Glaucoma Flashcards
POAG:
Symptoms: Asymptomatic until later stages which may include visual field defects.
Signs: IOP, Open angle on gonioscopy without PAS, loss of rim tissue on ONH, CD >0.6, VF defect (nasal step, paracentral scotoma, arcuate scotoma)
Treatment:
1. Prostaglandins (contraindicated in pregnant or those who want to become pregnant, active uveitis or CME)
2. Beta blockers (contraindicated in asthamtics, COPD, CHF) “-olols”
3. A2 receptor agonist “-idine”
4. CAI’s (contraindicated in slulfa allergy) “-amides”
5. ALT high energy, effective
6. SLT low energy with less tissue damage allowing for repeat
Follow Up: 4-6 weeks after inital treatment. Goal is 30% reduction in IOP. Once IOP is at adequate level, re-evaluate every 3-6 months, with annual gonioscopy, HVF and OCT
Low Tension POAG
POAG without IOP elevation
Signs: Drance heme. Believed to be related to poor vascularity (Raynaud’s Phenomenon)
Treatment: Lower IOP. Studies show Brimonidine 0.2% BID is superior to Timolol 0.%% BID in preveneting VF defect progression.
Ocular Hypertension:
Signs: IOP> 22 on two or more visits. Normal angle and ONH
Treatment: Not until IOP is >24. If above 24, consult with patient about treating. OHTS showed reduction in field loss from 9.5% to 4.4% in 5 years with a 20% average reduction of IOP
Acute Angle Closure
Symptoms: Nausea, pain, blurred vision, halos around lights, frontal headache, vomiting
Signs: CLosed angle, increased IOP, corneal edema, conj injection
Etiology: Pupillary block, PAS, neovascular membrane, lens-induced narrow angles, aphakic pupillary block Topiramate
Treatment: Compression gonioscopy to determine if the trabecular blockage is reversible. Topical therapy w/ B-blocker, alpha 2 agonist and CAI should be initiated immediately. In urgent cases, 3 rounds of each medication should be given with 15 minutes in between. Consider Systemic CAI, Acetazolamide 2 250 mg tablets in one dose.. Recheck IOP in 1 hour.
Glaucomatocyclitic Crisis/Posner-Schlossman Syndrome
Symptoms: Rare. Mild pain, decreased vision, rainbows around lights
Signs: High IOP (40-60), open angle, minimal conj hyperemia, mild AC rxn. Can mimic a mild anterior uveitis.
Treatment: Beta blockers, topical Alpha 2 agonist, topical CAI. Short course (1 week) of topical steroids to decrease inflammation. Oral indomethacin75-150 mg po daily or topical NSAID may be effective.
Follow Up: Every few days initially and then weekly until episode subsides.
Steroid response Glaucoma:
Signs: Increased IOP 2-4 weeks after using an ocular steroid.
Treatment: Stop steroid use, decrease the frequency or strength of steroid. Switch to NSAID, start anti-glaucoma therapy.
Consider anterior chamber paracentesis if IOP is dangerously high.
Pigment Dispersion Syndrome/Pigmentary Glaucoma
Symptoms: Mostly asymptomatic, but can have blurred vision, eye pain, and colored halos around lights, after exercise or pupillary dilation. Most common in young adult males (20-45). Generally bilateral, but asymmetric. May have risk of lattice and retinal detachment.
Signs: Midperipheral spokelike iris TIDs, dense pigmentation of TM on gonioscopy, krukenberg spindle on corneal endothelium, Sampaolesi Line. Pigment anywhere in the eye.
Treatment: Miotic agents (though not commonly used)
Main treatment is peripheral laser iridotomy to decrease the contact between iris and lens zonules, though this treatment is controversial. Anti-glaucoma meds. MIGS
Pseudoexfoliation Syndrome/Exfoliative Glaucoma
Symptoms: Generally asymptomatic
Signs: White flaky material on pupillary margin, bulls eye appearance on lens, peripupillary iris TIDs, glaucomatous optic neuropathy. Incidence increases with age.
Treatment: Anti-glaucoma medications.
Follow Up: every 1-3 months just with POAG.
Phacolytic Glaucoma
Symptoms: Unilateral pain, decreased vision, tearing and photophobia
Signs: Markedly increased IOP with white material in the AC. Severe pain, light perception.
Treatment: Remove cataract promptly. B-blocker, A-2 Agonist, CAIs, topical steroids.
Follow Up: Day after cataract surgery, then 1 week.
Plateau Iris
Symptoms: Asymptomatic
Signs: Persistent appositional angle after laser iridotomy.
Treatment: Treat medically, then a laser PI done within 3 days. If cannot control IOP medically, an emergent LPI is performed. Repeat gonioscopy 1 week later followed by weak Tropicamide 0.5%. If IOP significantly increases, plateau iris syndrome is diagnosed and should be treated with iridoplasty.
Follow Up: 1 week, 1 month, 3 months. If no acute angle closure, follow up every 6 months
Neovascular Glaucoma:
Symptoms: Asymptomatic or pain, redness, photophobia, decreased vision.
Signs: Neo of iris, TM or both, increase IOP, can have partial or complete angle closure
Treatment: Reduce inflammation and pain with steroid and cyclopgeic.
Reduce IOP if increased
