energy
Speculum
Heat sink to minimize K damage
Control eye
Focus energy = less to retina
LPI procedure
-lasers (2)
Nd:YAG 1064
-initial setting 3-6mJ
Argon or green diode
- initial setting 600mW
- green = thermal
LPI procedure
-thermal or YAG or both
Thermal = argon, green diode
- reduces risk of bleeding
- may require more energy
YAG
-generally most accepted method, esp for light eyes
Some advocate pre-tx with thermal, finish with YAG
-esp for dark irides
LPI procedure -tx locations —conventional wisdom —paradigm shift —none here —size
11 or 1 o’clock
3 or 9 o’clock
-trying to reduce stray light
12 o’clock
-bubbles
~1.5mm
LPI procedure -complications —hemorrhages - what do you do —IOP spike - when most occur, what to do —transient uveitis
Push - gentle pressure for a few seconds to tamponade
IOP spikes: 25% of cases in first 3 hours of >10mmHg
-most are transient, respond to topical meds
Mild uveitis occurs in virtually 100% of pts, responds well to topical steroids
LPI procedure
-complications
—diplopia/glare
—iridotomy closure
Placement crucial
Specialty contacts with opaque periphery in very rare cases
Confirmation of patency can be challenging
-important to see plume when performing sx
LPI procedure
-post-op care (3)
Check IOP ~1 hr after
Topical pred acetate 1% QID
Recheck 5-7 days (global period 10 days)
Iridoplasty
-describe
Uses thermal (green) laser to pull iris away from TM
Rarely performed
Most useful in plateau iris
Multiple burns placed concentrically close to iris insertion
-more burns = more contraction
