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Medical conditions > Glaucoma > Flashcards

Glaucoma Flashcards

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USMLE® Step 1 flashcards
1
Q

What is glaucoma?

A

A group of eye conditions that damage the optic nerve, often due to high intraocular pressure (IOP).

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2
Q

What are the types of glaucoma?

A

Primary open-angle glaucoma (POAG), angle-closure glaucoma, secondary glaucoma, congenital glaucoma.

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3
Q

Most common type of glaucoma.

A

Primary open-angle glaucoma (POAG)

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4
Q

Pathophysiology of primary open-angle glaucoma

A

Resistance to outflow at the level of the trabecular meshwork (?stiffening), leading to ↑IOP.

Chronic ↑IOP → damage to the optic nerve head → progressive loss of retinal ganglion cells and optic nerve fibre layer thinning.

Leading to optic nerve damage and visual field loss.

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5
Q

Epidemiology of primary open-angle glaucoma (POAG).

From which age group and ethnicity?

A
  • > 40, increasing with age.
  • african/afro-caribbean populations
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6
Q

What are the risk factors for glaucoma?

List 5

A

Age, family history, ethnicity, high IOP, myopia, diabetes, hypertension, steroid use.

High IOP is the most significance RF

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7
Q

What are the symptoms of primary open-angle glaucoma (POAG)?

Characterise the vision loss.

A

Often asymptomatic in early stages;

If symptomatic: gradual loss of peripheral vision, then progressing centrally. > tunnel vision.

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8
Q

A 60-year old patient comes in for a routine eye appointment.

What tests will help screen for glaucoma (open-angle)?

List 4 tests.

A
  • Applanation tonometry - eye pressure test (IOP measurement).

Optic nerve/visual field:

  • Retinal exam/Fundoscopy/slit lamp : optic disc (cup-to-disc ratio)
  • automated perimetry: Visual field test
  • Visual acuity test

Angle of anterior chamber- goinoscopy

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9
Q

How is the angle in the anterior chamber of the eye measured?

A

Goinoscopy

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10
Q

What is considered elavated IOP?

A

> 21 mmHg

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11
Q

How is intraocular pressure (IOP) measured?

A

Applanation tonometry

Goldmann-type
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12
Q

Automated test to measure visual field defect.

A

Perimetry

Peri- peripheral eyes

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13
Q

How is the retina visualised and tested?

A
  • Fundoscopy
  • OCT (optical coherence tomography)
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14
Q

What is optic nerve assessment?

A

Stereoscopic slit lamp biomicroscopy with pupil dilation if necessary.

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15
Q

What is Optical Coherence Tomography (OCT)?

A

Imaging of the optic nerve head and retinal nerve fiber layer.

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16
Q

What is gonioscopy?

A

Assessment of the anterior chamber angle.

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17
Q

How is open-angle glaucoma diagnosed?

A
  1. characteristic optic nerve damage and
  2. visual field defects, in conjunction with elevated IOP.
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18
Q

Why can’t glaucoma be diagnosed soley based on raised IOP?

Consider a normal IOP and a raised IOP differential.

A

Similar optic nerve damage and visual field loss can occur with normal IOP.

While raised IOP may not progress to glaucoma - and is just ocular hypertension.

This is called ‘Normal-Tension Glaucoma’: treated in basically the same way as POAG

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19
Q

IOP threshold for treatment (intraocular hypertension and glaucoma).

A

> 24 mmHg

Raised IOP = >21 mmHg

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20
Q

Treatment of glaucoma is under …?

A

Ophthalmologists.

21
Q

First-line management of primary open-angle glaucoma/OTN.

How does it work?

A

360° Selective Laser Trabeculoplasty (SLT)

SLT helps reduce IOP by improving aqueous outflow through the trabecular meshwork.

22
Q

Why is Selective Laser Trabeculoplasty (SLT) preferred as first-line treatment for open-angle glaucoma?

A

Delays the need for eye drops and a reduced risk of long-term medication use.

However, potential side effects include transient discomfort, blurred vision, and photophobia.

A second SLT may be necessary if the initial effect diminishes over time.

23
Q

What are the referral criteria for glaucoma?

A

Optic nerve head damage, visual field defect consistent with glaucoma, or IOP ≥ 24 mmHg.

24
Q

What are the 2 main pharmacological principles in treating raised IOP?

A
  1. Increased uveoscleral outflow
  2. Reduce aquous production
25
Q

Which medications increase uveoscleral flow?

A
  • PGA e.g. latanoprost.
  • A2-agonists e.g. brimonidine
  • Miotics e.g. pilocarpine
26
Q

Which medications decrease aqeous production in glaucoma?

List at least 2

A
  • beta blockers e.g. timolol
  • Carbonic anhydrase inhibitor e.g. dorzolamide (topical)
  • A2-agonist e.g. brimonidine
27
Q

What is the first-line pharmacological treatment for glaucoma/ocular hypertension? (Second-line for glaucoma)

A

Prostaglandin analogues (e.g., latanoprost).

