PXF

Question 1

Hallmark of PXF

Answer 1

Flaky deposits on lens

Scandinavian

Question 2

Why does PXF make for complicated CE

Answer 2

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

Question 3

Types of glaucoma related to cataracts

Answer 3

Phacolytic and phacomorphic

Always repeat gonio on phakic patients

Question 4

Signs of PXF

Answer 4

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

Question 5

PXF and elevated IOP

Answer 5

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

Question 6

Phacolytic glaucoma

Answer 6

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.

Question 7

Phacomorphic glaucoma

Answer 7

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

Question 8

PDS patients

Answer 8

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

Question 9

True exfoliation syndrome

Answer 9

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

Question 10

Wilson’s disease cataracts

Answer 10

Sunflower cataract

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

Question 11

PXFtreatment

Answer 11

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

Question 12

Indication of PUI

Answer 12

Angle closure or high risk of angle closure

Question 13

What does PI do

Answer 13

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

Question 14

Indication for goniotomy

Answer 14

Congenital glaucoma

Question 15

What does goniotomy do

Answer 15

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

Question 16

Indication for trabeculectomy

Answer 16

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

Question 17

What does a trabeculectomy do

Answer 17

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

Question 18

Indication for ALT or SLT

Answer 18

Open angle glaucoma with inadequate IOP control

Question 19

What does ALT and SLT do

Answer 19

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

Question 20

Indication for glaucoma shunt procedures

Answer 20

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

Question 21

What do glaucoma shunt procedures do

Answer 21

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

Question 22

Indication for cycloablation

Answer 22

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

Question 23

Laser peripheral iridoplasty indication

Answer 23

Angle closure, plautea iris syndrome

Question 24

What does a laser peripheral iridoplasty do

Answer 24

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

Question 25

Otomy

Answer 25

Incision

Question 26

Ectomy

Answer 26

Removal

Question 27

Oplasty

Answer 27

Repair

Question 28

MIGS

Answer 28

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

Question 29

BBlockers and breathing

Answer 29

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

Question 30

When is AREDS1 beneficial

Answer 30

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

Question 31

What type of patient is AREDs 1 contraindicated in

Answer 31

Smokers because of beta carotene

Question 32

Pattern standard deviation

Answer 32

- 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)

Question 33

Reliability on HVF

Answer 33

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

Question 34

Gray scale of HVF

Answer 34

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

Question 35

Total deviation on HVF

Answer 35

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

Question 36

Pattern deviation HVF

Answer 36

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

Question 37

Glaucoma hemifield tests

Answer 37

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)

Question 38

Mean deviation (MD)

Answer 38

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

Question 39

Visual field index (VFI)

Answer 39

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

Question 40

First step in interpreting the VF

Answer 40

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