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Disease/glaucoma Dr. Davey 2016 > Lecture 2 Background, Basics, and concepts > Flashcards

Lecture 2 Background, Basics, and concepts Flashcards

1
Q

When you take measures to prevent glaucoma, what is the goal?

A

To minimize loss of ganglion cells that happens from cupping due to high IOP. Even though some causes of glaucoma are unknown, all treatments aim to reduce IOP.

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2
Q

Where does glaucomatous damage occur?

A

On either side of the Lamina Cribrosa. This why we see laminar dots in advanced stages of glaucoma.

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3
Q

There are 2 main causes of high IOP, what are they and which is more common?

A

A person can have decraesed outflow of aqueous humor or an overproduction of aqueous humor. A decreased outflow, however, is more common.

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4
Q

*What is the purpose of aqueous humor?

A

To provide nutrition and antioxidants to the avascular structures of the anterior segment of the eye: lens and cornea, and remove metabolic waste products. It also maintains the shape of the globe and serves as a shock absorber. Refraction index of aqueous humor is 1.33332.

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5
Q

What happens if there is a decrease in or halt in aqueous production?

A

Metabolic waste products cannot be removed, side effect=cataracts.

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6
Q

In a healthy eye, the rate of production is ____ the rate of removal

a) the same as
b) greater than
c) less than

A

a) same as. You want a constant normal pressure, not too low or too high.

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7
Q

The ciliary body has which 3 kinds of muscle fibers?

A

1) Longitudinal fibers: attach ciliary body to limbus
2) Circular fibers: attach anterior and inner portions of the ciliary body
3) Radial fibers: connect longitudinal and circular fibers

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8
Q

What 4 major things does the ciliary body contain?

A

muscle, vessels, epithelial lined ciliary processes, autonomic nerve terminals

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9
Q

What are the 3 ciliary body vessels?

A

1) episcleral circle
2) intramuscular circle
3) Major arterial circle (MAC)-paralimbal branches of LPCA

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10
Q

The ciliary processes are supplied by which 2 branches of what?

A

the anterior and posterior ciliary process arterioles of the major arterial circle (MAC)

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11
Q

What is the functional unit responsible for the production of aqueous humor secretion?

A

The ciliary process

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12
Q

Ciliary process is made up of which 3 components?

A

1) Capillaries-in the center of the processes
2) Stroma
3) Epithelia-2 layers-non pigmented and pigmented

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13
Q

_____ is a carefully controlled filtrate of blood

a) The ciliary process
b) aqueous humor
c) non-pigmented epithelium
d) stroma

A

b) aqueous humor. This is why the capillary is in the center of the process, water comes from the blood and has to pass thru other layers to become a carefully controlled filtrate of blood.

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14
Q

Aqueous fluid carries oxygen similar to interstitial fluid. Comparatively, aqueous has very high concentration of _____ for _____ and a no _____

A

aqueous has high ascorbate (vitamin C) for antioxidants and no hemoglobin (nothing colored or proteins or lipids)-as these would diminish light transmission.

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15
Q

(T/F) Aqueous humor is secreted by the ciliary epithelium of the ciliary process and enters the posterior chamber

A

True. It first enters the posterior chamber before it travels between the lens and iris, through the pupil, into the anterior chamber then peripherally out to the Trabecular meshwork and Schlemms canal.

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16
Q
  • The bulk of aqueous humor comes from:
    a) diffusion
    b) ultrafiltration
    c) secretion
    d) they are all about equal
A

c) secretion- 80-90%. Diffusion is for lipid soluble substances. Ultrafiltration is for water and water-soluble substances. Secretion is for larger sized substances or greater charge.

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17
Q
  • When is aqueous humor production highest?
    a) 8am to noon
    b) afternoon
    c) midnight to 6pm
A

8am to noon. (2.97 +/- 0.77 microliters per minute) In normal eyes, Aqueous humor and IOP will both higher in the morning, however a with glaucoma IOP may spike in the evening because of bad outflow.

