Glaucoma Flashcards
(212 cards)
<p>What two structures make up the ciliary body?</p>
<p>Pars plana and pars plicata</p>
<p>How wide are the pars plana and pars plicata respectively?</p>
<p>4mm (pars plana)2mm (pars plicata)</p>
<p>What 3 structures make up the pars plicata?</p>
<p>ciliary muscles, ciliary vessels, ciliary processes</p>
<p>What are the 3 types of muscles that make up the ciliary muscle?</p>
<p>Longitudinal, radial and circular</p>
<p>Where do longitudinal muscles insert?</p>
<p>scleral spur</p>
<p>How does the longitudinal muscle affect IOP?</p>
<p>affects outflow facility (contraction of muscle increases outflow)</p>
<p>Which muscle fibers of the ciliary body are responsible for accommodation?</p>
<p>Circular</p>
<p>What is the blood supply of the ciliary body?</p>
<p>Anastomosis between branches of anterior and long posterior ciliary arteries</p>
<p>How many ciliary processes?</p>
<p>70</p>
<p>Name 5 functions of the ciliary body:</p>
<p>1. Suspends and alters shape of lens2. Produces aqueous3. Affects aqueous outflow4. Makes acid mucopolysaccharide component of vitreous5. Maintains blood aqueous barrier </p>
<p>Contraction of the longitudinal muscle creates what change in the lens?</p>
<p>shifts the lens forward and shallows the AC (DOES NOT CHANGE LENS SHAPE)</p>
<p>Contraction of the circular muscle creates what change in the lens? What refractive change?</p>
<p>relaxes the zonules making the lens more round with more refractive power (accommodation)</p>
<p>Relaxation of the circular muscle creates what change in the lens? What refractive change?</p>
<p>tightens the zonules making the lens flatter with less refractive power </p>
<p>By what method is aqueous humor produced?</p>
<p>Active secretion via Na+/K+ pump and carbonic anhydrase </p>
<p>How does glucose enter aqueous humor?</p>
<p>passive diffusion</p>
<p>What is the rate of aqueous production?</p>
<p>2-3microliters/min</p>
<p>What is the anterior chamber and posterior chamber volumes respectively?</p>
<p>250 microliters, 60 microliters</p>
<p>What is the rate of aqueous humor turnover?</p>
<p>1% per minute</p>
<p>What is fluorophotometry? What is it used for?</p>
<p>direct optical measurement of decreasing fluorescein concentration. Used to measure the rate of aqueous production.</p>
<p>How does the production of aqueous change daily and over a lifetime?</p>
<p>Decreases about 45% with sleep.Decreases about 2%/decade (counterbalanced by decrease outflow with increasing age)</p>
<p>What is the pH of aqueous?</p>
<p>7.2</p>
<p>Vitamin C concentration in aqueous is higher or lower than in plasma??</p>
<p>Much higher! 15x higher</p>
<p>Protein concentration in aqueous is higher or lower than in plasma??</p>
<p>Lower (provides optical clarity)</p>
<p>Name 3 functions of the aqueous?</p>
<p>1. Maintains IOP2. Provides nutrition to the lens/cornea3. removes metabolic waste</p>
Blood/aqueous barrier is maintained by what cells in the ciliary body?
outer pigmented epitheliuminner non pigmented epithelium
Outer pigmented epithelium is continuous with what structure posteriorly?
RPE (basal lamina continuous with Bruch's)
Inner nonpigmented epithelium is continuous with what structure posteriorly?
neurosensory retina (basal lamina continuous with ILM) Site of active secretion
How do the inner and outer pigmented epithelium relate to each other?
Apex to apex
What is flare in the AC?
increase in concentration of protein
How does atropine decrease flare?
By closing tight junctions of the blood/aqueous barrier
What is the traditional aqueous outflow pathway? What percentage of aqueous outflow is via the traditional pathway?
Outflow via the TM80-85%
Give the structural pathway of the traditional aqueous outflow path.
uveoscleral meshwork -> corneoscleral meshwork-> juxtacanalicular connective tissue -> scheme's canal -> collector channels -> aqueous veins -> episcleral and conj veins -> anterior ciliary and superior ophthalmic veins -> cavernous sinus
What structure provides the greatest resistance to aqueous outflow?
