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DDX > GLAUCOMA > Flashcards

GLAUCOMA Flashcards

1
Q

increased pigmentation of angle

A
  1. PDS (uniform)
  2. PXF (patchy, sampaolesi)
  3. surgery
  4. trauma
  5. inflammation
  6. hyphema
  7. angle closure
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2
Q

causes of arcuate defect

A

glaucoma

AION / NAION

disc drusen

BRVO / BRAO

optic nerve pit w/ serous detachment

optic nerve coloboma

myelinated nerve fibers

optic neuritis / C-R’itis

retinoschisis

retinitis pigmentosa

papilledema

laser

high myopia

shock optic neuropathy

melanocytoma

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3
Q

visual field defect with clear cut edge

A

Hyperope Rx (+6.00D on 30-2)

Brain surgery removed

Absolute defect in retinoschisis

RP

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4
Q

enlarged blind spot

A

Structural causes

  • Large disc/megalopapilla
  • ONH drusen
  • High myope

Eye disease

  • Early papilledema
  • Chronic papilledema
  • Early glaucoma
  • AIBSE (acute idiopathic B.S. enlargement)
  • MEWDS
  • diabetic or hypertensive papillitis
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5
Q

large disc > 4.09 mm2

A

physiologic

megalopapilla

high myopia

morning glory/pits

congenital glaucoma

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6
Q

small disc < 1.29 mm2

A

physiologic

high hyperopia

hypoplasia

drusen

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7
Q

thickest rim and most susceptible to glaucoma

A

thickest: I>S>N>T

most susceptible: I>S>T>N

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8
Q

K spindle

A

Age

PXF

PDS

Trauma

Surgery

Hyphema

Uveitis

Melanoma

Nevus of Ota

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9
Q

hyphema in an adult

A

Systemic causes

  • Bleeding diathesis – anemia – sickle cell
  • Anticoagulation
  • Leukemia / lymphoma
  • Behcet’s / HLA-B27

Local causes

  • Iris tumour
  • NVI
  • HSV / VZV
  • Fuchs
  • ocular surgery
  • UGH
  • trauma
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10
Q

causes of ectropion uvea

A

ICE
AR

uveitis

PPMD

NF-1

NVG

epi downgrowth

isolated congenital anomaly

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11
Q

causes of epi down growth

A

ECCE #1

PK

Glaucoma sx

Penetrating trauma

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12
Q

risk factors for OAG

A

IOP

Age

Race

FHx

thin CCT

(C:D, VF severity)

Soft: DM / myope / CRVO/ HTN/CVD

ass systemic diseases: sleep apnea, myopia, DM, BP, CRVO, migraine, thyroid, raynauds, hyperlipid

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13
Q

Risk factors for NTG

A

Female

Migraine

Disc H

Vasospasm / Raynauds

Smoking

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14
Q

risk factors for ACG

A

I Age

Race

Sex (F > M)

Hyperope

FHx

ocular biometrics

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15
Q

blacks vs white disease

A

3 – 6x white OAG

earlier onset (1 decade)

HIGHER IOP

Larger c:d ratios / ONH

More BLIND (8x increased risk)

Thinner cornea (CCT thin = underestimate)

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16
Q

causes of increased EVP

A
  1. AVM - SWS, AV fistula- carotid or dural cavernous sinus, orbital varix
  2. Venous obstruction -
    1. local - thyroid, retrobulbar tumour, CS thrombosis, orbital vein thrombosis
    2. systemic - CHF, SVC syndrome
  3. idiopathic
17
Q

blood in schlemms

A

artifact of goniolens occluding episcleral veins

high episcleral venous pressure

  • idiopathic uveal effusion syndrome
  • Sturge-Weber
  • carotid-cavernous fistula
  • dural-cavernous fistula
  • orbital AV fistula
  • retrobulbar tumor
  • mediastinal tumor
  • superior vena cava obstruction

low IOP

  • inflammation
  • hypotony
  • following trabeculectomy

normal eye

18
Q

unilateral IOP rise with uveitis

A

Trabeculitis (stellate KP – HSV / VSV / FHI / Posner / toxo / sarcoid / syphilis)

