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Flashcards in glaucoma Deck (231):
1

What are the 3 components of trabecular meshwork

uveal (at iris root), corneoscleral (sheets spanning from scleral spur to scleral sulcus), juxtacanalicular (major site of outflow resistance; next to canal of schlem)

2

What are the 3 mechanisms that aqueous enters the posterior chamber?

active secretion (via Na-K pumps), ultrafiltration (hydrostatic and oncotic pressures), and diffusion (movement of ions down concentrations gradient

3

aqueous production is via what kind of cells?

non pigmented ciliary cells

4

what is the Goldmann Equation of IOP?

IOP=(formation of aqueous-pressure insensitive uveoscleral pathway)/(Pressure sensitive trabecular pathway+episcleral venous pressure)

5

what are the two pathways of aqueous outflow?

via trabecular meshwork (schlem to episcleral veins) and uveoscleral pathway (root of iris/ciliary body to suprachoroidal space)

6

POAG risk factors

elevated IOP, African American, FMHx, thin corneas, age, decreased perfusion pressure, ischemic vascular diseases (HTN, DM...etc)

7

PACG risk factors

women, hyperope, inuit/asian

8

when is peak IOP during the day

early AM; decreases by half during sleep.

9

What is the rate of aqueous production

2-3microliters/min

10

what is the venous outflow path from canal of schlem?

schlemm to episcleral veins to anterior ciliary and superior ophthalmic veins then to cavernous sinus

11

what happens to cross section of canal of schlemm as IOP increases

cross section decreases as trabecular meshwork expands

12

uveoscleral drainage decreases with age and glaucoma. What increases uveoscleral drainage?

cycloplegics, adrenergic, prostaglandins.
Miotics decreases uveoscleral outflow

13

what 4 conditions increase episcleral vein pressure?

cavernous-carotid fistula, cavernous thrombosis, sturge weber, thyroid eye disease

14

what are factors influencing IOP?

time of day
body position, exercise, HR, BP, respiration
Fluid intake
Meds

15

what principle is tonometry based on?

Imbert Fick Priciniple

16

What is the inbert fick principle?

The pressure in a dry thin walled sphere equals the force necessary to flatten its surface divided by the area of flattening. P=F/A

17

What is the area that is flattened on Goldman application

3.06 mm diameter of the cornea

18

too much fluoresceine on Goldmann applanation leads to what falsely high or low pressures

high

19

what is CCT

central corneal thickness

20

whats normal CCT

520 microns

21

why are tonopens and pneumatic tonometers (both are Mackay Marg Type tonometers) useful for patients with corneal edema or scars?

because it only interacts with a small area of the cornea

22

what kind of tonometer is good for Peds?

rebound tonometer because it doesn't require topical anesthesia

23

How does the Schiotz tonometer work?

It indents the cornea with a known weight to be converted to IOP

24

what are three ways to clean tonometer prisms?

1:10 bleach, 3% hydrogen peroxide, 70% isopropyl alcohol for 5 mins.

25

Hyperemia in a patient with glaucoma you should think of what two causes?

elevated IOP or their drops

26

what are some adverse affects of IOP lowering drops?

follicular reaction, decreased tear production.

27

What characteristics of a bleb should you look at?

height, size, degree of vascularization, integrity, Seidel test

28

what are breaks in the decemets membrane secondary to enlargement of the cornea called?

Haabs striae (found in glaucoma patients at times)

29

Characteristic eye driness from glaucoma meds

infranasal PEEs

30

what's Van Herrick's method

fast method of estimating angle with thin slit lamp beam

31

In what situations can blood from episcleral veins enter the canal of schlemm?

whenever episcleral vein pressure is higher than IOP. In hypotony, sturge-weber, cavernous carotid fistula

32

What are normal vessels that can traverse the angle? how are they usually oriented?

radial iris vessels, ciliary body arterial circle, vertical branches of the anterior ciliary arteries.
Either vertically or radially.

33

what does PAS stand for? What could you possibly confuse this for at the angle?

peripheral anterior synechiae (more solid sheet like)
Can be confused with normal iris processes (uveal meshwork--which are open and lacy)

34

what is sampaolesi line?

pigment deposition anterior to Schwalbe's line from pseudo exfoliation syndrome.

35

what are the names of the two most common gonio grading systems?

