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Secondary Glaucoma Secondary Glaucoma Secondary Glaucoma

VIEWS: 231 PAGES: 17

									             Steven VL Brown, MD, FACS
               Glaucoma Section Chair
            Rush University Medical Center
                      July 2010                                                      Approaching Darkness   -Bruce Shields, MD




Overview of Secondary Glaucoma
(s)
                                                           Secondary Glaucoma (s)
    Pseudoexfoliation
    Pigment Dispersion Syndrome                           Pseudoexfoliation Syndrome
    Steroid                                               (PXF)
    Following retina surgery                                 Often accompanied by
    Episcleral Venus Pressure                                secondary OAG/NAG
    Uveitis                                                  Characterized by deposition
    Lens Induced                                             of pseudoexfoliative material
    Possner/Schlossman                                       on anterior lens surface and
                                                              iris. Commonly known as
    Fuch’s Heterochromic Iridocyclitis
                                                              exfoliation syndrome.
    Trauma
    Intraocular Heme




 Secondary Glaucoma (s)                                    Secondary Glaucoma (s)
 Pseudoexfoliation Syndrome -Epidemiology                   Pseudoexfoliation Syndrome
      Typically affects elderly patients                   Case Report: J.M.
      Commonly described among Scandinavians,                 67 y/o W/F – European Ancestry
       Europeans, Australian aborigines, Southern              Va 20/25 OU
       Bantu tribe of South Africa, Indians, Pakistanis,       SLE: Exfoliative material OD
       and Navajo Indians                                       ○ Pupil margin/anterior lens only
      More common among women in the United                    ○ Ruff atrophy OU
       States                                                   ○ Splotchy TM OU
                                                                ○ Pigmentation OU
                                                               TAP 26/19
  Secondary Glaucoma (s)                                         Secondary Glaucoma (s)
  Pseudoexfoliation Glaucoma                                     Pseudoexfoliation Glaucoma
  Case Report: J.M.                                               Clinicopath:
     Discs: 0.6 OD; 0.4 OS                                            Fibrillar protein deposition                         100 x mag
                                                                       ○ Ocular: Anterior lens surface – 3 zone
     VF: Full OU                                                         Endothelium, pupillary, border iris surface angle,
                                                                         CB, vitreous face,
                                                                       *More severe elastosis of lamina cribrosa vs. POAG
                                                                  Systemic: Skin and visceral organs
                                                                   involvement
                                       “to treat or not           *underlying abnormality of elastic system?
                                       to treat…”




  Secondary Glaucoma (s)                                         Secondary Glaucoma (s)
Pseudoexfoliation Glaucoma                                       Pseudoexfoliation Glaucoma
                                                                  Clinical findings
 Prevalence:
                                                                      Often unilateral (40-50%)
  Scandinavia: Highest
                                                                      Pseudoexfoliative material on lens, usually
  North America = Western                                              bulls-eye pattern. Also seen on corneal
    Europe                                                             endothelium, anterior chamber angle, zonules,
  Eskimos – Very low                                                   and ciliary processes
  Navajo Indians – Very high                                          “Moth-eaten” pattern of peripupillary iris
                                                                       transillumination
  African American < Caucasian
                                                                      Pupillary ruff defects
    American




  Secondary Glaucoma (s)
Pseudoexfoliation Glaucoma
 Clinical findings
   Increased pigment – trabecular meshwork – Sampaolesi line
   Heavy pigment dispersion after dilation
   May be element of angle closure
   May be associated with spontaneous dislocation of lens and
    phakodonesis
   IOP response to topical steroids similar to normal
Secondary Glaucoma (s)                          Secondary Glaucoma (s)
Pseudoexfoliation Syndrome                      Pseudoexfoliation Glaucoma
   Prevalence                                     Unilateral involvement: Probability of
    Framingham Eye Study: 0.6% in 52-64 y/o         developing in fellow eye:
                            5.0% in 75-85 y/o        7% over 5 years, 17% after 10 years
    Finnish Study: 10% in 60-69 y/o                  Some studies 30% - 40% after 5 years
                   28% in 70-79 y/o                  (highest rate due to ruff atrophy inclusion)
                   33% in 80-89 y/o