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18
Q

*Aqueous formation requires which 2 enzymes?

A

Na/K-ATPase and Carbonic Anhydrase. Inhibition of these enzymes decreases production. (aqueous humor production is an active process, it needs ATP)

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19
Q
  • Where is NA/K-ATP-ase bound?
    a) pigmented epithelium
    b) non pigmented epithelium
    c) it is not bound, it is free floating
A

b) non pigmented epithelium

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20
Q

(T/F) The enzymes involved in aqueous humor production help push sodium ions into the posterior chamber to which water follows

A

True. First into the posterior chamber then it flows into the anterior chamber.

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21
Q

*What are the 2 pathways that aqueous humor leaves the anterior chamber?

A

conventional/trabecular route and unconventional/uveoscleral route (these both decrease with age)

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22
Q

IOP=

a) Aqueous production minus removal
b) Aqueous production plus removal
c) Aqueous production times episcleral venous pressure
d) Aqueous production divided by episcleral venous pressure

A

a) Aqueous production minus removal

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23
Q

(T/F) IOP increases with increased episcleral venous pressure and episcleral venous pressure increases when you lie down and increases even more when you are inverted.

A

True. Episcleral venous pressure is lowest when you are standing upright. Increased episcleral venous pressure decreases outflow. This is why glaucoma pt’s should avoid inversion.

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24
Q

Which of the following is the correct CONVENTIONAL aqueous humor outflow route?

a) Trabecular meshwork–>episcleral venous circulation–>schlemms canal–>lumens–>collector channels–>aqueous veins
b) Schlemms canal–>trabecular meshwork–> aqueous veins–>lumens–>collector channels–>episcleral venous circulation
c) Trabecular meshwork–>schlemms canal–>lumens–>collector channels–>aqueous veins–>episcleral venous circulation

A

c) Trabecular meshwork–>schlemms canal–>lumens–>collector channels–>aqueous veins–>episcleral venous circulation

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25
Q

The unconventional/uveoscleral route is ______ to the TM

a) anterior
b) posterior
c) superior
d) inferior

A

b) posterior

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26
Q
  • Which of the following is the correct UNCONVENTIONAL aqueous humor outflow route?
    a) Trabecular meshwork–>episcleral venous circulation–>schlemms canal–>lumens–>collector channels–>aqueous veins
    b) iris root–>uveal meshwork–>anterior face of ciliary muscle–>through connective tissue between the muscle bundles–>through suprachoroidal space–>out through the sclera
    c) anterior face of ciliary muscle–>uveal meshwork–>iris root–>lumens–>connector channels–>though connective tissue between the muscle bundles–>out though sclera
A

b) iris root–>uveal meshwork–>anterior face of ciliary muscle–>through connective tissue between the muscle bundles–>through suprachoroidal space–>out through the sclera

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27
Q

(T/F) Prostaglandin analogs increase aq. humor outflow for the unconventional route and Carbonic anhydrase inhibitors target the conventional aq. humor outflow route.

A

True. Prostaglandins are a slower treatment. Use CAI’s to decrease IOP faster.

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28
Q

How do you measure uveoscleral aq humor outflow?

A

It is calculated, not a direct measurement. Total outflow minus Trabecular outflow equals uveoscleral outflow.

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29
Q

A breakdown of the blood aqueous barrier could cause IOP to ______.

a) increase
b) decrease

A

a) increase. Diseases, trauma, or drugs can induce a breakdown in the tight junctions of the blood aqueous barrier. Plasma components can get into the anterior chamber and into the aqueous humor, increasing IOP.

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30
Q

(T/F) If IOP increases, aqueous inflow by ultrafiltration is suppressed, slowing down the rise of IOP. This is called pseudofacility.

A

True. this is the means by which the eye protcts itself from sudden rises in IOP.

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31
Q

Name the 4 parts that make up the optic nerve head.