Juxtacanalicular tissue (4-7micrometer pore size)
How many collector channels are there from Schlemm's canal?
30
Uveoscleral outflow accounts for how much of the total aqueous outflow?
15-20%
Aqueous passes through what angle structure in the uveoscleral outflow tract?
CB -> suprachoroidal space -> CB veins, choroidal veins and scleral veins
A cyclodialysis cleft increases aqueous outflow through what mechanism?
increase uveoscleral outflow
What affect do cycloplegics have on aqueous outflow?
increase uveoscleral outflow
What affect do miotic agents have on aqueous outflow?
Decrease uveoscleral outflowIncrease TM outflow
Why are angle structures only visible on gonioscopy?
total internal reflection of the air/cornea
Anatomically, Schwalbe's line is...
Termination of Descemet's membrane
Name causes of increased pigmentation of TM.
Pseudoexfoliation syndrome, pigment dispersion syndrome, uveitis, melanoma, trauma, hyphema, darkly pigmented patients, age
Ddx of blood in Schlemm's canal
elevated episcleral venous pressure, oculodermal melanocytosis, hypotony, congenital ectropion uvea, neurofibromatosis
Name 7 cases of PAS
1. angle closure2. uveitis3. NVA4. flat AC5. ICE syndrome6. ciliary body tumors7. mesodermal dysgenesis
How do you tell a normal angle vessel from an abnormal angle vessel?
abnormal angle vessels cross scleral spur
DDx for abnormal vessels in the angle?
1. Neovascularization2. Iris neoplasm3. Fuch's heterochromic iridocyclitis (Amsler sign)
Angle recession is disinsertion of what two structures?
tear between longitudinal and circular fibers of the ciliary muscle
What percentage of patients with traumatic hyphema have angle recession?
60-90%
What percentage of patient's with angle recession have glaucoma?
5%
A cyclodialysis cleft is separation of what 2 structures?
ciliary body and scleral spurDIRECT COMMUNICATION BETWEEN AC AND SUPRACHOROIDAL SPACE
How are cyclodialysis clefts treated?
cycloplegics to relax ciliary body, argon laser, cryotherapy, suture CBB to SS, intravitreal air bubble to close superior cleft
Iridodialysis is....
disinsertion of the iris root
How many axons make up the adult optic nerve?
1.2 million
Retinal nerve fiber layer blood supply?
Central retinal artery
Prelaminar and laminar optic nerve blood supply?
Short posterior ciliary arteries
What is the Goldmann Fick equation?
IOP= F/C +EVPF is rate of aqueous formationC is facility of outflowEVP is episcleral venous pressure
Facility of outflow is measured by what?
tonography
Facility of outflow increases or decreases with age?
Decreases
What is normal EVP?
8-12 mmHg
What can cause EVP to increase?
venous obstruction, AV shunt
How do you measure EVP?
manometry
What is the distribution of IOP?
Non gaussian, skewed towards higher IOP
What is a normal range of diurnal variation of IOP?
2-6mmHg
How does season affect IOP?
IOP is higher in winter than in summer
How does posture affect IOP?
IOP is higher when you are laying down compared to sitting up
How does refractive error affect IOP?
IOP is typically higher in myopes
Name 3 types of tonometry.
1. Applanation2. non-contact3. indentation
What is a Schiotz tonometer?
A known weight indents the cornea and displaces a volume of fluid within the eye. Amount of indentation determines pressure.Falsely low with eyes with low rigidity: high myopia, retinal detachments, intraocular gasFalsely high with scleral rigidity and hyperopia
What is the Imbert Fick principle and what is it used for?
P = F/Afor an ideal thin-walled sphere, pressure inside sphere equals force necessary to flatten its surface divided by area of flattening
What is the diameter of the application tip?Why?
3.06mmAt this diameter corneal rigidity and tear meniscus pull of tonometer cancel each other out
Thick corneas overestimate IOP by about how much?
