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C.EyeMD > CG.laucoma > Flashcards

CG.laucoma Flashcards

1
Q

Goal of glaucoma therapy

A

To preserve visual function by lowering IOP below a level that is likely to produce further damage to the nerve

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2
Q

Classes of ocular hypotensive agents

A

Prostaglandin analogues, B-adrenergic antagonists, parasympathetics, CAI’s, adrenergic agonists, hyperosmotic agents, combination medications

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3
Q

Drug groups that decrease aqueous production

A

CAI, alpha agonist, beta-blocker (CAB)

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4
Q

Drug groups that increase outflow

A

PGA, alpha agonist, miotics (PAM)

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5
Q

MOA of prostaglandin analogues

A

Increase uveoscleral outflow

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6
Q

Ocular side effects of prostaglandin analogs

A

PERMANENT - darkening of iris and periocular skin (via inc melanosomes within melanocytes), REVERSIBLE - conjunctival hyperemia, hypertrichosis, trichiasis, distichiasis, hair growth around eyes; OTHERS - exacerbation of HSK, CME, Uveitis

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7
Q

Which of the prostaglandin analogues are prodrugs?

A

Latanoprost and Travaprost

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8
Q

True or false

Prostaglandin analogues work via pressure dependent and pressure independent mechanisms

A

True

Prostaglandin analogues work via pressure dependent and pressure independent mechanisms

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9
Q

How do prostaglandins increase uveoscleral outflow?

A

Increase in spaces between muscle fascicles w/in CB –> Increase in US outflow

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10
Q

For prostaglandin analogue users, there is least eye color change in those with ____ colored eyes

A

Blue

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11
Q

Which prostaglandin analogues present with hyperemia more commonly?

A

Bimatoprost, travoprost

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12
Q

Peak concentrations of prostaglandin analogues are seen after ___ hours of administration

A

10-14

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13
Q

MOA of beta-antagonists

A

Decrease IOP by inhibition of cAMP in ciliary epithelium; within 1 hour there is a decrease in aqueous production. Can also decrease IOP in other eye due to systemic absorption.

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14
Q

Washout period of B-blockers

A

4 weeks

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15
Q

Why is it important to give an early dose of B-blockers?

A

to block early morning IOP increase

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16
Q

Best partner for B-blocker

A

a-agonist

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17
Q

Decreased effectiveness of B-blockers over time is due to:

A

Short term escape due to receptor saturation

tachyphylaxis/long term drift

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18
Q

Difference of betaxolol versus other B blockers

A

Others are nonselective B1 and B2. Betaxolol is B1 only. But it is less effective.

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19
Q

What to WOF for thyroid patients who are going to discontinue b-blockers?

A

Abrupt withdrawal may exacerbate hyperthyroid symptoms

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20
Q

Ocular side effects of B-blockers

A

BOV, irritation, anesthesia, punctate keratitis, allergy

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21
Q

Systemic side effects of B-blockers

A

bronchospasm, bradycardia, heart block, dec BP, exercise intolerance, CNS depression, masking of DM symptoms

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22
Q

Contraindications for use of B-blockers

A

asthma, MG, heart block

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23
Q

MOA of parasympathomimetic agents

A

Increase outflow by contraction of longitudinal muscle of ciliary body which pulls on the SS to tighten the TM

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24
Q

Examples of Direct-Acting and Indirect-Acting parasympathomimetic

A

Direct-acting: Pilocarpine, acts on motor end plate
Indirect-acting: Echothiopate iodide, anti-ACTHase
Both: Carbachol

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25
Q

Ocular side effects of parasympathomimetcs

A

PS, keratitis, miosls, brow ache, paradoxic angle closure, myopia, RD, dermatitis (drug induced pseudopemphigoid), change in retinal sensitivity and color vision changes

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26
Q

Contraindication for use of parasympathomimetics

A

Use of depolarizing agents (succinylcholine)

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27
Q

Systemic side effects of parasympathomimetics

A

DUMBELS

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28
Q

MOA of CAI’s

A

Decrease aqueous formation by direct antagonist activity on ciliary epithelial carbonic anhydrase by production of acidosis

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29
Q

True or false

ACTZ is metabolized then excreted in the urine.
Methazolamide is metabolized in the kidney.

A

FALSE

ACTZ is not metabolized then excreted in the urine.
Methazolamide is metabolized in the liver.

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30
Q

Peak effect of CAI’s reached in:

A

2-4 h

or 3 hours for 3 letters

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31
Q

Dose-related side effects of oral CAI

A

paresthesia, bitter taste, renal stones, hypoK, thrombocytopenia, agranulocytosis

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32
Q

Side effects of topical CAI

A

bitter taste, BOV, punctate keratopathy, corneal decompensation

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33
Q

MOA of non-selective adrenergic agonists

A

Increase trabecular and uveoscleral outflow; stimulation of prostaglandin synthesis influenced by epinephrine

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34
Q

Example of a mixed a and b agonist with variable IOP lowering effect

A

Epinephrine

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35
Q

A prodrug with greater corneal penetration than epinephrine

A

Dipivefrin

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36
Q

Ocular SE of non-selective adrenergic agonists

A

Adenochrome deposits, pupillary dilation, vasoconstriction, lid retraction, allergic blepharoconjunctivitis, CME, rebound conjunctival hyperemia

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37
Q

Systemic SE of adrenergic agonists

A

Headache, inc BP, tachycardia, arrhythmia, nervousness

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38
Q

Effects of a2 agonists on the eye

A

IOP reduction, neuroprotection

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39
Q

MOA of apraclonidine

A

Prevents release of norepinephrine at nerve terminals, decreasing aqueous production and episcleral venous pressure; increases TRABECULAR outflow

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40
Q

What limits long-term use of apraclonidine?

A

Topical sensitivity and tachyphylaxis

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41
Q

MOA of brimonidine

A

Increase UVEOSCLERAL outflow, decreases aqueous production

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42
Q

When is the peak concentration of brimonidine achieved?

A

at 2 hours post dose

a2 at 2 hours

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43
Q

Brimonidine may cause an adverse reaction in patients taking ____ and ____ antidepressants

A

MAOI and TCA

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44
Q

Parts of body where carbonic anhydrase is present:

A

Corneal endothelium, iris, RPE, RBC, brain, kidney

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45
Q

Percent of enzyme activity needed to abolish to lower IOP

A

90%

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46
Q

Type of CAI that causes transient blurring

A

DORZOlamide

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47
Q

Type of CAI that causes white deposits

A

BRINZOlamide

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48
Q

Difference of methazolamide and ACTZ

A

methazolamide has a longer duration, is less protein bound and is less effective

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49
Q

Dangerous SE of oral ACTZ

A

aplastic anemia, thrombocytopenia, agranulocytosis, hypokalemia

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50
Q

Ocular SE of a2-agonists

A

follicular conjunctivitis, contact blepharitis, dermatitis

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51
Q

Systemic SE of a2-agonists

A

dry mouth, lethargy, derangements of neurotransmitters in CNS

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52
Q

Age group that should not receive brimonidine

A

Infants and children

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53
Q

Mechanism of hyperosmotic agents

A

increases blood osmolality and produces an osmotic gradient between the blood and vitreous, drawing water from vitreous

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54
Q

Examples of hyperosmotic agents

A

Oral: Glycerin
IV: mannitol

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55
Q

Ocular SE of hyperosmotic agents

A

Rebound increase in IOP if the agents penetrate the eye and reverses the osmotic gradient

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56
Q

Systemic SE of hyperosmotic agents

A

headache, mental confusion, backache, acute CHF, MI, glycerin may cause hyperglycemia and ketoacidosis in patients with DM

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57
Q

Contraindication of hyperosmotic agents

A

renal failure

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58
Q

Types of surgical management for glaucoma

A

Laser

Incisional

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59
Q

Surgical options for OAG

A

laser trabeculoplasty

fistulizing procedures

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60
Q

Indication for miotic therapy

A

Long term treatment of patients with high IOP whose drainage angles are persistently occludable despite LI; prophylaxis for ACG prior to iridectomy

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61
Q

Types of LTP

A

Argon
Diode
Selective

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62
Q

Laser energy is applied to TM in discrete spots

A

Laser trabeculoplasty

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63
Q

IOP % lowered by LTP

A

20-25%

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64
Q

Mechanism of IOP lowering by LTP

A

increases outflow by shrinkage of TM and stretching of adjacent areas; production of chemical mediators (IL-1B and TNF-a) -> induction of MMP

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65
Q

Full effect of LTP achieved in:

A

4-6 weeks for full effect

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66
Q

True or false

Retreatment of LTP yields lower success and higher complication rates

A

True

Retreatment of LTP yields lower success and higher complication rates

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67
Q

Indications of LTP

A

PPP

POAG
Pigmentary glau
PEX/EX

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68
Q

Contraindications of LTP

A 
Inflammatory glau
ICE
NVG
Synechial ACG
Developmental glau
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69
Q

Complications of LTP

A

Transient/persistent IOP rise
Low-grade iritis
Hyphema
PAS formation

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70
Q

Settings of ___

Spot size: 50 um, 40-50 shots
Duration: 0.1 second
Power: 300-1000 mW
Target area: Junction of ATM and PTM, <180 treated
Endpoint: Blanching of TM/tiny bubble
A

ALT

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71
Q

Settings of ___

Spot size: 300 um
Duration:0.3 ns
Power: 0.4-0.1 mJ
Target area: Intraceullular melanin
Endpoint: Blanching of TM/tiny bubble
A

SLT

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72
Q

Settings of ___

Spot size: 75 um
Duration: 0.1 second
Power: 600-1000 mW
Endpoint: Blanching of TM/tiny bubble/POPPING SOUND

A

DIODE

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73
Q

Advantages of SLT

A

Less coagulative damage

Fewer structural changes of TM

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74
Q

Goal of fistulizing procedures

A

to create new path for the bulk flow of aqueous humor from AC through a surgical defect in the sclera into the subconjunctival and subtenon space

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75
Q

A guarded partial-thickness filtering procedure.
Better outcomes with use of antifibrotic agents (MMC and 5FU)
Goal: to complete healing of epithelial and conjunctival wound; incomplete healing of the scleral wound.

A

Trabeculectomy

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76
Q

MCC of decreased VA post op

A

Cataract, hypotony maculopathy, CME

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77
Q

Considered when a patient whose ON function is failing or is likely to fail while on max tolerated medical therapy and is not likely to achieve sufficient IOP reduction with laser

A

Trabeculectomy

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78
Q

A block of peripheral corneal tissue beneath a scleral flap is removed. The scleral flap provides resistance and limits the aqueous flow.

