SECONDARY GLAUCOMA

UVEITIC GLAUCOMA

Block of trabecular meshwork by inflammatry cells 

POST UVIETIC GLAUCOMA

After inflammation subsides, extensive posterior synechiae, pupil block, iris bombe and peripheral anterior synechiae cause angle closure glaucoma

GLAUCOMATOCYCLIC CRISIS

Also called Posner-Schlossman Syndrome   is Acute recurrent mild uveitis with secondary glaucoma. The glaucoma is out of proportion  than inflammation.  no Posterior synechiae or anterior synechiae form. Pressure may be elevated to 40 -50 mm Hg. the condition subsides in weeks. recurrence is common

Fuchs heterochromic iridocyclitis

30-40 year old  patients with different iris colors, diffuse fine Keratic precipitates on corneal endothelium, mild AC activity  and vitreous floaters but no posterior synechiae. 90 % unilateral cases. first control inflammation with topical steriods and NSAIDs for at least 3 months. Also lower IOP below 20 then operate 

CAUSES

1. central retinal vein occlusion

2. diabetic retinopathy

3. central retinal artery occlusion

4. Retinal detachment

5. intra ocular tumors

6. intraocular inflammation

PATHOGENESIS

common etiological factor is chronic retinal ischemia which produces angiogenic factors most commonly VEGF to revascularize hypoxic area and results in iris neovascularization which leads to progressive angle closure

CLINCAL FEATURES

SYMPTOMS

1. NONE

2. EYE PAIN

3. REDNESS

4. DECREASED VISION

5. PHOTOPHOBIA

SIGNS

1. CORNEAL EDEMA

2. ELEVATED IOP

3. ANTERIOR CHAMBER REACTION AND HEMORRHAGE

4. PUPILLARY MARGIN BLOOD VESSELS

5. IRIS SURFACR VESSELS

6. ANGLE NEOVASCULARIZATION

7. CATARACT

8. POSTERIOR SEGMENT

   1. GLAUCOMATOUS OPTIC NEUROPATHY

   2. CAUSE MAY BE OBVIOUS

INVESTIGATIONS

1. FFA MAY DELINEATE ISCHEMIC AREA AND IDENTIFY CAUSE

2. B-SCAN to rule out retinal detachment or intraocular tumor in case no fundus view

3. anterior segment OCT for angle assessment

TREATMENT

TREAT THE CAUSE

MEDICAL

1. ATROPINE EYE DROPS TWICE DAILY WILL AVIOD POSTERIOR SYNECHIAE

2. TOPICAL STERIOD 

3. TOPICAL APROCLONIDINE

4. ORAL ACETAZOLAMIDE

LASER

PANRETINAL PHOTOCOAGULATION REVESRS NEOVASCULARIZATION

SURGICAL 

1. INTRAVITREAL VEGF INHIBITORS WHILE WAITING FOR PRP

2. RETINAL DETACHMENT REPAIR

3. CILIARY BODY ABLATION IF MEDICAL CONTROL OF IOP

4. FILTERATION SURGERY IF VISION HM OR BETTER

5. PARSPLANA VITRECTOMY WITH PEROPERATIVE ENDOLASER IN CASE OF VITROUS HEMORRHAGE ESPECIALLY DUE TO CRVO

IN PAINFULL BLIND EYE

1. RETROBULBAR ALCOHOL INJECITON

2. ENUCLEATION OR EVISCERATION

PHACOMORPHIC GLAUCOMA OR LENS SUBLUXATION

SECONDRY ANGLE CLOSURE GLAUCOMA DEVELOPS DUE TO INTUMESNT LENS PUSHING IRIS AGAINST CORNRA

OTHER MECHANISM IS ANTERIOR LENS SUBLUXATION OR DISLOCATION WHICH BLOCK PUPIL 

PHACOLYTIC GLAUCOAMA

SECONDARY OPEN ANGLE GLAUCOMA RESULT DUE TO RELEASE OF PROTEINS FROM HYPERMATURE CATARACT WHICH BLOCK THE ANGLE.

TREATMENT 

EXTRACTION OF CATARACT AFTER CONTROL OF INTRAOCULAR PRESSURE

Pathogenesis

1. pseudoexfoliation is grey white fibrillary material derived from abnormal extracellular matrix metabolism of ocular and other tissues.

2. material is deposited on lens capsules ,zonules , iris, trabeculum and conjunctiva

3. there is block of trabeculum with pseudoexfoliative material leading to secondary open angle glaucoma 

4. glaucoma remain to be present in one eye  in 2/3 rd patients

Clinical features

1. cornea: scattered pigment deposits on corneal endothelium are common. a vertical spindle ( Krukenberg ) is rarely present

2. anterior chamber: pseudoexfoliative particles

3. iris: material deposits, pupillary ruff loss and patchy transillumination defects at pupillary margin

4. lens: 

   1. central disc with peripheral deposits and clear zone in between  maintained by pupillary abrasion

   2. cataract 

   3. phacodonesis due to zonular weakness

5. anterior chamber angle

   1. Patchy trabecular and Schwalbe line hyperpigmentation is common, especially inferiorly.

   2. A Sampaolesi line, which is an irregular band of pigment running on or anterior to the Schwalbe line, is commonly seen

   3. zonular laxity may result in angle closure

6. IOP elevation result in glaucomatous damage

treatment

medical : similar to POAG

laser trabeculoplasty is more effective than in POAG

phacoemulsification may also reduce IOP

filtration surgery

THERE IS liberation of pigment granules from iris pigment epithelium and their deposition throughout the anterior segment.

risk factors

1. young age

2. male patients

3. myopes

4. white color

Secondary pigment dispersion can occur as a consequence of trauma, intraocular tumour and rubbing of a malpositioned IOL on the iris pigment epithelium.

pathogenesis

1. mid peripheral  portion of iris rubs against zonules due to posterior bowing of iris resulting in pigment shedding

2. it is supported by the fact that laser iridotomy flattens the iris and reduce iridozonular contact

3. the pigment epithelium my be itself susceptible to pigment shedding in some individuals

4. chronic or acute elevation of IOP due to pigment blocking trabecular meshwork

clinical feature

 cornea: Krukenberg spindle pigmentation on corneal endothelium

anterior chamber: deep and may show pigment granules

iris: radial spoke like transillumination defect 

gonioscopy : open angle with mid-peripheral iris concavity and trabecular hyperpigmentation

IOP: increased

posterior segment: 

1. signs and complications of myopia as retinal detachement are more common

2. glaucomatous optic neuropathy

treatment

review annually

life style modification: avoiding strenuous exercise

medical : A for POAG

laser trabeculoplasty is more effective

laser iridotomy

filtration surgery