Increases uveoscleral flow.

28
Q

Second-line/adjunctive pharmacological treatment of ocular hypertension/glaucoma (>24mmHg)

If prostaglandin is tried or unsuitable.

A
  • Topical beta-blocker.
  • Switching to, or adding in, topical sympathomimetic (alpha-2-agonsit), a topical carbonic anhydrase inhibitor, a topical miotics or a combination of treatments.
29
Q

When are beta-blockers used in glaucoma treatment?

A

If prostaglandin analogues are contraindicated or not tolerated.

30
Q

What are carbonic anhydrase inhibitors?

A

Topical (e.g., dorzolamide) or systemic (e.g., acetazolamide).

31
Q

What is the different indications for topical vs systemic carbonic anhydrase inhibitors in glaucoma?

A

Used systemically (acetazolamide) if high IOP needs to be decreased rapidly, i.e. in acute angle-closure glaucoma where pressure is often very high and vision is threatened.

32
Q

Which beta-blocker is used topically for glaucoma?

A

Timolol

33
Q

List an alpha agonist used in glaucoma management

A

Brimonidine

34
Q

What does monitoring for primary open-angle glaucoma involve?

A

Regular follow-up with IOP measurement, visual field testing, and optic nerve assessment.

35
Q

Why is regular monitoring and treatment compliance important in glaucoma?

A

It is a chronic, progressive condition. I.e. damage to retina is irreversible.

Prevention of blindness/severe visual defects rely on good management.

36
Q

What is a surgical option for open-angle glaucoma if conservative measures fail?

A

Trabeculectomy (creating a new drainage pathway), glaucoma drainage devices.

37
Q

What lifestyle modifications can help with glaucoma?

A

Regular exercise, healthy diet, avoiding smoking.

38
Q

What is Acute Angle-Closure Glaucoma (AACG)?

A

An ophthalmic emergency characterised by a rapid increase in intraocular pressure (IOP) due to the sudden blockage of the drainage angle in the eye

39
Q

Pathophysiology of acute angle-closure glaucoma.

A

Sudden obstruction of the trabecular meshwork (therefore causing a reduction in the anterior chamber angle → this blocks the outflow of aqueous humour → leading to a sudden rise in IOP.

The elevated pressure can cause optic nerve damage and visual field loss. Factors contributing to angle closure include pupil dilation, lens growth with age, and anatomical predispositions

40
Q

Which epidemiological features might make you suspect closed-angle glaucoma?

A
  • Increased age (>60)
  • Female
  • East Asian/inuit descent
  • hyperopia (farsightedness)
  • family history
41
Q

What are the symptoms of angle-closure glaucoma?

A

Sudden, severe eye pain, blurred vision, halos around lights, with systemic features e.g. headache, N/V.

Hard and tender red eye, fixed pupil semi-dilated.

42
Q

A 60 y/o patient complains of a recurrent, unilateral eye pain and blurry vision whenever she enters a dark room/ during night time. It is self-remitting.

What might you be worried about?

A

Chronic angle-closure glaucoma – which can develop into an acute episode.

43
Q

What is the emergency management principles for acute angle-closure glaucoma?

A
  1. Immediate referral to ophthalmology,
  2. medications to lower IOP, and later, possible laser or surgical intervention.
44
Q

Which 2 emergency medication (interim) may be given in a primary setting for acute angle-closure glaucoma?

A
  • pilocarpine eye drops, one drop of 2% in blue eyes or 4% in brown eyes;
  • acetazolamide 500 mg orally

Let the person lie flat with their face up and head not supported by pillows, as this may relieve some of the pressure on the angle.

CKS 2023

45
Q

Key diagnostic tests in suspected acute angle-closure glaucoma.

A

Slit-Lamp Examination: Reveals a shallow anterior chamber, corneal oedema, and a fixed, mid-dilated pupil.

Tonometry: Shows a significantly elevated intraocular pressure (IOP), will be above >21 mmHg but is typically above 40 mmHg.

Gonioscopy: It is the gold standard for confirming angle closure.

46
Q

Principles of immediate treatment vs definitive treatment in acute angle-closure glaucoma.

A

Immediate: decreased IOP to prevent permanent retinal damage.

Definitive: create flow.

47
Q

Immediate treatment of acute angle-closure glaucoma in secondary care.

List 4 medications

A

To decrease aqeuous production:
* Beta-blocker i.e. timolol
* carbonic anhydrase inhibitor e.g. systemic - acetazolamide.
* A2-agonist
* IV mannitol (hyperosmotic agent that draws fluid out of vitreous)

To open up the channel (miosis)
* Mioitics e.g. pilocarpine
* Steroids

https://cks.nice.org.uk/topics/glaucoma/management/acute-angle-closure-angle-closure-glaucoma/

48
Q

Definitive treatment of acute angle-closure glaucoma.

A

Bilateral laser peripheral iridotomy. (LPI)

Do in both eyes due to unaffected eye is also at high risk

Laser- minimally invasive and quick compared to trabeculectomy.

Medical conditions (38 decks)

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