A

1) Surface nerve fiber layer–feature: contains interaxonal glial tissue/shiny stuff in young people (innermost portion)
2) Prelaminar region–feature: increased astroglial tissue (anterior portion of Lamina cribrosa)
3) Lamina Cribrosa region–feature: fenestrated sheets of scleral connective tissue separated by astrocytes that allow bundles of axons to pass through (where all the action happens)
4) Retrolaminar–feature: decrease in astrocytes, myelination up to retrolaminar then unmyelinated into the eye (outermost portion)

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32
Q

Which statement is true regarding optic nerve vasculature:

a) The posterior ciliary artery is the main supply to the optic nerve, however, the NFL is supplied by retinal circulation
b) The posterior ciliary artery is the main supply to all 4 parts of the optic nerve
c) The choroid supplies blood to all parts of the optic nerve

A

a) The posterior ciliary artery is the main supply to the optic nerve, however, the NFL is supplied by retinal vessel circulation

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33
Q

What vessels anastamose to form the circle of Zinn-Haller?

a) LPCA’s (long posterior ciliary arteries)
b) SPCA’s (short posterior ciliary arteries)
c) branches of the CRA (central retinal artery)

A

b) SPCA’s (short posterior ciliary arteries)

34
Q

SPCA’s (short posterior ciliary arteries) are the primary blood supply of what 2 portions of the optic nerve?

a) surface NFL and prelaminar region
b) prelaminar and laminar region
c) laminar and retrolaminar region

A

b) prelaminar and laminar region. The SPCA’s anastomose to form the circle of Zinn-Haller.

35
Q

The arteriolar branches of the CRA (central retinal artery) is the main supply of which portion of the optic nerve?

a) surface NFL
b) prelaminar
c) laminar
d) retrolaminar region

A

a) surface NFL

36
Q

The medial and lateral perioptic SPCA is the main supply of which portion of the optic nerve?

a) surface NFL
b) prelaminar
c) laminar
d) retrolaminar region

A

d) retrolaminar region

37
Q

What is the venous drainage for the optic nerve?

A

entirely through the (CRV) Central Retinal Vein

38
Q

*(T/F) Astroglial support provides a continuous layer between the nerve fiber and blood vessels of the optic nerve head. They are described as thick and thin. THIN: accompany the axons in the NFL and THICK: direct axons from the prelaminar to the laminar region.

A

True. (think: the thin cheerleaders hang out with the NFL players, not the thick ones lol)

39
Q

Glaucoma pathogenesis takes place at the level of the:

a) surface NFL
b) prelaminar region
c) lamina cribrosa
d) retrolamina

A

c) lamina cribrosa (but this doesn’t mean there cant be damage elsewhere as well) axons will start to die on both sides of the lamina cribrosa

40
Q
  • Which of the following regarding the lamina cribrosa is incorrect?
    a) it is the porous region of the sclera consisting of fenestrated sheets of connective tissue and occasional elastic fibers.
    b) Hyaluronate is found in the surrounding myelin sheath which decreases with age and further decreases with high IOP
    c) it serves as the retinal blood barrier
A

c) it serves as the retinal blood barrier. (**important to remember that hyalonurate is found in the surrounding myelin sheath which 1) decreases with age and 2) further decreases with high IOP)

41
Q

Laminar dots are present in:

a) macular degeneration
b) diabetic retinopathy
c) bacterial conjunctivitis
d) glaucoma

A

d) glaucoma (duh, this is a glaucoma class)

42
Q

(T/F) The pores in the lamina cribrosa are largest inferiorly>superiorly>nasally>temporally

A

True. Think of it as following the ISNT rule. If the pores do not follow ISNT rule, it may be glaucomatous

43
Q

*(T/F) inferior and superior retinal nerve fiber layers cross at the horizontal midline

A

False. Both superior and inferior fields were created by separate groups of fibers. Visual field deficits respect the horizontal meridian in glaucoma (**arcuate fibers occupy superior and inferior temporal regions)

44
Q

Why is glaucoma “macula-sparing”

A

because papillomacular fibers spread approx. 1/3rd of the distal optic nerve inferior temporally and intermingle with extramacular fibers.