Schaffer and Spaeth

36

Criteria for angle recession glaucoma diagnosis on gonio?

1. abnormally wide ciliary body band
2. increased prominence of scleral spur
3. torn iris processes
4. marked variation of the ciliary face width and depth in 4 quadrants

37

what is cyclodialysis?

separation of ciliary body from scleral spur

38

diameter of anterior optic nerve?

1.5 mm

39

diameter of posterior optic nerve

3-4 mm

40

what are the 3 types of retinal ganglion cells in primates?

M cells (magnocellular neurons)
P cells (Parvocellular neurons)
Bistriated cells (koniocellular neurons)

41

What are M Cells? what kind of vision does it provide? where does it synapse?

They are large axonal cells of the retinal ganglion layer; responsible for dim changes in luminance--thus motion detection. They synapse on the Magnocellular layer of the lateral geniculate ganglion

42

What are P cells? where do they synapse? what are their function

They are located in the central retina with small diameter axons with slow conduction velocity. They synapse on the parvocellular layer of the lateral geniculate ganglion. They discern color and details. Best in luminance conditions.

43

what is the bistriated cells' function?

discerning blue-yellow oppnency. Activated when blue cones are stimulated and suppressed with red-green cones.

44

what are the 4 layers of anterior optic nerve?

nerve fiber layer--essentially same as RNFL
prelaminar layer--juxtaposed to the peripapillary choroid
laminar layer- juxtaposed to sclera and lamina cribosa
retrolaminar layer-Becomes myelinated and leptomeninges wraps around

45

how can you visualize the nerve fiber layer?

red free filter (green)

46

What is lamina cribosa?

structural layer of the optic nerve as it exits the eye along the Laminar portion of the optic nerve. It has extraceullar matrix for support, vessels for nourishment. Fenestrations allow traversing central retinal A and V to pass through

47

What is ring of Elschnig?

connective tissue ring layer next to the sclera/choroid supporting the optic nerve.

48

lamina cribosa is thinnest where?

superior and inferiorly

49

What are the two types of peripapillary atrophy (PPA)? Which is concerning

Alpha (normal and in glaucoma with hyper and hypopigmentation. Beta zone is associated with glaucoma and have atrophic RPE and largest in areas of neuroretinal loss

50

What is the ganglion cell complex?

Retinal layers including RNFL and ganglion cell layer and inner plexiform layer

51

What are the two other imaging techniques for RNFL/ONH other than OCT?

Confocal scanning laser ophthalmoscopy, scanning laser polarimetry

52

Clover leaf VF indicates what

Inattentive patient or malingering

53

What are the classic VF patterns of glaucomatous change?

Arcuate defect (Bjerrum scotoma), nasal step, paracentral scotoma, altitudinal defect, generalized depression, temporal wedge

54

What is trend based analysis

looking at all VFs throughout time.

55

what is event based analysis

looking at VFs against a baseline test

56

what are ways to measure progression based on Visual fields?

mean deviation, visual field index progression plot

57

What is FDT perimetry?

Frequency doubling technology perimetry. selectively evaluates M pathway for contrast sensitivity toward motion

58

What is SWAP?

short wavelength automated perimetry. uses narrow blue-violet stimulus against a bright yellow background to test the koniocellular layers projecting toward lat gen ganglion

59

What is FDF

flicker defined form perimetry. stimulates M pathway and may be useful for early glaucoma detection.

60

What is UBM and AS-OCT? what's good about each?

US biomicroscopy and ant seg-OCT. AS OCT has higher resolution. however AS OCT doesn't penetrate sclera well...thus UBM is better for ciliary body structures

61

How was the normal IOP range determined?

average IOP of 15.5 with +/- 2SD on either side. This is based on European studies

62

whats the average CCT?

540

63

what are the major associations risk factors for POAG?

age, race, family history, CCT, IOP

64

what is the association of HTN and POAG?

young people are protected against POAG and older are more susceptible

65

Which study found association of DM with POAG? which showed it's protective against POAG?

Beaver Dam showed DM is associated with POAG. OHTS showed it's protective

66

what are more obscure conditions associated with POAG?

migraines, thyroid, sleep apnea, HLD, low CSF pressure, corneal hysteresis, Raynaud

67

what characteristic of a POAG patient puts them at most likelihood of blindness?

visual field loss at the time of diagnosis

68

what's the technical term for normal tension glaucoma?

