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OD3 - Clinical Optometry Practice > DIS - Secondary Glaucoma I - Week 4 > Flashcards

DIS - Secondary Glaucoma I - Week 4 Flashcards

1
Q

List 5 common causes of secondary glaucoma.

A

Caused by trauma
Associated with ocular disease/degeneration
Associated with systemic disease/disorder
Iatrogenic secondary glaucoma
Caused by inflammation

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2
Q

What is the most common cause of secondary glaucoma? List three common mechanisms.

A

Restriction to aqueous circulation or trabecular outflow

  • due to trauma
  • pseudoexfoliation
  • pigment dispersion
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3
Q

If IOP is <24mmHg in secondary glaucoma, what is often all thats required in management?

A

Treat the underlying disorder, this is often all thats needed for IOP <24mmHg

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4
Q

If IOP is elevated (≥24 for 7 days or ≥30mmHg for 24h) what is the course of action (2)? When should the review be and what is expected?

A

Apply aqueous suppressents aggressively depending on IOP
Apply outflow modulators as needed (q5min x2 then prn)
Review in 24h, if IOP remains high (30+) with therapy, consider prompt referral for surgical intervention

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5
Q

Consider elevated IOP (30+) on review even with therapy. what is the main concern (3)?

A

Retinal vein occlusion
Iris ischaemia
RGC loss

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6
Q

How does the urgency of referral for surgical intervention compare in IOP of 24-30 vs 30+ (assuming after therapy)?

A

24-30 can wait a week

Prompt referral for 30+ IOP

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7
Q

What are the two most likely causes of secondary glaucoma with high IOP (30+)?

A

Primary angle closure (iridocorneal endothelial syndrome)

Trabeculitis

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8
Q

Consider the course of action taken for secondary glaucoma with high IOP (30+). Explain the logic behind why it is done in this manner (2). Also name the condition this high IOP can potentially cause.

A

Apply aqueous suppressants aggressively

  • dealing with sick tissue
  • response is likely blunted at normal drug concentrations
  • high IOP has potential for central retinal vein occlusion
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9
Q

If IOP is >30 in secondary glaucoma, must IOP be reduced quickly or is there no rush?

A

IOP must be reduced quickly

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10
Q

Describe the protocol for secondary glaucoma with high IOP (5).

A 
Start with 1gtt pilocarpine 2% and timolol 0.5%
Repeat after 5 mins
Then timolol 0.5% QiD for 24h
Repeat above after 24h until IOP <30mmHg
Then maintain Rx prn
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11
Q

After what amount of time does timolol have maximal effect in healthy eyes?

A

By 1h after instilling

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12
Q

Consider the protocol for secondary glaucoma with high IOP. what does it tell you if it doesnt work (2)?

A

It should be enough for healthy tissue

-if it doesnt work, tissue is likely not healthy

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13
Q

Consider the protocol for secondary glaucoma with high IOP. What if IOP has not decreased sufficiently on review 24h later (2)? What should you check for?

A

Add acetazolamide 250mg po or CAI eyedrop TiD

Check for iridocorneal endothelial syndrome

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14
Q

Consider the protocol for secondary glaucoma with high IOP. What is an alternative to pilocarpine?

A

PGA (xalatan 0.005%)

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15
Q

What is the most likely cause of secondary glaucoma with moderate IOP (24-30mmHg for >1 week)? List four mechanisms for this.

A

Open angle with TM disorder

  • dysfunctional trabecular cells
  • dysfunctional schlemms canal endothelial cells
  • blocked TM
  • compromosed outflow
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16
Q

Consider secondary glaucoma due to compromised outflow. List two mechanisms of this.

A

Venous congestion

Scleral spur malfunction

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17
Q

What is the management of secondary glaucoma with moderate IOP (2)?

A

Aqueous suppressants

Increase uveo-vortex flow to bypass TM

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18
Q

Describe the protocol for secondary glaucoma with moderate IOP including eyedrops and review (3). Explain what to expect on review.

A

Timolol 0.5% BiD
Prosaglandin analogue (xalatan 0.005%) noce
Review in 24h
Expect 20-30% drop in IOP

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19
Q

Describe the two mechanisms of secondary glaucoma due to trauma (blunt trauma).

A

Blocked TM with debris following trauma
-pigment, blood, material
Break ciliary muscle insertions to scleral spur, reducing schlemms canal pmping, reducing outflow

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20
Q

What is the treatment for secondary glaucoma due to trauma (3)?

A

Aqueous suppressants
-timolol, PGAs
Surgery for iridodialysis

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21
Q

What are pseudoexfoliative syndrome and pigment dispersion manifestations of?

A

Age related manifestations of genetic weakness in anterior structures (iris)

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22
Q

What is pseudoexfoliative syndrome an abnormality of (2)?

A

Collar blood vessels of the iris and GAG synthesis

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23
Q

What is pigmentary dispersion an abnormality of (2)?

A

Abnormality in major blood vessels and collagen tissues of the iris

24
Q

In what race is pesudoexfoliative syndrome greatest in?

A

Northern europeans - scandinavians

25
Q

Does pesudoexfoliative syndrome incidence increase or decrease with age or is it the same across all age groups?