A

Trabeculectomy

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79
Q

Contraindications of trabeculectomy

A 
blind eye
rubeosis iridis
active iritis - consider shunt
extensive conjunctival injury
thin sclera
necrotizing scleritis
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80
Q

Early complications of trabeculectomy

A 
Infection
Hypotony
shallow/flat AC
aqueous misdirection
hyphema
cataract
transient increase in IOP
CME
hypotony maculopathy
choroidal effusion
suprachoroidal hemorrhage
dellen formation
persistent uveitis
loss of vision
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81
Q

Late complications of trabeculectomy

A 
Bleb leakage/failure
cataract
blebitis
endophthalmitis/bleb infection
bleb migration
hypotony
ptosis
lid retraction
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82
Q

Contraindications of use of glycerol

A

hyperglycemia

ketoacidosis

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83
Q

ocular hypotensive drug class with best systemic profile

A

prostaglandin analogues

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84
Q

Contributory factors for progression of POAG

A

IOP spikes, thin CCT, sleep apnea, concomitant angle closure, compliance

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85
Q

The only category B drug for glaucoma

A

brimonidine

avoid timolol in nursing

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86
Q

surgical options for angle closure glaucoma

A 
laser iridectomy
laser gonioplasty/peripheral iridoplasty
incisional surgery
GDD
ciliary body ablation
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87
Q

Indications for LI

A 
PACS (relative) - need for repeated IO, poor access to care, FMHx of PACG
PACS (absolute) - PAC in fellow eye
PAC with significant pupillary block
PACG with significant pupillary block
ACG
Combined mechanism glaucoma
imperforate SI
suspected malignant glau
pupillary block after cataract operation
nanophthalmos
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88
Q

True or false

LI is useful also for eyes with complete synechial closure as a result of NV or chronic inflammation

A

False

NOT useful

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89
Q

Mechanism of argon laser vs Nd:YAG laser

A

Argon laser - Coagulative; ARGregate;

Nd:YAG laser - Disruptive

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90
Q

Complications of argon laser

A 
early closure of iridectomy
localized lens opacity
acute IOP rise
transient or persistent iritis
posterior synechiae
corneal and retinal burns
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91
Q

Complications of Nd:YAG laser

A 
bleeding
corneal burns
disruption of lens capsule/corneal endothelium
IOP rise
inflammation
delayed closure
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92
Q

Technique to deepen angle; Uses argon laser to induce stromal burns in the peripheral iris that cause contraction, flattening and thinning of the peripheral iris

A

Laser gonioplasty

Peripheral iridoplasty

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93
Q

Indication of PIR

A

plateau iris

nanophthalmos

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94
Q

Required if a patent iridectomy is not achieved with laser due to a hazy cornea, flat AC or uncooperative patient

A

PIR

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95
Q

Chamber deepening procedure where viscoelastic agent or cyclodialysis spatula is used to break synechiae

A

Goniosynechiolysis

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96
Q

Option for a patient with pupillary block and a visually significant cataract

A

LE

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97
Q

Two methods of ciliary body ablation

A

cyclocryotherapy

thermal laser - Nd:YAG, argon, diode

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98
Q

Reduction of aqueous secretion brought about by destruction of a part of the ciliary body

A

Ciliary body ablation

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99
Q

Indications of ciliary body ablation

A

Eyes with poor visual potential

Painful blind eye

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100
Q

Options for PCG

A

Goniotomy

Trabeculotomy

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101
Q

Needle-knife passed acrross AC, a superficial incision is made in the anterior aspect of the TM under gonioscopy control; requisite - clear cornea

A

Goniotomy

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102
Q

Fine wirelike instrument inserted into Schlemm’s canal from an external incision and rotated into the AC, tearing the TM; useful if cornea is too cloudy

A

trabeculotomy

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103
Q

Developmental glaucoma with congenital anomaly of the filtration angle

A

primary pediatric glaucoma

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104
Q

True or false

Sturge-Weber syndrome is both a primary and a secondary pediatric type of glaucoma

A

True

Sturge-Weber syndrome is both a primary and a secondary type of glaucoma

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105
Q

Heterogeneous group of disorders that result in elevated IOP and subsequent ON damage.

A

Childhood glaucoma

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106
Q

Types of primary pediatric glaucoma

A

congenital OAG
JOAG
glaucoma associated with systemic diseases
glaucoma associated with other ocular anomalies

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107
Q

Examples of secondary pediatric glaucomas

A

trauma, neoplasms, inflammation, lens-induced, surgical, angle closure, infection, NV, steroids, elevated episdcleral venous pressure

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108
Q

Definition of primary pediatric glaucoma

A

Developmental glaucoma with congenital anomalies of the filtration angle

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109
Q

Classic features of primary congenital glaucoma

A

Enlarged/cloudy cornea
Haab striae
Elevated IOP

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110
Q

Subclassification of PCG

A

At birth or before 1mo - NB
w/in first 2yrs of life - Infantile
After age 2 - late diagnosed PCG

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111
Q

Systemic diseases associated with Primary Pediatric glaucoma

A

Chromosomal conditions, connective tissue disease (Marfan, Stickler), phakomatosis, aniridia/Peter’s anomaly

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112
Q

Definition:

Due to dysplasia of the AC angle
Decreased aqueous outflow
No other ocular or systemic abnormalities or diseases that can raise IOP
Sporadic but may be recessive

A

Primary congenital/infantile glaucoma

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113
Q

Associated with other ocular/systemic congenital, inflammatory, neoplastic, hamartomatous or metabolic anomalies

A

Secondary infantile glaucoma

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114
Q

Genetic loci and genes involved in primary pediatric glaucoma

A

Loci:
GLC 3A
GLC 3B
GLC 3C

Genes:
CYPB1
LTBP2

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115
Q

Inheritance of primary pediatric glaucoma

A

Usually sporadic

10-40% familial pattern - AR with incomplete/variable penetrance

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116
Q

JOAG inheritance pattern

A

AD/sporadic
LT1GR
myoc at GLC1A

may be associated with dominant

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117
Q

Aniridia inheritance pattern

A

2/3 AD (PAX6)

1/3 sporadic

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118
Q

Genes involved in Axenfeld-Rieger

A

PITX2, PAX6, FOXC1 (also in Peter’s)

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119
Q

Encompasses primary and secondary glaucoma associated with other developmental ocular or systemic anomalies (inherited or acquired)

A

Developmental glaucoma

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120
Q

Age of onset of JOAG

A

4-35 y/o

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121
Q

MC type of congenital glaucoma

A

PCG (50-70%)

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122
Q

M:F ratio for PCG

A

65:35

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123
Q

% of PCG that is bilateral

A

70%

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124
Q

Age of diagnosis for PCG associated with better prognosis

A

3-12 mos; responds to angle surgery

Worse prognosis once cornea is 14 mm

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125
Q

IOP causes cornea to stretch until age __, leading to buphthalmos

A

3

after this age it causes myopia

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126
Q

Pathophysiology of Haab striae

A

corneal stretching -> breaks in DM -> Haab Striae -> corneal edema and opacification

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127
Q

Results from an abnormality of the trabecular meshwork which may represent a developmental arrest or relative immaturity of trabecular tissue causing increased resistance to aqueous outflow

A

Primary congenital glaucoma

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128
Q

Theories on the pathophysiology of the PCG

A
  1. Cellular or membranous abnormality in the TM (Barkan membrane); abnormality in neural crest derived tissue of AC angle
  2. More widespread anterior segment anomaly, including abnormal insertion of ciliary muscle
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129
Q

Classical triad of PCG

A

Epiphora
Photophobia
Blepharospasm

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130
Q

Treatment of PCG

A

Surgery

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131
Q

Orientation of Haab’s striae

A

Horizontally or concentric to the limbus

H = horizontal

in contrast to that seen in babies who underwent forceps delivery - striae is vertical or diagonal

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132
Q

PCG findings in gonioscopy

A 
Deep open angle
high and flat iris insertion
absence of angle recess
tenting of peripheral iris pigment epithelium
peripheral iris hypoplasia
thickened uveal TM
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133
Q

Differentials for corneal enlargement

A

Axial myopia
X-linked megalocornea
Exophthalmos
Shallow orbits

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134
Q

Differentials for ON abnormalities

A

Physiologic
Optic nerve coloboma and pit
optic atrophy
optic nerve hypoplasia

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135
Q

A form of POAG in ages 4 to 35 y/o. Usually AD inheritance and not associated with corneal stretching.

A

JOAG

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136
Q

Management of JOAG

A

Trab/GDD because medical therapy is usually unsuccessful

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137
Q

Hereditary pattern of Axenfield-Rieger syndrome

A

AD

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138
Q

Abnormal development of the tissues derived from the neural crest (angle, iris, TM); associated with high insertion of the peripheral iris on the TM preventing the complete posterior migration of the uvea.

A

Axenfield-Rieger syndrome

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139
Q

% of Axenfield-Rieger associated with glaucoma

A

50%, usually develops in middle or late childhood

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140
Q

Difference of Axenfield anomaly, Rieger anomaly, Rieger syndrome?

A

Axenfeld anomaly = Posterior Embryotoxon + adherent peripheral iris
Rieger anomaly = Axenfield anomaly + Iris hypoplasia, corectopia (RIeger IRis)
Rieger syndrome = Rieger anomaly + defect of teeth and bones

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141
Q

Cornea and Iris findings for Axenfield-Rieger syndrome

A

Cornea: PE + iridocorneal adhesion to SL
Iris: atrophy, corectopia, ectropion uveae

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142
Q

Sex predilection of Axenfield-Rieger syndrome

A

None

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143
Q

ICE vs Axenfield-Rieger

A

ICE is unilateral, presents in middle age, has corneal endothelial abnormalities, and changes are progressive

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144
Q

Inherited posterior embryotoxon vs Axenfield-Rieger

A

PE has no glaucoma and iris changes

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145
Q

Splitting of iris layers with atrophy of anterior layer

A

Iridoschisis

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146
Q

Peter’s abomaly vs Axenfield-Rieger

A

Peter’s has a corneal leukoma

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147
Q

Lens subluxation, pupillary displacement, axial myopia, RD, inc. corneal diameters, cataract, iris processes

A

Ectopia lentis et pupillae

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148
Q

Microphthalmia, microcornea, iris abnormalities, cataracts, glaucoma

A

Oculodentodigital dysplasia

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149
Q

Central (annular) corneal opacity with adhesions between the central iris and posterior cornea; 50% with glau

A

Peters anomaly

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150
Q

Hereditary pattern of Peters anomaly

A

Sporadic, AD and AR

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151
Q

% bilaterality of Peters anomaly

A

80%

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152
Q

Corneal leukoma in Peters anomaly corresponds to a defect in the:

A

corneal endothelium and underlying DM and posterior stroma

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153
Q

Why is glaucoma hard to treat in Peters anomaly?