POAG without elevated IOP

69

normal tension glaucoma can be split in to which two categories?

Senile sclerotic group-pale sloping neuroretinal rim
Focal ischemic group- deep focal notching of rim

70

How does VF differ in a NTG pt vs POAG?

NTG tend to be more dense centrally early on

71

Collaborative NTG Study (CNTGS) found what?

reducing IOP by 30% reduced progression of VF from 35% to 12%... after adjusting for the effect of cataracts

72

what kind of glaucoma has incisional surgery as first line of treatment?

primary congenital glaucoma

73

What's the general mechanism of Laser trabeculoplasty surgery?

increase outflow via targeting the trabecular meshwork

74

How does ALT work?

Thermal damage to trabecular meshwork leading to scarring and release of TNFa, INFb leading to stretching of adjacent areas of trabecular meshwork

75

How does SLT work?

targets pigmented cells only leading to increased inflammation and trabecular meshwork adjacent to areas targeted.

76

what are glaucoma suspects?

abnormal nerve appearance OR abnormal fields

77

pseudo exfoliation syndrome is associated with what gene?

LOXL1; but it's a multifactorial disease.

78

Classic pattern on exam for pseudo exfoliative syndrome?

- bullseye pattern
- transillumination defect
- Poor pupillary dilation
-weak zonules--phacodonesis, iridodonesis
- Pigment deposition (sampaolesi line) at the angle
- Krukenberg spindles

79

Intraop (cataract surgery) complications of pseudo exfoliation?

zone dehiscence, lens dislocation, vitreous loss

80

association of increase risk for progression in pseudoexfoliation syndrome in development of glaucoma was shown in what study?

Early management of glaucoma trial

81

prognosis of pseudo exfoliative glaucoma vs POAG?

pseudo is worse

82

What population is pseudoexfoliation syndrome associated with?

Scandinavians (up to 50% of glaucomas)

83

What are classic exam signs of pigment dispersion syndrome?

- transillumination defect
-pigment deposition (krukenberg spindle and in trabecular meshwork)
-Sampaolesi line

84

Zentamayer ring or scheme stripe is?

deposition of pigment on zoneules and equatorial region of lens in pigment dispersion syndrome.

85

How is pigmentary dispersion syndrome affected by age.

It may get better given pigment is reduced.

86

posterior bowing of iris seen in what glaucoma condition

pigment dispersion

87

Pigmentary dispersion glaucoma responds well to what?

medical, laser, and trabeculectomy filtering surgery (however caution in young myopes)

88

How can you distinguish phacoantigenic and phacolytic glaucoma?

phacolytic is nontraumatic/disturbed lens and NO KPs

89

How can tumors cause glaucoma?

direct angle invaions, angle closure, hemoorhage, NV, inflammation

90

how to treat retained lens particle glaucoma?

medical therapy to control IOP when the particle resorbs... If cannot be controlled then take it out

91

Hallmarks of Posner scholssman

High IOP in 40-50s, mild AC reaction, unilateral in middle age person

92

What is a theoretical cause of Fuch's heterochromic uveitis?

Rubella

93

Does fuch's heterochromic uveitis respond to steroids?

typically no

94

Classic findings in Fuch's heterochromic uveitis?

mild inflammation (stellate KPs), elevated IOP, asymptomatic, fine vessels crossing the trabecular meshwork but NO PAS

95

why are sickle cell patients at an elevated risk of IOP elevation after hyphema?

acidic aqueous induces sickling and traps RBCs in trabeculum. Sickle cell patients' optic nerves also are more prone to damage.

96

which two patient population with hyphema should you consider early surgical intervention

1. sickle cell as their optic nerves are more susceptible to damage
2. Young children to avoid corneal staining/amblyopia

97

what's the difference between traumatic hyphema, hemolytic glaucoma, and ghost cell glaucoma

hyphema is layering in AC, hemolytic glaucoma is AC RBCs from vitreous hemorrhage, ghost cells are degenerated hemolytic RBCs

98

glaucoma is a frequent side effect of PKP. why?

wound distortion of the trabecular meshwork and progressive PAS formation

99

what's IOP like in most rhegmatogenous RD? What is the issue if it's high? How do you treat this?

IOP is usually low. High IOP can be seen with Schwartz Syndrome given outer segment photoreceptor migration to AC and decreases aqueous outflow.

