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III. Glaucoma Management > Gonioscopy and Angle Closure Glaucoma (M) > Flashcards

Gonioscopy and Angle Closure Glaucoma (M) Flashcards

1
Q

What is a sign that occurs following acute angle closure?

A

glaukomflecken

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2
Q

What is a separation of the CB from Scleral Spur called?

A

cyclodialysis

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3
Q

What are the characteristics of primary angle closure?

A
  1. any degree of obscured posterior pigmented TM with one of the following: …symptoms, elevated IOP, PAS
  2. no disc damage or VF loss
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4
Q

How can you tell if you are pushing too hard on indentation gonio?

A
  1. wrinkles in cornea

2. blood in Schlemms canal

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5
Q

What is the condition in which the aqueous is misdirected posterior into the vitreous, increasing the volume of the vitreous, pushing the lens forward to shallow/close the anterior chamber? 1. What causes this? 2

A
  1. Aqueous Misdirection aka Malignant glaucoma

2. side effect from penetrating glaucoma surgeries

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6
Q

What are the treatments for aqueous misdirection?

A
  1. cycloplegics (atropine)
  2. aqueous suppressants
  3. vitrectomy with puncture of the anterior hyaloid face
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7
Q

What is the in-office post-operative PI medications given?

A

1 to 2gtts iopidine or AlphaganP to prevent IOP spikes

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8
Q

What causes acute angle closure (AAC)?

A

absolute pupillary block

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9
Q

What is the ongoing post-operative PI medications given?

A

pred forte q1hr x1d, then QID x2 to 4d

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10
Q

If the IOP in acute angle closure comes down in office what should be done?

A
  1. schedule PI within a few days

2. maintain 1 to 2% pilo QID, pred forte QID, and 0.5% timolol/cosopt/combigan BID until PI

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11
Q

Why is neovascular glaucoma a problem?

A

releasing fibrin and can glue angle closed, decreasing the outflow

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12
Q

If the IOP in acute angle closure does not come down in office what should be done?

A

refer immediately for LPI same day

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13
Q

What is it called when iridolenticular apposition prevents regular route of aqueous flow? 1. What does it result in? 2

A
  1. pupillary block

2. iris bombe and iris physically blocking outflow through TM

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14
Q

What is a contraindication of Argon Laser Peripheral Iridoplasty (ALPI) aka Gonioplasty?

A

peripheral anterior synechiae

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15
Q

What is the overall management guide of acute angle closure?

A
  1. try open angle using temporary compression gonio
  2. use all classes of aqueous suppressors (beta blockers, Alphagan/iopidine, Azopt/trusopt, pred forte) NO PROSTAGLANDINS
  3. 500mg oral diamox
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16
Q

What are the characteristics of primary angle closure suspect?

A
  1. more then 3 clock hours where there is no viewable posterior pigmented TM
  2. no symptoms, high IOP, PAS, VF loss, or disc damage
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17
Q

What are the characteristics of primary angle closure glaucoma?

A
  1. any degree of obscured posterior pigmented TM with:

2. disc damage or VF loss

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18
Q

What can too much light in a room do to the angle configuration while looking at gonio?

A

over estimate amount of openness of angle

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19
Q

What are the treatments for choroidal effusion?

A
  1. cycloplegics (atropine)
  2. aqueous suppressants
  3. discontinue Topamax
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20
Q

What are the three categorizations of angle closure glaucoma?

A
  1. primary angle closure suspect (PACS)
  2. primary angle closure (PAC)
  3. primary angle closure glaucoma (PACG)
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21
Q

What can you determine by performing gonioscopy?

A
  1. extent of open drainage structures
  2. configuration of angle and iris approach
  3. degree of pigment
  4. differentiate open angle, angle closure and plateau iris
  5. find secondary glaucoma characteristics
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22
Q

What are the signs of acute angle closure?

A
  1. conjunctival injection
  2. fixed mid-dilated pupil
  3. IOP over 40mmHg
  4. +/- corneal edema
23
Q

What is the management of acute angle closure if IOP is less than 50mmHg and VA is better than 20/400?

A
  1. 1gt 0.5% timolol
  2. 1gt 1% Alphagan
  3. 1gt Trusopt or Azopt
  4. 1gt Pred forte
  5. reassess IOP q20 to 30 min
  6. If NI in 1hr repeat drops and add 500mg Diamox
  7. Once IOP less then 40 = 1gt 2% pilocarpine
24
Q

What are the different types of angle configurations/iris approaches seen with gonio?

A
  1. normal/flat
  2. convex/steep
  3. concave/back bowed
25
Q

What is the in-office pre-operative PI medications given?

A
  1. 1 to 2% pilocarpine

2. 1 to 2gtts iopidine or AlphaganP to prevent IOP spikes

26
Q

What is the degree of pigmentation of the pigmented portion of the TM that receives a grade 1 to 2? 1. Grade 3? 2. Grade 4? 3

A
  1. TM pigment less than pigment of CB
  2. TM pigment equal to pigment of CB
  3. TM pigment more than pigment of CB
27
Q

What are the symptoms of acute angle closure?