A

Presence of iridocorneal dysgenesis

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154
Q

Treatment options for Peters anomaly

A

Meds, trab, GDD, cyclodestructive procedures

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155
Q

A bilateral condition associated with variable iris hypoplasia, limbal stem cell abnormalities causing pannus, AD (85%) or sporadic inheritance, association with WAGR, associated with small corneas, cataracts, ON and foveal hypoplasia

A

Aniridia

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156
Q

Pathophysiology of glaucoma in aniridia

A

Stump rotates anteriorly, covering the TM; gradual process that occurs in second decade of life or later

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157
Q

% of patients with aniridia that develop glaucoma

A

50-70%

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158
Q

Management of aniridia

A

Prophylactic goniosurgery in infants with strong FMHx of aniridic glaucoma; if closed may do trab, GDD, diode. Serial gonioscopy is important.

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159
Q

AR condition associated with aniridia (2%) + cerebellar ataxia and intellectual disability

A

Gillespie syndrome
AAA
Aniridia, ataxia, abnoy :)

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160
Q

AKA encephalotrigeminal angiomatosis, a unilateral condition associated with ipsilateral facial cutaneous hemangioma (nevus flammeus or port-wine stain), ipsilateral cavernous hemangioma of the choroid, ipsilateral leptomeningeal angioma; 30-70% develop glaucoma due to increased episcleral venous pressure (usu when lids are affected)

A

Sturge-Weber syndrome

a phakomatosis

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161
Q

Possible systemic findings of Sturge-Weber syndrome

A

Seizures, focal neurologic defects or intellectual stability

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162
Q

Management of Sturge-Weber syndrome

A

trabeculectomy

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163
Q

Inheritance of neurofibromatosis

A

AD in 50%

sporadic

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164
Q

Ectropion uvea, lisch nodules, optic nerve gliomas, eyelid neurofibroma, glaucoma are see in:

A

Neurofibromatosis

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165
Q

Systemic findings of NF1

A

cafe au lait spots

axillary and inguinal freckling

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166
Q

Difference of NF1 and NF2 in terms of eye involvement

A

NF1: Glaucoma
NF2: Cataract (Ca2ract)

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167
Q

Gene affected for NF1 (von Recklinghausen/peripheral NF)

A

band 11 of long arm of chromosome 17

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168
Q

Systemic findings of NF2 (central NF)

A

bilateral acoustic neuromas (we have 2 ears)

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169
Q

More common - NF1 or NF2

A

NF1

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170
Q

What finding in neonates should prompt workup for NF?

A

Ectropion uvea

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171
Q

Trauma, inflammation, ROP, lens-associated disorders, steroid use, pigmentary glaucoma, intraocular tumors, RB, Juvenile XG, medulloepithelioma, rubella, congenital cataract are causes of ___ glaucoma

A

Secondary

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172
Q

What % of aphakic patients develop glaucoma?

A

15-50%, usually within 3 years of cataract surgery

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173
Q

Risk factors for aphakic glaucoma

A

Cataract surgery in 1st YOL, post op complications, small corneal diameter;

avoid by removing all cortical material intraop

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174
Q

Normal corneal diameter of newborns

A

10-10.5 mm

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175
Q

Which GA drug does not lower IOP during sedation?

A

Chloral hydrate

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176
Q

Which GA drug causes increase in IOP?

A

Ketamine

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177
Q

Normal IOP in newborns

A

low teens

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178
Q

In patients with congenital glaucoma and Down syndrome, the CCT is ____ than normal

A

Lower

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179
Q

What type of goniolens is usually used in children for direct visualization of angle structures?

A

Koeppe

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180
Q

Difference of the baby vs. adult angle

A

TM is less pigmented, SL is less prominent, junction of SS and CBB less distinct in children

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181
Q

Gonioscopy finding in aniridia

A

Rudimentary iris root with progressive narrowing and angle closure

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182
Q

Is there a difference in the success rates of goniotomy and trabeculotomy?

A

None significant

70-80% success rate

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183
Q

Incises the internal layers of the TM using a goniolens and a goniotomy knife; goal is to remove obstructing tissue and to open a route for aqueous humor to exit the AC unto Schlemm’s canal

A

Goniotomy

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184
Q

Complications of goniotomy

A

Small iridodialysis, small cyclodialyses, shallow AC

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185
Q

Advantage of trabeculotomy

A

No post op scarring, faster, less trauma, can be done in opacified cornea, can convert to trabeculectomy

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186
Q

Schlemm’s canal is cannulated from an external approach then tearing is done through the TM into the AC; alternatively, 6-0 polypropylene suture may be fed thru the Schlemm’s canal for 360 degrees and pulled taughtly in the AC

A

Trabeculotomy

Recent innovation: Fiberoptic microcatheter

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187
Q

Why is trabeculectomy associated with poor outcomes in PCG?

A 
Lower scleral rigidity
Rapid healing
Exuberant scarring process
Enlargement of eyes with thinning
Distortion of intraocular anatomy
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188
Q

Complications of Seton/Drainage implant surgery

A

Tube-cornea touch, tube erosion, tube migration, cataract

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189
Q

What to do if goniotomy/trabeculotomy fail?

A

May repeat OR

Do trab/GDD if 2 failed OR’s, adjuct medical management is inadequate or if with other glaucoma

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190
Q

Procedure used for refractory glaucoma.

Destroys regions of CB.

A

Cyclodestruction

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191
Q

Cyclophotocoagulation vs Endoscopic cyclophotocoagulation

A

Cyclophotocoagulation - non invasive and applied transclerally
Endoscopic cyclophotocoagulation - intraocular, causes less damage to adjacent tissues, useful in eyes with distorted anterior segment anatomy and in eyes with prior unsuccessful CPC/cryo

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192
Q

Difference in management of primary glaucoma in children and in adults

A

Surgical in children

Medical management first in adults

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193
Q

What to do when laser trabeculoplasty fails?

A

Consider trabeculectomy because repeat LTP is associated with lower success and higher complication rates

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194
Q

Selective absorption of energy by trabecular pigmented cellls, sparing adjacent cells and tissues from thermal damage

A

SLT

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195
Q

True or False

Aphakic and pseudophakic eyes respond well to LTP

A

False

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196
Q

What is the pediatric dosage of ACTZ?

A

10-20 mg/kg/day

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197
Q

Alpha-agonists are contraindicated for ages

A

3 and below

May give in 3-10 with punctal occlusion

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198
Q

Higher risk for follicular conjunctivitis: Brimonidine or apraclonidine?

A

Apraclonidine

But it is better tolerated systemically in children

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199
Q

Name the study:

ALT as initial therapy is effective but eventually patients will require meds

A

GLT/ Glaucoma Laser Trial

ALT as initial therapy is effective but eventually patients will require meds

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200
Q

What drugs blunt post op pressure elevation after laser?

A

Apraclonidine/Brimonidine

May also use BB, pilo, CAI

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201
Q

Laser wavelength of SLT

A

Frequency doubled 532 nm Q-switched Nd-YAG with 400 um spot size

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202
Q

Advantage of SLT vs ALT

A

You can repeat SLT because it is selective and it has less scarring

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203
Q

Success rate of SLT is highest in

A

POAG and PEX

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204
Q

Factors than enhance longevity of trabeculectomy/guarded procedures

A

MMC, 5FU, releasable sutures, LSL

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205
Q

Fornix-based vs Limbus-based flap

A

Fornix-based

  • easier but more careful suturing needed
  • encourages posterior aqueous flow and formation of a more Fosterior bleb

Limbal-based

  • limbal bleb
  • more challenging
  • need to secure closure well away from limbus (incision 8-10 mm posterior to limbus)
  • reduced risk for post op leakage
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206
Q

Advantage of fornix-based trabeculectomy

A

Subconjunctival scar anterior to scleral flap; gives posterior flow

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207
Q

Disadvantage of limbus-based flap

A

Subconjunctival scar POSTERIOR to scleral flap, impeding flow of aqueous; bleb closer to limbus

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208
Q

Steps of trabeculectomy

A
  1. exposure
  2. conjunctival incision
  3. scleral flap
  4. paracentesis
  5. sclerostomy/keratectomy
  6. iridectomy
  7. closure of scleral flap
  8. closure of conjunctiva
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209
Q

Why is an iridectomy done for trabeculectomy?

A

To reduce risk of occlusion of the sclerostomy; but it is not required if the AC is deep

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210
Q

Effect of antifibrotic agents on trabeculectomy

A

Lowers IOP
Higher risk for hypotony maculopathy
Use with caution in young patients and myopes

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211
Q

Mechanism of 5dUMP and acts on thymidylate synthesis to decrease fibroblast proliferation and decrease scarring

A

5FU (50 mg/mL)

Injected 180 dec from trab site or upper fornix

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212
Q

MC complication of 5FU

A

Corneal epi defect

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213
Q

Naturally occurring compound that is used as an antibiotic and an anti-neoplastic; an alkylating agent that affects DNA cross linking

A

MMC (0.1-0.5 mg/mL)

Toxic intracam

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214
Q

What are these?

Hoskins
Ritch
Madelkom
Blumenthal

A

Types of LSL lens

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215
Q

When is LSL done?

A

3-4 weeks post op or before fibrosis; may be longer if antifibrotics are used

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216
Q

In Black patients, the success rate of filtering surgery is:

A

Lower

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217
Q

Risk factor for wipeout

A

Preop VF with macular splitting and early post op hypotony

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218
Q

Indications of combined cataract and filtering surgery

A
  • cataract requiring extraction in an advanced glau
  • cataract requiring extraction in a glaucoma patient who requires meds to control IOP but who tolerates medical therapy poorly or has inadequately controlled IOP
  • cataract requiring extraction in a glau pt using multiple medications
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219
Q

True or false:

Success rate is higher for ECCE-Trab or Phaco-Trab

A

False

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220
Q

Relative contraindications of combined procedures (Do glau surgery alone instead)

A
  • Glau that requires very low target IOP

- advanced glaucoma with uncontrolled IOP and immediate need for successful reduction

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221
Q

Goal of LI

A

Relieve pupillary block

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222
Q

Disadvantage of inferior trab site

A

7.8% risk for infection (vs 1.3 for superior)

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223
Q

Causes of early bleb leak

A

Ineffective wound closure or buttonhole

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224
Q

Causes of late leakage

A

more frequent post full thickness procedures such as posterior lip sclerectomy or after antifibrosis drugs

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225
Q

How are choroidal effusions managed?

A

Medically with cycloplegics

Inject visco to AC, drain choroidals, deepen AC through paracentesis

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226
Q

How are bleb leaks managed?

