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Douglas J. Rhee, MD
Associate Chief, Operations and Practice Development
Massachusetts Eye and Ear In rmary
Associate Professor
Harvard Medical School
Boston, Massachusetts
SERIES EDITOR
Christopher J. Rapuano, MD
Director and Attending Surgeon, Cornea Service
Co-Director, Refractive Surgery Department
Wills Eye Institute
Professor of Ophthalmology
Jefferson Medical College of Thomas Jefferson University
Philadelphia, Pennsylvania
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o my lovely wi e, ina, I dedica e my con ribu ions o you and am so gra e ul or your pa ience and suppor .
o my daugh ers, Ashley and Alyssa, I dedica e his book wi h my hopes or your u ure happiness and success.
o my a her and mo her, Dennis and Serena Rhee, in apprecia ion or your endless love, sacrif ce, suppor ,
and dedica ion, I hank you. o Susan Rhee or your unders anding and kindness.
Finally, o all my amilies—Rhee, Chang, Kim, Chomakos, and Joseph.
Con ribu ors
Augus o Azuara-Blanco, MD, PhD Francisco Fan es, MD
Consul an Oph halmic Surgeon Associa e Pro essor o Oph halmology
Aberdeen Royal In rmary Bascom Palmer Eye Ins i u e
Honorary Clinical Senior Lec urer Universi y o Miami School o Medicine
Universi y o Aberdeen Miami, Florida
Aberdeen, Uni ed Kingdom
a hryn B. Freidl, MD
Oscar V. Beaujon-Balbi, MD Florida Eye Specialis s
Clinica Luis Razet i and Me ropoli an Cen er o Jacksonville, Florida
Oph halmology
JoAnn A. Giaconi, MD
Francisco Risquez Hospi al
Heal h Sciences Assis an Pro essor o
Caracas, Venezuela
Oph halmology
Oscar Beaujon-Rubin, MD Jules S ein Eye Ins i u e
Clinica Luis Razet i and Me ropoli an Cen er o David Ge en School o Medicine, UCLA
Oph halmology Chie o Oph halmology
Francisco Risquez Hospi al Ve erans Adminis ra ion o Los Angeles
Caracas, Venezuela Los Angeles, Cali ornia
José I. Belda, MD, PhD, FEBO Rober J. Goule III, MD
Chairman, Depar men o Oph halmology Boling Vision Cen er
Hospi al de orrevieja Elkhar , Indiana
Alican e, Spain
Shelly R. Gup a, MD
Nicole Beni ah, MD Assis an Pro essor o Oph halmology
Priva e Prac ice Glaucoma Division
Cali ornia Ohio S a e Universi y
Havener Eye Ins i u e
Ronald Buggage, MD
Columbus, Ohio
Chie Scien i c Of cer
Novagali Pharma Alon Harris, MS, PhD, FARVO
Evry, France Lois Le z er Pro essor o Oph halmology
Pro essor o Cellular and In egra ive Physiology
Gabriel Chong, MD
Direc or, Glaucoma Research and Diagnos ic
Glaucoma Specialis
Cen er
Raleigh Oph halmology
Indiana Universi y School o Medicine
Raleigh, Nor h Carolina
Indianapolis, Indiana
Mary Jude Cox, MD
Ribhi Hazin, MD
Eye Physicians
Gradua e S uden
Voorhees, New Jersey
Harvard School o Public Heal h
Syril Dorairaj, MD Bos on, Massachuset s
Einhorn Clinical Research Cen er
Malik Y. ahook, MD
New York Eye and Ear In rmary
Associa e Pro essor
New York, New York
Chie o Glaucoma Service
Universi y o Colorado Hospi al Eye Cen er
Denver, Colorado
vi
CO NTRIBUTO RS vii
ix
Acknowledgmen s
I would like o hank he many au hors and con ribu ors who par icipa ed in his endeavor.
I believe ha he diversi y o represen a ions is one o he s reng hs o his ex .
x
Pre ace
C olor A las & Synopsis o Clinical
Oph halmology—Wills Eye Ins i u e—
Glaucoma at emp s o cover as many o he
In his second edi ion, we have added several
new chap ers o encompass he evolving ech-
niques and echnologies o he surgical man-
glaucoma syndromes as possible. No condi ion agemen o glaucoma as well as enhanced he
appears iden ical in all cases. T ere ore, many sec ion on acu e angle closure. Fur hermore,
di eren represen a ive images are presen ed several new gures appear hroughou he
or he more common condi ions in an at emp book. I hope ha you will nd his a las o be
o re ec he diversi y o presen a ions. a use ul re erence and an aid o your clinical
endeavors.
Douglas J. Rhee, MD
Edi or
xi
Con en s
Con ribu ors vi
Abou he Series ix
Acknowledgmen s x
Pre ace xi
Ch a pt er 3 onome ry 14
Rajesh K. Shet y
Goldmann Applana ion onome er 14
Schiö z onome er 16
Perkins onome er 18
ono-Pen 19
Pneumo onome er 20
Dynamic Con our onome ry 21
Ch a pt er 4 Gonioscopy 22
Oscar V. Beaujon-Balbi and Oscar Beaujon-Rubin
Direc Gonioscopy 22
Indirec Gonioscopy 25
Es ima ing he An erior Chamber Dep h 28
echnique 30
Elemen s o he Angle Ana omy 32
Iden i ca ion o Angle S ruc ures 34
Classi ca ion o he Angle 38
xii
CO NTENTS xiii
Ch a pt er 6 Op ic Nerve Imaging 64
T omas D. Pa rianakos
S ereopho ography 64
Con ocal Scanning Laser Oph halmoscopy 67
Scanning Laser Polarime ry 71
Op ical Coherence omography 75
S ruc ural es s 99
Pho ography 99
Scanning Laser Polarime ry 102
Con ocal Scanning Laser Oph halmoscopy 105
Op ical Coherence omography 110
Re inal T ickness Analyzer 119
Index 437
C H AP T ER
2
Introduction to Glaucoma Diagnosis 3
Basics o Aqueous
Flow and he Op ic Nerve
Arthur J. Sit and Douglas J. Rhee
4
Aqueous Flow 5
hough o be he region where regula ion o re urns o i s baseline value over a f xed ime
aqueous humor ou ow akes place. Wi hin in erval (usually 2 or 4 minu es).2 Di eren
he M, especially under condi ions o ele- devices can be used or onography measure-
va ed IOP, he jux acanalicular area appears men s, including weigh ed pneuma onom-
o have he highes resis ance o ou ow e ers or elec ronic Schio z onome ers. T ese
(Fig. 2-5). devices share he charac eris ic o being able
o record IOP con inuously over he measure-
IOP is physiologically de ermined by he ra e
men in erval, ei her on a paper char or elec-
o aqueous produc ion in he ciliary body,
ronically (Fig. 2-7). egardless o he device,
resis ance o ou ow hrough he conven ional
all share he same limi a ions including he
ou ow rac ( M and Schlemm’s canal),
assump ion ha aqueous humor produc ion
resis ance o ou ow hrough he unconven-
ra e, episcleral venous pressure, and ou ow
ional ou ow rac (uveoscleral ou ow), and
acili y are cons an during he measuremen
episcleral venous pressure. In he Goldmann
in erval.3 In normal individuals, ou ow acil-
equa ion [P0 = (F/ C) + Pv], P represen s he
i y is ypically be ween 0.23 and 0.33 µL/
IOP, F is he ra e o aqueous orma ion, and
min/ mm Hg.4
C is he acili y o ou ow, which roughly cor-
responds o he inverse o he o al resis ance Aqueous humor produc ion ra e is measured
o ou ow. As one can imagine, eleva ions o using uoropho ome ry.5,6 Wi h his ech-
episcleral venous pressure can resul in an ele- nique, a uorescein depo is es ablished in
va ed IOP (Fig. 2-6). he cornea using eye drops. Over ime, he
uorescein is removed rom he cornea as i
di uses in o he an erior chamber and is car-
MEASUREMENT OF ried away by aqueous humor ow. T e ra e o
AQUEOUS HUMOR uorescein removal can be es ima ed by using
DYNAMICS a uoropho ome er o measure he change
over ime o uorescence in he cornea and
leading o uncer ain y in he measuremen o 10. Zeimer C, Gieser DK, Wilensky J , e al. A prac ical
episcleral venous pressure. Normal values venomanome er. Measuremen o episcleral venous
pressure and assessmen o he normal range. Arch
repor ed or mean episcleral venous pressure Ophthalmol. 1983;101(9):1447–1449.
have ranged rom 7 o 14 mm Hg.8–10
BIBLIOG APH Y
EFE ENCES Bill A. T e drainage o aqueous humor. Invest Ophthalmol
1. Alm A, Nilsson SF. Uveoscleral ou ow–a review. Exp Vis Sci. 1975;14:1–3.
Eye Res. 2009;88(4):760–768. Bill A, Phillips CI. Uveoscleral drainage o aqueous
2. Gran WM. onographic me hod or measuring he humour in human eyes. Exp Eye Res. 1971;12:
acili y and ra e o aqueous ow in human eyes. Arch 275–281.
Ophthal. 1950;44(2):204–214. Gran WM. Fur her s udies on acili y o ow hrough
3. Brubaker F. Goldmann’s equa ion and clinical he rabecular meshwork. Arch Ophthalmol. 1958;60:
measures o aqueous dynamics. Exp Eye Res. 2004; 523–533.
78(3):633–637. Maepea O, Bill A. Pressures in he jux acanalicular is-
4. Becker B. onography in he diagnosis o simple sue and Schlemm’s canal in monkeys. Exp Eye Res.
(open angle) glaucoma. Trans Am Acad Ophthalmol 1992;54:879–883.
Otolaryngol. 1961;65:156–162. Maepea O, Bill A. T e pressures in he episcleral veins,
5. Jones F, Maurice DM. New me hods o measuring Schlemm’s canal and rabecular meshwork in mon-
he ra e o aqueous ow in man wi h uorescein. Exp keys: E ec s o changes in in raocular pressure. Exp
Eye Res. 1966;5(3):208–220. Eye Res. 1989;49:645–663.
6. McLaren JW, Brubaker F. A wo-dimensional scan- Moses R , Grodzki WJ, E heridge EL, e al. Schlemm’s
ning ocular uoropho ome er. Invest Ophthalmol Vis canal: T e e ec o in raocular pressure. Invest
Sci. 1985;26(2):144–152. Ophthalmol Vis Sci. 1981;20:61–68.
7. McLaren JW. Measuremen o aqueous humor ow. Pederson JE, Gaas erland DE, MacLellan HM.
Exp Eye Res. 2009;88(4):641–647. Uveoscleral aqueous ou ow in he rhesus monkey:
8. Phelps CD, Armaly MF. Measuremen o episcleral Impor ance o uveal reabsorp ion. Invest Ophthalmol
venous pressure. Am J Ophthalmol. 1978;85(1):35–42. Vis Sci. 1977;16:1008–1017.