Secondary Glaucoma (s)                          Secondary Glaucoma (s)
Pseudoexfoliation Glaucoma                      Pseudoexfoliation Glaucoma
   Non-glaucomatous eyes with PXF have            Case Report J.M.
    increased risk of developing glaucoma           Exfoliation with glaucoma have:
    over time:                                        ○ More severe clinical course compared
     5-year probability = 5%                          to POAG
     10-year probability = 15%                       ○ Higher mean intraocular pressure
                                                      ○ More extensive cupping/field defects
                                                      ○ More rapidly progressive compared to
                                                       POAG
Secondary Glaucoma (s)                         Secondary Glaucoma (s)
Pseudoexfoliation Glaucoma                        Pseudoexfoliation Glaucoma
   Management: Medical Treatment                    Management: Medical Treatment
     More resistant than POAG                         Prostaglandin
     Higher failure rate                              B-Blocker
     Efficacy shorter                                 CAI-Topical
                                                       Combination
                                                       Alpha Agonist
                                                       Miotics




Secondary Glaucoma (s)                         Secondary Glaucoma (s)
Pseudoexfoliation Glaucoma                        Pigment Dispersion Syndrome
   Management: Laser                              Epidemiology
     Usually very effective >80% IOP  but            More common in women than men
     20% develop sudden late  IOP and                Pigment dispersion with increase in IOP or
                                                        visual field loss and optic disc changes more
     Hypotensive effect short lived
                                                        common in men
     ? Re-treatment benefit                           Onset usually third decade in men, later in
                                                        women
                                                       May decrease in severity later in life
                                                       Described but rare in blacks




                                               Secondary Glaucoma (s)
                                              Pigment Dispersion Syndrome
                                                 Clinical Findings
                                                      ○ Krukenberg’s spindle = pigmented endotheilium
                                                      ○ Midperipheral iris transillumination defects and pigment
                                                       deposition on anterior iris surface
                                                      ○ Pigment on zonules/posterior lens capsule/ant. hyaloid
                                                      ○ Dense homogeneous band of trabecular
                                                       pigment/pigment anterior to Schwalbe’s line; concavity
                                                       of midperipheral iris
Secondary Glaucoma (s)
Pigmentary Glaucoma
   Iris inserted typically posterior
   Peripheral iris concave configuration
   Iridolenticular contact greater than normal
   Reverse pupillary Block: Blinking moves
    aqueous posterior to anterior chamber
   ?benefit laser iridotomy




                                                  Secondary Glaucoma (s)
                                                  Pigment Dispersion Syndrome
                                                   Clinical Findings
                                                     ○ Exercise and mydriasis may liberate pigment
                                                     ○ Pigment may initially obstruct trabecular
                                                       meshwork
                                                     ○ May be more difficult to control than POAG
                                                     ○ Approximately 6% develop retinal
                                                       detachments
Secondary Glaucoma (s)                              Secondary Glaucoma (s)
Pigment Dispersion Syndrome                         Corticosteroid-Induced Glaucoma
 Management                                         Clinical Findings
   Similar to treatment of POAG                         May be caused by exogenous
                                                          corticosteroids
   Miotics eliminate contact between zonules
                                                         Topical corticosteroids more likely to
   and iris                                               increase IOP than systemics
   LTP; initially good response but may lose            Effect of systemic and topical corticosteroids
   effect within months                                   may be additive
   Response to filtering surgery generally good         Increased IOP as early as 1 to 2 weeks after
                                                          treatment begins




Secondary Glaucoma (s)                              Secondary Glaucoma (s)
Corticosteroid-Induced Glaucoma                     Corticosteroid-Induced Glaucoma
 Epidemiology
   Affects a minority of general population           Secondary open angle glaucoma induced
   Greater risk of developing increased IOP in         by chronic use of topical or systemic
   patients with POAG                                   corticosteroids
   ? Genes controlling IOP response to
   corticosteroids and the inheritance of POAG
   are related