A 
Oversized CTL
Aq suppressants
Suture
tissue glue
autologous blood injection
oral antibiotics
bleb excision +- conjunctival graft/advancement
Conjunctival flap
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227
Q

Initial management of failing bleb

A

Massage

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228
Q 
A bleb with the ff:
decreased height
increased wall thickness
vascularization
loss of conjunctival microcysts
increased IOP 
is...
A

failing

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229
Q

Risk factors for bleb failure

A 
AS neovascularization
Black race
Aphakia
prior failed filtering procedure
Uveitis
Cataract
Young
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230
Q

Management of EOR in patients with trab

A

CTL difficult
May do refractive surgery prior to trab
GDD may be better

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231
Q

_______ theory:

Iris acts as valve
AC IOP > PC IOP pushing peripheral iris membrane posteriorly
Melanin granules released because iris rubs on zonules

A

Reverse pupillary block theory

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232
Q

Contraindications for LI

A

flat AC
poor visualization
active rubeosis iridis

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233
Q

Preferred type of laser when doing LI in aspirin users

A

Argon instead of NdYAG

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234
Q

Preferred type of laser for LI

A

Q-switched Nd:YAG

fewer pulses, less energy, does not as often close, 2-8 mJ

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235
Q

Principle behind Argon-Nd:YAG combination settings

A

Excavation by argon
Penetration by Nd:YAG

(alphabetical)

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236
Q

Endpoint of LI

A

100-500 um hole
gush of fluid and pigments
visualization of lens capsule
chamber deepening

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237
Q

Complications of LI

A

visual disturbances, iritis/inflammation, bleeding, PAS formation, IOP spikes, corneal injury, lens injury, LI closure

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238
Q

Laser used for PIR

A

Argon green

0.1-0.5 s, 200-500 um, 200-500 mW power

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239
Q

Uses low-energy burns directed to peripheral iris with the goal to widen angle or break PAS

A

ALPIR/PIR

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240
Q

Indications for PIR/ALPI

A 
Break an acute angle closure attack
Plateau iris
Nanophthalmos
Microphthalmos
Iris cysts
angle close/occludable angles
to widen angles prior to trab
to further widen angles in tandem with or after LI
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241
Q

Contraindications for PIR/ALPI

A

Flat AC
Extensive PAS
poor visualization –> severe corneal edema, corneal scar

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242
Q

Endpoint of PIR/ALPI

A

Slight contraction of iris
no visual burn
burns may appear later

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243
Q

Complications of ALPIR

A 
mild iritis
IA
PAS
IOP spikes
corneal endothelial burns
corneal decompensation
late failure
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244
Q

Indication for ____

NVG
Aphakic/pseudophakic glau
PKP with glau
RD with glau
ICE
traumatic glau
uveitic glau
prior failed glau sx
epithelial downgrowth
refractory infantile glau
CTL wearers who need glau filtration surgery
A

GDD implantation

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245
Q

Types of GDD

A
  1. Valved - molteno, baerveldt, ahmed

2. Non-valved

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246
Q

Used for difficult cases of glaucoma where filtering failed

A

GDD

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247
Q

Site of choice for GDD

A

Superotemporal

248
Q

Areas where tube can be placed

A

AC, ciliary sulcus, PP

249
Q

Materials used to cover tube:

A

Sclera, pericardium, cornea; avoid dura

250
Q

Advantage of GDD over trabeculectomy

A

the flow of aqueous is not solely dependent on the status of the bleb

251
Q

Indications of ciliary body ablation

A

Eyes with poor visual potential

Painful blind eye

252
Q

Contraindications of GDD

A

borderline corneal endothelial function

253
Q

Complications of GDD

A
  • tube-cornea touch secondary to overfiltration
  • tube erosion
  • plate migration
254
Q

Complications of diode ciliary body ablation

A

hypotony, pain, inflammation, CME, hge, phthisis, SO

255
Q

Types of non-penetrating glaucoma surgery

A

Deep sclerectomy
Viscocanalostomy
Canaloplasty

256
Q

Pathway of aqueous fluid

A

CB - PC - zonules - AC - trab meshwork - Schlemm’s canal - 25-30 collector channels - venous plexus - aqueous veins

257
Q

Primary risk factor for glaucoma

A

elevated IOP

258
Q

Definition of glaucoma

A

Characteristic ON with development of distinctive patterns of visual dysfunction (structure and function)

259
Q

Site of aqueous production

A

Ciliary body

260
Q

Site of conventional aqueous outflow

A

Trabecular meshwork - Schlemm canal system and episcleral venous plexus - SOV - cavernous sinus

261
Q

Determinants of optic nerve damage and visual field changes

A

IOP level

resistance of nerve to damage

262
Q

Glaucomatous changes in optic disc in patients with normal visual field as determined by white on white perimetry

A

Preperimetric glau

263
Q

Genes involved with glaucoma

A

GLC1A (TM inducible glucocorticoid response/myocillin gene; TIGR1 myoc)
codes for TIGR protein and is a TM glucocorticoid gene on chromosome 1

264
Q

Study:

Higher % of monozygotic twins corcondant for glaucoma

A

Finnish Twin Cohort Study

265
Q

Resistance to aq outflow through the TM-Schlemm canal system in the absence of gross anatomic obstruction

A

open angle

266
Q

Pupillary block leading to peripheral iris obstruction of the TM

A

angle closure

267
Q

not asssociated with known ocular or systemic disorders that cause inc resistance to aq. outflow or damage to ON; usually assoc w/ elevated IOP

A

POAG

268
Q

continuum of POAG; term used when IOP is not elevated

A

NTG/normal tension glaucoma

269
Q

normal OD + VF associated with elevated IOP

A

ocular hypertension

270
Q

suspicious OD or VF regardless of IOP

A

Glaucoma suspect

271
Q

increased resistance to TM outflow associated w/ other conditions or increased posttrabecular resistance

A

secondary OAG

272
Q

movement of aq humor from PC to AC restricted at the point of iridolenticular contact: resulting in anterior iris bowing and contact with TM

A

PACG

273
Q

occurs when IOP rises rapidly as a result of relatively sudden blockage of the TM

A

acute ACG

274
Q

repeated brief episodes of angle closure with mild symptoms and elevated IOP, often a prelude to acute angle closure

A

Subacute ACG/intermittent ACG

275
Q

IOP elevation caused by variable portions of AC angle being permanently closed by PAS

A

CACG

276
Q

Pupillary block occurs as a result of a mechanism other than the anatomical configuration of the anterior segment

A

Sec ACG w/ pupillary block

277
Q

Posterior pushing mechanism: lens iris interface pushed forward

A

secondary ACG w/o pupillary block

278
Q

an anatomical variation in the iris root in which narrowing of the angle occurs independent of pupillary block

A

plateau iris syndrome

279
Q

primary glaucoma presents at birth or within the first few yrs of life

A

PCG

280
Q

Prevalence of POAG

A

7%

281
Q

Risk factors for progression of POAG

A 
Elevated IOP
Reduced perfussion pressure
Advanced age
Thin CCT
Race 
FMHx

Inconclusive - gender, DM, HPN, atherosclerosis, ischemic vascular disease

282
Q

Prevalence of PACG in Inuits?

A

20-40x higher than for whites

283
Q

MC age for Acute ACG

A

55-65 y/o

284
Q

RF for PACG

A

Race, Gender, Age, Refraction, Inheritance

285
Q

Inheritance of PACG

A

AD, polygenic, late onset, increase penetrance, environmental factors

286
Q

Exit of aqueous humor through the root of the iris and CM, into the suprachoroidal space and through the sclera

A

Uveoscleral pathway

287
Q

Estimated volume of AC angle

A

200 uL

288
Q

Depth of the AC at the center

A

3 mm

289
Q

3 parts of the TM

A

Uveal
Corneo-scleral
Juxtacanalicular

290
Q

Roughly triangular in cross section, apex at SL and base formed by SS

A

Trabecular meshwork

291
Q

Major site of outflow resistance

A

Juxtacanalicular meshwork

292
Q

Formed by a continuous monolayer or nonfenestrated endothelium and a thin connective tissue well; endothelial cells are joined by tight junctions

A

Schlemm’s Canal

293
Q

Double layer of epithelium over a core of stroma

A

Ciliary body

294
Q

True or false

Apical surfaces of the outer pigmented and inner non-pigmented layers of epithelium face each other and are joined by tight junctions (BAB)

A

True

Apical surfaces of the outer pigmented and inner non-pigmented layers of epithelium face each other and are joined by tight junctions (BAB)

295
Q

Actual site of aqueous production

A

Inner nonpigmented cells which have numerous mitochondria and microvilli; rich supply of fenestrated capillaries

296
Q

What is the effect of hyperthermia and alkalosis on aqueous production?

A

Increase production

297
Q

What is the effect of hypothermia, acidosis, DM, RD, ocular inflammation, cycloablation, cyclodialysis, choroidal detachment?

A

Decrease production

298
Q

Effect of the ff on IOP:

Inc EVP, pressure on eye, body T, hormones, LSD, topiramate, steroids, anticholinergics

A

Increase

299
Q

Effect of the ff on IOP:

Alcohol, heroin, marijuana, acidosis, pregnancy

A

Decrease IOP

300
Q

Avascular, smooth, pigmented structure; 3-4 mm from limbus

A

Pars plana

301
Q

Richly vascularized structure, consisting of approximately 70 radial folds of ciliary processes

A

Pars plicata

302
Q

Innervation ofparasympathetic fibers of CN III

A

short ciliary nerves

303
Q

Number of axons of the ON

A

1.2 to 1.5 million

304
Q

Diameter of optic nerve

A

1.5 mm

305
Q

Goldmann equation

A

P0 = (F/C)+ Pv

P0: IOP
F: rate of aqueous formation in uL/min
C: facility of outflow in uL/min/mmHg
Pv: EVP
Resistance to outflow R = inverse of facility C
306
Q

Enzyme involved in active secretion of aqueous humor during active secretion or transport

A

Carbonic anhydrase II

Electrolytes: sodium, chloride, bicarbonate

Independent of pressure

307
Q

3 mechanisms by which aqueous is formed and secreted:

A
  1. active secretion - double layered ciliary epithelium
  2. ultrafiltration - pressure dependent movement along a gradient
  3. simple diffusion
308
Q

Passive movement of ions based on charge and concentration across a membrane

A

Diffusion

309
Q

Contents of aqueous humor

A

Excess of hydrogen and chloride, ascorbate

Deficit of bicarbonate

Enzymes, prostaglandins, cAMP, catecholamines, steroid hormones, hyaluronic acid

310
Q

Average rate of aqueous humor formation

A

2-2.5 uL/min

311
Q

Rate of turnover of aqueous

A

1%

312
Q

Most common method used to measure rate

A

fluorophotometry

313
Q

Factors that affect aqueous humor formation

A
  • Integrity of the BAB
  • Blood flow to ciliary body
  • Neurohumoral regulation of vascular tissue and the ciliary epithelium
314
Q

Number of trabecular meshwork in cells

A

200-300k/eye

315
Q

True or false

The inner wall of the Schlemm’s canal is composed of giant vacuoles with direct communication with intertrabecular spaces

A

True

316
Q

Range of facility of outflow

A

0.22 to 0.30 uL/min/mmHg

317
Q

Site of pressure dependent outflow

A

Trabecular meshwork

318
Q

Site of pressure-independent outflow

A

uveoscleral outflow

AC - ciliary muscle - supraciliary and suprachoroidal spaces - sclera, nerves, vessels

319
Q

Uveoscleral outflow is ____ by miotics

A

Decreased (but it increases traditional outflow)

320
Q

Uveoscleral outflow is _____ by cycloplegia, adrenergic agents prostaglandin analogues

A

Increased

321
Q

Normal range of episcleral venous pressure

A

8-10 mm Hg

IOP rises 1 mm Hg for every 1 mm Hg increase in EVP

322
Q

How does elevated episcleral venous pressure increase IOP?

