1
Q
Aqueous secretion
A
By the ciliary epithelium of the ciliary body pars plicata
1. Sympathetic nervous system
➕beta 2 receptors
➖alpha 2 receptors
2. Enzymatic action: Carbonic anhydrase
2
Q
Aqueous outflow
A
PC➡️pupil➡️AC➡️
1. Trabecular outflow (%90)➡️Schlemm➡️episcleral veins 2. Uveoscleral drainage (%10)➡️suprachoroidal space➡️venous circulation 3. Iris
3
Q
Applanation tonometry-sources of error
A
- Inappropriate fluorescein pattern
- Pressure on the globe
- CCT
- Corneal oedema
- Astigmatism
- Incorrect calibration
- Wide pulse pressure
- Repetead readings over a short period
- Tight collar, breath-holding
4
Q
Angle structures
A
- Schwalbe line
- Corneal wedge
- Trabeculum
- anterior: non-functional, whitish
- posterior: functional, pigmented
- Schlemm canal
- Scleral spur
- Ciliary body
- Iris processes
- Blood vessels
5
Q
Grading of angle width
A
Schaffer system - Grade:
4⃣ (35-45): ciliary body
-myopia, PF
3⃣ (25-35): scleral spur
2⃣ (20): trabeculum
1⃣ (10): only Schwalbe
Slit angle: no angle structures+no iridocorneal contact
0⃣ (0): closed due to iridocorneal contact
6
Q
Pathological findings-PAS
A
- Primary angle-closure glaucoma
- Anterior uveitis
- Iridocorneal endothelial (ICE) syndrome
7
Q
Pathological findings-NV
A
- NV glaucoma
- Fuchs heterochromic cyclitis
- Chronic anterior uveitis
8
Q
Pathological findings-Hyperpigmentation
A
- Physiological variant
- Pigment dispersion syndrome
- Pseudophakic pigment dispersion
- Pex syndrome
- Blunt ocular trauma
- Anterior uveitis
- Following acute angle-closure glaucoma
- Following YAG laser iridotomy
- Iris or angle melanoma or naevus
- Iris pigment epithelial cysts
- Naevus of Ota
9
Q
Pathological findings-Trauma
A
- Angle recession
- Trabecular dialysis
- Cyclodialysis
- Foreign bodies
10
Q
Pathological findings-Blood in the Schlemm canal
A
- Physiological variant
- Carotid-cavernous fistula and dural shunt
- Sturge-Weber syndrome
- Obstruction of the VCS
11
Q
OD size
A
1.5-1.7 mm
12
Q
Subtypes of glaucomatous damage
A
- Focal ischemic discs
- localized field defects
- Myopic disc with galucoma
- dense superior and inferior scotomas
- younger, male patients
- Sclerotic discs
- peripheral visual field loss
- older patients
- Concetrically enlarging discs
- diffuse visual field loss
13
Q
Non-specific signs of glaucomatous damage
A
- Disc haemorrhages
- most: inferotemporal
- Baring of circumlinear blood vessels
- early sign
- Bayoneting
- Collaterals btw two veins at the disc
- uncommon
- Loss of nasal NRR
- moderately advanced
- The laminar dot sign
- advancing
- Sharpened edge / sharpened rim
- advancing
14
Q
Peripapillary changes in glaucoma
A
- Alpha(outer) zone
- Beta(inner) zone
- its location seems to indicate the orientation of likely visual field loss
15
Q
RNFL defects in glaucoma
A
- Localized wedge-shaped defects
- Diffuse defects with indistinct borders
- use red-free(green) light
- not specific (can be seen in neurological diseases/normal people)
16
Q
The visual field
A
50
⬆️
(T)90⬅️ ➡️60(N)
⬇️
70
-blind spot: temporal btw 10-20 and slightly below the horizontal
17
Q
Apostilbs (asb)
A
The intensity or brightness of a light stimulus
18
Q
Decibels (dB)
A
Sensitivity of retina
19
Q
False positives in perimetry
A
-The printout appears;
abnormally pale
-SITA➡️>%15
Full-threshold➡️>%33 is highly significant
20
Q
False negatives in perimetry
A
-the printout has a
clover leaf shape🍀
-SITA➡️>%15
Full-threshold➡️>%33 is highly significant
21
Q
Most important defects in glaucoma occur…
A
Centrally-within a 30 radius from the fixation point
22
Q
Prostaglandin derivatives
A
-‘uveoscleral’ aqueous outflow⬆️
-IOP lowering effect is greater than alternatives:
🏆1⃣st-line treatment in glaucoma (1x1 at bedtime)
✔️latanoprost (XALATAN)
🔺fewer ocular adverse effects
✔️travoprost (TRAVOPROST)
✔️bimatoprost (LUMIGAN)
🔺greater IOP-lowering effect, more conjunctival hyperemia
🔺periorbital fat loss
✔️tafluprost
23
Q
Side effects (ocular) - prostaglandin derivatives
A
OCULAR
-conjunctival hyperaemia-common
☑️more with bimatoprost, less with tafluprost
-eyelash lengthening, thickening, hyperpigmentation
-iris hyperpigmentation-in 1/4 patients after 6 months, irreversibl
-hyperpigmentation of periocular skin-reversibl
-periorbital fat loss
☑️common with bimatoprost
-increased risk of CMO following cataract surgery when used preoperatively⚠️
-anterior uveitis, promotion of herpetic keratitis
⚠️use with caution in those patients!