Secondary Glaucoma (s)                              Secondary Glaucoma (s)
Corticosteroid-Induced Glaucoma                     Corticosteroid-Induced Glaucoma
 Clinical Findings                                  Management
   IOP may become markedly elevated                     Dx confirmed by discontinuing medication with
                                                          subsequent drop in IOP
   Resembles primary infantile glaucoma in
                                                         IOP usually declines in a few days to several
    young children
                                                          weeks
   Can resemble normal tension glaucoma if
                                                         Pressure may need medical treatment until
    previous history of IOP fluctuations coincide         response
    with corticosteroid use
                                                         If steroids are necessary, use a weaker drug,
   May be difficult to distinguish in uveitis            lower concentration or dosage, or another drug
Secondary Glaucoma (s)                                 Secondary Glaucoma (s)

Corticosteroid-Induced Glaucoma                        Corticosteroids: Ocular Complications
 Management                                           Cataract/Increased IOP
   With periocular injections, may be necessary           Approximately 20% to 30% show increased IOP
    to remove residual drug                                 after topical steroids
                                                           Periocular > topical > systemic > skin
   If persistent IOP elevations are
                                                           Steroid related complications/responsiveness
    unresponsive to medical therapy, consider               function of length of use and type of steroid
    LTP (ALT/SLT)                                           preparation
   Glaucoma filtering surgery may be                      IOP elevation rare before 10 days
    necessary                                              Anti-inflammatory potency = pressure inducing effect




Secondary Glaucoma (s)
                                                       Glaucoma and Retina Surgery:
                                                       Reattaching the Retina but
Corticosteroids: Ocular Complications                  Killing the Optic Nerve
Discontinuation of steroids
   Substitution of steroid less potency
    ○ Intraocular pressure normalization 1-4 weeks
    ○ 2.8% chronic intraocular pressure elevation
     (positive family history of GLC)



                                                         Steven V.L. Brown, M.D., F.A.C.S.
                                                         Associate Professor, Rush University Medical Center, Chicago, IL
                                                                     Presented at Retinaws; August 12, 2007




Secondary Glaucoma (s)                                 Secondary Glaucoma (s)
Glaucoma after:                                        General Considerations:
                                                       Glaucoma not infrequent occurrence
  Scleral             Intravitreal          Silicone
                                                       after retinal detachment surgery
 Buckling                 Gas                  Oil         ○ Pre-existing POAG experience RD rate higher than
                                                             normal eyes
                                                           ○ Prevalence of POAG in eyes with RD 4 to 12 x greater
                                                             than in general population (unclear as to reason)
                                                           ○ Prevalence of myopia common risk factor for both
                                                             glaucoma and RD.
                                                           ○ Patients with pigment dispersion syndrome increased
                                                             incidence of RD
Secondary Glaucoma (s)                                          Secondary Glaucoma (s)
               LXII Edward Jackson Lecture:                                LXII Edward Jackson Lecture:
         Open Angle Glaucoma after Vitrectomy                           Open Angle Glaucoma after Vitrectomy
                        Stanley Chang, MD
                     Am J Ophthalmol. 2006 Jun
                                                                Conclusions:
•   Retrospective case study of 453 eyes that had               • Increased risk of OAG after vitrectomy
    undergone prior vitrectomy were reviewed for                • Presence of lens may be protective
    postoperative OAG.
•   Patients were followed for 7-192 months post                • Glaucoma meds may increase after surgery for
    vitrectomy.                                                   established glaucoma patients prior to vitrectomy
•   Patients were placed in three outcome groups:               • Oxidative stress is hypothesized to have a role in the
     Glaucoma Suspects                                           pathogensis
     Patients in whom glaucoma developed after operation
     Patients with pre-existing glaucoma




Secondary Glaucoma (s)                                          Secondary Glaucoma (s)
Glaucoma after Scleral Buckling                                 Glaucoma after Scleral Buckling
 Pathogenesis                                                   Incidence
•   Induced by impaired venous drainage from vortex                 • Angle closure incidence 1.4 to 4.4%
    veins
                                                                    • Usually short lived
    →Obstruction leads to congestion/swelling of ciliary
      body                                                          • Responds well to medical management
    →Ciliary body rotates anteriorly
    →Lens-iris diaphragm shifts
    →Angle closure
•   Similar mechanisms seen post PRP, CRVO, choroidal
    hemorrhage, uveal effusion, sulfa medications