A

Collapse of Schlemm canal; increased outflow resistance

323
Q

Mean IOP

A

15.5 mmHg SD 2.6 mmHg

324
Q

Only modifiable RF for glaucoma

A

IOP

325
Q

Normal diurnal variation in health patients

A

2-6 mm Hg

326
Q

When does IOP peak?

A

Early AM hours while pt is still in bed

327
Q

Findings of AGIS/advanced glau intervention study

A

IOP lowering -> dec. VF loss
IOP of at most 18 mm Hg on all visits during 1st 18 mos after surgery –> less VF loss
- trab increases risk for cataracts

328
Q

Imbert-fick principle

A

P=F/A

329
Q

Area flattended by AT

A

3.06 sq mm

330
Q

CCT where AT is most accurate

A

520 um

331
Q

Excessive fluorescein

A

Falsely high reading

332
Q

Corneal scar gives a ____ reading

A

falsely high

333
Q

PRK and LASIK give _____ IOP values due to decreased corneal thickness

A

lower

334
Q

Measures time necessary for a given force of air to flatten a given area of the cornea

A

Noncontact tonometry

335
Q

Based on the principle of indentation tonometry; measures depth of corneal indentation made by a small plunger of a known weight

A

Schiotz tonometry

336
Q

Portale applanation tonometer; uses Goldmann biprism, may be used upright or supine

A

Perkins tonometer

337
Q

Has a gas-filled chamber with a silastic diaphragm/fenestrated diaphragm through which air escapes. IOP calculated based on balance between flow of air from machine and resistance to flow from the cornea.

A

Pneumatic tonometer

338
Q

Newer method of tonometry w/c uses solid state sensor and corneal contour matching surface; measures IOP relatively independent of corneal mechanical properties

A

Dynamic contour tonometer

339
Q

Applanates a small area of the cornea; useful in the presence of corneal scars and edema

A

Tono-pen

340
Q

A form of rebound tonometry

A

iCare

341
Q

Infectious agents that can be recovered from tears

A

AIDS, hepatitis, EKC, other viruses

342
Q

Methods of sterilizing tonometer

A
  1. soaking in 1:10 NaOCl, 3% H2O2, or 70% isopropyl alcohol for 5 min, or thorough wiping with alcohol sponge
343
Q

Hyperopic or myopic?

At risk for ACG -
At risk for pigment dispersion -

A

At risk for ACG - Hyperopic

At risk for pigment dispersion - myopic

344
Q

Haab striae is seen in _____.

A

Developmental glaucoma

345
Q

Krukenberg spindle is seen in _____.

A

Pigmentary glaucoma

346
Q

Deposits of exfoliation material is seen in ____.

A

Exfoliation syndrome

347
Q

Beaten bronze appearance of the endothelium

A

ICE

348
Q

Findings in tuberous sclerosis/Bourneville syndrome

A

Glaucoma sec to vit hem
Anterior segment RD’s
RD
Ashleaf sign (hypopigmented lesion) + red bown papular rash on nose and cheeks

349
Q

Findings in NF1

A

Glaucoma sec to developmental abnormalities of AC angle
Subcutaneous plexiform neuromas (hallmark)
S-shaped eyelid (at risk for glaucoma)

350
Q

Findings in Juvenile Xanthogranuloma

A

Yellow/orange papules o the skin of head and neck

351
Q

Findings in Oculodermal melanocytosis (nevus of Ota)

A

Hyperpigmentatiion of periocular skin

At risk for glaucoma and melanoma

352
Q

Findings in Axenfield Rieger syndrome

A

AD, variable penetrance, glaucoma in 50%

Microdontia, hypodontia, anodontia, maxillary hypoplasia

353
Q

Causes of elevated episcleral venous pressure

A
  • encephalofacial angiomatosis (Sturge-Weber syndrome); nevus flammeus/portwine stain, facial cutaneous angioma, hemifacial hypertrophy
  • Klippel Trenaunay Weber - cutaneous hemangiomas
  • orbital varices
  • AVF
  • SVC
  • TRED
354
Q

Slit lamp method to examine AC depth

A

Van Herrick

355
Q

Microcystic corneal edema is indicative of __ IOP

A

high

356
Q

Eliminates total internal reflection by replacing tear film-air interface with a tear film-goniolens interface

A

Goniolens

357
Q

In this type of gonioscopy, light rays from the angle are viewed directly and without reflection from inside the lens

A

Direct gonioscopy

358
Q

In this type of gonioscopy, mirrors are used to reflect rays from the angle; a mirror provides a mirror image of the opposite angle

Patient must be upright and on a slit lamp

A

Indirect gonioscopy

359
Q

Koeppe, Barkan, Wurst, Swan Jacob, Richardson are types of _____ lens.

A

Direct goniolens.

360
Q

Image formed by direct goniolens

A

inverted and slightly foreshortened image of opposite angle

361
Q

Posner, Sussman, Zeiss are examples of ____.

A

Indirect gonioscopy lenses

362
Q

Why is a coupling substance required when using a 3 mirror goniolens?

A

Because the curvature of the contact surface of the lens is steeper compared to the cornea.

363
Q

The angle is usually wider ____.

A

Inferiorly

364
Q

Name the classification

Grade 4 - angle bet iris and surface of TM is 45 degrees
Grade 3 - 20 to 45 degrees
Grade 2 - 20 degrees
Grade 1 - 10 degrees
Slit: < 10 degrees, angle closure very likely

A

Shaffer

365
Q

Difference of Spaeth from Shaffer

A

Spaeth adds peripheral iris contour, insertion of iris root and effects of dynamic gonioscopy on the angle configuration

366
Q

What are the normal blood vessels which may be seen in the angle?

A

Radial iris vessels
Portion of the arterial circle of the CB
vertical branches of anterior ciliary arteries

367
Q

Characteristics of abnormal blood vessels in angle

A

Cross the SS to reach TM

368
Q

Appearance of angle vessels in FHI

A

Branching, fine, unsheathed, meandering

369
Q

Appearance of angle vessels in NVG

A

trunklike vessels, crossing CB and SS, arborizing over TM

370
Q

Differentiate iris processes from synechiae

A

Iris processes are open, lacy, follow the normal course of the angle

Synechiae are solid and sheet like

371
Q

Demarates temrination of DM and anterior limit of TM

A

Schwalbe’s line

372
Q

Recors angle in degrees between 2 imaginary tangential lines

A

Shaffer system

373
Q

Characteristic of angle pigmentation in PEX vs in Pigment Dispersion syndrome

A

patchy in PEX
uniform in pigment dispersion syndrome
both with sampaolesi line

374
Q 
Abnormally widened CBB
history of trauma
increased prominence of SS
torn iris processes
marked variation of ciliary face width and angle in different quadrants of the same age
A

Post traumatic angle recession

375
Q

CB separation from SS

Gap between SS and CBB, widening of suprachoroidal space

A

Cyclodialysis

376
Q

Tear between longitudinal and circular muscles of the ciliary body

A

Angle rcession

377
Q

Tear in the root of the iris

A

Iridodialysis

378
Q

Cells responsible with Motion

Luminance changes in dim illumination; no response to color

A

M cells

379
Q

Fine
Central retina
Smaller diameter reactions, small receptive field

A

P cells

380
Q

Detects blue-yellow opponency

Stimulated when Blue cones are activated

A

Bistratified/konocellular

381
Q

Discs and cups in blacks and myopes are (larger, smaller)

A

Larger

382
Q

Regions of the anterior optic nerve

A

Prelaminar - adjacent to peripapillary choroid
laminar - continuous w/ sclera, composed of lamina cribrosa
retrolaminar - posterior to lammina cribrosa, beginning of axonal myelination, surrounded by leptomeninges

383
Q

Illumination used to examine NFL loss

A

Red-free

384
Q

Major support of the ON

A

lamina cribrosa

385
Q

Characteristic of fenestrations of lamina cribrosa

A

Larger superiorly vs inferiorly (like bubbles in water)

386
Q

Seen between ON and adjacent choroidal and retinal tissue

A

Ring of Elschnig

387
Q

Temporal crescent seen in myopia with no hyper/hypopigmentation and no impact on glaucoma

A

alpha PPA

388
Q

Type of PPA seen in glaucomatous eyes; associated with loss of choriocapillaries and RPE leaving only large choroidal vessels and sclera; location correlates with position of VF loss

A

Beta “bad” PPA

389
Q

The ophthalmic artery gives rise to ____ posterior ciliary arteries

A

1-5

Usually 2-4 which gives rise to 10-20 short posterior ciliary arteries

390
Q

Non-continious arterial circle within the perineural sclera

A

Circle of Zinn Haller

391
Q

Where does the central retinal artery penetrate the optic nerve?

A

10-15 mm behind globe

392
Q

Blood supply of the superficial NFL

A

Recurrent retinal arterioles from the CRA

393
Q

Blood supply of the prelaminar ON

A

Direct branches of the SPCA and by branches of Zinn Haller

394
Q

Blood supply of lamina cribrosa ON

A

SPCA and Zin Haller

395
Q

Blood supply of retrolaminar ON

A

SPCA and Pial arterial branches

396
Q

Drainage of ON

A

Central retinal vein

397
Q

What is more common in glaucoma, diffuse or focal NFL loss?

A

Diffuse

398
Q

Definition of SITA

A

Swedish Interactive Thresholding Algorithm

399
Q

Definition of TOP

A

Tendency Oriented Perimeter (Octopus)

400
Q

Sin qua non of all forms of glaucoma

A

Glaucomatous ON

401
Q

Site where loss of tissue starts?

A

Lamina cribrosa

402
Q

Best method to examine nerve

A

Slit lamp exam using Hruby lens, a posterior pole contact lens

403
Q

How to estimate disc size using lenses?
60D
78D
90D

A

60D - height of slit equals disc diameter
78D - multiply by 1.1
90D - multiply by 1.3

404
Q

True or False

SITA FAST is useful for glaucoma

A

False. Do only if unable to perform SITA standard.