5mmHg per 70micrometersSame is true for thin corneas
If the patient has astigmatism, what changes need to be made with application?
if >1.5D of astigmatism, must align red mark with axis of MINUS cylinder
What is a Perkin's tonometer?
Portable form of a Goldmann tonometer
What is a Mackay-Marg tonometer? What are some examples?
Applanates a small area so good for corneal scars. Ex: tonopen and pneumotonometer
What is the Scheie classification for gonioscopy?
Grade 1- wide open (CBB)Grade 2- SS visibleGrade 3- only ATM visibleGrade 4- closed
What is the Schaffer classification system for gonioscopy?
Grade 1- 10% open Grade 2- 20% open Grade 3- 30% open Grade 4- 40% open
What is the first element of the Spaeth classification system for gonioscopy?
First element is a CAPITAL LETTERA- anterior to TMB- at TMC- at SSD- CBB visibleE- large CBB with indentation gonioscopy, put first impression then indent and write actual insertion in (_)
What is the 2nd element of the Spaeth classification for gonioscopy?
iridocorneal angle width in degrees from 5-45
What is the 3rd element of the Spaeth classification for gonioscopy?
Peripheral iris configurationr= regular (flat)s= steep (convex)q= queer (concave)
What is the 4th element of the Spaeth classification for gonioscopy?
Amount of pigmentation graded from 0 to 4
Which gonioscopy lens gives a direct view of the angle?
Koeppe
Which lenses can perform indentation gonioscopy?
Zeiss, Posner, Sussman
Which indirect viewing lens CANNOT perform indentation gonioscopy?
Goldmann (too big)
What is the degree or extent a person with normal visual fields can see in all directions?
Nasal- 60Superior- 60Inferior 70-75Temporal 100-110
Define fixation loss.
patient responds to target that is displayed in the blind spot
Define false positive
patient responds when there is no stimulus
Define false negative
patient does not respond to a super threshold stimulus at a spot that was previously responded to (lack of attention, cloverleaf)
What is mean deviation?
the average departure of each test point from the age-adjusted normal value
what is the background illumination for HVF?
31.5 apostilbs
what is the stimulus duration for HVF?
0.2s
What is the technical name for a nasal step?
Nasal step of Ronne
What is a seidel scotoma?
Small scotoma connected to the blind spot.
When performing direct ophthalmoscopy and looking at the RNFL, what is the best setting/light to visualize the RNFL?
red free
What cells die in glaucoma?
ganglion cells, amacrine and muller
Where do you find the earliest histological changes in glaucoma?
lamina cribrosa
What is Schnabels Cavernous Optic Atrophy? What causes it?
atrophy of neural element of the optic nerve and replacement with hyaluronic acid.
Glaucoma or atherosclerotic disease and normal IOP
Schnabels Cavernous Optic Atrophy stains classically __________ with ___________.
Hyalouronic acid (mucopolysaccharide) with colloidal iron (blue)
Glaucoma is the _______ leading cause of blindness in the US.
(first, second, third or fourth)
Second
Steroid responders have __% chance of developing glaucoma in the next 5 years.
31%
If a patient has glaucomatous damage in one eye, what is the risk of developing glaucoma in the fellow eye in 5 years?
29%
What is the most common genetic cause of POAG?
OPTN (optineurin) mutation
JOAG has been mapped to what gene?
MYOC/TIGR on chromosome 1q21-q31
Name 6 risk factors for glaucoma
1. age
2. increased C/D
3. thin CCT (<550)
4. family hx (6x increase in 1st degree relatives)
5. increased IOP
6. race (6x increased risk in African Americans)
7. Possibly DM, HTN, migraines??
Decrease in what two colors is the first to occur with glaucomatous damage?
blue - yellow
Name 5 causes of secondary open angle glaucoma.
1. clogging of TM (RBCs, macrophages, neoplastic cells, pigment, lens proteins, photoreceptor outer segments, visco)
2. Toxic/medication (steroids, siderosis, chalcosis)
3. Inflammation (uveitis, interstitial keratitis)
4. Increased EVP
5. Trauma (angle recession, chemical injury)
_______% risk of glaucoma is hyphema is more than 50% the AC volume
_________% risk of glaucoma with total hyphema
27%, 52%
What class of medication should be avoided in patients with sickle cell and hyphema?