9. oris CB, Yablonski ME, Wang YL, e al. Aqueous Seiler , Wollensak J. T e resis ance o he rabecular
humor dynamics in he aging human eye. Am J meshwork o aqueous humor ou ow. Graefes Arch
Ophthalmol. 1999;127(4):407–412. Clin Exp Ophthalmol. 1985;223:88–91.
Aqueous Flow 7
A B
FIGURE 2-2. Hema oxylin and eosin (H&E)–s ained sec ion o he ciliary body. T e mul iple olds help increase
he overall sur ace area.
8 2 BASICS O F AQ UEO US FLO W AND THE OPTIC NERVE
FIGURE 2-3. Route o aqueous f ow. Schema ic diagram showing he rou e o aqueous rom he ciliary body
o he ou ow rac . (From Rhee DJ, Budenz DL. Acu e angle-closure glaucoma. In: A las o O ce Procedures.
Philadelphia, PA: Saunders; 2000, 3( 2) :267–279.)
FIGURE 2-4. H&E-s ained sec ion o he an erior chamber angle showing he ou ow rac s o he eye.
T e conven ional ou ow pa hway consis s o seven layers o M beams (corneoscleral and uveal M) , he
jux acanalicular region, Schlemm’s canal, collec ing channels, and episcleral veins. T e uveoscleral pa hway
consis s o he uveal ace, wi h ow even ually moving in o he choroidal space. T is pa hway is no well
unders ood. T ere is evidence o show ha he aqueous drains ou he vor ex veins and hrough he scleral wall.
Aqueous Flow 9
FIGURE 2-5. Con ocal microscopy o the juxtacanalicular region o TM. Green ( uorescein labeled)
indica es s aining or a nonspecif c secre ed ma ricellular pro ein. Red ( exas red labeled) indica es s aining or
smoo h muscle ac in ( wi hin he M endo helial cells) , whereas he blue (DAPI) s ains or nuclear ma erial.
T ese smaller, bubble-shaped nuclei correspond o he cells o he inner wall o Schlemm’s canal, whereas he
elonga ed nuclei correspond o he M endo helial cells. One can see ha he uveal and corneoscleral M
consis s o endo helial cell–lined beams, whereas he jux acanalicular region is an amorphous area o ex racellular
ma rix and M endo helial cells.
10 2 BASICS O F AQ UEO US FLOW AND THE O PTIC NERVE
A B
D
C
A
B
FIGURE 2-7. Measurement o acility using tonography. A. Elec ronic Schio z onome er recording o a
paper char ( V. Mueller & Company, Chicago, IL) . B. Digi al Schio z onome er recording o compu er ( Mayo
Clinic, Roches er, MN) . C. Per orming Schio z onography on a subjec . D. Paper char recording o IOP over a
4-minu e in erval. T e slow decay in pressure is recorded as an increase in he Schio z scale. A curve is manually
drawn hrough he da a o de ermine he ra e o IOP decay. E. Recording o IOP and curve f t ing o da a rom a
4-minu e onography measuremen , using a digi al Schio z onome er. T e scale is reversed compared wi h he
paper char .
12 2 BASICS O F AQ UEO US FLOW AND THE O PTIC NERVE
B
A
FIGURE 2-8. Measurement o aqueous humor production rate. A. Scanning wo-dimensional an erior
segmen uoropho ome er ( Mayo Clinic, Roches er, MN) . B. Per orming uoropho ome ry on a subjec o
measure uorescein concen ra ion in he cornea and an erior chamber.
FIGURE 2-10. Pho ograph o he op ic nerve showing an in erior no ch rom a pa ien wi h glaucoma. No e he
rela ive absence o pallor. (Cour esy o L. Jay Ka z, MD, Wills Eye Hospi al, Philadelphia, PA.)
A B
FIGURE 2-11. H&E stained histopathologic section o optic nerves. A. Normal op ic nerve. B. Op ic nerve
rom advanced glaucoma ( bean po cup). (Cour esy o Ralph J. Eagle, MD, Wills Eye Hospi al, Philadelphia, PA.)
C H AP T ER
onome ry
Rajesh K. Shet y
14
Goldmann Applanation Tonometer 15
A
B
B
FIGURE 3-2. Applanation technique. A. An individual demons ra ing blepharospasm on at emp ed
applana ion. B. Success ul con ac be ween he onome er ip and he cornea, wi h he examiner demons ra ing
proper echnique o placing suppor ing rac ion only on he orbi al rims, no on he globe i sel .
16 3 TO NO METRY
A
FIGURE 3-3. Schiötz tonometer. A. Image o he Schiö z onome er wi h he 7.5- and 10-g weigh s shown.
B. Schiö z inden a ion onome ry can be used only on pa ien s in a supine posi ion.
18 3 TO NO METRY
FIGURE 3 4. Perkins tonometer. Perkins onome ry is commonly used in he examina ion o in an s under
anes hesia.
Tono-Pen 19
B
FIGURE 3 5. Tono Pen ©. A. T e ono-Pen XL is a handheld device ha does no require a sli lamp. B. Proper
placemen o he ono-Pen is 90 degrees perpendicular o he sur ace o he cornea. T e small diame er o he
ono-Pen makes i also use ul in children.
20 3 TO NO METRY
A
FIGURE 3-6. Pneumotonometer. A. T e Pneumo onome er readou includes a paper racing wi h he average
in raocular pressure in mm Hg which demons ra es he rela ionship o he pa ien ’s pulse. B. T e ip mus be held
perpendicular o he cornea wi h he ngers no exer ing orce on he globe.
Dynamic Contour Tonometry 21
D ynamic con our onome er (DC ) or ure, as igma ism, an erior chamber dep h, and
Pascal onome er is a novel device or axial leng h. IOP measured by DC correla es
he noninvasive measuremen o in raocular wi h Goldmann applana ion onome ry, how-
pressure (Fig. 3-7). T e concave pressure- ever, DC may have signi can ly higher read-
sensing ip (10.5 mm radius o curva ure) is ings. Variabili y be ween observers and wi h
sligh ly f at er han ha o he average human he same observer over ime may be less wi h
cornea. Since he con our o he 7-mm rans- his device han wi h applana ion onome ry.
ducer head ma ches ha o he cornea, here is I is possible o measure bo h he dias olic and
minimal dis or ion o he cornea. T e 1.7-mm he sys olic in raocular pressures and de er-
piezoresis ive pressure sensor a he cen er o mine he di erence be ween he wo, ha
he concavi y measures he in raocular pres- is, he ocular pulse ampli ude. Ocular pulse
sure a he cornea 100 imes per second wi h ampli ude is an indirec measure o choroidal
less han 1 g o apposi ional orce. per usion and may have a role in he pa ho-
physiology o glaucoma.
FIGURE 3-7. DCT. Dynamic con our onome ry is a novel echnique ha may be less inf uenced by he
s ruc ural charac eris ics o he eye.
C H AP ER
4
Gonioscopy
Oscar V. Beaujon-Balbi and Oscar Beaujon-Rubin
A B
FIGURE 4-1. Direct gonioscopy instruments. A. Direc gonioscopy. B. Koeppe lens.
B
A
FIGURE 4-5. Diagram o an open angle conf guration. T is f gure shows ha wi h an open angle, you can
view any objec in a re ec ive mirror, no mat er he heigh or dis ance rom he cen er, because you do no have
any in er erence.
Indirect Gonioscopy 27
FIGURE 4-6. Observer and obstacle. T is f gure shows ha when here is an obs ruc ion (in his example, he
hill; wi h gonioscopy, he convex iris o a narrow angle) , i is bet er o be higher and closer o he cen er. T is is
analogous o using a goniolens whose mirrors are higher and closer o he cen er.
28 4 GO NIO SCO PY
D
FIGURE 4-7. Van Herick’s technique or angle depth estimation. A. Schema ic showing proper placemen
o he sli beam; magnif ed view shows ha he dep h o he an erior chamber (AC) ( black) is grea er han
50% o he corneal sli beam (whi e) , es ima ing a wide angle. B. Demons ra ion o he preceding placemen
in a live pa ien . In his example, he AC dep h is approxima ely 90% o he corneal sli beam. C. Schema ic
showing proper placemen o he sli beam; magnif ed view shows ha he AC dep h ( black) is less han 50% o
he corneal sli beam (whi e) , es ima ing a narrow angle. D. Demons ra ion o he preceding placemen in a live
pa ien . In his example, he AC dep h is approxima ely 10% o 15% o he corneal sli beam.
30 4 GO NIO SCO PY
A B
A B
FIGURE 4-10. Angle structure elements. A. Schwalbe’s line (S) , scleral spur (E) , and ciliary body (C) .
B. Angle s ruc ure elemen s in a human cadaver eye. S.L., Schwalbe’s line; S.S., scleral spur.
Elements o the Angle Anatomy 33
A B
A B
FIGURE 4-13. Schwalbe’s line. A. Pos erior embryo oxon ( arrow) . B. Schwalbe’s line in gonioscopy ( arrow) .
A B
FIGURE 4-14. Schwalbe’s line. A. Schwalbe’s line localiza ion using he edges o he corneal sli beam.
T e di eren beam re exes are shown; “b” corresponds o an erior cornea and “a” o pos erior cornea.
B. Gonioscopic view demons ra ing ha Schwalbe’s line is loca ed where he an erior and pos erior ligh re exes
o he corneal sli beam converge. S.L., Schwalbe’s line ( arrow) . (A, Reproduced wi h permission rom Beaujon-
Rubin O, ed. Glaucoma Primario: Diagnos ico & ra amien o. Caracas, Venezuela: Venezuelan Socie y o
Oph halmology; 1983.)
FIGURE 4-15. Schwalbe’s line. Schwalbe’s line localiza ion using he corneal sli beams in a narrow angle.
36 4 GO NIO SCO PY
FIGURE 4-16. Gonioscopy. Open angle. .M., rabecular meshwork; S.S., scleral spur.
FIGURE 4-17. Iris processes. Gonioscopic view o he an erior chamber angle demons ra ing iris processes
(I.P.; arrow) .
Identifcation o Angle Structures 37
FIGURE 4-18. Iris processes. Iris processes inser ing on o Schwalbe’s line ( arrow) .
A B
FIGURE 4-19. Peripheral anterior synechiae. Examples o peripheral an erior synechiae ( arrow) .
38 4 GO NIO SCO PY
FIGURE 4-20. Sha er ’s classif cation. Diagram o Sha er’s classif ca ion o angle ampli ude.
Classifcation o the Angle 39
FIGURE 4-21. Narrow angle. Aspec o he narrow angle on gonioscopy. No e he marked convexi y o he iris,
some imes re erred o as iris bowing. T e angle s ruc ures are di cul o visualize.
B
FIGURE 4-22. Spaeth’s classif cation. Spae h’s classif ca ion, which provides addi ional in orma ion and de ail.
(Cour esy o Dr. George L. Spae h, Wills Eye Hospi al, Philadelphia, PA.)