405
Q

Means to measure ONH and RNFL quantitatively

A
  • confocal scanning laser ophthalmoscopy
  • scanning laser polarimetry
  • OCT
406
Q

What is the Visual Field of Traquair?

A

Island hill of vision in sea of darkness

407
Q

Tests differential light sensitivity and ability of subject to distinguish stimulus from uniform background

A

Perimetry

408
Q

Uses of perimetry

A
  • Identify and quantify abnormal fields

- Assess and detect progresion

409
Q

Standard for assessing visual function
Uses white stimuli on white b/g
Staircase algorithm

A

Automated static perimetry

410
Q

Perimetry type

Uses a stationary test object
Stimulus increased in intensity from below threshold until perceived

A

Static perimetry

411
Q

Perimetry type

Test object of fixed intensity is moved along several medians toward fixation
Points where object is perceived is plotted in circle

A

Isopter/kinetic

412
Q

2 types of clinical perimetry

A
  1. automated static - bowl perimetry or video monitor

2. manual kinetic and static perimetry - Goldmann type bowl perimetry

413
Q

Differential light sensitivity

Stimulus of given size and duration seen 50% of the time; dimmest spot detected

A

Threshold

414
Q

How does presentation time affect results of perimetry?

A

Up to 0.5 seconds, temporal summation can occur

415
Q

Pupil size than can cause artifacts on VF

A

less than 2.5 mm

416
Q

3 important factors to be considered in deciding on glaucoma therapy

A
  • life expectancy
  • stage
  • rate of progression
  • IOP
417
Q

Findings of CIGTS

Collaborative Initial Glaucoma Treatment Study

A

Outcomes if medical or surgical approach is done first are just equal.
If worse baseline, better off to start trab initially.

418
Q

How does systemic beta blockers affect the utility of topical beta blockers for glaucoma?

A

(+) systemic BB - lesser IOP lowering effect of topical

419
Q

Topical ocular hypotensive that increases uterine contractility among pregnant women

A

Prostaglandin analogue

420
Q

Concentration of mannitol given to control IOP acutely

A

20%
0.5 to 2 g/kg BW
Contraindicated in patients with renal failure or on dialysis

421
Q

Concentration of glycerol used to control IOP acutely

A

50%
1-1.5 g/kg BW
May cause DKA in DM patients

422
Q

Average CCT

A

530 to 540 um

423
Q

Chronic, slowly progressive optic neuropathy with characteristic patterns of ON damage and VF loss
No identifiable contributing factor
Insidious, slowly progressive
Usually bilateral

A

POAG

424
Q

Signs of glaucoma

A

Asymmetry of neuroretinal rim/cupping
Focal thinning/notching of the neuroretinal rim
Optic disc hemorrhage
Change in the disc rim appearance or surrounding retinal nerve

425
Q

When is repeat gonioscopy done among POAG patients?

A
  • when chamber becomes shallow
  • when strong miotics are prescribed
  • after laser trabeculoplasty or iridectomy
  • if IOP rises
426
Q

Findings of Baltimore study in relation to BP among glau patients?

A

(+) Systemic HPN - lower risk for glaucoma in younger patients
Increase risk for higher BP

427
Q

Findings of Barbados eye study in relation to BP among glau patients?

A

RF < 1 in all age groups

Lower ocular perfusion pressure is a strong risk factor

428
Q

Findings of studies pertaining to age as a RF in development of glaucoma?

A

Baltimore Eye Survey: OHTS
- glaucoma prevalece increases dramatically with age

OHTS
- increased risk of OAG with age

CIGTS
- VF defects more likely to develop in >60 vs. <40 yrs

429
Q

True or False

Blacks are at 3-4x higher risk for POAG compared to other races.

A

True

More likely to be diagnosed at younger age, more likely also to be advanced at diagnosis

430
Q

Having a sibling with POAG will increased a person’s risk for POAG by how much?

A

3.7 fold (Baltimore Eye Survey)

431
Q

% inheritance for Chronic OAG based on Finnish Twin Cohort Study

A

10.2%

432
Q

True or False

All studies agree that DM is a risk factor for POAG

A

False.

(+) association - Beaver Dam Eye Study, Blue Mountains Eye Study, Los Angeles Latino Eye Study
(-) association - Framingham, Baltimore, Barbados, Rottedam
Decrease risk - OHTS

433
Q

How does CV disease increase risk for POAG?

A

Hypothesis: Microcirculatory effects of systemic hypertension on the ON increases susceptibility to glaucoma

434
Q

True or false

Glaucoma and OHT are risk factors for CRVO.

A

TRUE.

Glaucoma and OHT are risk factors for CRVO.

435
Q

2 groups of NTG

A

based on disc appearance

  1. senile sclerotic group - shallow, pale sloping of neuroretinal rim
  2. focile ischemic hroup - deep, focal notching of neuroretinal rim
436
Q

Atypical findings in glaucoma

A 
Unilateral
Decreased central vision
Dyschromatopsia
Young
RAPD
Neuroretinal rim pallor
Inconsistent VF loss

need to r/o anemia, carotid artery insufficiency, syphilis, vitamin deficiency, temporal arteritis

437
Q

Findings of EMGT (Early manifest glaucoma trial)

A

In the management of POAG, 25% IOP reduction reduced progression from 62% to 45% at 6 years

438
Q

Findings of AGIS (Advanced glaucoma intervention study)

A

Patients with IOP <18 Hg did not show progressive VF loss

Patients with IOP <14 fared better than those with IOP > 17.5

439
Q

A higher prevalence of vasospastic disorders such as migraine headache, Raynaud phenomenon, ischemic vascular disease, autoimmune disease, coagulopathies is seen in which type of glaucoma?

A

NTG

There is bilateral, progressive disease despite IOP lowering

440
Q

Findings of CNGTS (Collaborative normal tension glaucoma study)

A

Lowering IOP by at least 30% reduced rate of VF progression (35 to 12%).

441
Q

Characteristic of VF defects in NTG vs POAG

A

More focal, deeper, and closer to fixation

Dense paracentral scotoma may be initial defect

442
Q

Average CCT in NTG patients

A

510-520 um

443
Q

Criteria for initiating therapy in NTG patients

A
  1. VF loss threatening fixation
  2. disc hge
  3. documented VF or ON progression
444
Q

Definition of glaucoma suspect

A

An adult with one of the ff in at least one eye:

  1. ON or NFL defect suggestive of glaucoma
  2. VF abnormality consistent with glaucoma
  3. Elevated IOP greater than 21 mm Hg

Normal angle on gonioscopy

445
Q

RF for glaucoma development in patients with OHT based on OHTS

A
  1. elevated IOP
  2. reduced CCT
  3. increase CDR

9.5% progression in observation group vs 4.4% progression in treatment group

446
Q 
Monocular/binocular, strongly age related
Fibrillar material in anterior segment
Hoarfrost ring
Pigmented TM
Transillumination defects
Poorly dilating pupil
Phaco/iridodonesis
Greater IOP with greater fluctuatins
A

Exfoliation syndrome

447
Q

Management of exfoliation syndrome

A

LTP
Trab
LE does not alleviate condition

448
Q

Occurs MC in white males, myopic, bet 20-50 yrs
Pigment deposition
Krukenberg spindle
Spokelike transillumination defects in iris midperiphery
Posterior bowing of iris

A

Pigmentary glaucoma

449
Q

Management of pigmentary glaucoma

A

Medical
LTP
Filtering surgery

450
Q

Pigment deposits near equator of lens

A

Zentmayer line

451
Q

Vertical spindle pattern in corneal endothelium secondary to phagocytosis of pigments by corneal endothelium

A

Krukenberg spindle

452
Q

Inflammatory glaucoma caused by lens protein leakage thru capsule of mature/hypermature cataract; lens proteins phagocytosed by macrophages obstruct TM; seen in elderly patients

A

Phacolytic glaucoma

Do LE.

453
Q 
Markedly elevated IOP
microcystic coreal edema
(+)c,f, (-) KP's
cellular debris in angle
large white particles in AC
mature cataract
A

Phacolytic glaucoma

454
Q

Obstruction of TM by lens cortex particles following cataract surgery or trauma, may occur weeks, mos or years later

A

Lens particle glaucoma

455
Q 
Free cortical material in AC
Elevated IOP
Mod. AC reaction
Microcystic corneal edema
PS
PAS
A

Lens particle glaucoma

456
Q

Mechanism by which intraocular tumors cause glau

A
  • direct tumor invasion of angle
  • angle closure
  • intraocular hemorrhage
  • angle NV’s
  • tumor/inflammatory/cellular debris deposition
457
Q

Mechanism of glaucoma in choroidal melanoma

A

sec. ACG due to fluid shift in lens iris interface

458
Q

Mechanism of glaucoma in necrotic tumors

A

Inflammation –> PS

459
Q

Mechanism of glaucoma in choroidal melanoma, medulloepitheliomas, RB

A

AS NV –> angle closure

460
Q

The ff are types of ____ glaucoma:

FHI
HSK Uveitis
HZK
Toxoplasmosis
JIA
PS
A

Inflammatory

thru blockage of TM by fibrin and inflammatory cells, presence of PAS, or steroid use

461
Q

Granulomatous inflammation ff sensitization to own lens protein secondary to surgery/trauma

A

Phacoantigenic/phacoanaphylactic glaucoma

462
Q 
Moderate AC reaction
KP's
Low grade vitritis
PS
Residual lens material
A

Phacoantigenic/phacoanaphylactic glaucoma

Steroids, aq. suppressants
Surgical removal of lens material

463
Q

Other name for Posner-Schlossman syndrome

A

Glaucomatocyclitic crisis

464
Q

Recurrent bouts of markedly increased IOP and low grade AC reaction in middle-aged indivuals. Presents with unilateral BOV with mild eye pain that spontaneously resolves within a few weeks. (+) KP’s on TM - trabeculitis

A

Possner-Schlossman Syndrome

465
Q

Insidious and unilateral condition.
M=W.
Iris heterochromia (lighter eye affected)
Low grade reaction with pancorneal small stellate KP’s
PSC
Glaucoma not corresponding to degree of inflamation

A

Fuch’s Heterochromic Iridocyclitis

466
Q

Management of FHI

A

Medical, Steroids, Aqueous suppressants

467
Q

Viral infection implicated with FHI

A

Rubella

468
Q

Gonioscopy findings in FHI

A

Multiple fine vessels crossing TM

No PAS and secondary angle closure

469
Q

Gonioscopy findings in elevated episcleral venous pressure

A

Blood in Schlemm’s canal

470
Q

Normal episcleral venous pressure

A

5-9 mm Hg

471
Q

Filtering surgery in patienhts with elevated EVP may be complicated by:

A

Cilichoroidal effusion and suprachoroidal hemorrhage

472
Q 
Brown, broad angle recess
Absent or torn iris processes
White, glistening SS
Depression in overlying TM
PAS at the border of the recession
A

Traumatic angle recession

473
Q

Management of Angle recession

A

Medical
LTP limited role
Poor response to trab

474
Q

True or false

OAG is a long term sequelae of siderosis/chalcosis from retained metallic FB

A

True

475
Q

Mechanisms by which IOL implantation can lead to glaucoma

A
  • UGH
  • secondary pigmentary glaucoma
  • pseudophakic pupillary block
476
Q

What is the Schwartz-Matsuo syndrome?