A
  1. painful red eye
  2. photophobia
  3. blurred vision, halos
28
Q

What is the treatment of glaucoma that creates a hole in the peripheral iris to allow safety valve for aqueous to pass through to the anterior chamber?

A

Laser Peripheral Iridotomy (LPI or PI)

29
Q

What are the types of traumatic glaucoma?

A
  1. angle recession
  2. cyclodialysis
  3. iridodialysis
  4. trabecular damage
30
Q

How can you differentiate between the vessels in neovascular glaucoma and the prominent greater arterial circle of the iris?

A

neo goes perpendicular to the angle

31
Q

What surgery besides a PI is considered for an non-acute case of PACS or PAC?

A

cataract surgery to deepen chamber

32
Q

What is the procedure in which laser burns are placed in the extreme iris periphery to contact the iris stroma between the burn site and the angle, opening the appositionally closed angle?

A

Argon Laser Peripheral Iridoplasty (ALPI) aka Gonioplasty

33
Q

What are the mechanisms that lead to angle closure (in order from most common)?

A
  1. pupillary block
  2. plateau iris
  3. aqueous misdirection (malignant glaucoma)
  4. choroidal effusion
34
Q

What is the other term for primary angle closure suspect?

A

iridotrabecular contact (ITC)

35
Q

When trying to decide if a structure is the TM or CB what are the best methods to differentiate them?

A
  1. indentation gonio

2. corneal wedge

36
Q

What are the items that are recorded for gonioscopy findings?

A
  1. most posterior visible structure
  2. degree of pigment (grade 1 to 4)
  3. iris approach
  4. +/- peripheral synechiae
  5. nodules, cysts, processes, angle recession
37
Q

What is a tear or separation of the iris root called?

A

iridodialysis

38
Q

How can you differentiate between aqueous misdirection and pupillary block?

A
  1. misdirection has entire lens and iris pushed forward, not just iris bombe
  2. misdirection has a flat chamber
  3. both have high IOP
39
Q

What is a tear between the longitudinal and circular muscles of the CB called?

A

angle recession

40
Q

What is checked for following PI surgery during an exam?

A

patency of PI (still open)

41
Q

What is the order of structures from most posterior to anterior seen in gonioscopy?

A
  1. iris
  2. ciliary body
  3. Scleral spur
  4. pigmented TM
  5. nonpigmented TM
  6. Schwalbe’s line
42
Q

What are the indications for a PI?

A
  1. primary open angle glaucoma (PACG)
  2. chronic primary angle closure (PAC)
  3. primary angle closure suspect (PACS)
43
Q

What is pigment in Schwalbe’s line called? 1. When is it common? 2

A
  1. Sampaolesi’s line

2. secondary glaucoma

44
Q

What are the types of lasers used for a PI? 1. Where is the PI usually located in the iris? 2

A
  1. argon, diode, Nd: Yag

2. was done at 12 but now done at 3 and 9 o’clock

45
Q

What are the characteristics of a plateau iris?

A
  1. normal central anterior chamber depth
  2. flat iris plane
  3. narrow anterior chamber angle
  4. affects younger women
  5. steep approach of iris
  6. angle remains appositionally closed or occludable even after PI
  7. rolling of peripheral iris on identation
46
Q

What is must aqueous misdirection be differentially diagnosed from?

A
  1. hypotony

2. pupillary block

47
Q

What is it called when the peripheral iris adheres to the cornea, impacting the outflow? 1. What are the causes of this? 2

A
  1. peripheral anterior synechiae (PAS)
  2. uveitis, surgeries on angle
  3. narrow angles
48
Q

What is the management of acute angle closure if IOP is greater than 50mmHg and VA is worse than 20/400?

A
  1. 500mg Diamox
  2. 1gt 0.5% timolol
  3. 1gt 1% Alphagan
  4. 1gt Pred forte
  5. reassess IOP q20 to 30 min
  6. If NI in 1hr repeat drops
  7. Once IOP less then 40 = 1gt 2% pilocarpine
49
Q

What are the top causes of neovascular glaucoma?

A
  1. diabetes

2. CRVO

50
Q

What are the contraindications for a peripheral irdotomy?

A
  1. corneal edema
  2. flat anterior chamber
  3. angle closure not caused by pupillary block (plateau iris, malignant glaucoma, choroidal effusion)
51
Q

What are the indications for Argon Laser Peripheral Iridoplasty (ALPI) aka Gonioplasty?

A
  1. plateau iris configuration
  2. chronic angle closure with limited response to PI
  3. acute angle closure attack
52
Q

What is the cause of choroidal effusion? 1. What are the signs? 2

A
  1. effects of Topamax

2. swelling and displacement of choroid and CB with dramatic myopic shift and narrowing of chamber

53
Q

What is hypotony a side effect from? 1. How can you differentiate it from aqueous misdirection? 2

A
  1. more common SE following surgery that can result in a flat chamber
  2. hypotony will have a very low IOP and Misdirection IOP will be high

III. Glaucoma Management (9 decks)

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