40 4 GO NIO SCO PY
A B
FIGURE 4-23. Pigmentar y glaucoma. A. Pigmen ary deposi ion on he rabecular meshwork (arrow) in an
eye wi h pigmen dispersion syndrome. B. Pigmen ary deposi ion on he pos erior lens capsule ( Zen meyer line,
arrow) in an eye wi h pigmen dispersion syndrome.
FIGURE 4-25. Lens pseudoex oliation. Deposi o pseudoex olia ion ma erial on he lens zonule (arrow) .
42 4 GO NIO SCO PY
FIGURE 4-26. Uveitis. Irregular pigmen deposi s on he angle in a pa ien wi h uvei is (arrow) .
FIGURE 4-27. Angle closure glaucoma. Pigmen pa ches ormed a er angle-closure crisis ( arrow) .
Pigment Deposition and Gonioscopy 43
A B
FIGURE 4-28. Neovascular glaucoma. A. Fibrovascular membrane over he angle ( arrow) . A his s age, he
angle is open bu occluded. T ere is marked corneal edema, giving a hazy view. B. Diagram o a f brovascular
membrane growing over he angle and causing peripheral an erior synechiae rom con rac ion in neovascular
glaucoma.
44 4 GO NIO SCO PY
FIGURE 4-29. Error actors in gonioscopy. Placing obliquely direc ed pressure on he sclera.
Error Factors on Gonioscopy 45
A B
FIGURE 4-30. Dynamic gonioscopy. A. Schema ic demons ra ing dynamic, compression, or inden a ion
gonioscopy. B. Dynamic gonioscopy demons ra ing peripheral an erior synechia orma ion (C.A., closed angle)
and chronic angle-closure glaucoma in a pa ien wi h narrow angles. Par o he angle is s ill open (O.A., open
angle) .
46 4 GO NIO SCO PY
Cyclodialysis
Contusion Trauma
Cyclodialysis is a comple ed dehiscence
When he cornea is hi , a wave o uid
o he ciliary body rom he sclera, opening a
abrup ly orms. T is wave moves oward he
communica ion pa hway o he suprachoroi-
angle because he iris–lens diaphragm ac s
dal space (Fig. 4-34).
as a valve, preven ing he uid rom going in
a pos erior direc ion. T is uid movemen T ese gonioscopic pat erns can be ound
can harm he s ruc ures o he angle, crea ing in he same pa ien and are requen ly accom-
acu e lesions ha are rela ed o rauma in en- panied by hyphema.
si y (Fig. 4-31).
Iridodialysis
Separa ion o he iris inser ion rom he
Iridodialysis occurs when here is sepa-
scleral spur, ermed iridodialysis, causes one
ra ion o he iris inser ion rom he scleral
o hese lesions (Fig. 4-32).
spur.
Angle Recession
Angle recession occurs when he ciliary
body is separa ed, leaving he ex ernal wall
FIGURE 4-32. Iridodialysis. T e iris roo (arrow) has allen, exposing he underlying ciliary body processes.
A B
FIGURE 4-33. Angle recession a er trauma. A. Ex ensive angle recession a er rauma. In his example,
he normal angle inser ion is no visible, which could ool an examiner in o hinking ha he angle is normal.
B. Angle recession a er rauma. In his example, here is a smaller degree o angle recession and he border
be ween he recessed angle and he normal angle is seen. A.R., angle recession; S.S., scleral spur; .M., rabecular
meshwork.
FIGURE 4-34. Cyclodialysis. T e ciliary body is comple ely de ached, exposing he underlying sclera (arrow).
C H AP T ER
48
Angle-Closure Glaucoma 49
aqueous pressure in he pos erior chamber an eriorly si ua ed ciliary processes are rarely
orces he iris an eriorly (Fig. 5-4A), causing visualized by AS-OC , i can be used o con rm
an erior iris bowing and angle narrowing. An a clinical suspicion o pla eau iris con gura ion
an eriorly convex con gura ion o he en ire (Fig. 5-9).7
iris can be imaged using AS-OC (Fig. 5-5).
Pupillary block may be absolu e, i he iris PHACOMO PHIC GLAUCOMA
is comple ely bound o he lens by pos e- Lens enlargemen may cause shallowing o he
rior synechiae, bu mos of en is a unc ional an erior chamber and precipi a e acu e angle
block, ermed relative pupillary block. Rela ive closure by orcing he iris and ciliary body an e-
pupillary block usually causes no symp oms. riorly. Mio ic herapy increases he lens axial
However, i i is su cien o cause apposi- leng h and causes i o move an eriorly, which
ional closure o a por ion o he angle wi hou ur her shallows he an erior chamber, and may
eleva ing in raocular pressure (IOP), periph- paradoxically worsen he si ua ion (Fig. 5-10).
eral an erior synechiae may gradually orm AS-OC is use ul in his condi ion, because
and lead o chronic angle closure (Fig. 5-6). an erior chamber dep h, iris con gura ion, and
I he pupillary block becomes absolu e, he angle s ruc ures can be evalua ed a a glance.
pressure in he pos erior chamber increases
and pushes he peripheral iris ar her orward
o cover he rabecular meshwork and close MALIGNANT GLAUCOMA
he angle wi h an ensuing rise o IOP (acu e Malignan (ciliary block) glaucoma is a mul i-
angle closure) (Fig. 5-7). ac orial disease in which he ollowing com-
ponen s may play varying roles: (1) previous
Laser irido omy elimina es he pressure di -
acu e or chronic angle closure, (2) shallow
eren ial be ween he an erior and pos erior
an erior chamber, (3) orward lens move-
chambers and relieves he iris convexi y. T is
men , (4) pupillary block by he lens or vi re-
resul s in several changes in an erior segmen
ous, (5) zonular laxi y, (6) an erior ro a ion
ana omy. T e iris assumes a a or planar con-
or swelling o he ciliary body, or bo h, (7)
gura ion (Fig. 5-4B), and he iridocorneal
hickening o he an erior hyaloid membrane,
angle widens. T e region o iridolen icular
(8) vi reous expansion, and (9) pos erior aque-
con ac ac ually increases, as aqueous ows
ous displacemen in o or behind he vi reous.
hrough he irido omy ra her han he pupil-
lary space. UBM reveals a shallow supraciliary de ach-
men , no eviden on rou ine B-scan or clini-
cal examina ion. T is e usion appears o be
PLATEAU I IS he cause o he an erior ro a ion o he ciliary
In pla eau iris, he ciliary processes are ei her body. Aqueous humor is secre ed pos erior o
large or an eriorly si ua ed, or bo h, so ha he lens (pos erior aqueous displacemen ),
he ciliary sulcus is obli era ed and he cili- increasing vi reous pressure, pushing he lens–
ary body suppor s he iris agains he ra- iris diaphragm orward, and causing angle clo-
becular meshwork. T e an erior chamber is sure and shallowing o he an erior chamber
usually o medium dep h and he iris sur ace (Fig. 5-11). Al hough changes in he shape
only sligh ly convex. Argon laser peripheral or posi ion o he ciliary body canno be accu-
iridoplas y con rac s and compresses he ra ely assessed, an an eriorly displaced iris–lens
peripheral iris, pulling i away rom he rabecu- diaphragm and shallow an erior chamber are
lar meshwork (Fig. 5-8).6 Al hough large or well demons ra ed using AS-OC (Fig. 5-12).
Angle-Closure Glaucoma 51
A B
FIGURE 5-1. Measurement o cornea and anterior chamber parameters using AS OCT. Corneal thickness,
corneal radius o curvature, anterior chamber depth and volume, pupil diameter, and distance between scleral
spurs (A), as well as anterior chamber angle parameters such as AOD500 (angle opening distance at 500 µm
rom the scleral spur) , ISA500 (trabecular–iris space area at 500 µm rom the scleral spur), and IA500
(trabecular–iris angle at 500 µm rom the scleral spur) (B) can be measured using AS-OC .
A B
FIGURE 5-2. Ef ect o ambient light on angle con guration. A. Under light conditions the angle is open.
Aqueous has access to the trabecular meshwork (arrows) . B. In the dark, the angle is capable o occlusion
(arrows) .
52 5 ANTERIO R SEGMENT IMAGING
A B
FIGURE 5-3. Anatomy o normal eye. UBM (A) and AS-OC (B) o normal eye showing anterior chamber
(AC) , cornea (C) , ciliary body (CB), iris (I) , lens capsule (LC) , posterior chamber (PC) , sclera (S) , scleral spur
( black arrow), Schwalbe’s line ( vertical white arrow) , and angle recess ( horizontal or oblique white arrows) .
A B
FIGURE 5-4. Iris con guration be ore and a er laser iridotomy (UBM). Convex iris conf guration
(arrowheads) be ore (A) and planar conf guration a er (B) laser iridotomy in an eye with relative pupillary block.
FIGURE 5-5. Iris con guration with relative pupillar y block (AS OCT). Convex conf guration o entire iris
(arrowheads) is visualized in one rame.
Angle-Closure Glaucoma 53
FIGURE 5-7. Iris con guration with absolute pupillar y block (AS OCT). Extremely convex iris with absolute
pupillary block caused by 360-degree posterior synechiae ( arrows) .
A B
FIGURE 5-8. Plateau iris syndrome (UBM). A. In plateau iris syndrome, the angle remains closed (arrowhead)
a er laser iridotomy because the ciliary processes are large and anteriorly positioned. T e ciliary sulcus is absent
(asterisk) . B. Following peripheral iridoplasty, the appositional angle closure is relieved.
54 5 ANTERIO R SEGMENT IMAGING
FIGURE 5-9. Plateau iris syndrome (AS OCT). Plateau conf guration o the iris is prominent, although the
ciliary body is not visualized.
FIGURE 5-10. Phacomorphic glaucoma (UBM). T e intumescent lens (L and arrowheads) pushes the iris (I)
and ciliary body into the angle.
FIGURE 5-11. Malignant glaucoma (UBM). Malignant glaucoma can result rom aqueous misdirection or
rom annular ciliary body detachment. T e ciliary body (CB) is rotated anteriorly (white arrow) . Fluid is visible in
the supraciliary space. S, sclera; I, iris.
Angle-Closure Glaucoma 55
FIGURE 5-12. Malignant glaucoma (AS OCT). Anteriorly pushed iris and lens result in angle closure with
shallow anterior chamber. Ciliary body is not visualized.
A B
FIGURE 5-13. Pseudophakic pupillar y block. A. T is eye shows peripheral anterior ( black arrows) and
posterior synechiae ( white arrows) , resulting in an iris bombé conf guration. B. A er laser iridotomy, the iris
conf guration is at while the peripheral anterior synechiae ( black arrows) still hold the iris root to the trabecular
meshwork.
FIGURE 5-14. Pseudophakic malignant glauoma. Peripheral iridocorneal touch (white arrow) with angle
closure is visible (scleral spur at black arrow) . T e haptic is visible beneath the iris (arrowhead) .
56 5 ANTERIO R SEGMENT IMAGING
A B
FIGURE 5-16. Ex oliation syndrome. A. Normal zonules. B. Deposited ex oliation material produces a di use
patchy granular appearance to the zonules ( arrow) .