A

Liberation of photoreceptor OS due to chronic RRD –> TM obstruction

477
Q

In sickle cell hemoglobinopathy, why do RBC’s sickle in the AC?

A

Due to decreased PH

478
Q

True or false

Sickle cell hemoglobinopathy presents with a higher incidence of elevated IOP and increased susceptibility to optic neuropathy and CRAO.

A

True

Sickle cell hemoglobinopathy presents with a higher incidence of elevated IOP and increased susceptibility to optic neuropathy and CRAO.

479
Q

Management of increased IOP due to sickle cell

A

Aqueous supression
Hyperosmotic agents

However, CAI and hyperosmotics may induce sickle cell crisis

480
Q

True or false

The threshold for surgery fpr hyphema (ACWO + iridectomy) should be higher in sickle cell.

A

False. Lower.

481
Q

Hemoglobin laden macrophages block trabecular outflor

A

Hemolytic glaucoma

482
Q

Degenerated RBC’s, khaki colored cells accumulate in angle

A

Ghost cell glaucoma

483
Q

Management of hemolytic and ghost cell glau

A

ACWO
PPV
incisional glaucoma surgery

484
Q

Steroids with weaker IOP rise

A

FML
Rimexolne
Medrysone
Loteprenol

485
Q

Eye drop that can increase IOP in individuals with open angles

A

Cycloplegics/atropine sulfate

486
Q

Primary pathology is anatomic.

(+) resistance to aqueous outflow proximal to TM.

A

ACG

487
Q

Most frequent cause of angle closure

A

pupillary block

obstructed aq. flow -> pressure gradient -> peripheral iris bowing to TM

488
Q

True or False

Secondary glaucoma is rare in post PKP patients

A

False.

Common due to wound distortion and progressive angle closure

489
Q

Study that validated the results of OHTS

A

EGPS - European glaucoma prevalence study.

490
Q

What is the EMGT (Early manifest glaucoma trial)?

A
  • Compared observation vs betaxolol + ALT for OAG
  • Risk for progression: (-) tx, age, inc IOP, exfoliation, more severe VF defect
  • Risk for progression decreases by 10% for every 1 mm Hg IOP lowered
491
Q

What is the AGIS (Advanced Glaucoma Intervention Study)

A
  • Compared argon laser trabeculoplasty-trabeculectomy-trabeculectomy vs. trabeculectomy, ALT - trabeculectomy outcomes
  • Black: better TAT
  • White: better ATT
    Risk for ALT failure; young with high IOP
    Risk for trab failure; young with high IOP and DM
492
Q

At what position of the pupil is the risk for pupillary block maximal?

A

Mid-dilated position

493
Q

No movement of aqueous through pupil due to 360 deg PS

A

Seclusio pupillae

Absolute pupillary block

494
Q

Restricted movement of aqueous through pupil

A

Relative pupillary block

495
Q

Causes of iris-induced angle closure

A
  • anterior iris insertion into SS (anterior cleavage abnormality)
  • thick peripheral iris
  • anteriorly displaced ciliary processes
  • rudimentary iris leaflets rotate into the angle
496
Q

Management of malignant glaucoma/AMS

A

Vitrectomy

497
Q

Occludable angle with normal IOP, optid disc and VF, (-) PAS

A

PACS

498
Q

Occludable angle with either raised IOP or primary PASl; normal optic disc and VF

A

PAC

499
Q

PAC + glaucomatous damage to optic disc and VF

A

PACG

500
Q

Race with highest risk for PAC

A

Inuits

501
Q

Risk factors for PAC

A 
shallow AC (ACD < 2.5 mm)
Thick lens
Short AL
increased anterior curvature of the lens
small corneal diameter and radius of curvature
502
Q

Why do females have 2-4x higher risk for PAC compared to males?

A

Smaller anterior segment and AL

503
Q

True or false

FMH is a significant RF for PAC

A

True

504
Q

Occurs when IOP rises rapidly as a result of relatively sudden blockage of TM by iris

A

Acute PAC

505
Q

Used to differentiate between appositional and synechial angle closure

A

Dynamic gonioscopy

506
Q

Diagnosis?
High IOP, iris bombe, corneal epithelial edema, conjunctival injection, shallow AC, mild AC c/f, mid-dilated sluggish irregularly shaped pupil

A

Acute PAC

507
Q

The ff findings point out to ___________.

  • sectoral IA
  • pigmentary dusting
  • iris sphincter muscle ischemia
  • glaucomflecken
A

IOP induced ischemia

508
Q

Management of acute attack

A

Do LI/Pupilloplasty
Then do PIR
Pilo, CAI, BB, a-agonist, hyperosmotics
Dynamic gonioscopy

509
Q

Cholinergic agents such as pilocarpine 1-2% may be used for acute PAC. However, strong concentration should be avoided because…?

A

It can increase pupillary block

510
Q

What is the risk for a fellow eye to develop acute attack if the other eye has an episode of acute PAC?

A

40-80% over 5-10 years

511
Q

Examples of provocative tests for occludable or narrow AC angle?

A

Dilation
Dark room prone position test
IOP increase of 8 or more is a positive result
Asymmetric pressure rise is also a positive result.

512
Q

Indication for iridotomy

A 
Narrow angle w/
appositional/near appositional closure
PAS
increase segmental TM pigmentation
Hx of previous angle closure
(+) provocative test result
513
Q

True or false

The ff may precipitate angle closure:
Drugs, pain, emotional upset, fright

A

True

The ff may precipitate angle closure:
Drugs, pain, emotional upset, fright

514
Q

True or false

In predisposed eyes with shallow AC’s, mydriatic/miotic agents can precipitate angle closure

A

True

515
Q

MOA of miotics

A

Pulls peripheral iris away from AC but relaxes zonules (lens iris interface moves forward)
Do gonio aftr giving this

516
Q

Drugs that can precipitate angle closure

A 
sympa/parasympathetics
allergy and cold meds
antidepressants
dapiprazole
thymoxamine
urological drugs
517
Q

Diagnosis?

Episodes of BOV, halos, mild pain, caused by increase IOP. Symptoms resolve spontaneously. Normal IOP between episodes.

A

Subacute/intermittent angle closure

518
Q

Creeping angle closure, persistence of synechial closure after acute attacks. Presence of permanent PAS.

A

Chronic Angle Closure

519
Q

Options for chronic angle closure

A 
Peripheral iridectomy
Argon laser gonioplasty
GSL
Filtering procedures
Iridoplasty
520
Q

Atypical AC angle configuration; angle closure caused by ciliary processes positioned anteriorly which push peripheral iris forward; (+) pupillary block component

A

Plateau iris

521
Q

More anterior junction of iris dilator muscle to ciliary epithelium, w/c causes the iris root to be more articulated

A

Plateau iris

522
Q

How is plateau iris confirmed?

A 
Gonioscopy (double hump sign)
UTZ biomicroscopy (CB rotated)
523
Q

Management of plateau iris

A

LI
Long term miotic
Laser PIR

524
Q

Diagnosis?

Intumescent lens, relative pupillary block, shallow AC, iris bombe

A

Phacomorphic glau

Due to mass effect

525
Q

Management of phacomorphic glaucoma

A

LI then LE

526
Q

Causes of ectopia lentis

A 
ExS
Trauma
Marfan
Homocystinuria
Microspherophakia
Weill-Marchesani
527
Q

Management of ectopia lentis

A

LI

lensectomy - definitive

528
Q

How do cycloplegics treat pupillary block?

A

Tightens zonules, flattens lens, pulls lens posteriorly

In contrast, miotics would rotate the CB forward and loosen the zonules, allowing the lens to be more globular

529
Q

MC form of acquired zonular insufficiency and crystalline lens subluxation

A

Exfoliation syndrome

530
Q

MC causes of NVG

A

DM, CRVO, carotid occlusive disease

531
Q

Management of NVG

A

PRP, PR cryo (hazy media), anti-VEGF, medical, surgical or laser tx
Topical meds, filtering sx, GDD (rocedure of choice)
Failure - endoscopic/transcleral cyclophotocoagulation

532
Q

Where do NV’s start to develop in NVG?

A

Pupillary margin

533
Q

Diagnosis?

Severe progressive IA
Heterochromia
Corectopia
Ectropion uvea
Iris stromal and pigment atrophy
Hole formation
A

Essential iris atrophy

534
Q

MC in the spectrum of ICE. Minimal IA and corectopia Cornea and angle findings predominate.

A

Chandler (50%)

535
Q

Subset of ICE.

Presence of tan pedunculated nodules and diffuse pigmented lesions on iris. IA is less severe.

A

Cogan-Reese

536
Q

Corneal endothelium findings in ICE:

A

(+) filopodial processes, cytoplasmic actin filaments

Asymmetric loss of endothelial cells in one eye.

537
Q

Epithelium invades AC thru wound

A

Epithelial downgrowth

538
Q

Risk factors for epithelial/fibrous ingrowth

A 
Prolonged inflammation
Wound dehiscence
Delayed closure
DM tear
DSAEK
539
Q

Management of epithelial/fibrous ingrowth

A

Argon laser - white burn on TM

540
Q

Thick gray-white vascular retrocorneal membrane with irregular bands

A

Fibrous ingrowth

541
Q

Group of disorders characterized by abnormal corneal enothelium that cause varying degrees of IA, sec ACG, corneal edema. More common in women bet 20-50 y/o.

A

ICE syndrome

542
Q

Characteristic findings in ICE

A

Beaten bronze corneal endothelium

High PAS

543
Q

Management of ICE

A 
Addressed inc. IOP by aqueous suppressants
Filtering procedures (shunts)
544
Q

Devastating complication following ocular surgery in pts with angle closure, cataract surgery or laser procedures in OPEN ANGLE patients

A

Malignant glaucoma

545
Q

Findings in aqueous misdirection

A

Anterior rotation of CB, posterior misdirection of aqueous

546
Q

Fluid accumulation at the potential space bet choroid and sclera; anterior rotation of CB; forward displacement of lens-iris diaphragm

A

Uveal effusion

547
Q

Treatment of uveal effusion:

A

aqueous suppressants and steroids

548
Q

How does retinal surgery cause glaucoma?