Secondary Glaucoma (s)                                          Secondary Glaucoma (s)
                                                                Glaucoma after Scleral Buckling
                                                                Risk Factors
                                                                •   Pre-existing angles
                                                                •   Use of encircling band
                                                                •   Placement of encircling band anterior to the
                                                                    equator
                                                                •   High myopia
                                                                •   Older age
                                                                •   Ciliochoroidal detachment

   Gedde, Current Opinion in Ophthalmology 2002, 13: 103-109
Secondary Glaucoma (s)                                                         Secondary Glaucoma (s)
 Glaucoma after Scleral Buckling                                               Glaucoma after Scleral Buckling
 Treatment                                                                     Surgical Management
                                                                               •   Glaucoma drainage implants:
 •    Most cases resolve spontaneously-days to weeks                                 Silicone tube/shunt to preexisting encircling element
 •    Laser iridotomy not beneficial                                                  (Sidoti, et al. 1994):
                                                                                     85% success ( < or equal to 21 mmHg) : 11 of 13 eyes
       Laser iridoplasty +/- benefit
 •    Medical therapy:
       Cycloplegics, topical steroids, aqueous
        suppressants, CAI’s, avoid miotics




Secondary Glaucoma (s)                                                         Secondary Glaucoma (s)
 Glaucoma after Scleral Buckling:                                              Glaucoma after Scleral Buckling
 Surgical Management                                                           Surgical Management
 •    Baerveldt drainage implant:                                              • Cyclodestructive procedures:
       250 mm2 - 350 mm2
                                                                                    Oftentimes unpredictable/irreversible effect
 •    Trimmed “wings” implanted beneath band
 •    Full size 350mm2 implanted in quadrant with least                             Less attractive if good visual potential
      retinal hardware positioned over or behind encircling                        DIODE CPC
      band
                                                                                    270° TX : 1500 msec/1500 mw
 •    Success 80% IOP <21 mmHg
        ○ Smith, Ophth 1998                                                         Total spots: 20-22
        ○ Scott, Archives of Ophth 2000




Secondary Glaucoma (s)                                                         Secondary Glaucoma (s)
Glaucoma after Intravitreal Gas
•Commonly       employed to tamponade breaks                                   Glaucoma after Intravitreal Gas
•Expansile,     all properties                                                 Incidence/Risk Factors
                          Maximum         Time to maximal                      •   Titrating concentration/volume critical
       Intraocular         volume            expansion
           Gas            expansion           (hours)       Longevity (days)
                                                                               •   IOP elevation ranges from 6.1% to 67%
                           (times)                                             •   100% SF6: 11 of 101 (11%) CRAO*
Air                           0           Immediate              5-7           •   8-59% elevated IOP with perfluorcarbon
Sulfur                        2             24 to 48            10-14          •   Eyes with fibrinous anterior chamber exudates
Hexafluoride                                                                       post operatively greater risk of developing IOP
(SF6)                                                                              elevation (e.g. diabetics)
Perfluoropropane              4             48 to 72          55 to 65
(C3F8)                                                                                                          *Abrams et. al. ASO 1982

                          ** Perfluoroethane ( C2F6) – Not FDA Approved
    Secondary Glaucoma (s)                                            Secondary Glaucoma (s)
                                                                             Risk Factors for elevated intraocular pressure after
                                                                             the use of intraocular gases in vitreoretinal surgery
                                                                                                        Chen PP, Thompson JT

                                                                                             Ophthalmic Surg Laser. 1997 Jan; 28 (1): 37-42.


