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BOARDS2: Glaucoma > PXF > Flashcards

PXF Flashcards

1
Q

Hallmark of PXF

A

Flaky deposits on lens

Scandinavian

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2
Q

Why does PXF make for complicated CE

A

Sampaolesi line on gonio, plus TM damage, plus damage to lens zonules

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3
Q

Types of glaucoma related to cataracts

A

Phacolytic and phacomorphic

Always repeat gonio on phakic patients

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4
Q

Signs of PXF

A

Flaky white deposits on the pupillary margin, the anterior lens capsule (bulls eye pattern), the lens zonules, and the TM

Deposits on the lens zonules may cause the release of pigment from the posterior iris epithelium, resulting in pigment deposits within the TM

The lens zonules are weaker in PXF (resulting in phacodonesis), and the pupil usually dilates poorly

Ocular findings are usually bilateral and asymmetric, but may also be unilateral

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5
Q

PXF and elevated IOP

A

At an increased risk for increased IOP due to the accumulation of toxic fibrillation deposits and pigment within the TM, leading to decreased AH outflow. An estimated 15% of patients with PXF develop glaucoma within 10 years

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6
Q

Phacolytic glaucoma

A

Hypermature cataract leaks lens material into the AC, resulting in obstruction of AH outflow though the TM and markedly elevated IOP. Cells, flare, and iridescent lens particles will be present within the AC.

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7
Q

Phacomorphic glaucoma

A

Occurs when the lens thickens (cataracts) and pushes the iris forward into the angle, resulting in angle closure glaucoma

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8
Q

PDS patients

A

Usually young myopic caucasian males.
Bowing of the iris backward, K spindle, TIDs, pigment on the iris surface and anterior lens capsule, and dense TM pigmentation

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9
Q

True exfoliation syndrome

A

Delamination of the anteiror lens capsule due to infrared exposure or thermal radiation (glass blower). This is very rare

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10
Q

Wilson’s disease cataracts

A

Sunflower cataract

Due to deposition of copper within the lens in a petaloid pattern

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11
Q

PXFtreatment

A

Managed the same as POAG, although IOP is often more difficult to control and PXF glaucoma is often more progressive compared to POAG
Initial therapy is topical ophthalmic medication. Glaucoma surgeries are reserved for severe cases of PXF glaucoma that are not controlled with max topical therapy. Removing the lens is not beneficial in PXF, as the white flaky deposits are more produced by the lens, the deposits will continue to accumulate within the TM, resulting in increased IOP

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12
Q

Indication of PUI

A

Angle closure or high risk of angle closure

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13
Q

What does PI do

A

Created an opening in the iris tissue that equalizes the pressure gradient between the posterior and the anterior chambers, allowing AH to flow freely into the AC, and causing the iris to move away from the angle. PI is performed with a laser; peripheral iridectomy is a similar procedure that is performed during intraocular surgery with instruments

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14
Q

Indication for goniotomy

A

Congenital glaucoma

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15
Q

What does goniotomy do

A

Makes an incision in the TM to allow for better AH outflow

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16
Q

Indication for trabeculectomy

A

Progressive glaucoma with inadequate IOP control with topical ophthalmic medication or laser trabeculoplasty

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17
Q

What does a trabeculectomy do

A

A small portion of the TM is surgically removed underneath a scleral and conjunctival flap, providing an alternative route of AH outflow through the partial thickness scleral flap and into the episcleral and conjunctival vessels. AH outflow elevates the conjunctiva over the scleral flap, creating a bleb. The bleb is most often located superiority due to a lower risk of endophthalmitis compared to lower blebs

18
Q

Indication for ALT or SLT

A

Open angle glaucoma with inadequate IOP control

19
Q

What does ALT and SLT do

A

ALT causes scarring of small areas of the TM, resulting in tissue contraction and opening of the pores in areas of the TM not damaged by the laser; ALT is thought to stimulate the endothelial cells and macrophages of the TM, resulting in less debris within the TM and increased AH outflow

20
Q

Indication for glaucoma shunt procedures

A

Severe glaucoma with inadequate IOP control with optical ophthalmic medications, laser, and/or failed trab

21
Q

What do glaucoma shunt procedures do

A

A tube is inserted into the AC, allowing AH to flow from the AC to the extraocular plate attached to the tube to drain through the episcleral and conjunctival vessels. The plate my be located underneath a partial thickness scleral flap or inserted under the EOMs