58 5 ANTERIO R SEGMENT IMAGING
A B
FIGURE 5-17. Cyclodialysis cle . UBM (A) and AS-OC (B) reveal the separation between the longitudinal
muscle o the ciliary body and the scleral spur (arrows) . Note the supraciliary e usion ( asterisks) .
Other Conditions 59
A B
FIGURE 5-18. Iridociliar y cysts. Iridociliary cysts ( asterisks) in UBM (A) and AS-OC (B) images are
characterized by an echolucent lumen. T e angle is ocally closed (arrows) .
FIGURE 5-19. Ciliar y body melanoma. In this eye with ciliary body melanoma (asterisk) , the angle is ocally
closed ( arrows) .
60 5 ANTERIO R SEGMENT IMAGING
FIGURE 5-20. Iridoschisis. Extensive stromal separation ( arrowhead) reaches the cornea and compromises
aqueous out ow ( vertical arrow) .
Surgery and Glaucoma 61
FIGURE 5-21. Functioning ltering bleb. T e internal ostium (I) , intrascleral uid pathway (asterisk) , and
scleral ap (S) are seen. T e bleb (B) is moderately elevated and homogeneously spongy with uid-f lled spaces.
C, cornea; Cb, ciliary body; PI, peripheral iridectomy.
FIGURE 5-22. Failed bleb. T e internal ostium (I) and intrascleral uid pathway are patent, but the scleral
pathway or aqueous is closed ( arrow) .
A B
FIGURE 5-23. Bleb encapsulation. enon cyst wall ( ) is thick due to f broblastic proli eration. T e
intrascleral uid pathway is patent (A, asterisk) or closed (B). Cb, ciliary body; I, internal ostium; PI, peripheral
iridectomy; S, scleral ap.
Surgery and Glaucoma 63
A B
A B
FIGURE 5-25. Glaucoma drainage implant. UBM (A) and AS-OC (B) showing the path o the tube rom
the anterior chamber.
C H AP T ER
6
Op ic Nerve Imaging
T omas D. Patrianakos
64
Stereophotography 65
TABLE 6-1. Principles and Clinical Parameters o Various Optic Nerve Imaging Devices
Device Principles Clinical Parameters Measured
Stereophotography Simultaneous photographs taken Subjective interpretation o ONH
with two cameras or two separate and RNFL anatomy (pallor, disc
photographs o same nerve at dif erent hemorrhages, peripapillary atrophy)
angles
HRT CSLO Optic disc tomography
GDx SLP/ bire ringence RNFL thickness
OCT Inter erometry Optic disc tomography and RNFL
thickness
ONH, optic nerve head; RNFL, retinal nerve ber layer; CSLO, con ocal scanning laser ophthalmoscopy; SLP, scanning laser
polarimetry.
FIGURE 6-1. Stereophotography uses two simultaneous disc photos. With the use o a special viewer,
stereovision is achieved. Stereophotography is use ul to assess optic nerve changes over time. (Courtesy o
ara A. Uhler, MD.)
Con ocal Scanning Laser Ophthalmoscopy 67
FIGURE 6-3. HR progression analysis demonstrating worsening o GON on topographic analysis with areas
o red/ yellow in the ref ectivity image represents statistically signi cant worsening. rend analysis o certain
stereometric parameters over time additionally documents deterioration o the ONH. (Courtesy o David
Hillman, MD.)
Scanning Laser Polarimetry 71
T he glaucoma diagnosis (GDx) es (Laser scan. Addi ionally, each eye scanned is
Diagnos ics echnologies, San Diego, assigned a quali y number or q value (scale 0
CA) is he pro o ypical scanning laser polarim- o 10; 10 = per ec scan), which can also be
e ry (SLP), which uses he bire ringence prop- used o gauge he quali y o he es . In general,
er ies o he NFL o measure i s hickness. A any hing wi h a q value ≥7 is accep able or
780-nm diode laser passes hrough an orderly in erpre a ion.
arrangemen o axons and micro ubules sur- T e NFL hickness map (Fig. 6-4C) is
rounding he ONH. As ligh passes hrough a color-coded image corresponding o he
he NFL i undergoes a change in polariza- hickness o he NFL. Brigh red or yellow
ion re erred o as re arda ion. T e degree o colors represen areas o hick NFL and are
change in polariza ion is propor ional o he normally seen in an hourglass dis ribu ion
hickness o he NFL and is de ec ed by a superiorly and in eriorly. Blue colors rela e
buil -in ellipsome er. T ese changes are hen o areas o hin NFL and are normally seen
rans ormed o a opographical map o NFL nasally and emporally. GON is charac erized
hickness measuremen s and given a numeric by increasing blue colors o he superior/ in e-
value by he GDx so ware using an assumed rior por ion o he ONH.
cons an bire ringence value.1 However, bire-
ringence is no cons an around he ONH in T e devia ion map (Fig. 6-4D) reveals he
all individuals and hus NFL values may be loca ion and magni ude o NFL de ec s over
alsely repor ed. Addi ionally, he abundance he en ire hickness o he map and how much
o bire ringen issues in he eye can con ami- hey devia e rom he race- and age-ma ched
na e he ac ual values o he NFL. Newer norma ive da abase. T ese are color coded
GDx models con ain a variable corneal com- and assigned a rela ive s a is ical signif cance
pensa or (GDx-VCC) (Zeiss Medi ec, Dublin, based on probabili y o normali y.
CA) (Fig. 6-4A) which elimina es he re arda- T e SNI ( emporal, superior, nasal, in e-
ion con ribu ed by he cornea. However, his rior, emporal) graph (Fig. 6-4E) maps ou he
is based on he macula as an in ernal re erence pa ien ’s NFL modula ion curve and super-
and can be in uenced by macular pa hologies. imposes i on a norma ive NFL modula ion
T e la es version o he ins rumen uses indi- curve. Normal NFL modula ion should ol-
vidualized an erior segmen compensa ion or low a sinusoidal pat ern (double hump a he
eyes wi h low signal- o-noise ra io called an superior and in erior por ion) wi h at ening
enhanced corneal compensa or (ECC).2 o he humps represen ing NFL loss consis-
A undus image (Fig. 6-4B) is used by he en wi h glaucoma.
opera or o manually def ne he ONH. A T e ac ual numeric values calcula ed o rep-
calcula ion circle wi h a f xed band measuring resen he NFL hickness are lis ed in he
0.4 mm wide (inner diame er 2.4 mm; ou er SNI parame ers (Fig. 6-4F). T ese values
diame er 3.2 mm) is au oma ically aligned are also color coded and assigned a rela ive
around he disc based on illumina ion pat erns s a is ical signif cance based on he probabili y
and highligh s he area where he NFL o normali y. S udies have demons ra ed ha
measuremen s will be derived. Image quali y he nerve f ber indica or (NFI) correla es bes
and reliabili y o he es can be quan if ed wi h he exis ence o glaucoma.3 I represen s
72 6 O PTIC NERVE IMAGING
A B
D
C
FIGURE 6-4. A. GDx with VCC o a glaucoma suspect demonstrating slight in erior RNFL loss in the le
eye. B. Fundus image with the calculation circle. C. RNFL thickness map demonstrating bright red or yellow
colors representing areas o thick RNFL normally seen in an hourglass distribution superiorly and in eriorly.
D. Deviation map with color-coded areas exempli ying RNFL deviation rom a race- and age-matched normative
database.
(continued)
74 6 O PTIC NERVE IMAGING
TS NIT OD OS
Pa ra me te rs Actua l va l. Actua l va l.
NFI 15 21
FIGURE 6-5. Progression o GON with GDx-guided progression and trend analysis comparing ollow-up scans
to a baseline scan. T e deviation map shows ocal thinning o the superior and in erior RNFL which is urther
exempli ed by color-coded di erence rom baseline scans. SNI parameters also demonstrate worsening o
glaucoma by increasing NFI values and decreasing RNFL values over time.
Optical Coherence Tomography 75
FIGURE 6-7. Stratus D-OC ONH analysis scan demonstrating topographic analysis and measurements o
the optic nerve.
Optical Coherence Tomography 79
FIGURE 6-8. Stratus D-OC macular thickness analysis scan demonstrating the RNFL and RPE o the macula.
80 6 O PTIC NERVE IMAGING
FIGURE 6-9. Cirrus SD-OC RNFL imaging scan o a patient with glaucoma demonstrating classic thinning o
the superior RNFL in both eyes.
Optical Coherence Tomography 81
FIGURE 6-10. Cirrus SD-OC progression analysis so ware demonstrating no evidence o progression over
time on both event- and trend-based analysis.
C H AP T ER
7
Evalua ion o he Op ic Nerve
and Nerve Fiber Layer
Zinaria Y. Williams, Kimberly V. Miller, and Joel S. Schuman
82
Functional Tests 83
FIGURE 7-2. Glaucoma hemif eld es ing. Superior visual f eld zones used in he glaucoma hemif eld es .
Each zone is compared wi h i s mirror zone below he horizon al meridian. (Adap ed wi h permission rom
Eps ein DL. Chandler and Gran ’s Glaucoma. 4 h ed. Bal imore, MD: Williams & Wilkins; 1997.)
Functional Tests 85
B
FIGURE 7-3. SITA, normal eye. A. Normal op ic nerve head (ONH) pho ograph. B. Normal SI A visual f eld.
Functional Tests 87
B
FIGURE 7-4. SITA, glaucoma ous eye. A. ONH pho ograph o an eye wi h glaucoma B. SI A visual f eld
showing a superior arcua e sco oma and an in erior nasal s ep.
88 7 EVALUATION O F THE O PTIC NERVE AND NERVE FIBER LAYER
FIGURE 7-5. GPA, glaucoma ous eye. GPA showing devia ion rom baseline and likely progression near f xa ion.
Functional Tests 89
FIGURE 7-6. VFI, glaucoma ous eye. VFI showing progression over ime and projec ed progression.
90 7 EVALUATION O F THE O PTIC NERVE AND NERVE FIBER LAYER
B
FIGURE 7-7. SWAP, normal eye. A. Normal ONH pho ograph. B. Normal SWAP visual f eld.
92 7 EVALUATION O F THE O PTIC NERVE AND NERVE FIBER LAYER
FIGURE 7-9. FDT, glaucoma ous eye. FD o he same glaucoma ous eye shown in Figure 7 4. T e righ eye
shows a superior and in erior s ep de ec .
Functional Tests 95
Multifoca l ERG
~50°
Conta ct Le ns
Ele ctrode
Amplifie r
100k ga in 10-300 Hz
Compute r
fa s t M tra ns form
103 foca l 1 µv
ERGs
100 ms
FIGURE 7-10. m ERG. Schema ic display o he m E G showing s imulus array, he response race array, and
hree- and wo-dimensional plo s. (Cour esy o Erich Sut er, PhD, Elec ro-Diagnos ic Imaging, San Ma eo, CA.)
Functional Tests 97
A B
FIGURE 7-11. m VEP. A. S imulus and response array o a normal m VEP. (A, B, Cour esy o Erich Sut er,
PhD, Elec ro-Diagnos ic Imaging, San Ma eo, CA.) B. Diagram o elec rode placemen s above and la eral o he
inion.