45
Q

Which of the following axonal facts are not true

a) we are born with 700,000 to 1.2 million
b) axon fiber diameter is 0.65 to 1.10 micrometers (isnt rule)
c) small variation

A

c) small variation. Nope, we have a large variation.

46
Q
  • The size of the optic nerve head is ____ before age 1
    a) 20%
    b) 50%
    c) 75%
    d) 95%
A

d) 95%. Connective tissue of the lamina cribrosa is not completely developed at birth, infants have a greater susceptibility to damage. A child with pediatric glaucoma will have more cupping (larger and deeper) because the tissue is more pliable, however there is a potential for reversal.

47
Q

(T/F) Smaller diameter nerves have a greater chance of cell death.

A

False. Larger nerves have a greater chance of cell death because with a larger surface area it can be more greatly affected by increased IOP.

48
Q

(T/F) cupping is more indicative of glaucoma than color/palor

A

true. cupping is absence of tissue. also, rim decreases with increasing cupping.

49
Q

Glaucoma is a neurodegenerative disease characterized by the slow, progressive degeneration of retinal _____ cells

a) ganglion
b) amacrine
c) horizontal
d) rods only, not cones

A

a) ganglion

50
Q

(T/F) glaucoma damage is not limited to ganglion cell axons, soma, and dendrites. Neurons in LGN and visual cortex are also lost.

A

True

51
Q

The causes of damage to ganglion cells can include: (pick 4)

a) high IOP that blocks neutrophins and other target derived factors that send and receive information to and from the brain
b) microcirculation (hypoxia or ischemia)
c) drug use and injury
d) aberrant immunity cells
e) excessive glutamate stimulation

A

a) high IOP that blocks neutrophins and other target derived factors that send and receive information to and from the brain
b) microcirculation (hypoxia or ischemia)
d) aberrant immunity cells
e) excessive glutamate stimulation

52
Q

How does glutamate excitotoxicity cause ganglion cell death?

A

It overstimulates NMDA and Kainate glutamate receptors which causes an increase in intracellular calcium via 3 different injection techniques: subcutaneously, intravitreally, and in-vitro.

53
Q
  • Which is NOT true regarding Nitric oxide
    a) it is a vaso-constrictor
    b) it is neurotoxic in high concentrations
    c) it inhibits mitochondrial function and disrupts DNA
A

a) it is a vaso-constrictor. (Nitric oxide is a vaso-dilator and Endothelin–1 is a vaso-constrictor)

54
Q

(T/F) ocular ischemia is poor blood flow caused by vasoconstriction

A

True

55
Q

What are the 2 main theories of glaucoma?

A

1) Mechanical: elevated IOP causes compression of ganglion cells which impairs the trophic factor axonal flow transport causing cell death.
2) Vascular: Ischemia plays a role in the obstruction of axoplasmic flow in response to elevated IOP. The retina can auto-regulate IOP in a healthy eye but glaucoma pts have a dysfunction in auto regulation.

*truth is mechanovascular: both mechanisms play a role in glaucomatous pathology

56
Q

What is perfusion pressure?

A

The difference between arterial and venous pressure. (mean ocular perfusion pressure=mean BP - IOP

57
Q

Describe the 2 types of auto regulatory mechanisms

A

1) Metabolic: (chemistry) Endothelial cells secrete vasodilators (nitric oxide) and vasoconstrictors (endothelin)
2) Myogenic (muscles) operates when blood flow is above normal (mechanism unclear)