Carbronic anhydrase inhibitors.
increase vitamin C in AC (decreases pH) and increases sickling
Non-clearing VH causes what type of glaucoma?
Ghost cell, khaki colored degenerated RBCs
What does "lytic" mean when referring to glaucoma?
macrophages filled with something are obstructing the TM
Hemolytic (hemosiderin)
Phacolytic (lens proteins)
Melanomalytic (melanin from malignant glaucoma)
Melanocytomalytic (melanin from necrotic melanocytoma)
What is phacolytic glaucoma? What cause it?
When lens proteins leak through the capsule in the setting of a hypermature cataract, macrophages engulf lens proteins and then become stuck in TM
Who is your typical patient with pigmentary glaucoma?
young myopic male
What percentage of patient with pigment dispersion develop pigmentary glaucoma?
50%
How is pigment dispersion syndrome inherited?
AD
What is the mechanism of pigment dispersion?
Reverse pupillary block. Iris bows back wards and there is mechanical rub against the pigmented posterior iris
What corneal abnormalities can be present in PDS?
Kruckenberg spindle (endothelium metabolizes released melanin)
Describe the TIDs of PDS.
Midperipheral, spoke like, radial
Patients with PDS have a higher liklihood of having what 2 retinal pathologies?
Lattice (20%), RD (5%)
What is the treatment for PDS?
miotics, excellent response to SLT
True or False: SLT is recommended in patients with PDS.
True! respond very well to SLT
What is the gene for pseudoexfoliation?
LOXL1
What percentage of patients with Pseudoexfoliation Syndrome have secondary glaucoma?
50%
True/False: PXE is a systemic disease.
True!
What finding on gonioscopy is typical of PXE?
Sampaolesi's line
(band of pigment anterior to schwalbe's line)
PXE is most common in what ethnic group?
Scandinavians
In PXE, what changes can you see in the iris?
1. blood-aqueous barrier defect
2. pseudouveitis
3. iris rigidity
4. posterior synechiae
5. poor dilation
In PXE, what changes can you see in the cornea?
1. Reduced endothelial cell count (interesting huh?)
2. endothelial decompensation
3. endothelial proliferation over TM
True/False: PXE can cause both open and closed angle glaucoma.
True! weak zolunes can allow anterior movement of the lens and can cause intermittent angle closure glaucoma
Treatment for PXE?
usually have a very good response to laser trabeculopasty
usually have higher initial IOP and more difficult to control IOP with medical treatment alone compared to POAG
What is Schwartz's syndrome?
high IOP associated with RRD
What material blocks TM outflow in Schwartz syndrome?
photoreceptor outer segments and pigment release from RPE
What is the treatment for Schwartz syndrome?
repair RRD
What is lens particle glaucoma?
lens particles block TM following trauma or cataract surgery (retained lens fragments). Greater inflammation than with phacolytic glaucoma
What are some typical findings of lens particle glaucoma?
very high IOP, PAS, posterior synechiae and inflammatory membranes
What is alpha-chymotrypsin?
How does it induce glaucoma?
An enzyme used to melt the zonules in intracapsular cataract extraction (ICCE)
Zonular fragments accumulate in TM, alpha-chymotrypsin itself does not cause damage
Who gets steroid induced glaucoma?
1. Patients with POAG
2. Patients with Fam Hx
3. Older patients
4. High myopes
5. DM
True or False: Oral steroids raise IOP more than topical steroids.
FALSE
Siderosis (iron) and chalcosis (copper) cause glaucoma how?
TM toxicity and scarring from IOFB
Name 4 types of non-infectious uveitis that are notorious for causing glaucoma.
1. JRA (20% develop glaucoma)
2. Posner Schlossman syndrome (episodic trabeculitis)
3. Fuch's heterochromic iridocyclitis (60% develop high IOP, glaucoma more common in those with spontaneous hyphema and bilateral disease)
4. UGH
Glaucoma develops in ___% of patients that have >180 degrees of angle recession.