Retina reattachment to treat

100

What is Schwartz syndrome

migration of outer segment photoreceptors to AC and decreasing aqueous outflow thereby increasing IOP

101

what are risk factors for corticosteroid induced glaucoma? 6

POAG, first degree relative with POAG, young age <6 years, connective tissues disease, Type 1 DM, myopia

102

CIGTS trial. Purpose? Results/big points?

collective initial glaucoma tx study
Purpose: medical vs filtering surgery for initial treatment of POAG
Results: surgery lowered IOP more, but progression were about the same long run. Worse baseline VF and surgery resulted in less progression

103

OHTS trial. purpose? results/big points

ocular hen study
purpose: efficacy and safety of topical antihypertensives in ocular HTN.

topical were effective preventing onset of POAG.
5 year risk of OAG risks were: older, CDR/morphology, higher pattern standard deviation, baseline IOP. CCT.

104

EMGT trial. purpose and big points

early manifest glaucoma trial
Purpose: effectiveness of IOP lowering with new, early OAG
Results: no tx progressed more than tx.. risk factors for progression --age, high IOP, pseudo exfoliation, more advanced field loss, bilateral glaucoma

105

primary angle closure suspect (PACS) definition
vs primary angle closure (PAC) vs Primary angle closure glaucoma (PACG)

iridotrabecular contact >180deg no trabecular/optic nerve damage.
iridotrabecular contact with IOP elevation or PAS, no optic nerve damage
iridotrabecular contact AND optic neuropathy

106

population most susceptible to angle closure glaucoma

Asian females (inuits the highest)

107

name some secondary causes of angle closure glaucoma?

NVG, intumescent lens. lax zonules--marfans/pseudoexfoliation, chronic uveitis, corneal endothelial migration, epithelial ingrowth, posterior mass

108

most common cause of angle closure?

pupillary block

109

anterior chamber depth of less that what depth is prone to PAC

2.5mm

110

biometric parameters predisposing to PAC?

short AL, shallow AC (2.5mm), thick lens, small K diameter

111

which gene is associated with PACG?

ABCC5

112

general risk factors for PACG?

female, Asian, biometric measures, FMHx, hyperopes

113

when should you definitely do an LPI for an anatomical narrow angle patient?

appositional closure, PAS, increased segmental trabecular meshwork pigmentation, hx of previous angle closure, high risk factors

114

PAC symptoms/signs

eye pain, blurry vision, halos, HA
high IOP, mid dilated pupil, K edema, shallow AC

115

strategies to break an PAC attack.

miotics cholinergic (with care, this may worsen some types without pupillary block), beta blockers, alpha2 agonists, prostaglandins, carbonic anhydrase inhib, globe compression with gonio, LPI

116

lowered IOP after an acute angle closure attack doesn't necessarily mean angle is open...why?

ciliary body ischemia may lead to decreased aqueous production leading to lowered IOP...therefore you need to gonio to make sure anle is open

117

what is subacute angle closure

also called intermittent angle closure... angle closes now and then and resolves --esp while sleeping (miosis). Pt has intermit HA, IOP elevation, eye pain

118

what is chronic angle closure glaucoma? how do you treat it?

slow progression of PAS at angle. can be confused with POAG. must do LPI

119

what is double hump sign

plateau iris

120

how to treat plateau iris?

LPI, lensectomy, iridoplasty

121

treatment phacomorphic glaucoma?

cataract surgery vs LPI then cataract surgery

122

iris bombe treatment

LPI 180 degrees apart. then lensectomy

123

Why does pseudophakic, aphakic, and AC IOL angle closure occur?

vitreous pushes forward to these interphases

124

what is capsular block?

fluid or visco enters capsular bag and pushes IOL forward narrowing the angle.

125

NVG occurs mostly with which conditions?

DR, CRVO, BRVO, ocular ischemic syndrome

126

NVG and ICE both can cause ectropion uvea and PAS in the angle. what feature distinguishes them?

in NVG PAS ends at the Schwalbe line. ICE extens to corneal endothelium.

127

what conditions causes NVI that's not associated with retinal ischemia?