                                                                          171 eyes retrospectively investigated after vitreoretinal surgery
                                                                           using air, sulfur hexafluoride (SF6) or perfluoropropane (C3F8)

                                                                      Results:
                                                                      IOP’s greater than 22mmHg occurred in 74 of 171 eyes (43%)
                                                                      Elevated IOP was associated with:
                                                                           increasing patient age
                                                                           Expansile gas concentrations
        Gedde, Current Opinion in Ophthalmology 2002, 13: 103-109         Use of C3F8
                                                                           Circumferential scleral buckles




    Secondary Glaucoma (s)                                            Secondary Glaucoma (s)
Glaucoma after Intravitreal Gas                                       Glaucoma after Intravitreal Gas:
Medical Therapy                                                       Surgical Management
                                                                      •   Standard filter?: Dependent on conjunctival
•       Aqueous suppressants                                              scarring/recession
•       Aspiration of portion of gas                                       General poor prognosis even with anti-metabolites

•       Laser treatment: laser iridotomy if pupillary block present   •   Glaucoma Drainage Devices (GDD)
                                                                           Insertion through pars plana after complete vitrectomy if
                                                                             extensive PAS and phakic
                                                                           Results comparable to limbal tube insertion
                                                                           Greater posterior segment complications with pars plana
                                                                             insertion, e.g. choroidal detachment, suprachoroidal
                                                                             hemorrhage, retinal detachment, vitreous hemorrhage
                                                                           Can avoid hypotony if create new sclerostomy for tube




    Secondary Glaucoma (s)                                            Secondary Glaucoma (s)
                                                                                            Glaucoma after
    Case Report: TD
    •    67-year-old attorney
                                                                                          macular hole surgery
    •    S/P complicated phaco, disruption of PC, sulcus                               Ophthalmology, 1998 Jan; 105 (1): 94-9
         fixation PC IOL→RD repair with vitrectomy and
         SF6.                                                                                                 Chen CJ

    •    Secondary IOP elevation with angle closure→gas
         removed→angle opened but persistent increased                    Restrospective review of 40 patients with macular
         IOP despite MTMT                                                    holes that underwent pars plana vitrectomy,
    •    GDD (Ahmed) limbal based→6 month post                             removal of posterior hyaloid membrane, and 14%
         operative VA 20/25, IOP 14mmHg no meds →                                 perfluoropropane gas tamponade
         visual field showed inferior nasal step
Secondary Glaucoma (s)                                                                  Secondary Glaucoma (s)
                            Glaucoma after                                          Case Report :DP
                          macular hole surgery                                      •       73 year-old female – phakic – Va HM
                                                                                    •       Angle closure following macular hole repair with gas
Results:
•       21 patients (52%) experienced transient intraocular pressure elevation to   •       Elevated IOP OS secondary to ACG
        more than 30 mmHg                                                           •       S/P vitrectomy, gas for macular hole  IOP’s 30 mmHg
         9 patients (22%) had pressure elevation in 2-4 hours post surgery
         6 patients (15%) had pressure elevation within 24 hours of surgery
                                                                                             MTMT unsuccessful  SF6 Gas removal (-) benefit
         6 patients (15%) had pressure elevation within 1 week of surgery                  Laser Iridotomy (-) benefit  Va HM
                                                                                    •       Limbal GDD Post Op: IOP 14 mmHg -
Conclusion:                                                                                 no meds  No improvement in vision
  Glaucoma is a significant complication after stage 3 macular hole                         secondary to Optic Nerve damage
  surgery. Elevation of intraocular pressure in most cases is transient
  and can be controlled by medication




Secondary Glaucoma (s)                                                                  Secondary Glaucoma (s)
    Glaucoma after Silicone Oil Injection                                               Glaucoma after Silicone Oil
    Pathogenesis: Mechanism of Glaucoma                                                 Incidence/Risk Factors
    •   Adjunct in surgical pair of complicated RD                                      •    Variable: 5.9% to 56%
    •   Pupillary block: infrequent in phakic and
                                                                                        •    Higher viscosity silicone oil (>5000 centistokes)
        pseudophakic
                                                                                             reduced glaucoma incidence
    •   Inflammation
                                                                                        •    Greater risk in preexisting glaucoma, diabetes,
    •   Synechial angle closure
                                                                                             aphakia
    •   Rubeosis : ant seg neovascularization
                                                                                        •    Reduce risk by avoiding overfilling
    •   Migration of emulsified/non-emulsified oil into A/C
    •   Idiopathic open angle glaucoma