Structural Tests 99
hickness. T ese are among he reliable signs When to Use Stereoscopic Photography
o glaucoma and i s progression. S ereoscopic op ic nerve head pho ogra-
T e developmen o noninvasive, objec ive phy should be used whenever available every
echniques ha measure re inal s ruc ures 1 o 2 years o evalua e glaucoma suspec s and
mos likely o su er glaucoma ous damage glaucoma pa ien s or progressive disease.
aids in he diagnosis o glaucoma and in he Limitations
moni oring o progressive glaucoma ous dam-
age. S ereoscopic and NFL pho ography are S ereoscopic op ic nerve head pho og-
among he simples echnologies ha can be raphy does no o er an objec ive sys em or
used or assessing glaucoma ous s ruc ural in erpre a ion o he op ic nerve.
damage; however, new compu erized image How NFL Photography Works
analysis echniques have been developed or
more objec ive and quan i a ive measuremen s T e NFL is composed o he axons rom he
o he re inal NFL and op ic nerve head. ganglion cells, neuroglia, and as rocy es. Axons
o he ganglion cells ravel oward he op ic
nerve in an organized ashion (Fig. 7-13).
PHOTOGR PHY
T e NFL is bes observed using a red- ree,
S ereoscopic op ic nerve head pho ogra-
phy is one o he mos widely used op ic
nerve head imaging echnologies. NFL pho-
blue or green ligh . Green or blue waveleng hs
are highly absorbed by he re inal pigmen
epi helium and choroid, while he axon
ography, more di cul and less requen ly bundles re ec he ligh and appear as silvery
used han op ic nerve head pho ography, s ria ions (Figs. 7-14 and 7-15).
permi s ex ended evalua ion o he NFL ol-
lowing a pa ien examina ion. Speci c re i- When to Use NFL Photography
nal abnormali ies associa ed wi h glaucoma NFL examina ion is use ul in dis inguish-
include ocal and di use NFL hinning. NFL ing be ween glaucoma suspec s and rue glau-
losses in glaucoma correla e wi h visual eld coma damage.
abnormali ies.
De ec s in he NFL may precede
How Stereoscopic Photography Works op ic nerve head and visual eld changes.
T ere ore, correla ing NFL appearance wi h
S ereo images can be produced using visual elds is an objec ive way o con rming
sequen ial (consecu ive) or simul aneous a subjec ive nding in au oma ed perime ry.
pho ographic echniques.
Sequen ial s ereoscopic pho ography cap- Limitations
ures wo consecu ive images using a manual Media opaci ies such as ca arac , poorly
shif o he camera joys ick. ocused pho ographs, and poor con ras
Simul aneous s ereoscopic pho ography because o a ligh ly pigmen ed undus are
cap ures ins an aneous s ereo images wi h a among he ac ors ha can cause di cul y in
single exposure o produce a spli - rame image evalua ing or pho ographing he NFL.
100 7 EVALUATIO N O F THE O PTIC NERVE AND NERVE FIBER LAYER
A B
FIGURE 7-12. S ereoscopic pho ography. A. S ereo pho ograph o normal eye. B. S ereo pho ograph o an
op ic nerve; however, supranasally, here is a NFL de ec .
FIGURE 7-13. NFL represen a ion. Lower drawing represen s he opography o he NFL where he dis al
ganglion cell axons projec o he peripheral area o he op ic disc rim. ( eprin ed wi h permission rom Schuman
JS. Imaging in Glaucoma. T oro are, NJ: SLACK; 1997.)
Structural Tests 101
FIGURE 7-16. SLP, normal eye. SLP o a normal eye showing he CSLO image in he upper le corner and
he bire ringence represen a ion in he upper righ . T e re ardance (NFL hickness) da a are shown in he
middle le panel. T e subjec eye is shown in dark blue, while he 95% conf dence in erval or he normal range
is illus ra ed in ligh blue. T e “Devia ion rom Normal” char is shown in he middle righ panel. Nerve f ber
analysis parame ers are displayed a he bot om.
104 7 EVALUATIO N O F THE O PTIC NERVE AND NERVE FIBER LAYER
FIGURE 7 17. SLP, glaucoma ous eye. SLP o he same glaucoma ous eye shown in Figures 7-4 and 20-9.
No e he general reduc ion in re arda ion illus ra ed in he “Nerve Fiber Layer” graph, and he devia ion rom
normal represen ed in he middle righ panel. NFL parame ers ha are borderline or ou side o normal limi s
are highligh ed.
Structural Tests 105
B
FIGURE 7-18. CSLO, normal eye. CSLO o a normal eye using he H I. A. opographic image (le ) and
re ec ivi y image ( righ ) showing he ONH image and con our graph. In he graph, he whi e line represen s
he re erence plane a which here is a heigh o zero. T e red line represen s he heigh o he re erence line
be ween he cup and disk. T e green line is he re inal heigh o he subjec eye a he con our line showing he
ypical double-hump ea ure a he superior and in erior poles. B. opographic image wi h he cup represen ed
in red, he sloping neural issue in blue, and he rim in green. T e ONH parame ers and subjec classif ca ion are
lis ed on he righ . T e classif ca ion number or he H I is de ermined by an au oma ed algori hm devised by
Frederick Mikelberg based on he ONH and re inal parame ers. T e classif ca ion number or H II is derived
rom an algori hm developed by Wolls ein e al. a Moorf elds Eye Hospi al.
Structural Tests 107
B
FIGURE 7-19. CSLO, glaucoma ous eye. CSLO o he same glaucoma ous eye shown in Figures 7 4, 7 9, and
7 17. A. opographic and re ec ivi y images. B. ONH analysis and measured parame ers.
108 7 EVALUATIO N O F THE O PTIC NERVE AND NERVE FIBER LAYER
FIGURE 7 20. Moorf eld’s regression analysis prin ou , glaucoma ous eye. Signal s reng h and disc size
described a op o page. Applica ion o he MR represen ed as red X, yellow “!,” and green check over. Con our
line represen ed by green line circum eren ial o op ic nerve.
Structural Tests 109
FIGURE 7-22. TCA. Progression shown by increasing area o red signal in he in ero emporal neurore inal rim.
110 7 EVALUATIO N O F THE O PTIC NERVE AND NERVE FIBER LAYER
FIGURE 7-23. OCT, normal eye. OC peripapillary circular scan o a normal eye. NFL hickness is graphed
below he scan image. Average overall NFL hickness is shown in he righ middle panel. NFL hickness by
quadran and clock hour is displayed on he bot om righ . T e bot om le image shows a video rame o he
undus during scanning.
112 7 EVALUATIO N O F THE O PTIC NERVE AND NERVE FIBER LAYER
FIGURE 7-24. OCT, glaucoma ous eye. OC peripapillary circular scan o he same glaucoma ous eye shown
in Figures 7 4, 7 9, 7 17, and 7 19. No e he considerably hinner NFL hickness measuremen s.
Structural Tests 113
FIGURE 7-25. Cirrus spec ral domain OCT, glaucoma ous eyes. OC o peripapillary re inal NFL showing
generalized and superior and in erior hinness in bo h eyes.
114 7 EVALUATIO N O F THE O PTIC NERVE AND NERVE FIBER LAYER
FIGURE 7-26. Spec ralis spec ral domain OCT, glaucoma ous eye. OC o peripapillary re inal nerve f ber
laying showing ocal de ec in ero emporally.
Structural Tests 115
FIGURE 7-27. RTVue spec ral domain OCT, glaucoma ous eye. OC o macular ganglion cell complex in
glaucoma ous eye showing ocal hinness in ero emporally in he le eye.
FIGURE 7-28. Cirrus spec ral domain OCT progression analysis. OC GPA showing progression
superiorly, in eriorly, and overall in a glaucoma ous eye.
116 7 EVALUATIO N O F THE O PTIC NERVE AND NERVE FIBER LAYER
FIGURE 7-29. OCT, normal eye. OC macular scan o a normal eye. T e macula has a ring o issue
surrounding he ovea ha is hicker han he ovea cen ralis, as can be seen in he macular hickness map. T e
map is displayed in alse color, and he quan i a ive da a are shown o i s righ .
Structural Tests 117
FIGURE 7-30. OCT, normal eye. OC ONH scan o a normal eye. T is scan prof le illus ra es he op ic disc
physical charac eris ics.
118 7 EVALUATIO N O F THE O PTIC NERVE AND NERVE FIBER LAYER
FIGURE 7-31. OCT, glaucoma ous eye. OC macular scan o ano her glaucoma ous eye showing macular
hinning.
Structural Tests 119
FIGURE 7-32. Re inal hickness mapping. Normal eye analyzed wi h he A. T e wo- and hree-
dimensional images are shown in alse color.
C H AP T ER
8
Psychophysical es ing
Douglas J. Rhee, Tara A. Uhler, and L. Jay Katz
120
Purpose of Test 121
Blind s pot
Fove a
FIGURE 8-1. T e “hill o vision.” A hree dimensional represen a ion o he visual hreshold in various
loca ions wi hin he visual f eld o a normal eye. (From Haley MJ, ed. T e Field Analyzer Primer. 2nd ed. San
Leandro, CA: Humphrey Ins rumen s; 1987:4. Fig. 1.)
FIGURE 8-2. Comparison o static and kinetic perimetr y. Slopes and sco omas are shown bet er by s a ic
han by kine ic perime ry. A. Al hough he normal visual f eld wi h i s gradual slope and absence o abnormal
sco omas is well ou lined by kine ic es ing, he presence o f eld de ec s makes his me hod less precise han
s a ic es ing. B. T e a emporal slope migh yield a response a any poin be ween 40 degrees and 12 degrees
i he es objec were op imum or es ing ha zone. Nasally, he bes chosen kine ic es migh be repor ed
anywhere be ween 25 degrees and 7 degrees, and i would miss he rela ive sco oma be ween 7 degrees and
12 degrees. C. When he slope is s eep, kine ic perime ry usually ou lines he de ec well wi h a ew well chosen
es objec s, bu he choice is o en arbi rary and may ail o reveal he ac ual s eepness o he slope. S a ic
es s elucida e well he a slopes and small sco omas in D and bo h kinds o slope in E. (From Leydhecker
W. Glaucoma. Symposium, u zing Cas le, held in Connec ion wi h he 20 h In erna ional Congress o
Oph halmology, Munich, Augus 1966; 1967:151–186. Wi h permission rom S. Karger AG, Basel, Swi zerland.)
124 8 PSYCHO PH YSICAL TESTING
FIGURE 8-3. Goldmann visual f eld testing. Goldmann visual f eld es o he righ eye showing superior nasal
s ep and arcua e de ec .
FIGURE 8-4. Oc opus AASVF es wi h corresponding op ic nerve pho ograph and Heidelberg re inal
omography (HR ) scan.
Common Optic Nerve Visual Fields Found in Patients with Glaucoma 125
FIGURE 8-5. Glaucomatous damage to nerve bundles and location o resulting visual abnormalities.