22
Q

Indication for cycloablation

A

Last resort in advanced glaucoma with inadequate IOP control with optical ophthalmic drops, laser, trab, and/or shunt

23
Q

Laser peripheral iridoplasty indication

A

Angle closure, plautea iris syndrome

24
Q

What does a laser peripheral iridoplasty do

A

Argon laser is applied to the peripheral iris, resulting in scarring and tissue contraction that helps to pull the iris away from the angle

25
Q

Otomy

A

Incision

26
Q

Ectomy

A

Removal

27
Q

Oplasty

A

Repair

28
Q

MIGS

A

Minimally invasive glaucoma surgery
May also lower IOP in patients with mild to moderate glaucoma.
Assocaited with in Ab interno micro-incision that results in minimal trauma to surrounding tissue and rapid recovery.
Examples are iStent, trabectome, and canaloplasty

29
Q

BBlockers and breathing

A

Cause bronchoconstriction, leading to increased shortness of breath and difficulty breathing. Remember to check the pulse of all patients on topical ophthalmic BBlockers. Betaxolol is a selective B1 receptor antagonist that has fewer pulmonary side effects compared to non selective BBlockers

30
Q

When is AREDS1 beneficial

A

Category 4 AMD (CNVM or central GA in one eye, with ARMD reducing vision to <20/32 in the fellow eye)

31
Q

What type of patient is AREDs 1 contraindicated in

A

Smokers because of beta carotene

32
Q

Pattern standard deviation

A
  • a high PSD represents a “lumpy” hill of vision with focal loss that is characteristic of glaucoma
  • a low PSD represents a “smooth” hill of vision and is characteristic of healthy patients

Recall that glaucoma can often present with a low PSD, as the hill of vision is the same shape as a healthy patietns, but the overall sensitivity is reduced due to diffuse damage of the optic nerve. A larger stimulus size (V) may be needed for patients with advanced glaucoma who can no longer see the default stimulus size III; remember that stimulus size tangoes from I-V (smallest to largest)

33
Q

Reliability on HVF

A

Indicated by the number of FLs, FPs, FNs, and STF (short term fluctuations). STFs are determined by randomly retesting certain points. FLs are tested by shining lights in the patients blind spot. FLs>20% or FP/FNs > 33% are often flagged by the instrument as “reduced reliability” or “abnormally high sensitivity.” Glaucoma patients tend to have high FN, which will cause the field to appear better than what it actually is

34
Q

Gray scale of HVF

A

Gross representation of VF; darker areas indicate reduced sensitivity. Used for patient educated, but should never be used to make diagnostic or management decisions

35
Q

Total deviation on HVF

A

Compares how well the patient performed at each point compared to the database of age matched healthy normals. A value of 0 indicates the patient performed as expected; a positive value indicates the patient performed better than expected; a negative value indicates the patient performed worse than expected. The darker the box on the total deviation plot, the greater the patient deviated from the values of the healthy norms

36
Q

Pattern deviation HVF

A

Filters out overall depression (cataracts, small pupils, incorrect refractive error correction) from the total deviation probability plot to demonstrate areas of focal damage; this is very important in the interpretation of glaucomatous defects, as early to moderate glaucoma resutls in focal rather than diffuse damage

37
Q

Glaucoma hemifield tests

A

Compare the same points in the upper and lower hemifield to detect asymmetry in the VF; recall that glaucoma causes asymmetric damage to the optic nerve, resulting in asymmetric VF loss between the upper and lower hemifields. The GHT isreported as within normal limits, borderline, outside of normal limits, or reduced sensitivity (overall depression)

38
Q

Mean deviation (MD)

A

Averages all fo the dB in the patients visual field and compares this number to the averaged values of healthy normals; indicates focal areas of depression that are characteristic of glaucoma. A higher PSD indicates more focal damage

39
Q

Visual field index (VFI)

A

Detects change in the VF over time; expressed as a percentage, with 100% indicates there is no visual field loss

40
Q

First step in interpreting the VF

A

Look at the optic nerve. The location of the damage to the optic nerve will indicate the area that will be depressed in the visual field. Any possible progression on the VF should be confirmed to ensure it is a true progression rather than a normal fluctuation in the visual field. In general, VF testing should be repeated annually, although there are exceptions depending on the individual patients

BOARDS2: Glaucoma (4 decks)

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