Secondary Glaucoma (s)                                                                  Secondary Glaucoma (s)
    Glaucoma after Silicone Oil                                                         Glaucoma after Silicone Oil
       Medical/Laser Therapy:                                                          Surgical Management
                                                                                        •    Oil removal controversial (risk of re-detachment?)
          Cycloplegics/anti-inflammatories/hypotensive agents                          •    Budenz, et al. (Ophthalmology 2001)
                                                                                              43 eyes
       Laser Therapy:                                                                        Success defined greater than 5mmHg, less than 21mmHg, no re-
          Laser iridotomy lessens risk of angle closure but                                     operation
                                                                                                69% - 6 months
           closure of LI occurs in approximately 14% of the                                     60% - 12 months
           cases                                                                                56% - 24 months
          Laser CPC Diode                                                                      48% - 36 months
            ○ Successful IOP control in 74% to 82% at one year
            ○ Multiple treatments required
                                                                                            Conclusions:
                                                                                              Silicone oil removal alone→persistent elevated IOP
            ○ Vision loss common
                                                                                              Concurrent oil and glaucoma surgery→hyptony
Secondary Glaucoma (s)                                         Secondary Glaucoma (s)
                                                                  Bibliography:

 Conclusions                                                      Cashwell, Martin. Malignant glaucoma after laser iridotomy. Ophthalmol 1992;
                                                                   99:651-9.
 •    Secondary glaucoma may complicate retina-                   Chen. Glaucoma after macular hole surgery. Ophthalmol 1988; 105: 94-100.
                                                                   Chen, Thompson. Risk Factors for elevated intraocular pressure after the use of
      vitreous surgery                                         
                                                                   intraocular gases in vitreoretinal surgery. Ophthamic Surg Lasers. 1997; 28: 37-42.
                                                                   Edward Jackson lecture: open angle glaucoma after vitrectomy, Am J Ophth. 2006
 •    In persisting cases, surgical tx very effective but is   
                                                                   June: 141 (6) : 1033-1043.
      associated with high risk of hypotony                       Han, Lewis, Lambrou, et al. Mechanisms of intraocular pressure elevation after pars
                                                                   plana vitrectomy. Ophthalmol 1989; 96: 1357-62.
 •    Despite adequate IOP control, there may be                  Massicotte, Schuman. A Malignant Glaucoma-like Syndrome Following Pars Plana
                                                                   Vitrectomy. Ophthamol 199, 106: 1375-1379.
      progressive cupping of disc due to either retinal           Scott, Gedde, Budenz, et al: Baerveldt drainage implants in eyes with a preexisting
                                                                   scleral buckle. Arch Ophthalmol 2000, 118: 1509-1513.
      pathology or too high target pressure                       Smith, Doyle, Fannous. Modified aqueous drainage implants in the treatment of
                                                                   complicated glaucomas in eyes with pre-existing episcleral bands. Ophthalmol 1998,
                                                                   105: 2237-2242.
                                                                  Thompson, Sjaara, Glaser, Murphy. Increased intraocular pressure after macular
                                                                   hole surgery. Am J Ophth 1996; 121:615-22.




                                                               Secondary Glaucoma (s)
                                                               Glaucoma and Increased Episcleral
                                                                 Venous Pressure

                                                                   Group of conditions associated with increased
                                                                    episcleral venous pressure and, in some
                                                                    cases, a secondary glaucoma




Secondary Glaucoma (s)                                         Secondary Glaucoma (s)
Glaucoma and Increased
  Episcleral Venous Pressure -                                 Glaucoma and Increased Episcleral Venous
  Clinical Findings                                              Pressure – Differential Diagnosis
      Episcleral venous pressure normally                          Obstruction to venous outflow
       8 to 12 mmHg                                                               Thyroid ophthalmopathy
      Prominence of conjunctival and                               Superior vena cava syndrome
       episcleral blood vessels and blood in
       Schlemm’s canal                                              Arteriovenous fistulas
      Causes include                                                ○ Carotid cavernous fistula

        1. obstruction to venous outflow                             ○ Dural shunt syndrome

        2. arteriovenous fistulas                                    ○ Orbital varices

        3. familial                                                  ○ Sturge-Weber Syndrome