Damage a he lower pole o he op ic disc causes abnormali ies in he visual f eld as shown ( le eye) . (From
Anderson DR, Pa ella VM. Au oma ed S a ic Perime ry. 2nd ed. S . Louis, MO: Mosby; 1999:51. Fig. 4-4.)
Common Optic Nerve Visual Fields Found in Patients with Glaucoma 127
B C
FIGURE 8-6. emporal wedge. A. Humphrey AASVF es ing. B. Corresponding op ic nerve pho ograph
showing some nasal hinning. C. Corresponding HR scan.
128
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Common Optic Nerve Visual Fields Found in Patients with Glaucoma 129
B C
FIGURE 8-8. More advanced superior nasal step de ect. A. Humphrey AASVF es ing. B. Corresponding
op ic nerve pho ograph showing more advanced in ero emporal hinning. C. Corresponding HR scan.
130 8 PSYCHO PH YSICAL TESTING
B C
FIGURE 8-9. Arcuate de ect. A. Humphrey AASVF es ing. B. Corresponding op ic nerve pho ograph
showing some nasal hinning. C. Corresponding HR I scan.
Common Optic Nerve Visual Fields Found in Patients with Glaucoma 131
FIGURE 8-10. AASVF test rom a Humphrey machine demonstrating a combination o de ects. T ere are
bo h superior and in erior nasal s eps wi h bo h in erior and superior arcua e de ec s. T e in erior arcua e is more
prominen han he superior arcua e.
FIGURE 8-11. Summary o charac eris ic glaucoma ous visual f eld de ec s ha localize o he re inal nerve
f ber layer.
132 8 PSYCHO PH YSICAL TESTING
FIGURE 8-12. Schematic o unctional reserve. Yellow bar schema ically represen s he ull undamaged
number o ganglion cells. T e blue bars schema ically represen he level o ganglion cells in which symp oma ic
dys unc ion would occur. T us, he di erences as represen ed by he red and green brackets represen he
unc ional reserve.
Newer Psychophysical Testing: Frequency-doubling Perimetry and Short-wave Automated Perimetry 133
B
FIGURE 8-13. Visual elds rom he same pa ien using he 24–2 es ing s ra egies o he (A) Humphrey
f eld analyzer ( Zeiss) wi h he SI A FAS s ra egy, (B) 24–2 SI A SWAP, and (C) 24–2 FDP. (D) T e
corresponding op ic nerve.
(continued)
134 8 PSYCHO PH YSICAL TESTING
C D
FIGURE 8-13. ( Continued)
Newer Psychophysical Testing: Frequency-doubling Perimetry and Short-wave Automated Perimetry 135
9
Blood Flow in Glaucoma
Alon Harris, Brent Siesky, and Deepam Rusia
136
Blood Flowin Glaucoma 137
S LO – IC G
P OBF
S LO -
F lu o r e s c e in
H R F \ LDF
S RO
C DI Do p p le r O C T
FIGURE 9-1. Instruments used to measure hemodynamics. Dif erent technologies measure hemodynamics
in speci c ocular tissue beds.
138 9 BLO O D FLO W IN GLAUCO MA
Description
SCA
SCAN
AN N IN
I N G LA
LASER
ASERR
Fluorescein dye is used in conjunc ion
OP
PHH H ALMOSCO
AL M O SC
C O PE
E wi h a low-pene ra ing laser beam requency
AN
NGGIO
IO
OGGRAPH
RAPH HY o op imize visualiza ion o re inal vessels.
High clari y allows isola ion o individual re i-
FLUORESCEIN SLO
ANGIO GRAPHY
Purpose
Evalua ion o re inal hemodynamics
Scanning Laser Ophthalmoscope Angiography 139
FIGURE 9-2. SLO angiography. T e SLO can use either uorescein or indocyanine green dye to look at retinal
or choroidal vessels.
FIGURE 9-3. Fluorescein SLO angiography. Fluorescein SLO angiography provides high-clarity visualization
o retinal vessels.
FIGURE 9-4. AVP time. AVP time equals the time dif erences in dye arrival between the isolated retinal artery
and adjacent retinal vein.
140 9 BLO O D FLO W IN GLAUCO MA
FIGURE 9-5. Indocyanine green SLO angiography. Indocyanine green SLO angiography allows analysis o six
areas o the choroid: two areas near the optic disk, and our areas centered around the macula.
FIGURE 9-6. Area dilution analysis. Area dilution analysis measures the brightness o an area to determine
the time required to reach prede ned levels o brightness ( 10% and 63%) . It also allows relative brightness
comparisons to be made between the six areas.
142 9 BLO O D FLO W IN GLAUCO MA
FIGURE 9-7. CDI. CDI is per ormed by placing a single, multi unction probe (usually 5 to 7 MHz) over the
closed eye.
A B
FIGURE 9-8. CDI. A. Speci c retrobulbar vessels can be chosen with the CDI. T ese include the ophthalmic,
central retinal, and posterior ciliary arteries. B. T e PSV and EDV are taken rom the peak and trough o the
velocity plot. Pourcelot’s RI can then be calculated rom these two values.
144 9 BLO O D FLO W IN GLAUCO MA
A B
FIGURE 9-9. POBF. A. T e POBF device provides real-time measurement o IOP approximately 200 times
per second. B. T e POBF tonometer is placed on the cornea to record the amplitude o the IOP pulse wave.
FIGURE 9-10. POBF. T e IOP pulse wave is thought to correlate primarily with systolic choroidal blood ow.
146 9 BLO O D FLO W IN GLAUCO MA
FIGURE 9-12. HRF. T e amplitudes o Doppler-shi ed requencies caused by moving blood cells are used to
create a ow map o the peripapillary retina and optic disk.
FIGURE 9-13. HRF. Pointwise analysis o the HRF ow maps provides a more robust interpretation o ow
map by providing a description o the varying degrees o per used and avascular tissues.
148 9 BLO O D FLO W IN GLAUCO MA
FIGURE 9-14. SRO. T e spectral retinal oximeter uses the spectrophotometric properties o oxygenated and
deoxygenated hemoglobin to determine the oxygen tension in the retina and optic nerve head. (Copyright
Glaucoma Research and Diagnostic Center.)
Doppler Ocular Coherence Tomography 149
10
Introduction to Clinical Syndromes
Douglas J. Rhee
150
Introduction to Clinical Syndromes 151
11
Developmen al Glaucomas
(Congeni al Glaucomas)
Oscar V. Beaujon-Balbi, Oscar Beaujon-Rubin, and Douglas J. Rhee
152
Primary Congenital Glaucoma 153
FIGURE 11-1. Unilateral primar y congential glaucoma. T is photo demonstrates a cloudy cornea and
buphthalmos.
A B
FIGURE 11-4. Gonioscopy. A. Flat iris insertion. B. Concave iris insertion.
Primary Congenital Glaucoma 157
FIGURE 11-5. Gonioscopy. Note the relative paucity o anterior chamber pigment o a normal anterior
chamber angle in an in ant.
FIGURE 11-6. Buphthalmos. An extreme example o buphthalmos with corneal and scleral thinning.
158 11 DEVELO PMENTAL GLAUCO MAS (CO NGENITAL GLAUCO MAS)
FIGURE 11-7. Congenital glaucoma during goniotomy. Note the di erence in angle con guration between
the goniotomy-treated portion o trabecular meshwork ( white arrow) and the nontreated portion ( black arrow) .
A B
C D
FIGURE 11-9. Goniotomy procedures. A and B. raditional goniotomy per ormed with a Barkan lens,
goniotome kni e, with xation o the superior and in erior rectus muscles using locking toothed orceps. T is
technique relies upon an assistant to xate the orceps and rotate the eye to allow the surgeon access to a wider
portion o the angle. C and D. Alternative method that does not require an assistant using a modi ed Swan lens
and goniotome kni e.
160 11 DEVELO PMENTAL GLAUCO MAS (CO NGENITAL GLAUCO MAS)
A B
FIGURE 11-11. Suture trabeculectomy with i rack. T e red illuminated tip helps identi y the location o the
catheter.
162 11 DEVELO PMENTAL GLAUCO MAS (CO NGENITAL GLAUCO MAS)
GLAUCOMA ASSO CIATED opaci ca ion and pannus usually occur cir-
WITH CONGENITAL cum eren ially in he periphery.
ANOMALIES Glaucoma associa ed wi h aniridia does
no usually develop un il la e childhood or
ANIRIDIA early adul hood. I may be a resul o rabecu-
Aniridia is a bila eral congeni al anomaly lodysgenesis or o progressive closure
in which he iris is markedly underdeveloped, o he rabecular meshwork by he residual
bu here is generally a rudimen ary iris iris s ump. I i develops during in ancy,
s ump o variable ex en visible on examina- a gonio omy or rabeculec omy may be
ion o he angle (Fig. 11-12). indica ed.
wo- hirds o cases are dominan ly rans- I has been sugges ed ha early gonio omy
mit ed wi h a high-degree pene rance. wen y may preven he progressive adherence o
percen are associa ed wi h Wilms’ umor. he residual peripheral iris o he rabecular
meshwork.
A dele ion o he shor arm o chromo-
some 11 has been associa ed wi h Wilms’ In older children, medical herapy o
umor and sporadic aniridia. con rol in raocular pressure should rs
be at emp ed. Any orm o surgery has he
Poor visual acui y is common because risk o injuring he unpro ec ed lens and
o oveal and op ic nerve hypoplasia. O her zonules, and l ering procedures have an
associa ed ocular condi ions include kera- increased risk o vi reous incarcera ion.
opa hy, ca arac (60% o 80%), and ec opia Cyclodes ruc ive procedures may be neces-
len is (Fig. 11-13). Pho ophobia, nys agmus, sary in cer ain pa ien s wi h uncon rolled
decreased vision, and s rabismus are common advanced glaucoma.
mani es a ions in aniridia. Progressive corneal
FIGURE 11-12 Aniridia. Gonioscopic photograph showing an iris remnant with ciliary processes below.
Glaucoma Associated with Congenital Anomalies 163
FIGURE 11-13 Aniridia and cataract. Arrows indicate the remnant portion o the iris.
164 11 DEVELO PMENTAL GLAUCO MAS (CO NGENITAL GLAUCO MAS)
A B
FIGURE 11-15 Rieger’s syndrome. A. Notice prominent anterior embryotoxon (white arrows) and iris
hypoplasia ( black arrow) . B. T e mother o the patient in A, showing prominent anterior embryotoxon,
corectopia, and polycoria.
166 11 DEVELO PMENTAL GLAUCO MAS (CO NGENITAL GLAUCO MAS)
FIGURE 11-16 Rieger’s syndrome. Lef . Facial anomalies, maxillary hypoplasia. Right. Dental anomalies,
hypodontia, and anodontia. (Courtesy o Dr. Adael Soares, Escola Paulista de Medicina, UNIFESP, São Paulo,
Brazil.)