10%
True or False: Acidic burns cause scarring of the TM more commonly than basic burns.
FALSE
A patient with TAO is in your clinic and you notice that in upgaze the patients IOP in about 5mmHg higher than in primary gaze. Why?
calse elevation of IOP caused by IR fibrosis and resistance to upgaze
What are some etiologies of elevated episcleral venous pressure?
CC fistula, cavernous sinus thrombosis, Sturge-Weber, NF, orbital mass, TAO, superior vena cava obstruction, mediastinal tumors and syndromes
Elevated episcleral venous pressure can cause what finding on gonioscopy?
blood in Schlemms canal
What is the mechanism of pupillary block?
In susceptible patients, iridolenticular touch causes resistance of aqueous flow from posterior to anterior chamber causing increased posterior pressure. When pupil in MID-DILATED (stress, low ambient light, sympathomimetric or anticholinergic meds), elevated posterior chamber pressure causes peripheral iris to bow forward and occlude angle
What ethnic group comes to mind that is particularly known for having ACUTE angle closure?
Eskimos and Asians
What racial group comes to mind that more commonly has CHRONIC angle closure?
African Americans more than asians
At what age is a patient at highest risk for angle closure?
55-65 years old
5% of patients over age 60 have angles that can be occluded and 0.5% of those patients with occludable angles will develop angle closure
Is angle closure glaucoma usually unilateral or bilateral?
Bilateral. 75% risk of untreated fellow eye in 5 years
What anatomic features predispose to angle closure?
1. small anterior segment (hyperopia, nanophthalmos, microcornea, microphthalmos)
2. Hereditary narrow angle
3. anterior iris insertion (eskimos, asians and AA)
4. Shallow AC (large lens, plateau iris, loose or dislocated lens)
You decide to treat a patient that you suspect is in acute angle closure with glycerin. What co-morbidity do you need to check the patients chart for before administering glycerin?
DM
True or False: Acute angle closure glaucoma can cause optic nerve edema.
True
After an episode of acute angle closure, what are some findings you may see in the lens? Iris?
Lens- glaukomflecken
Iris- atrophy from focal iris stromal necrosis, dilated irregular pupil from sphincter necrosis
What do you call focal anterior lens epithelial necrosis after an episode of acute angle closure?
Glaukomflecken
If you suspect a patient may be susceptible to angle closure, what are some in office tests you may consider?
Prone test
Darkroom test
Prone darkroom test
pharmacologic pupillary dilation
You suspect a patient may be suseptible to angle closure so you decide to put them in a dark room, prone in your office. After 1 hour you check the IOP and it has risen by 6mmHg from baseline. Is this a positive or negative test?
Negative. IOP has to rise >8mmHg to be positive
You suspect a patient is in acute angle closure and decide to give IV mannitol. What adverse events could possibly occur?
cardiovascular
You give a patient with acute angle closure pilocarpine and nothing happens. Why?
You give a patient with acute angle closure pilocarpine and the IOP goes up. Why?
1. sphincter ischemia
2. iris lens diaphram moves forward and worsens pupillary block
What is the difinitive treatment of angle closure?
PI
You suspect a patient is in angle closure. Besides drops and lasers, what other treatment options do you have?
compression gonioscopy. Can force aqueous through block and open angle
In a patient with angle closure glaucoma... if the iris is in ________ position, an LPI will not be as effective treatment of a treatment. Instead you should try what type of laser?
Plateau iris.
Laser iridoplasty
What is a potential serious adverse reaction to IV mannitol?
cardiovascular adverse effects
In a patient in acute angle closure in one eye, what is the chance of ACG in the other eye in the next 5 years?
75%
Name 2 exam findings you could see in a patient with a history of previous AACG or intermittent angle closure glaucoma.
PAS and glaukomflecken
What is glaukomflecken?
gray-white epithelial and anterior cortical lens opacities that occur following an episode of markedly elevated IOP. Histopathologically, glaukomflecken are composed of necrotic lens epithelial cells and degenerated subepithelial cortex.
Name a few causes on Secondary Angle-Closure glaucoma WITH PUPILLARY BLCOK.