24
Q
Side effects (systemic) - prostaglandin derivatives
A
SYSTEMIC
- headache
- precipitation of migraine
- malaise
- myalgia
- skin rash
- mild upper respiratory system symptoms
25
Beta-blockers
-aqueous production⬇️ (mediated by an effect on the ciliary epithelium)
-tachyphylaxis in %10
-2x1
-should not be instilled on bedtime⚠️ (BP⬇️)
-preferred when: Monoocular treatment, ocular inflammation, CMO, history of HSV keratitis (❌PG❌)
✔️timolol (TIMOPTIC) - usually used in combinations
🔺non-selective➡️❌asthma, bradycardia, AV block❌
✔️betaxolol (BETOPTIC)
🔺lower hypotensive effect
🔺Ca channel blocking effect➡️optic nerve blood flow⬆️ ➡️ visual field preservation may be superior
🔺relatively cardioselective(B1)➡️less bronchoconstriction️️➡️ advantage in asthma
✔️levobunolol
✔️carteolol (CARTEOL)
🔺intrinsic sympathomimetic activity
🔺more selective on 👀 than on the cardiopulmonary system➡️less systemic side effect, advantage in bradycardia, AV block
✔️metipranolol
🔺granılomatosis anterior uveitis
26
Side effects (ocular) - beta blockers
```
OCULAR
-allergy
-punctat keratitis
-granulomatous uveitis
☑️metipranolol
```
27
Side effects (systemic) - beta blockers
```
SYSTEMIC
-bronchospasm
⚠️critical to exclude asthma before prescribing
-cardiovascular: heart block, bradycardia, worsening of heart failure, hypotension
⚠️pulse should be assessed before prescription
⚠️caution in patients with peripheral vascular disease(Reynaud)
-sleep disorders
-reduced exercise tolerance
-hallucinations
-confusion
-depression
-fatigue
-headache
-nausea, dizziness
-decreases libido
-dyslipidemia
```
28
Combined preparations
```
timolol ➕ ...
dorzolamide ➡️ COSOPT, OFTOMIX, DORZOTIM -2x1
brinzolamide ➡️ AZARGA -2x1
brimonidine ➡️ COMBIGAN -2x1
latanoprost ➡️ XALACOM -1x1
travoprost ➡️ DUOTRAV -1x1
bimatoprost ➡️ GANFORT -1x1
pilocarpine ➡️ TIMPILO -2x1
```
brimonidine ➕ brinzolamide ➡️ SIMBRINZA -2x1
29
Alpha-2 agonists
-aqueous production⬇️ (via an effect on the ciliary epithelium) and 'uveoscleral' outflow⬆️
-probably neuroprotective
-cross the blood-brain barrier➡️severe CNS depression and hypotension in young children
⚠️contraindicated
30
Topical carbonic anhydrase inhibitors
-aqueous secretion⬇️
-3x1 (monotherapy) or 2x1 (adjunction)
-slightly less effective than beta-blockers
-probably neuroprotective
-may precipitate corneal decompensation in patients with corneal endothelial disfunction⚠️
-some benefits in the treatment of CMO
-idiosyncratic bone marrow supression
-chemically related to sulfanomide antibiotics
⚠️relatively contrandicated in patients allergic to sulfanomides
✔️dorzolamide (TRUSOPT✖️)
✔️brinzolomide (AZOPT)
31
Side effects - topical carbonic anhydrase inhibitors
- stinging
- transient bitter taste following administration
- allergic blepharoconjunctivitis
☑️more with dorzolamide
-a white residue may be left on the eyelids after instillation
☑️brinzolamide
32
Systemic carbonic anhydrase inhibitors
-aqueous secretion⬇️
-used for short-term treatment
-chemically related to sulfanomide antibiotics
⚠️relatively contrandicated in patients allergic to sulfanomides
✔️acetazolamide (DIAZOMID) -2/4x1
✔️dichlorphenamide
✔️methaxolamide
33
Side effects - systemic carbonic anhydrase inhibitors
```
OCULAR
-choroidal effusion, particularly after cataract surgery
-angle closure