Lens-related (lytic / anaphylactic /particle)

UGH

Other: JRA (20%)

HLA-B27 (Reiter’s)

Lyme

TB

VKH

Behcet’s

19
Q

Causes of NVI NVA

A

DDx - NVI/NVA - 97% d/t ischemia – 3% d/t inflammation d/o

ocular vascular dz

  • DR (30%)
  • CRVO (30%) – 90 day glaucoma
  • CRAO / BRVO
  • ROP / FEVR / Eales
  • sickle cell
  • Coats disease
  • PHPV
  • syphilitic vasculitis
  • sarcoid
  • anterior segment ischemia

other ocular dz

  • ocular ischemic syndrome
  • chronic uveitis
  • chronic RD
  • endophthalmitis
  • Stickler syndrome
  • retinoschisis

Intraocular tumors

  • uveal melanoma
  • metastatic carcinoma
  • RB
  • reticulum cell sarcoma

ocular therapy

  • radiation therapy
  • postvitrectomy in DR

systemic vascular dz

  • carotid occlusive dz
  • carotid artery ligation
  • CCF
  • GCA
  • Takayasu (pulseless) disease

Trauma

Rare causes FHI, Uveitis, Iris melanomas, PXF

20
Q

ONH analyzers

A

HRT (Heidelberg Retinal Tomogram)

– confocal scanning laser- tomographic slices are manipulated to form a 3D construct, can calculate NFL measurements

GDx (Glaucoma Diagnostix)

– scanning laser polarimeter- takes advantage of hte birefringent properties of hte rNFL arising from parallel microtubules - as light passes through NFL polarization state changes, deeper layers of retinal tissue reflect light back to the detector where the degree to which polarization has changed can be recorded.

– polarized lite shift measures relative NFL thickness

OCT (Optical Coherence Tomography)

– interferometer; low coherence lite

– high resolution (10 um)

– measures absolute NFL thickness

21
Q

when to treat with cycloplegic

A

Pseudophake /aphake

ACIOL pupil block

Microspherophakia (pulls lens back – LIE on BACK!)

Malignant glaucoma

Post-SB (band too tight!) – pushes L-I back

Uveitis (posterior synechiae)

Cyclodialysis cleft (low IOP) – it closes it

22
Q

congenital glaucoma problems

A

whole eye:

  • anterior segment dysgenesis (A-Reigers / Peters)
  • nanophthalmos / microphthalmia
  • high hyperopia

cornea

  • sclerocornea
  • cornea plana
  • megalocornea
  • microcornea (closed angle)
  • aniridia: 50% get glaucoma

lens:

  • microspherophakia
  • dislocation DDX

retina / vitreous:

  • PHPV / ROP

nerve:

  • morning glory
23
Q

blind painful eye

A

Make sure correct dx – r/o malignancy! (B-scan)

Atropine / Pred Forte

Cauterize cornea

Retrobulbar EtOH / chlorpromazine (lasts 6 mos – 1 year & immediate results)

Cycloablation

! Laser (diode / trans-scleral YAG)

! Cryo

Enucleate / eviscerate (DEFINITIVE!)

24
Q

How do you define progression

A
  • need at least two confirmatory tests
  • in CNTGS used thresold testing - If two or more points within or adjacent to an existing scotoma worsened by at least 10 dB or three times the average of the short-term fluctuations= progression if seen on two further fields… may not apply to Swedish Interactive Threshold Algorithm (SITA) visual fields for two reasons. First, the short-term fluctuation is not measured in the SITA program. Second, a 10-dB change in full threshold may not be equivalent to a 10-dB change in a SITA field.
  • In EMGTS for the indication of likely progression, used the Glaucoma Progression Analysis software requires that three consecutive visual field tests contain three or more identical points that have changed at a statistically significant level
  • total dev plot two spots that are less than 5 % suspicious for defect…or one spot that is less than 1% repeat
25
Q

when are you worried about neuro disease

A
  1. optic nerve pallor out of proportion to degree of cupping
  2. VFD greater than expected based on amount of cupping
  3. VF patterns not typical of glacuoma
  4. unilateral progression of VFD despite equal IOP
  5. decreased visual acuity out of proportion to the amount of cupping or field loss
  6. color vision loss (esp in red green)
26
Q