Fuch's heterochromic uveitis., pseudoexfoliation, iris melanoma

128

what is Schwabe's line

where descemet meets trabecular meshwork

129

what is posterior embryotoxon

thin gray arcuate line marking anteriorly displaced schwalbes line

130

what are some contraindications for incisional filtering surgery?

conj scarring/surgery, active scleritis/uveitis, active anterior segment NV

131

whats the definitive treatment for NVI

PRP, antiVEGF

132

What are the triads of ICE syndrome.

iris atrophy, angle closure, corneal edema

133

patient population of ICE syndrome

middle age, women, unilateral

134

What are the three clinical variants of ICE syndrome?

Essential progressive iris atrophy, Cogan-Reese syndrome, Chandler syndrome

135

What is unique about PAS formed in ICE syndrome?

high PAS reaching pass schwalbe's line

136

what is essential progressive iris atrophy?

clinical variant of ICE syndrome characterized by extreme iris atrophy: heterochromia, corectopia, ectropion uveal,, iris stromal atrophy, holes

137

What is Chandler syndrome

ICE variant characterized by corneal edema and angle closure mostly with minimal iris atrophy

138

What is Cogan Reese syndrome?

ICE variant characterized by tan pedunculate nodules on iris surface

139

what is the percentage of patients with ICE who develop glaucoma?

50%

140

two conditions with beaten bronze endothelium appearance?

Fuch's, ICE

141

Treatment for ICE? medical? surgical?

targeting K edema and ACG. Hypertonic topicals, aqueous suppressant, prostaglandins. Filtering surgery is good. YAG can be used if endothelial cells grow over filtering fistula

142

what is malignant glaucoma?

AKA aqueous misdirection or ciliary block. mostly postop with sudden onset pain/IOP, diffusely shallowing of the AC--AVOID miotics

143

what's the definitive treatment for malignant glaucoma? what about in the interim prior to definitve tx.

vitrectomy with anterior hyaloidozonulectomy and deepening the AC.
-can do topicals, YAG to disrupt anterior vitreous in pseudophakics, and Argon photocoagulation of ciliary processes in the interim

144

How do you confirm a diagnosis of epithelial ingrowth?

argon laser produces white burns on epithelium

145

define nanophthalmos. other features?

axial length <20mm. small cornea, lens is relatively large compared to eye, thick sclera (impede vortex veins drainage)

146

surgical risks of nanophthalmic eyes

choroidal effusion, nonrhegmatogenous RD, angle closure

147

what can topiramate cause? how to treat?

bilateral sudden onset angle closure and myopic shift. usually bilateral. Stop topiramate and get IOP down

148

what are meds that can cause secondary acute angle closure?

topiramate, Bactrim, acetazolamide/methazolamide,

149

what should you think of with bilateral angle closure and myopic shift.

topiramate

150

what are the 4 categories of primary pediatric glaucomas?

1. congenital open angle glaucoma
2. juvenile open angle glaucoma
3. glaucoma due to ocular anomalies
4. glaucoma due to systemic diseases

151

three classic features of primary congenital glaucoma (PCG?)

high IOP, large cornea, haabs striae

152

whats the time frame of new born primary congenital glaucoma?

at birth or witin 1 month of age

153

whats the time frame of late diagnosed primary congenital glaucoma?

up to 2 years of life

154

what's the time frame of juvenile open angle glaucoma? what's it associated with? general prognosis?

after 2 years of life (4-35 usually) associated with anterior segment abnormalities. px most will end up need trabs and tube shunts.

155

juvenile open angle glaucoma is associate with what genes?

TIGR, MYOC --both of GLC1A locus

156

mode of inheritance of primary congenital glaucoma?

sporadic and autosomal rescessive

157

mode of inheritance of juvenile open angle glaucoma?

autosomal dominant

158

genetic association of aniridia?

PAX6, usually autosomal dominant

159

genetic associations of axenfeld rieger?

PITX2, FOXC1

160

genetic associations of Peter's syndrome

PAX6, FOXC1, PITx2, CYP1b1

161

gender association of primary congenital glaucoma?

boys (65%)>girls

162

good prognostic factors in primary congenital glaucoma?

diagnosis between 3 mo and 1 year

163

bad px factors in primary congenital glaucoma?

dx at birth or after 1 year, K diameter >14mm

164

classic presenting triad of congenital glaucoma?

photophobia, blepharospasm, epiphora

165

why are corneas large in congenital glaucoma?