B
A
FIGURE 11-17 Peter’s anomaly. A. Diagram o anomaly. B. Note the corneal opacity ( leukoma) , along with
corneal pannus.
Mar an Syndrome 167
FIGURE 11-19 Mar an syndrome. Anterior ectopia lentis. In this eye, the crystalline lens has dislocated anteriorly.
Microspherophakia 169
FIGURE 11-20 Microspherophakia. T e small, round lens can be visualized within the aperture o the dilated
pupil.
170 11 DEVELO PMENTAL GLAUCO MAS (CO NGENITAL GLAUCO MAS)
FIGURE 11-21 Sturge–Weber syndrome. Note unilateral rontal and maxillary distribution. (Courtesy o
Dr. Claudia Pabon Bejarano, Escola Paulista de Medicina, UNIFESP, São Paulo, Brazil.)
Sturge–Weber Syndrome Encephalotrigeminal Angiomatosis 171
A B
FIGURE 11-23 Neuro bromatosis. Note ca é-au-lait spots and plexi orm neuro broma o the upper lid.
(Courtesy o Dr. Claudia Pabon Bejarano, Escola Paulista de Medicina, UNIFESP, São Paulo, Brazil.)
C H AP ER
12
Primary Open-angle Glaucoma
George L. Spaeth, Shelly R. Gupta, and Robert J. Goulet III
174
Defnition 175
developmen o s a is ical heory, he avail- exquisi e pain being considered o have “angle
abili y o he onome er, and he concep o closure,” bu no being considered o have
disease as a devia ion rom normal, all led “angle-closure glaucoma.” Recen ly, some
o glaucoma being de ned solely in erms o au hors have subdivided glaucoma in o pres-
eleva ed in raocular pressure (IOP) above 21 sure-dependen and pressure-independen
mm Hg (i.e., grea er han wo s andard devia- ypes. While i is cer ain ha here are ac ors
ions above he mean) or IOP above 24 mm ha increase or decrease he suscep ibili y
Hg (grea er han hree s andard devia ions o he ocular issues o damage by IOP, i is
above he mean). no clear ha hese ac ors ever ac alone and
wi hou some con ribu ion rom he e ec s
S udies conduc ed largely in he 1960s
o IOP, even when he IOP is in he normal or
showed ha only around 5% o individuals
subnormal range.
wi h an IOP above 21 mm Hg ac ually devel-
oped op ic nerve damage and visual eld loss. In Figure 12-1, glaucoma is de ned as he
O her s udies showed ha around one- hird process leading o charac eris ic progressive
o he pa ien s who had charac eris ic op ic ocular issue damage, a leas par ially caused
nerve and visual eld changes o glaucoma by IOP, regardless o he level o IOP. Findings
had IOPs in he range o normal. T ese wo and symp oms o early or modera e glaucoma
observa ions orced a o al re hinking o he are ound in almos all people, even hose who
de ni ion o glaucoma. Many au hors began do no have glaucoma. T ere is no hing diag-
using he erms “low- ension glaucoma” or nos ic, or example, abou a cup- o-disc ra io
“normal-pressure glaucoma” or “high- en- o 0.5. While his could represen a signi can
sion glaucoma.” As more at en ion became glaucoma ous change, i may also occur in a
ocused on he idea o glaucoma as an “op ic person wi hou glaucoma. Fur hermore, here
neuropa hy,” he idea ha glaucoma could be is no hing diagnos ic abou an IOP o 25 mm
rela ed solely o eleva ed pressure, as occurs Hg. T is is a common nding in people who
in he angle-closure glaucomas, became less do no have glaucoma. T us, iden i ca ion o
recognized. T is led o he s range si ua ion charac eris ics ha occur only (or almos only)
o a person wi h an IOP o 80 mm Hg in in glaucoma is impor an (Fig. 12-2).
176 12 PRIMARY O PEN-ANGLE GLAUCO MA
FIGURE 12-1 How he def ni ion o glaucoma has changed over he years.
FIGURE 12-2 Overlap o charac eris ics ha occur in pa ien s wi h and wi hou glaucoma.
Epidemiology 177
Vasospasm Hypotension
Anemia
Elevated IOP
Ischemia
Autoimmunity,
Mechanical excitotoxicity,
Cell
deformation growth factor
damage
deficiency
Decreased Cell
intracranial death
pressure
Structural
change
Functional
loss
ABLE 12-1. Some Fac ors Involved in he Developmen o issue Damage in Glaucoma
Mechanical injury
Stretching o lamina cribrosa, blood vessels, corneal endothelial cells, etc
Abnormal glial, neural, or connective tissue
Metabolic deprivation
Direct compression o neurons, connective tissue, and vasculature by intraocular pressure
Lack o neurotrophins
Secondary to mechanical blockade o axons
Genetically determined
Defcient nerve growth actors
Ischemia and hypoxia
Abnormal autoregulation o retinal and choroidal vessels
Decreased per usion
Acute/ chronic
Primary/ secondary
Abnormal oxygen trans er
Autoimmune mechanisms
De ective protective measures
Defcient or inhibited nitric oxide synthase
Abnormal heat shock protein
Toxicity to retinal ganglion cells and other tissues
Glutamate
Genetic predisposition
Abnormal optic nerve structure
Large laminar pores
Large scleral canal
Abnormal connective tissue
Abnormal vasculature
Abnormal trabecular meshwork
Decreased permeability o extracellular matrix
Abnormal endothelial cells
Abnormal molecular biology
180 12 PRIMARY O PEN-ANGLE GLAUCO MA
on he re ina approxima ely 1.3 mm in diam- a disc wi h a narrow rim ha respec s Jonas’s
e er. T is is he size o he middle-sized beam ISN rule, which s a es ha he rim should
on some Welch-Allyn oph halmoscopes and be wides in eriorly, nex wides superiorly,
o he smalles beam on some o her Welch- nex wides nasally, and narrowes temporally.
Allyn oph halmoscopes. T e examiner should Despi e he large cup, here is no visual eld
learn he size o he beam or he oph halmo- loss (Fig. 12-7B). Figure 12-8 shows a disc
scope he or she is using. T is can be readily wi h a rela ively small “cup- o-disc ra io,” bu a
done by projec ing he beam on he re ina rim- o-disc ra io o 0 a he in erior pole. Cup-
nex o he op ic nerve, no ing he heigh o o-disc ra ios are misleading and should no be
ha beam rela ive o he op ic nerve, and hen used. Figure 12-9 shows wo discs o di eren
using he s rong plus lens o ge an exac mea- sizes. Figure 12-9A is a small disc wi h a disc
suremen o he heigh o he projec ed beam. diame er o approxima ely 1.2 mm. Figure
Once his has been de ermined, he size o he 12-9B is a large disc wi h a disc diame er o
op ic nerve can be de ermined rela ively accu- approxima ely 2.2 mm. T e examiner may be
ra ely wi h he direc oph halmoscope i sel . misled by he rela ive size o he cup in hese
In eyes wi h more han 5 diop ers o hyperopia wo discs and incorrec ly conclude ha he
or 5 diop ers o myopia, he disc size will be disc in Figure 12-9B is less heal hy han ha
abnormally large or abnormally small, respec- in Figure 12-9A. In ac uali y, i is he o her
ively, when viewed wi h he s rong plus lens way around.
due o magni ca ion or mini ca ion.
T e rim area is rela ively cons an in all
T e op ic nerve can be bes examined using a heal hy discs. T us, in large discs, he rim area
direc oph halmoscope wi h bo h he pa ien is spread over a much grea er area (recall ha
and he examiner in he sea ed posi ion. T e area involves he square o he radius). T e
examiner’s head mus be in a posi ion o consequence o his is ha he normal rim o
avoid obs ruc ing he pa ien ’s gaze wi h he he large, healthy disc is narrower han he nor-
o her eye, because ha o her eye mus xa e mal rim o he small, healthy disc. T e rim area
rmly o allow care ul evalua ion o he eye in Figure 12-9B is ac ually grea er han he
being examined. T e examiner direc s pri- rim area in Figure 12-9A.
mary at en ion o he 6 and 12 o’clock posi-
T e rela ive heal h o he op ic nerve can be
ions o he nerve: Wha is he rim wid h? Is
es ima ed by s aging he disc according o he
an acquired pi or a disc hemorrhage presen ?
sys em illus ra ed in Figure 12-10.
Is here peripapillary a rophy? Are he vessels
displaced, ben , engorged, narrowed, or “bayo- In younger pa ien s, or pa ien s whose op ic
ne ed”? T e examiner also es ima es he wid h nerves are in he rela ively early s ages o
o he neurore inal rim a he 1, 3, 5, 7, 9, and glaucoma ous damage, speci cally s ages 0
11 o’clock posi ions. T is is done in erms o a o 3 (see glaucoma graph), evalua ion o he
rim- o-disc ra io, ha is, he rela ive wid h o nerve ber layer can be help ul. T e examiner
he rim in comparison o he diame er o he ocuses me iculously on he re inal sur ace,
op ic nerve in ha axis. T us, he maximum pre erably wi h a red- ree ligh in he direc
rim- o-disc ra io is 0.5. oph halmoscope, and looks or lines ha
would ollow he course o he nerve ber lay-
In Figure 12-6, he rim- o-disc ra io a
ers. A rough can indica e he presence o such
1 o’clock is 0.2; a 3 o’clock, 0.15; a 5 o’clock,
a de ec illus ra ed in Figure 12-11. In mos
0.0; a 7 o’clock, 0.25; a 9 o’clock, 0.20, and
cases, however, he opography o he op ic
a 11 o’clock, 0.25. Figure 12-7A illus ra es
184 12 PRIMARY O PEN-ANGLE GLAUCO MA
nerve provides more valuable clues han does he in erior or superior pole o he disc, are
he na ure o he nerve ber layer. pa hognomonic or glaucoma ous damage.
T e observer also speci cally looks or he
T e op ic nerves o he wo eyes should be
presence o a disc hemorrhage on he re ina
symme ric. Where asymme ry is presen , one
crossing he rim. Such hemorrhages may be
o he nerves is almos always abnormal, unless
signs ha he glaucoma ous process is ou o
he op ic nerves are o di eren sizes, as indi-
con rol. However, hese hemorrhages may
ca ed in Figure 12-9. Figure 12-12 shows he
have o her e iologies, such as an icoagula-
righ and lef eyes o a pa ien wi h unila eral
ion or pos erior vi reous de achmen . T ey
op ic nerve damage resul ing rom glaucoma.
are no reliable signs o poor glaucoma con-
T e examiner should search ou he pres- rol. Disc hemorrhages are seen more of en
ence o an acquired pi o he op ic nerve. in pa ien s wi h average-pressure glaucoma.
T ese localized de ec s immedia ely adjacen Fur her in orma ion abou he op ic disc is
o he ou er edge o he rim, jus emporal o ound in Chap er 5.
A B
1. Size
2. Read reticule
3. Use correction factor
FIGURE 12-5 Me hod o measuring ver ical diame er
o he disc.
FIGURE 12-6 Op ic nerve pho ograph o a le eye showing an acquired pi a approxima ely 5 o’clock.