58
Q
  • Which one of the following is NOT evidence in favor of the vascular theory?
    a) association of NTG (normal tension glaucoma) with migraines (which are caused by poor blood flow)
    b) Raynaud’s phenomenon: excessive peripheral constriction of vessels to cold (blue toes and fingers)
    c) nocturnal blood flow in glaucoma patients
    d) lower plasma concentration of endothelin-1
    e) delayed filling of superficial vessels of optic nerve in glaucoma
A

d) lower plasma concentration of endothelin-1. Greater plasma concentration of endothelin-1 is evidence in favor of the vascular theory (remember endothelin is a vaso-constrictor so a higher amount of it would contribute to worse blood flow, hence support the vascular theory)

59
Q

*Regardless of the mechanism, death of ganglion cells happens via _____

A

apoptosis. Apoptosis is also the manner in which photoreceptors die when exposed to excessive light, conj cells when exposed to ocular preservatives, and corneal epithelial cells after wounding. (**cells decrease in size–>content becomes more concentrated–>nucleus fragments–>cells separate into small bodies–>these bodies are phagocytosed without an inflammatory response)

60
Q
  • Which of the following is the order in which apoptosis occurs from beginning to end:
    a) cell decreases in size–>nucleus fragments–>cell separates into small bodies–>pieces are phagocytosed WITHOUT an inflammatory response
    b) cell decreases in size–>nucleus fragmeents–>cell separates into small bodies–>pieces are phagocytosed WITH an inflammatory response
    c) nucleus fragments–>cell decreases in size–>cell separates into small bodies–>pieces are phagocytosed WITH an inflammatory response
    d) c) nucleus fragments–>cell decreases in size–>cell separates into small bodies–>pieces are phagocytosed WITHOUT an inflammatory response
A

a) cell decreases in size–>nucleus fragments–>cell separates into small bodies–>pieces are phagocytosed WITHOUT an inflammatory response

61
Q

(T/F) The neural rim is the tissue responsible for cupping and loss of visual field.

A

True. C/D ratio alone doesn’t tell you much but C/D ratio along with rim tissue is helpful.

62
Q
  • Fundus biomicroscopy:
    a) 66D=___x
    b) 78D=___x
    c) 90D=___x
A

a) 66D=1x
b) 78D=1.2x
c) 90D=1.3x

63
Q

When viewing the optic nerve head in the photos, the ONH should take up what portion of the box?

A

1/3rd of the box. the box is 15 degrees, a normal OHN is 5 degrees

64
Q

(T/F) When viewing the ONH of a glaucoma patient, you will most always find symmetry in damage/vision loss between the 2 eyes.

A

False. There must be asymmetry in glaucoma between the 2 eyes.

65
Q

Describe the ONH in tilted disc syndrome.

A

The ONH is horizontal and oval, completely tilted 90 degrees. The ISNT rule will not apply in this situation and there is no other rule for this.

66
Q

*Describe the ONH in myopia.

A

The ONH is vertical and oval shaped. Thinning of temporal neural rim (causes scleral crescent). Prominent peripapillary halo

67
Q
  • Match the following:
    1) A thin, even white, 360 degree. Represents anterior extension of sclera between choroid and optic disc
    2) Broader more irregular area of depigmentation (hypopigmentation). Represents retraction of RPE and thinning or absence of choroid
    3) Peripalliary crescent of increased pigmentation (hyperpigmentation). Represents malposition of embryonic fold with double layer or irregularity of RPE

A) Zone Alpha
B) Zone Beta
C) Scleral lip

A

1=C 2=B 3=A. If zone beta is larger there is a higher risk of glaucoma. Rim tissue tends to be thinnest where zone beta is widest. Zone alpha is found adjacent to zone beta or next to the disc if zone beta is absent.

