ICT role in 21st century education and it's challenges.
Evaluation of a glaucoma patient
1. EVALUATION OF A GLAUCOMA
PATIENT
Presented by
Dr. (Maj.) Rashed
F.C.P.S Part-II Trainee
CMH Dhaka
2. Introduction
Glaucoma refers to a group of diseases
having common characteristic of progressive
optic neuropathy with associated visual field
loss as progresses in which elevated
intraocular pressure (IOP) is one of the key
modifieable factors.
Normal IOP: 10-22 mmHg.
Three risk factor determine the IOP:
◦ rate of aqueous humor production by ciliary body
◦ resistance to aqueous outflow across the trabecular
meshwork-Schlemm’s canal system
◦ The level of epischeral venous pressure
5. Clinical Evaluation
Appropriate management of glaucoma
depends on the clinician's ability to
diagnose the
◦ specific form of glaucoma in a given
patient,
◦ severity of the condition,
◦ progression in that patient's disease
status.
6. History
Patient's current complaint
History of present illness
Past ocular, medical, and surgical
history
Refraction history
Past medications history
Social history
History of alcohol and tobacco use
Occupation
Family history
7. Clinical examination and
investigations
• BCVA distant & near
• Pupillary reaction, relative afferent pupillary
defect
• Slit lamp examination of lids, lid margins,
conjunctiva, cornea, anterior chamber & lens
• IOP and time of measurement
• CCT
• Gonioscopy
• Detailed examination of:
Lens
Biomicroscopy of ONH and RNFL
Fundus
• Automated perimetry
• OCT of ONH & RNFL
8. Clinical examination
External Adnexa
◦ Variety of conditions associated with
secondary glaucomas
Neurofibromatosis type- I
Oculodermal melanoeytosis (nevus of Ota)
Axenfeld-Rieger syndrome
Orbital varices
Thyroid associated orbitopathy
◦ External ocular manifestations of
glaucoma therapy.
Prostaglandin analogue
9. Slit lamp biomicroscopy
Conjunctiva
◦ Acute IOP
◦ Chronic IOP
◦ Long term use of sympathomimetics
and prostaglandin analogoues
◦ Long term use of epinephrine
derivatives
◦ Filtering bleb +/-
Episclera & Sclera
◦ Dilation of the episcleral vessels
◦ Sentinal vessels
10. Cornea
◦ Developmental glaucoma
◦ Acute IOP
◦ Medication toxicity
◦ Corneal endothelial abnormality
◦ Scar
◦ CCT
A/C
◦ Uniformity of depth of the anterior chamber
◦ Width of the chamber angle
** Before dilation of pupil; pupillary light
reaction, iris & A/C should be examined **
12. IOP
Schiotz tonometry: indentation procedure, now
obsolete.
Goldmann applanation tonometer : most
appropriate
Noncontact tonometer (NCT): screening
purpose
Tonopen: very small area, useful in corneal scar or
edema
Digital pressure
13.
14. Possible source of error in
Tonometry
Squeezing of the eyelids
Breath holding or Valsalva maneuver
Pressure on the globe
Extra-ocular muscle force applied to a restricted
globe
Tight collar or tight necktie
Obesity or straining to sit on slit lamp
An inaccurately calibrated tonometer
Excessive or inadequate amount of fluorescein
High corneal astigmatism
Corneal thickness greater or less than normal
Corneal scarring or band keratopathy
15. Dynamic contour tonometry
The tip of the device exactly matches the contour of
the cornea, the pressure measured by a transducer
placed on its tip.
Measure true IOP irrespective of CCT
Capable of measuring the ocular pulse amplitude
19. VAN HERICK METHOD
Peripheral
Chamber
Depth
In Corneal
Thickness
Angle
Grade
Comment
≥ Cornea 4 Wide open
1/4 to 1/2 3 Incapable of closure
1/4 2
Should be
gonioscoped
<1/4 1
Dangerously narrowed
angle
22. The 7 parameters to look for…
1)Disc size
2)Neuroretinal Rim (NRR):
- ISNT rule
3)Cup: Disc ratio
- Vertical C/ D Ratio.
4) Optic Disc Hemorrhage
5) Nerve Fiber Layer Defect:
- focal & diffuse
6) Para Papillary Atrophy:
- Size, location & Configuration
7) Retinal Arterial Attenuation:
- focal & diffuse
23. Ophthalmoscopic sign of glaucoma
Generalized Focal Less specific
o Large optic cup
o Asymetrical of the
cup
o Progressive
enlargement of
cup
o Notching of the rim
o Vertical elongation
of the cup
o Region pallor
o Splinter
hemorrhage
o Nerve fiber layer
loss
o Exposed lamina
cribrosa
o Nasal
displacement of
the vessels
o Baring of
circumlinear
vessels
o Peripapillary
crescent
28. Perimentry
Kinetic
◦ Two dimensional
◦ Moving stimulus
◦ Known Luminance
◦ From non-seeing area
to seeing area until it is
perceived.
◦ e.g. confrontation
Tangent screen
Lister perimeter
Goldmann
perimeter
Static
◦ Three dimensional
◦ Static stimulus
◦ varying luminance in
the same position
◦ e.g. Octopus
Humphrey
Hensen