SYSTEMIC
-paraesthesia
-hypokalemia
-malaise and lowered mood
-GIS symptoms
-renal stones
-Stevens-Johnson syndrome (very rare)
-dose-related bone marrow suppression
-idiosyncratic aplastic anaemia
```
34
Miotics
-cholinergic agonists
-used in angle-closure
-opens the angle (by pulling the iris away from trabeculum) ➕ 'trabecular' outflow⬆️ (by contraction of the ciliary muscle)
✔️pilocarpine -4x1
🔺equal effect to beta-blockers
✔️carbachol
35
Side effects - miotics
```
LOCAL
-miosis
-brow ache
-myopic shift
-exacervation of symptoms of cataract
SYSTEMIC (rare)
-confusion
-bradycardia
-bronchospasm
-GIS symptoms
-urinary frequency
```
36
Osmotic agents
-creates an osmotic gradient so that water is 'drawn out' from the vitreous into the blood
-when a short-term reduction in IOP is required
-of limited value in inflammatory glaucoma, in which the integrity of the blood-aqueous barrier is compromised⚠️
✔️mannitol
🔺peak action occurs within 30 minutes
✔️glycerol
🔺metabolized to glucose➡️be careful in diabetics⚠️
✔️isosorbide
37
Side effects - osmotic agents
```
-CVS overload
⚠️caution in patients with cardiac or renal disease
-urinary retention
-headache
-backache
-nausea
-confusion
```
38
Lens-related glaucoma
```
PHACOLYTIC:
Open angle, deep AC, intact capsule
PHACOGENIC/PHACOANAPHYLACTIC:
Compromised lens capsule
PHACOMORPHIC:
Angle closure, shallow AC
```
39
BAIT - BADI
Moxifloxacine
BAIT: iris pigment epithelium
BADI:iris stroma
40
Secondary-open angle-pre trabecular
Neovascular glaucoma
ICE syndrome
Epithelial ingrowth
41
Ocular HT-risk factors
```
Age
IOP
CCT
C/D ratio
PSD
—————
African-American race
Gender
Heart disease
```
⚠️increased risk of RVO
42
POAG and NTG-risk factors
```
Age
Race
IOP
Family history of POAG
OD area
Ocular perfusion pressure
Translaminar pressure gradient
Vascular disease(HT,CVD,migraine vb)
DM
Myopia
Contraceptive pill
```
```
FOR NTG:
+Gender
+CCT
+Systemic hypotension
+OSAS
+Autoantibody levels
+Thyroid disease
```
43
PACG-risk factors
```
Age
Gender
Race
Family history
Refraction
AL
```
44
TRAB-high risk for failure
```
NVG➡️➡️➡️➡️AGV
Inflammatory glaucoma
POS-traumatic angle recession
ICE
Previous failure
```
✳️USE MMC
45
NF
NF1➡️glaucoma, retinal astrocytoma
| NF2➡️cataract
46
Wilms tumor
Aniridia (sporadic) ⚠️ ⚠️%75 risk of glaucoma
47
Peters anomaly
Bilateral
⚠️%50 risk of glaucoma
Central corneal opacity
Posterior corneal defect-iridocorneal or lenticulocorneal adhesions
48
Axenfeld Rieger syndrome
Bilateral
⚠️%50 risk of glaucoma
Axenfeld anomaly: posterior embryotoxon, attached strands of peripheral iris
Rieger anomaly: posterior embryotoxon, iris stromal hypoplasia, ectropion uveae, corectopia, full-thickness iris defects
Rieger syndrome: dental anomalies, facial anomalies, redundant paraumblical skin, hypospadias
49
Malignant glaucoma
High IOP, shallow AC, absent bleb, negative Seidel
| Treatment: Atropine
50
Pupillary block
High IOP, shallow AC, flat bleb, negative Seidel, iris bombe
| Treatment: LPI
51
Inflammatory glaucomas
```
FUS-%60
JIA
Herpes Zoster-Simplex
Toxoplasma
Posner-Schlossman
```
Ciliary body shutdown, steroid responders, CLOSE: angle closure with/without pupillary block, OPEN: trabecular obstruction, acute trabeculitis, trabecular scarring
Kanski
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