68
Q
  • Which of the following is not true:
    a) Myopic crescent overlies both zone beta and zone alpha
    b) Peripapilary atrophy is an indicator for glaucoma
    c) Peripapillary atrophy =chorioscleral cresent=zone alpha and zone beta (these are all the same)
    d) focal atrophy of the neural rim is called notching
    e) NFL gets thicker with age
A

e) NFL gets thicker with age. NFL actually decreases with age

69
Q

While looking at the ONH, you notice a vessel goes all the way to the edge of the rim, indicative of relative thinning compared to the surrounding rim tissue. What would you call this?

a) barring
b) notching
c) nasal cupping
d) bayonetting

A

b) focal atrophy of the neural rim aka notching

70
Q

While looking at the ONH, you notice a gap between the vessel and the rim tissue. what do you call this?

a) barring
b) notching
c) nasal cupping
d) bayonetting

A

a) barring. As the rim becomes thinner and thinner it leaves an area of pallor between the rim and circumlinear blood vessels. Mainly seen in vessels supero and infero temporally. If it has a large gap, however, it may be hard to say for certain it had rim support to begin with.

71
Q

*While looking at the ONH, you notice an optic disc hemorrhage (aka drance hemorrhage). How may this correlate with glaucoma?

A

It was thought that a hemorrhage indicates where glaucoma damage will occur. However, we now know that damage may or may not occur in the area of the hemorrhage. Hemorrhages can be transient; appearing and disappearing. Large hemorrhages can take up to 2 months to resolve. Monitor pt, recheck in 3 months. This could make them at higher risk for glaucoma. If it is correlated with glaucoma it will get progressively worse.

72
Q

While looking at the ONH, you notice a straight vessel that leaves the ONH nasally and there is more space between the nasal rim and the blood vessels. What could this be?

a) barring
b) notching
c) nasal cupping
d) hemorrhage

A

c) nasal cupping. Usually seen in advanced glaucoma. The vessel appears straight because there is no rim tissue left for support. Nasal cupping is only used in conjunction with glaucomatous damage.

73
Q

In laminar dot sign, the pores at the base of the cup are distorted. Pressure is pushing the Lamina Cribrosa causing stretching of the laminar pores. In which 2 situations could you see this?

A

In glaucoma pt’s and in high axial myopes.

74
Q

While looking at the ONH, you notice a vessel that travels up and switches direction upon exiting or looks like it disappears then reappears. What could this be?

a) barring
b) notching
c) nasal cupping
d) bayonetting

A

d) bayonetting or double angulation of a blood vessel.

75
Q

(T/F) When it comes to proximal constriction of retinal arteries they will look pinched close to the ONH and appear thicker as you look further away. A normal healthy artery should get thinner as it gets farther from the nerve.

A

True. This indicates a disruption in the vascular system and can come and go.

76
Q

(T/F) torturous shunt vessels are a sign of advanced glaucoma and are a last ditch effort of the eye to save the optic nerve.

A

true.

77
Q

While looking at the retina, you notice a dark wedge shape parallel to the normal striations of the NFL. This wedge meets a notch on the ONH. What could this be?

a) barring
b) notching
c) nerve fiber bundle defect
d) hemorrhage

A

c) nerve fiber bundle defect. The wedge is dark because it is a loss of NFL. It is common after disc hemorrhages.

78
Q

The ISNT rule is ____ accurate

a) 25%
b) 50%
c) 70%
d) 85%

A

c) 70%. The isnt rule is only used when monitoring a glaucoma suspect, not used when someone has glaucoma.

79
Q

What does palor mean?

A

It is when the ONH is featureless and cannot tell disc/rim ratio. Cupping is more indicative than palor when diagnosing glaucoma.

80
Q
  • Which of the following is not true regarding pediatric glaucoma?
    a) connective tissue of lamina cribrosa is incompletely developed and has a greater suseptibity to damage
    b) children with pediatric glaucoma will have large deep cupping because the tissue is pliable
    c) potential reversible cupping in pediatric population
    d) all of the above are correct
A

d) all of the above are correct

81
Q
  • Which one of the following is TRUE?
    a) larger optic discs tend to have larger cups
    b) larger optic discs tend to have smaller cups
    c) smaller optic discs tend to have larger cups
A

a) larger optic discs tend to have larger cups

Disease/glaucoma Dr. Davey 2016 (13 decks)

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