IOP elevation causes K and scleral stretch up to 3 years old--leading to large K and bulthalmos. Causing K edema and Haab's striae

166

what origin are trabecular meshwork cells?

neurocrest

167

what is axenfeld anomaly

posterior embryotoxon with peripheral iris strands

168

what is Rieger anomaly?

axenfeld anomaly (Posterior embryotoxon) +corectopia, iris atrophy, ectropion uvea

169

what is axenfeld-Rieger syndrome?

ocular( posterior embryotoxon, corectopia, iris atrophy, glaucoma), dental malformation, maxillary hypoplasia, redundant periumbilical folds, hypospadias, pituitary abnl

170

eye manifestations of Peter's anomaly

leukoma (stromal, decemet, endothelial abnls), iris strands, aniridia,

171

systemic manifestation of Peter's anomaly?

cardiac, urogenital, musculoskeletal, ear, palate, spine

172

Peters anomaly mode of inheritan

sporadic-- both autos dom and rece also exist

173

what percent of Peters anomaly patients develop glaucoma? What about Axenfeld rieger?

50% for both

174

why is aniridia associated with glaucoma?

angle closure occurs when rudimentary iris stomp rotates forwards and forms PAS over time

175

aniridia is associated with what cornea abnl?

limbal stem cell deficiency-->pannus formation

176

aniridia mode of transmission? associated genes?

autosomal dominant. PAX6, WT1 (wilms tumor)

177

systemic syndromes associated with aniridia?

Wagr (wilms tumor, aniridia, genitourinary, retardation)-autosomal dom
Gillespie: autos recessive-aniridia, cerebellar ataxia, retardation

178

sturge weber-- % associated with glaucoma? why glaucoma?

30-70%. increased episcleral venous pressure and malformation of the trabecular meshwork

179

associations of sturge weber (systemic)

leptomeningeal angioma, choroidal cavernous hemangioma, calcifications, seizures, focal neurologic deficits, cognitive impairement

180

ocular surgical risk in patients with sturge weber?

choroidal effusion, choroidal hemorrhage

181

neonate with ectropion uvea-- you should work them up for what?

NF1

182

NF1 ocular findings? systemic findings?

Lisch nodules, optic nerve gliomas, eyelid neurofibromas, glaucoma.

café aulait spots, cutaneous nerofibromas, axillary freckling

183

aphakic glaucoma risk factors?

cataract surgery within 1st year of life, post op complications, small K diameter

184

normal corneal diameter in new born and 1 year old?

9.5-10.5 at birth, 11-12 mm at 1 year

185

anesthesia all lower IOP except for what? and what increases IOP

chloral hydrate.
ketamine incrases IOP

186

what are the therapies of choice for primary congenital glaucoma?

surgical: goniotomy (for clear corneas) or trabeculotomy (for cloudy corneas)

70-80% success for patients diagnosed 3 mo to 12 mo.

187

trabeculectomy or tube shunts are reserved for which pediatric patients?

if they have failed two conservative surgeries (goniotomy/trabeculotomy)

188

what are some complications of cyclodestruction

phthisis bulbi, uveitis, hypotony, RD

189

what is trabeculotomy?

sclerotomy and then cannulating the canal of schlem 360.

190

what is goniotomy?

incision at the uveal trabecular meshwork with a gonio lens in place and through a clear corneal incision

191

trabeculectomy has a low success rate in which patients?2

younger than 2 y/o and aphakic

192

what are the aqueous suppressing meds?

alpha agonist, beta blocker, carbonic anhydrase

193

side effects of betablockers?

bronchospasm, hypotension

194

what are side effects of carbonic anhydrase? who should NOT be given these?

diarrhea, hypokalemia, sickle cell crisis, SJS, aplastic anemia

sulfa allergies, poor renal function

195

side effect of alpha blockers? contraindications?

crosses BBB, therefore apnea, hypotension, bradycardia, hypothermia, hypotonia, somnolence, follicular conjunctivitis with long term use

contraindicated in children <3

196

which are the outflow promoters?

alpha agonists, prostaglandins, cholinergics

197

possible side effect of prostaglandins?

exacerbates uveitis.
hypertrichosis, trichiasis, conj hyperemia, periocular pigmentation, darkening of iris color, prostaglandin associated periorbitaopathy (sunken in eyes), CME

198

general rule of thumb with target IOP in glaucoma pts?