        4. idiopathic
 Secondary Glaucoma (s)                             Secondary Glaucoma (s)
Glaucoma and Increased Episcleral Venous            Glaucoma and Increased Episcleral
  Pressure                                            Venous Pressure – Idiopathic
Differential Diagnosis                                   Typically in elderly
   Familial Increased Episcleral Venous Pressure        Usually unilateral
   ○ Unilateral or bilateral                             Cause of increased pressure unknown
   ○ No associated history of trauma                     Associated glaucoma may be severe
   ○ No clear etiology




 Secondary Glaucoma (s)                             Secondary Glaucoma (s)
 Glaucoma and Increased Episcleral                  Glaucoma and Increased Episcleral
   Venous Pressure – Management                       Venous Pressure
     Eliminate cause; repair arteriovenous         Case Review
     fistulas                                            A.L. - presented at age 13
     Aqueous suppressants (beta-blockers, CAI)
                                                         VA 20/400 OS, IOP 50 OS
      are most effective
                                                         Amblyopia 2⁰ to LUL Hemangiona
     ALT has minimal role
                                                         DX: Retinal Choroidal Hemangioma
     Consider prophylactic sclerotomies
                                                         Encephalitis Ptosis
                                                         Filtration Surgery with 5FU
                                                         Last seen: bleb dysthesia




 Secondary Glaucoma (s)                             Secondary Glaucoma (s)
Uveitis-Associated Glaucoma
                                                    Uveitis-Associated Glaucoma
  Secondary glaucoma associated with ocular
   inflammation from a variety of causes. May        Clinical Findings
   be associated with open angle, angle                IOP elevation may be secondary to:
   closure, or a combination of the two.                  ○ Development of peripheral anterior synechiae
                                                            unrelated to pupillary block
                                                          ○ Release of prostaglandins and breakdown of
                                                            blood-aqueous barrier with subsequent
                                                            increase in aqueous proteins
                                                          ○ Anterior segment neovascularization
                                                          ○ Corticosteroid therapy
Secondary Glaucoma (s)                               Secondary Glaucoma (s)
Uveitis-Associated Glaucoma                          Uveitis-Associated Glaucoma
 Clinical Findings                                    Other uveitic disorders associated with
  Gonioscopically, may be normal-appearing              glaucoma:
   angle, PAS, and prominent or abnormal                 ○ Vogt-Koyanagi-Harada Syndrome
   vessels.                                              ○ Sympathetic ophthalmia
                                                         ○ Interstitial keratitis
                                                         ○ Lens induced uveitis, scleritis, and episcleritis




Secondary Glaucoma (s)                               Secondary Glaucoma (s)
Uveitis-Associated Glaucoma                          Uveitis-Associated Glaucoma
 Clinical Findings                                   Clinical Findings
  IOP elevation may be secondary to                       ○ Conjunctival injection and ciliary flush

    ○ Swelling; dysfunction of trabecular sheets          ○ Keratic precipitates of cornea
      and/or endothelial cells                            ○ Anterior chamber cells, flare and fibrin
    ○ Accumulation of inflammatory material within        ○ Iris nodules
      the trabeculum                                      ○ Posterior synechiae
    ○ Angle closure secondary to iris bombe caused        ○ Peripheral anterior synechiae
      by dense posterior synechiae                        ○ Cataract
                                                          ○ Vitreous cells and debris
                                                          ○ Chorioretinitis




Secondary Glaucoma (s)                               Secondary Glaucoma (s)
Uveitis-Associated Glaucoma                          Uveitis-Associated Glaucoma
 Differential Diagnosis                              Differential Diagnosis
  Trabeculitis                                          Acute anterior uveitis
  Other uveitic disorders associated with
                                                        Fuchs’ heterochromic iridocyclitis
    glaucoma:
    ○ Infectious diseases                               Glaucomatocyclitic crisis (Posner-
    ○ Behcet’s disease                                  Schlossman Syndrome)
    ○ Joint diseases                                    Sarcoidosis
    ○ Gastrointestinal disease
    ○ Pars planitis
Secondary Glaucoma (s)                               Secondary Glaucoma (s)
Uveitis-Associated Glaucoma                          Uveitis-Associated Glaucoma
 Management                                          Management
   If pupillary block, laser iridotomy                 Control of inflammation with
   LTP: ALT/SLT                                         ○ Topical, periocular or systemic corticosteroids