Phacomorphic
dislocated lens
seclusio pupillae
nanophthalmos
SO
microspherophakia
Name a few causes of Secondary Angle Closure WITHOUT PUPILLARY BLOCK and with posterior pushing mechanism.
Posterior pushing:
1. Anterior rotation of CB:
inflammation (scleritis, uveitis, s/p PRP)
choroidal effusion (uveal effusion, hypotony)
suprachoroidal hemorrhage
2. Aqueous misdirection (AKA Malignant glaucoma)
3. Pressure from posterior segment
tumor, expansive gas, exudative RD
4. Contracture of retrolental tissue
PHFV, ROP
Name a few causes of Secondary Angle Closure WITHOUT PUPILLARY BLOCK with anterior pulling mechanism.
1. Epithelial downgrowth
2. endothelial downgrowth (ICE syndrome, PPMD)
3. NVG
4. adhesion from prior trauma
Define nanophthalmos:
Hyperopia of....
axial length of....
corneal diameter of....
Hyperopia of >10D
axial length of <20mm
corneal diameter of <10.5mm
Name some risk factors for development of malignant glaucoma.
uveitis
angle closure
nanophthalmos
hyperopia
s/p laser or incisional surgery in patients with PAS or CACG
What clinical findings do you see in malignant glaucoma?
entire AC is shallow (vs with angle closure only the periphery is shallow)
IOP higher than expected
patent iridectomy
no suprachoroidal fluid or blood
On POD1 after glaucoma surgery you do a Bscan on a patient and are concerned for a choroidal detachment. What patient SYMPTOM would be more indicative of a choroidal hemorrhage than a choroidal effusion? What CLINICAL FINDING?
Symptom: Pain more indicative of suprachoroidal hemorrhage. No pain with choroidal effusion.
Exam Finding: IOP elevated with suprachoroidal hemorrhage and low with effusion.
What percentrage of cases of malignant glaucoma resolve with medical therapy alone?
50%
Name 3 different laser/surgical options for management of malignant glaucoma.
1. Argon to ciliary process (shrink them?)
2. YAG to anterior hyaloid face
3. PPV with disruption of anterior hyaloid face
What is the most common mechanism by which an intraocular malignant melanoma produces glaucoma?
Direct invasion of the TM (can induce NVA and melanin laden macrophages can obstruct the TM (malanomalytis)
What is melanomalytic glaucoma?
Secondary open angle glaucoma caused by obstruction of TM with melanin laden macrophages (intraocular malignant melanoma of uveal tract)
This endothelial dystrophy looks like "snail tracks" and causes glaucoma by what mechanism?
BONUS: How is it inherited?
Posterior Polymorphous Corneal Dystrophy (PPMD) (don't think about the letters too hard)
Abnormal corneal endothelial cells migrate into angle
Autosomal dominant
Name 4 proposed mechanisms of NTG.
Nocturnal hypotension (compromised blood supply to nerve)
Autoimmune (increased incidence of proteinemia and autoantibodies)
Vasospasm
Previous hemodynamic crisis (excessive blood loss)
What exam finding is more commong in patients with NTG than POAG and can be a sign that IOP is not adequately controlled?
optic nerve splinter hemorrhages
In NTG, visual fields differ from POAG in what way?
deeper defects, closer to fixation
In ALT, what are the settings?
Power?
spot size?
Duration?
# of spots over what area?
400-1200mW power
50micrometers spot size
duration 0.1s
50 spots over 180 degrees
On average, ALT reduces IOP by what percentage?
30%
If a burn is placed too posterior with ALT, what is a risk?
PAS
ALT is successful most often in what type of glaucoma?
PXG (best) > PG > POAG > NTG > aphakic (worst)
On gonioscopy, the more _________, the more likely ALT is to lower IOP.
pigment
ALT may worsen IOP in what conditions?
uveitic glaucoma, angle recession, ACG, congenital glaucoma, steroids glaucoma
The majority of glaucoma is inherited in a _________ fashion. The exception is ___________ glaucoma, which is inherited __________.
The majority of glaucoma is inherited in an autosomal dominate fashion. The exception is congenital glaucoma, which is inherited autosomal recessive.