>25%, but should be individualized

199

what are the 6 classes of glaucoma meds?

alpha agonist, beta blocker, carbonic anhydrase, prostaglandin, cholinergics, hyperosmotics

200

what are the 4 prostaglandins and what's special about each

latanoprost/travoprost: lowers by 25-32%
bimatoprost: lowers by 27-33%
Tafluprost: only preservative free

201

what's special about betaxolol

it's a beta 1 selective inhibitor. less effective than the nonselectives

202

pilocarpine is used for what?

plateau iris syndrome, pigmantart glaucoma

203

serious side effects of hyperosmolars?

CHF, MI, confusion, subdural/subarachnoid hemorrhage. Contraindicated in renal failure

204

which glaucomas are good for laser trabeculoplasty?

POAG, steroid induced, pseudoexofliation, pigmentary

205

which glaucomas should not be treated with laser trabeculoplasty?

developmental, inflammatory, NVG, ICE

206

which is the only category B glaucoma med in pregnancy?

brimonidine

207

what are the 3 lasers used for laser trabeculoplasty?

argon (ALT), nd;yag (SLT), iodide

208

what is peripheral iridotomy used for?

primary angle closure, pupillary block, or PAC suspects

209

contraindications of LPI?

completely flat chamber--avoid K damage
hazy view
secondary angle closures w/o pupillary block
360 PAS
NVI

210

how do you deal with bleeding during LPI?

push laser lens on the eye to tamponade the bleed. if that doesn't work use argon laser to coagulate it

211

what is gonioplasty/iridoplasty?

argon laser to the peripheral iris to allow AC to deepen by causing stromal shrinkage. This is done after LPI in angle closure/plateau iris

212

what are the cyclodestruction techniques

endoscopic cyclophotocoagulation
transscleral cyclophotocoagulation
cyclocryotherapy (higher risk of phthisis, hypotony)

213

when do you do cyclodestruction

poor visual potential, poor candidate for incisional surgery. "painful NLP eye"

214

methods of treating painful NLP eyes?

retrobulbar alcohol, retrobulbar chlorpromazine, enucleation, transscleral cyclophotocoagulation

215

what are the contraindications of external cyclodestruction?
what are contraindications of endoscopic cyclophotocoagulation?

external (cryo, transscleral): contraindicated in good vision, NV--> high risk of phthisis
endoscopic CP: contraindicated in blind eyes due to sympathetic ophthalmia risk

216

what are indications for incisional surgery

uncontrolled IOP, progression of field loss, medication nonadherence

217

contraindications for trabeculectomy. 3

active uveitis/infection, bad conj/sclera, blind eye

218

whats the most common cause of vision loss s/p trabeculectomy? what are other causes?

cataract formation. others include macular edema, hypotony maculopathy, "wipe out" loss of vision for no apparent reason, blebitis/endophthalmitis

219

short term complications of trabeculectomy?

wound leak, hypothyroidism, shallow AC, choroidal effusion/hemorrhage.

220

long term complications of trabeculectomy

blebitis, endophthalmitis, bleb leak/failure/scaring/over hang, hypotony associated maculopathy, choroidal hemorrhage, eye lid issues, dellens, contact fitting issues

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risk factors for bleb related endophthalmitis

chronic bleb leak, blepharitis, conjunctivitis, trauma, nasolacrimal duct obstruction, CL use, male, young

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risk factors for bleb failure?

young, African American, aphasia, uveitis, anterior NV, prior cataract surgery, prior failed filtering surgery

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name the two nonvalved tube shunts?

molten, baervaldt

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name a valved tube shunt

ahmed

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what did the tube vs trabecular study show?

-both were similar in terms of IOP and required medications
-tube was more successful in eyes with prior intraocular surgery
-tubes required fewer additional procedures

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indications for tubes?

-failed trabeculectomy
-active uveitis
-NVG
-inadequate conj
-aphakia
-CL lens use

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contraindications of tube shunts?

poor corneal endothelial function

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tube shunt complications?

hypotony, corneal touch, tube obstruction, plate migration, tube erosion, endophthalmitis

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which is more likely for leaks? fornix based or limbus based trabeculectomy?

fornix based is more likely to leak bc the incision is at the limbus

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when is surgical iridectomy indicated?

when laser iridotomy can't be done-- cloudy cornea, shallow/flat AC, inadequate pt cooperation

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goniosynechialysis can be done in PAS of what duration?

6-12 months