A

Shallowing of AC angle due to buckling

Injection of air, gas, silicon oil

549
Q

How do PFV and ROP cause glaucoma?

A

Contracture of retrolental tissue and forward displacement of lens-iris diaphragm.

550
Q

Small normal shaped eye
Shortened AP diameter <20 mm
Small corneal diameter
Relatively large lens

A

Nanophthalmos

551
Q

Management of nanophthalmos

A

LI, ALPIR, medical therapy

AVOID surgery; high risk for choroidal effusion

552
Q

Anti-epileptic and anti-depressant known to cause acute myopic shift and acute bilateral ACG within one month of use

A

Topiramate

553
Q

Management of drug-induced increased IOP?

A

D/c medication
Aqueous suppressant
Cycloplegia

554
Q

How does PFV cause glaucoma?

A

Contracting retrolental tissue causes progressive AC shallowing. Becomes cicatricial in 3 to 6 months. Usually unilateral and associated with microphthalmos ad elongated ciliary processes.

555
Q

GDI are indicated for all except:

a. elevated IOP despite max medical tx
b. failed trab
c. conjunctival scarring
d. poor prognosis for success of trab
e. ICE syndrome

A

a. elevated IOP despite max medical tx

Trab would be indicated

556
Q

1 week post trab, flat AC, iris-cornea touch but NO LENS-CORNEA TOUCH, AT 0, choroidal effusions, (+) Seidel’s. Single most important step?

A

Close leak

557
Q

True of elevated EVP

a. may be seen with facial hemangiomas
b. can cause collapse of Schlemm’s canal and an increase in aqueous humor resistance
c. causes 1mmHg inc in IOP for every 1mm increase in EVP in acute conditions
d. AOTA

A

AOTA

558
Q

Measured IOP tends to be (higher/lower) for eyes with low scleral rigidity

A

Lower

559
Q

S/p LASIK for myopia. IOP using AT will be _____.

A

falsely low

560
Q

D1 post trab
Flat AC, flat bleb, high IOP
Consider the ff except:
a. failing bleb, b. pupillary block, c. malignant glau, d. suprachoroidal hge?

A

a. failing bleb

561
Q

70/F
red and painful eye
hazy cornea, (+++)c/f, (-) KP’s, dense cataract, open angle

A

Phacolytic glau

562
Q

In CNTG, progresion was reduced by neearly threefold by a reduction of the IOP by?

A

30%

563
Q

In an eye with CCF, least IOP lowering effect (Topical cholinergic, B-antagonist, CAI, PA)

A

Topical cholinergic therapy

564
Q

Best a-adrenegic agent for glaucoma patient who is 10 years old?
brimonidine, timolol, betaxolol, pilocarpine

A

brimonidine

565
Q

Vessel supplying the surface nerve fiber layer of the ONH?

a. SPCA, b. peripapillary choroidal vessels, c. pial vessels, d. CRA

A

CRA

566
Q

Eye condition least likely to be associated with aqueous misdirection syndrome:
a. ACG, b. uveitis, c. myopia, d. nanophthalmos

A

MYOPIA

The rest are “small” eyes

567
Q

Reliability of VF testing becomes suspect when pupil diameter decrease below what mm?
(4, 3, 2, 1?)

A

3 mm

2.5 mm in AAO

568
Q

What commonly causes failure to control IOP after glaucoma filtering surgery?
a. mild AC, b. choroidal det, c. episcleral fibrosis, d. overfiltration

A

c. episcleral fibrosis

569
Q 
50 y/o
BCVA OD 20/20 OS 20/25
IOP OD 17 OS 16
CDR 0.6 OS 0.7
On latanoprost HS OU with miimal conjunctival congesion.
0.2 dB/year. Next mgt?
a. add BB
b. shift to another PGA
c. request OCT ONH
d. cont latanoprost HS OU
A

d. cont latanoprost HS OU

570
Q

40/M
VA 20/20 OU, IOP 21 OU, CDR 0.5 OU, slight shallow AC, ATM to CBB all quadrants. Managemet?
a. perform LI OU b. perform LI one eye at a time c. request OCT ONH d. observe

A

d. observe

571
Q

Indications for surgical interventon after traumatic hyphema includes ff except
a. corneal blood staining, b. prolonged presence of a large clot after 15 days, c. rebleeding, d. IOP greater then 45 mm Hg despite max-tolerated topical and systemic medications

A

rebleeding

572
Q

Proper sequence of conventional outflow

A 
TM
Schlemm's canal
Collector channels
Aqueous veins
Episcleral veins
Orbital veins
Cavernous sinus
573
Q

1 y/o with congenital glau. Least important evidence of progression?

a. inc AL
b. amblyopia
c. inc. horizontal diameter
d. inc. myopia

A

Amblyopia

You can’t measure progression

574
Q

According to GLT, all of the ff are true /

a. ALT is at least as effective at reducing IOP as one glaucoma medical agent, timolol.
b. the majority of pts treated with laser first did not require any additional meds to maintain IOP control c. laser-treated eyes had a slightly lower IOP than medication treated eyes, D. ALT is a safe alternate and may be offered as initial herapy to POAG patients

A

b. the majority of pts treated with laser first did not require any additional meds to maintain IOP control

575
Q

Surgical procedure used to manage congenital glaucoma involves surgery from an ab interno approach
a. GDD, b. trabeculectomy, c. trabeculotomy, d. goniotomy

A

Goniotomy

576
Q

Pt underwent uncomplicated trab. D1, IOP 40 mm Hg. Pt has a deep, patent PI, low bled and the posterior segent was remarkable. IOP falls to 12 mmHg and bleb rose. After 4 hours, IOP 37. Mgt?
a. continue massage, b. LSL, c. LI, d. reinstitution of medical therapy, e. IV mannitol

A

LSL

577
Q

Initial management for blebitis?

A

Topical fortified antibiotic therapy

not IV antibiotic therapy, not PPV, not injection of antibiotics in AC

578
Q

True or false

Decreased pigmentation is common ff ocular trauma with hyphema

A

False

Increased pigmentation is common ff ocular trauma with hyphema

579
Q

Mechanism of secondary angle closure for the ff:

Intumescent lens, microspherophakia, ectopia lentis

A

Pupillary block

580
Q

Important first step for NVG?

A

PRP

or anti-VEGF?

581
Q

In an eye with a shallow chamber, which of the ff will be the primary basis in performing a laser PI?

a. elevated IOP
b. gonioscopic findings
c. cupping
d. VF loss

A

GONIOSCOPIC FINDINGS

582
Q

In which case would a laser PI most likely relieve angle close glau?
(pseudophakic pupillary block, angle close glau post PKP, NVG, ICE)

A

pseudophakic pupillary block

583
Q

Post filtering surgery complication that requires the most urgent surgical management?

A

Shallow AC with lens-cornea touch

584
Q

Endophthalmitis 2 years after glau filtering surgery?

A

Strep pneumoniae

585
Q

18M, 5 yr hx of unilateral IOP 40-50
Fine KP’s and faint flare during episodes
Mild ciliary flush
No iris changes

A

Posner-Schlossman syndrome

586
Q

2M with cutaneous facial redness, ipsilateral glau, hemiplegia. Diagnosis?
Sturge Weber, Nevus of OTA, NF, Tuberous sclerosis

A

Sturge-Weber

587
Q

Complication of trab increased with use of anti-fibrotics?

Blebitis, AMS, CME, encapsulated bleb

A

Blebitis

588
Q

Improper use of wc lens can lead to false narrow angles

Zeiss, Posner, Sussman, Goldman

A

Goldman

589
Q

Variant of ICE predominantly with corneal changes with minimal iris abnormalities?

A

Chandlers’s syndrome

590
Q

Tissue loss starts in what structure of the eye

A

lamina cribrosa

591
Q

Which is closer to the nerve? beta or alpha PPA?

A

Beta

Binner, Auter

592
Q

Rate of aqueous humor formation

A

2-3 ul/min

593
Q

True or false

Trabecular outflow is pressure-sensitive
Uveoscleral outflow is pressure-insensitive

A

True

Trabecular outflow is pressure-sensitive
Uveoscleral outflow is pressure-insensitive

594
Q

Area of TM with highest resistance

A

JuXtacanalicular

Resist your X!

595
Q

Antichonlinergics, steroids, ketamine, LSD, topiramate can ____ IOP

A

INCREASE

596
Q

Effect of elevated body temperature on the IOP

A

Increase aqueous humor production

597
Q

Alcohol, heroine, marijuana can ____ IOP

A

DECREASE

598
Q

Time when IOP is highest

A

early AM when still asleep

599
Q

Causes of artificially high IOP

A

Thick CCT
Corneal scarring or band K
breath holding, Valsalva

600
Q

Common artifacts in VF

A

Lens rim - may project into central 30 degrees
Incorrect corrective lens - gen depression
partial eyelid ptosis - artificial superior VF defect
cloverleaf VF - pt stops paying attention, malingering
high false positive rate
high false negative, generalized field depression - high gen field depression can cause high false negative

601
Q

Mechanism of secondary glaucoma in topiramate use

A

Acute myopic shift
Acute bilateral angle closure

Management - dc topiramate
IOP resolves in 1 to 2 days
Myopia resolves in 1 to 2 weeks

602
Q

Side effect of PGA

A

Parang glam make up.
Smoky eyes, sunken eyes, long lashes
+CME

603
Q

Do IO before giving this drug:

A

Pilocarpine

604
Q

Gene associated with PEX Syndrome

A

LOXL1

605
Q

PEX is usually (unilateral or bilateral).

A

Unilateral

606
Q

Associated with a concave iris configuration

A

Pigment dispersion syndrome

607
Q

True or false

Goniotomy and GSL are ab interno procedures.

A

True.

Goniotomy and GSL are ab interno procedures.

608
Q

NVG. Tube vs Trab?

A

Tube

609
Q

If you see a double-hump sign on gonioscopy, next step?

A

LI

LI muna bago PIR.

610
Q

Characteristic of bleb when there is overfiltration

A

HIGH

If bleb is flat, may ibang pinupuntahan ang aqueous

611
Q

Causes of CB shutdown

A

Inflammation
Chemical Toxicity
Ischemia

Just observe

612
Q

Primary differential for patient with severe sudden onset eye pain after trabeculectomy

A

Suprachoroidal hemorrhage

613
Q

Posterior diversion and pooling aqueous in vit

Uniform shallowing or flattening of AC

A

Malignant glaucoma

614
Q

How to differentiate blebitis from bleb-related endophthalmitis?

A

Vitreous is clear in blebitis

Patient may retain pre-blebitis VA

615
Q

Associated with increased risk or converting from ocular hypertension to POAG?
decreasing age, hx of DM, reduced CCT, small CDR

A

reduced CCT

C.EyeMD (8 decks)

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