OHTS who to treat

A
  • highest risk were those with IOP greater than 25.75 and CCT < 555 (36%)
  • patietns with CCT > 588 and IOP < 23.75 had the least risk (2%)
27
Q

Contraindications to SLT

A

ABSOLUTE

  1. uveitis
  2. congenital/developmental glaucoma
  3. ICE/NVG/PPMD
  4. PAS

Relative:

  1. Angle recession
  2. lack of effect in fellow eye
  3. advanced glaucoma
28
Q

Cx of ALT/SLT

A
  1. IOP spike 1-4 hours after treatment
  2. IOP increased requiring filtering sugery
  3. hyphema
  4. PAS
  5. rarely - corneal opacity

RECALL risk factor for IOP spike after ALT/SLT: higher energy level, 360 degree treatment, posterior placement of burns, more heavily pigmented angle

29
Q

Mechanism for steriod response

A
  1. increased extracellular matrix layed down in TM (increased GAGs)
  2. decreased migration of macrophage to clear out extracellumar matrix
  3. swelling of TM
  4. inflammatory cells blocking TM

RECALL: risk factors for IOP response: known POAG, family history, age, DM, mypopia

RECALL: steriods take 4-6 weeks on avg to get response, IOP should decrease by 2 months

30
Q

Risk for re bleed

A
  1. Hypotony or increased IOP
  2. 50% or greater hyphema
  3. systemic HTN
  4. ASA
  5. black

Recall: 5-10% chance of re bleed, with re bleed 50% change increased IOP, 5-10% chance of glaucoma with >180 degrees of angle recession

31
Q

Mechanisms of angle closure

A

PUSHING

pupillary block, aqueous misdirection, ciliary body swelling, anteriorly located ciliary processes, choroidal swelling, serous or hemorrhagic detachments or effusions, posterior seg tumours, contracting retrolental tissue, anteriorly displaced lens, encircling bands

PULLING

contraction of inflammatory membrane or fibrovascular tissue, migration of corneal endothelium (ICE, PPMD), fibrous ingrowth, epi ingrowth, iris incarceration

32
Q

bleb failure risks

A
  1. ant seg NV
  2. black race
  3. aphakia
  4. young
  5. prior CE IOL
  6. uveitis
  7. prior failured filtering procedures
33
Q

risk factors for endophthalmitis

A
  1. bleb leak, inferior or nasal bleb, high bleb
  2. intraoperative MMC
  3. conjunctivitis/blepharitis/ NLD obstruction
  4. upper respiratory infection
  5. diabetes
  6. trabeculectomy alone compared to combined procedure
  7. chronic antibiotic us
  8. CL use
  9. male
  10. young
34
Q

risk factors for blebitis

A
  1. bleb leak
  2. intraoperative MMC
  3. antibiotic use after the postoperative period
  4. high axial length
  5. conjunctivitis
  6. upper respiratory infection,
  7. winter season
35
Q

complications of filtering surgery

A

early

  • infection
  • hypotony
  • shallow or flat AC
  • aqueous misdirection
  • hyphema
  • transient IOP elevation
  • CME

late

  • leakage or failure
  • cataract
  • blebitis
  • endophthalmitis
  • dysesthetic bleb
  • bleb migration
  • hypotony
  • maculopathy
  • ptosis
  • plate migration
  • tube occulsion
  • eyelid retraction

DDX (6 decks)

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