A

Increases with age

26
Q

Describe pesudoexfoliative syndrome. Is the optic nerve affected? What does it lead to (2)?

A

Dandruff-like flakes on the lens and iris
Optic nerve unaffected
Leads to IOP rise and spikes

27
Q

In what percentage of pesudoexfoliative syndrome patients does glaucoma occur?

A

50%

28
Q

in what percentage of pesudoexfoliative syndrome patients is glaucoma bilateral?

A

28%

29
Q

What are the symptoms of pesudoexfoliative syndrome (1)?

A

Asymptomatic

30
Q

List three objective signs of pesudoexfoliative syndrome.

A

White deposits on the anterior lens, iris, and TM
Iris transillumination at pupil margin
Pigment loss/dispersion from collar

31
Q

What is pigment loss/dispersion in pesudoexfoliative syndrome due to?

A

Iris hypoxia

32
Q

What is the main differential diagnosis for pesudoexfoliative syndrome?

A

Essential iris atrophy

33
Q

Describe essential iris atrophy and what it is due to (2). What happens pigment epithelium and what does it look like as a result?

A

Age related loss of tissue at the iris margin
-due to age related atherosclerosis and local hypoxia
Results in shrinkage of the pigment epithelium
-leaves a translucent stromal sheet at the collar

34
Q

Consider pesudoexfoliative syndrome. In what shape are sections of the pigment epithelium lost (2)?

A

Wedge shapes or crypts that join up

35
Q

What is essential to detecting pesudoexfoliative syndrome?

A

Need to dilate

36
Q

Describe the slit lamp technique to detecting pesudoexfoliative syndrome including what to look for (2).

A

Shine a spot into the iris and look for:

  • scalloped pupil margin with transillumination
  • exfoliative material - central plugs/sheets
37
Q

Can gonioscopy be used to detect pesudoexfoliative syndrome? Explain.

A

Yes, grade pigment and deposits in the angle

38
Q

Aside from physical examination of the eye with a slit lamp, how else can pupil dilation detect pesudoexfoliative syndrome and why?

A

Poor dilation - due to iris atrophy

39
Q

Describe the rationale on choosing between tropicamide and phenylephrine for dilating an eye with pesudoexfoliative syndrome.

A

Given hypoxia at the collar region, the dilator muscle may be more effective than the sphincter muscle at dilating

40
Q

What are two dilation considerations with a suspected case of pesudoexfoliative syndrome?

A

Glaucoma may already be present
-do not want IOP spike
Angle is narrow in some people with pesudoexfoliative syndrome
-gonioscopy before dilating recommended

41
Q

If a patient with pesudoexfoliative syndrome has VF/ON/RNFL changes, what is the conclusion? What should be done?

A

They have pesudoexfoliative glaucoma

Monitor for change

42
Q

What percentage of pesudoexfoliative syndrome patients will develop high IOP within 6 years of diagnosis/treatment? What percentage will progress to pesudoexfoliative glaucoma?

A

74% will develop high IOP

18% will progress to glaucoma

43
Q

What is the management for pesudoexfoliative syndrome (20?

A

Aqueous suppressants

PGAs to facilitate alternate outflow

44
Q

How common is pigment dispersion syndrome in individuals >70 years of age?

A

Rare

45
Q

What percentage of pigment dispersion syndrome patients will develop glaucoma?

A

35%

46
Q

Consider how the iris bends in pigment dispersion syndrome. What does pilocarpine do?

A

The iris bows posteirorly towards the iris

Low dose pilocarpine will stretch the iris and straighten it

47
Q

What is a symptom of pigment dispersion syndrome (1)?

A

Asymptomatic

48
Q

Can a history of heavy exercise cause pigment dispersion syndrome or is this just a myth?

A

Yes it can due to high IOP

49
Q

In what four locations can you find pigment in pigment dispersion syndrome?

A

anterior iris (mostly inferior due to gravita)
Lens capsule behind iris
Corneal endothelium
TM (with gonioscopy)

50
Q

What can be done with IOP measurement and dilation on a suspected case of pigment dispersion syndrome?

A

Always measure IOP first
Then dilate with tropicamide
Check for an IOP spike

51
Q

What are krukenberg spindles? What shape can it have?

A

Pigment collections on the corneal endothelium

Small little dots in the shape of a line or an inverted cone, base down

52
Q

What is the review for pseudoexfoliative syndrome / pigment dispersion syndrome?

A

Monitor 4-12 monthly depending on risk (according to pigment grade)

53
Q

What is the management for pseudoexfoliative syndrome / pigment dispersion syndrome (4)? Include what techniques to do and the schedule for them. What about for glaucoma?

A 
ON photo/image 12/12
VF 4/12
Gonioscopy with pigment grade 12/12
IOP every visit
-same for glaucoma with the inclusion of reducing IOP with meds
54
Q

Above what sustained IOP should you refer for pseudoexfoliative syndrome / pigment dispersion syndrome?

A

> 24mmHg sustained

55
Q

Are meds as effective for treating pseudoexfoliative syndrome / pigment dispersion syndrome?

A

No, not as effective

OD3 - Clinical Optometry Practice (114 decks)

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