Flashcards in Glaucoma Deck (11):
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)
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.
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.
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.
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