   Glaucoma filtering surgery                             and cycloplegia
                                                         ○ Nonsteroidal anti-inflammatory agents and
   Further modalities include
                                                           immunosuppressive agents
    ○ Aqueous shunt device
                                                        Aqueous suppressants
    ○ Cyclodestructive procedure




Secondary Glaucoma (s)                               Secondary Glaucoma (s)
Lens-Induced Glaucoma                                Lens-Induced Glaucoma
 Related to                                          Clinical Findings
   Phacomorphic: Increasing lens size                  Advanced cataract leaks lens proteins
   Lens dislocation                                     produces aqueous cells and intense flare
   Phacolytic: Release of abnormal proteins
                                                         with obstruction of trabecular meshwork
                                                        Intense inflammatory reaction secondary to
   Release of lens material post trauma or
    surgery                                              immune sensitization to patient’s own lens
                                                         protein
   Phacoanaphylaxis: Inflammation related to
    immune sensitization to lens material




Secondary Glaucoma (s)                               Secondary Glaucoma (s)
Lens-Induced Glaucoma                                Lens-Induced Glaucoma
 Clinical Findings                                   Management
   Increasing lens thickness = progressive             Lens extraction or (if not an option) relieve
    closure of anterior chamber angle through           pupillary block with laser iridotomy
    displacement of lens-iris diaphragm and             If lens dislocated and pupillary block, treat
    increased pupillary block                           by laser iridotomy, cycloplegia, and
   Anterior lens dislocation into pupillary space      sympathomimetic agents
    of anterior chamber
Secondary Glaucoma (s)
Lens-Induced Glaucoma
 Management
     If phacolytic, lens extraction
     If lens particle glaucoma, remove lens or
      liberated lens material
     Treat inflammation and secondary
      glaucoma, removal of residual lens material




Secondary Glaucoma (s)                                    Secondary Glaucoma (s)
Secondary Open Angle Glaucoma                             Secondary Open Angle Glaucoma
   Glaucomatocyclitic Crisis –                            Fuchs’ Heterochromic Iridocyclitis
    Possner/Schlossman                                       Primarily unilateral, iris heterochromia, mild
    General:         Young, middle-aged adults                uveitis, fine stellate KP, iris-angle
                     Unilateral greater than bilateral        neovascularization, cataract, no PAS
    Mechanism:       ? Inflammation of TM, mild iritis,      Anti-inflammatories ineffective
             fine KP, no PAS, usually self                   Etiology: Ischemia
             limited
    Therapy:         Steroids, glaucoma meds




Secondary Glaucoma (s)                                    Secondary Glaucoma (s)
Secondary Open Angle Glaucoma                             Secondary Open Angle Glaucoma
 Trauma                                                   Trauma
    Blunt +/- Penetrating:                                  Retained intraocular foreign body:
      ○ Acute IOP elevation in absence of angle               ○ Siderosis (iron)
        damage                                                ○ Chalosis (copper)
      ○ Iridocyclitis                                       Chemical:
      ○ Intraocular hemorrhage                                ○ Inflammation, scleral collagen shrinkage,
      ○ Trabecular damage (angle recession): usually            PAS, TM damage, prostaglandin release
        involves recession greater than 180 with
        reported increase in IOP 4-9%
Secondary Glaucoma (s)
Secondary Open Angle Glaucoma
 Trauma
  Ghost Cell
    ○ Degenerated RBC’s (erythroclasts) TM
     obstruction
    ○ Rigid khaki-colored cells in AC
    ○ Tx: AC washout; vitrectomy




Secondary Glaucoma (s)
Secondary Open Angle Glaucoma
 Inflammation
  Mechanism:
    ○ Meshwork obstruction by inflammatory cells
    ○ Endothelial swelling
    ○ Increased aqueous viscosity
  Etiology:
    ○ Viral – H. simplex, Zoster, rubella, mumps
    ○ Episcleritis/scleritis – 10% incidence of IOP
     increase

								
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