SLT parameters:
spot size?
power?
number of shots over what degree?
400 micrometer spot size
power 0.6-0.9mJ
50 shots over 180 degrees
You can do an LPI with either YAG or Argon laser (or both). What is the benefit and risk of each?
YAG bleed more but close less
Argon bleeds less, more pronounced iritis
What are the laser settings for iridoplasty?
power?
spot size?
duration?
200-400 mW power
500 micrometer spot size
duration 0.5-1.0 seconds
What patients are at higher risk of bleb failure with trabeculectomy?
previous surgical failure, darker skin, hx of keloid, younger, intraocular inflammation, scarred conjunctiva, hyperopia, shallow AC
Mitomycin C is an antibiotic isolated from _________.
streptomyces caespitosus
What is MMC mechanism of action?
intercalates with DNA and prevents replication, suppresses fibrosis and vascular ingrowth after exposure to the filtation site. Toxic to fibroblast in all stages of cell cycle, 100x more potent than 5-FU
What happens if MMC gets in the eye?
corneal decompensation due to endothelial damage
AC inflammation
necrosis of CB
retinal toxicity
What is 5-FUs mechanism of action?
affects the S-phase of the cell cycle
What happens if 5-FU gets in the eye?
nothing at normal concentrations
If IOP is high post operatively after trabeculectomy, what do you do?
laser suturelysis or digital massage
POD1 trabeculectomy.
Bleb high, IOP low.
What is DDx and Tx?
DDx: overfiltration
Tx: revision
POD1 trabeculectomy.
Bleb flat, IOP low.
What is DDx and Tx?
DDx: choroidal detachment
Tx: cycloplegics, steroids and +/- drainage
DDx: bleb leak
Tx: Antibiotis, IOP suppressants, stop steroid, reform AC, pressure patch, glue, surgery?
POD1 trabeculectomy.
Bleb flat, IOP elevated.
What is DDx and Tx?
DDx: suprachoroidal hemorrhage.... Tx: Drainage
DDx: pupillary block.... Tx: cycloplegics, steroid, PI
DDx: malignant glaucoma..... Tx: cycloplegics, aqueous suppressants, PI, YAG to anterior hyaloid, PPV
POD1 trabeculectomy.
Bleb high, IOP high.
What is DDx and Tx?
Dx: encapsulated bleb
Tx: needling, aqueous suppressants, bleb revision
Most common organism to cause blebitis?
Staphylococcus
Treatment of blebitis?
aggressive topical antibiotics, observe daily for endophthalmitis
Bacteria most commonly associated with bleb associated endophthalmitis?
streptococcus or H flu
Bleeding of this vessel causes a suprachoroidal hemorrhage after trab.
long posterior ciliary artery stretches until it ruptures
What are risk factors for suprachoroidal hemorrhage after trabeculectomy?
increased age, HTN, CAD, aphakia
What was the main conclusion of the Advanced Glaucoma Intervention Study? (AGIS)
African Americans: ATT
(ALT then trab then trab)
Caucasians: TAT
(trab first)
What was the main conclusion from the Ocular Hypertension Treatment Study? (OHTS)
At 5 years, the risk of development of POAG in a patient with ocular HTN decreases from 9.5% to 4.4% with treatment of ocular hypertension.
What was the main conclusion from the Collaborative Initial Glaucoma Treatment study (CIGTS)?
Initial treat of POAG with surgery or medical therapy results in similar VFs at 5 years.
VA loss was initially worse in the surgical group, but evened out by 5 year follow up.
What was the main conclusion of the Early Manifest Glaucoma Trial?
Each 1mmHg of IOP suppression resulted in 10% decreased risk of progression.
Treatment of early glaucoma halves the chance of progression
What was the main conclusion of the Glaucoma Laser Trial? (GLT)
initial treatment with ALT is at least as good as initial treatment with timoptic
What was the main outcome of the Collaborative Normal Tension Glaucoma Study?
IOP is a factor the pathogenesis of NTG and lowering IOP by 30% is beneficial.
In NTG, what are the factors that increase the rate of progression?
female gender, hx of migrains, disc hemorrhages