186 12 PRIMARY O PEN-ANGLE GLAUCO MA
C
FIGURE 12-7 A. A disc wi h a narrow rim ha respec s Jonas’s ISN rule. B. Corresponding Goldmann visual
f eld showing no abnormali y. C. Corresponding Humphrey visual f eld showing no abnormali y.
Clinical Examination 187
A B
FIGURE 12-9 wo discs o dif erent sizes. A. Small disc wi h a disc diame er o approxima ely 1.2 mm.
B. Large disc wi h a disc diame er o approxima ely 2.2.
FIGURE 12-8 Small cup to disc ratio. A disc wi h a rela ively small cup- o-disc ra io, bu a rim- o-disc ra io o
0 a he in erior pole.
188 12 PRIMARY O PEN-ANGLE GLAUCO MA
DDLS For S ma ll Dis c For Ave ra ge For La rge Dis c DDLS 1.25 mm optic 1.75 mm optic 2.25 mm optic
S ta ge <1.50 mm S ize Dis c >2.00 mm S ta ge ne rve ne rve ne rve
1.50-2.00 mm
FIGURE 12-10 T e DDLS. T e Disc Damage Likelihood Scale (DDLS) is a way o describe quan i a ively and
simply he changes ha occur in he Op ic Nerve Head (ONH) ( he disc) . I is used o quan i y he heal h o he
op ic disc, specif cally as i rela es o glaucoma.
T e DDLS is based on wo charac eris ics o he disc: (1) he wid h o he neurore inal rim and (2) he size o
he op ic disc. T e DDLS scale goes rom 1 o 10, 1 being he mos normal and 10 he mos pa hologic. T e wid h
o he neurore inal rim is described in erms o he rim- o-disc ra io. T us, he wides possible neurore inal rim
would be a rim- o-disc ra io o .5. T e narrowes would be .0.
Firs , one measures he size o he op ic disc and classif es he disc as small, average, large, or very large. Small
is less han 1.5 mm in heigh , average be ween 1.5 and 2.0 mm in heigh , large be ween 2 and 3 mm in heigh ,
and very large grea er han 3 mm. T e size is easily measured wi h he sli lamp or, bet er, by using he beam o
an oph halmoscope. Nex , one looks or where he neurore inal rim is he narrowes . (Please no e: “ hin” is he
wrong word, as hin re ers o he hickness o he issue, no o i s wid h.) T e narrowes rim would be .0 and he
wides rim possible would be .5. When he wid h o he rim is be ween .4 and .5 rim- o-disc ra io, hen i is s age
1; be ween .3 and .4, i is s age 2; be ween .2 and .3, i is s age 3; be ween .1 and .2, i is s age 4; and less han .1
bu s ill presen , i is s age 5—all in average-sized discs. Five is he area o indecision. A value o 5 can occasionally
be normal, bu usually i is pa hological and associa ed wi h visual f eld loss. T e DDLS also depends on disc size,
so he wid h o he rim mus be correc ed or disc size. In a small disc, one uni should be added o he DDLS. In
a large disc, one uni should be sub rac ed. In a very large disc, wo uni s should be sub rac ed. T us, an average-
sized disc wi h a rim- o-disc ra io o .25 would be a DDLS o 3; a small disc wi h a rim- o-disc ra io o .25 would
be a DDLS o 4; a large-sized disc wi h he same rim- o-disc ra io o .25 would be a DDLS o 2; and in a very large
disc wi h he same rim- o-disc ra io would be a DDLS o 1.
Some pa ien s wi h glaucoma lose an area o he neurore inal rim comple ely. When his happens, one hen
uses he circum eren ial amoun o rim loss o de ermine he DDLS score. I he amoun o rim loss is less han
45 degrees, hen i is a DDLS o 6; be ween 90 and 180 degrees, a DDLS o 7; and be ween 90 and 180 degrees, a
DDLS o 8. I he amoun o rim loss is grea er han 180 degrees, bu less han 270 degrees, hen i is a DDLS o 9,
and i here is vir ually no rim le , hen i is a DDLS o 10. Again, all o hese numbers re er o he average-sized
disc. Consider a disc wi h a no ch in which here is no rim or 30 degrees. In an average-sized disc, i would be a
DDLS o 6, and in a small disc, a DDLS o 7. In a large disc, i would be a DDLS o 5, and in a very large disc, i
would be a DDLS o 4. Discs wi h DDLS o 6 or more are never normal.
Clinical Examination 189
FIGURE 12-11 A disc wi h an in ero emporal no ch and a nerve f ber layer de ec in ero emporally.
A B
FIGURE 12-12 Unilateral optic nerve damage rom glaucoma. Righ and le eyes o a pa ien wi h unila eral
op ic nerve damage caused by glaucoma. T ere is a loss o in erior rim issue in he righ eye.
190 12 PRIMARY O PEN-ANGLE GLAUCO MA
ABLE 12-5. Risk o Losing Func ion I o change is de ermined by serial evalua ions
No In erven ion o he his ory and op ic nerve. T e dura ion
Low with: he glaucoma will con inue o cause damage
is, in mos cases, de ermined by a reasonable
Healthy optic nerve
es ima e o he pa ien ’s remaining years o li e.
Negative amilyhistoryo visual loss due to glaucoma
Good sel care skills
IOP reduc ion decreases he ra e o disease
progression in glaucoma pa ien s. Lowering
Good access to good care
IOP is he only rea men proven o be bene -
Estimated years remaining less than 10 years cial or pa ien wi h glaucoma. In he Uni ed
Intraocular pressure below 15 mm Hg S a es, a usual prac ice pat ern o lower IOP is
No ex oliation or pigment dispersion syndrome o s ar wi h he use o medica ions. I medi-
changes ca ions ail, laser rabeculoplas y is usually
Normal cardiovascular status advised in appropria e pa ien s. Surgery is yp-
Moderate with a situation between “low”
ically reserved or pa ien s who do no respond
and “high” o o her measures ( ables 12 6 and 12 7).
High with: wo impor an poin s should be no ed abou
Optic nerve already damaged by glaucoma his algori hm. Firs , here is con roversy
Positive amily history o visual loss due to glaucoma amongs oph halmologis s abou whe her use
or presence o recognized “gene” or glaucoma o medica ions is appropria e as rs -line her-
apy. Medica ions require he pa ien o adhere
Poor sel care skills
o an in rusive daily schedule. As he number o
Poor access to good care medica ions prescribed o a pa ien increases,
Estimated years remaining over 15 years he likelihood o he pa ien main aining such
Intraocular pressure over 30 mm Hg a schedule decreases. Addi ionally, medica-
Ex oliation syndrome ions are wrough wi h local and sys emic
Poor cardiovascular status side e ec s ha can be debili a ing or even li e
hrea ening o pa ien s. T ere are some physi-
cians who believe laser rabeculoplas y is more
appropria e as an ini ial in erven ion because
i avoids hese concerns. T e con roversy
or he need o change he vigor o rea men
requires ha he physician have a good idea
o he likelihood ha he pa ien ’s glaucoma
will ul ima ely cause unc ional problems. ABLE 12-6. Expec ed Benef o rea -
o make his de ermina ion appropria ely, men Rela ed o Amoun o Lowering o
he physician mus consider our issues: (1) In raocular Pressure*
he s age o he glaucoma, (2) he ra e o Expected beneft great i intraocular pressure lowering
change o he glaucoma, (3) he dura ion ha greater than 30%
he glaucoma will con inue o exis , and Expected beneft possible to probable i intraocular
(4) socioeconomic mat ers. T e use o he pressure lowering is 15%–30%
“Glaucoma Graph” can be o grea help in his No beneft expected i intraocular pressure lowering
regard (Fig. 12-13). S age o he glaucoma is less than 15%
is de ermined by u ilizing he Disc Damage
*In some cases stabilization o intraocular pressure appears to
Likelihood Scale (DDLS) (Fig. 12-10). Ra e be benefcial in itsel .
reatment 193
ABLE 12-7. Rela ive A ec o Various hese is well es ablished wi h advan ages and
rea men s on In raocular Pressure and on disadvan ages o i s own. T e lat er has he
Developmen o Side E ec s disadvan age o lowering pressure by reduc-
Usual decrease in intraocular pressure: ing aqueous in ow. Newer procedures have
been developed in an at emp o achieve he
In response to • 15%(range 0%–50%)
IOP lowering observed wi h rabeculec omy
medications
while avoiding he complica ions associa ed
In response to argon • 20%(range 0%–50%)
wi h his surgery. None o he newer proce-
laser trabeculoplasty
dures (inaccura ely re erred o as “minimally
In response to f ltering • 40%(range 0%–80%) invasive”) have been proven o sa is y hese
surgery quali ca ions. Fur her s udies may provide
Likelihood o side ef ects as a result o evidence o suppor adop ion o one or more
treatment o hese echniques. T e con inued pursui o
From medications • 30% new surgical op ions highligh s he need or
From argon laser Almost no lasting side improvemen upon wha is curren ly available
trabeculoplasty e ects or he care o medically re rac ive pa ien s.
From selective laser Rare, but some
T e amoun ha he IOP should be lowered
trabeculoplasty permanent and disabling
in order o preven de eriora ion, s abilize he
From incisional • 60%* condi ion, or resul in improvemen varies
surgery
rom individual o individual, bu guidelines
*T e lower the fnal intraocular pressure the greater the have been developed. A arge pressure is an
likelihood o side e ects rom the surgery; the rate varies IOP level believed likely o be low enough o
with the type o surgery, severity o condition, and skill and
preven ur her damage. One me hod o arriv-
judgment o the surgeon.
ing a a arge pressure is shown in Figure
12-14. I is impor an o remember, however,
ha he arge IOP is only a rela ive, en a ive
exis s because laser rabeculoplas y is no
guide o rea men . T e only valid me hod o
wi hou i s own risks. Also, here is a percep-
es ablishing he s a e o con rol in a pa ien
ion in he general popula ion ha laser rea -
wi h primary open-angle glaucoma is by
men is more invasive han use o medica ions.
de ermining s abili y or ins abili y o he op ic
Please see he separa e chap er on his subjec .
nerve or visual eld, or bo h. T us, i he op ic
T e second impor an poin o be made nerve and visual eld are s able despi e an IOP
abou he rea men algori hm rela es o sur- higher han he calcula ed arge pressure, i is
gery done o lower IOP. T ere are a varie y o no wise o at emp o lower he pressure more
ways one may accomplish his goal, bu , he vigorously in order o achieve he arge IOP.
gold s andard con inues o be rabeculec omy Conversely, i he arge pressure is achieved,
(guarded l ra ion procedure). Even hough bu he op ic nerve or visual eld con inues
he echnique has improved, his surgery s ill o de eriora e, hen he arge pressure is oo
has a signi can risk o complica ions ha high, here is ano her cause or he con inu-
can lead o decrease in vision, loss o vision, ing de eriora ion o her han glaucoma, or he
or loss o he eye. O her procedures include neurons are so badly damaged ha de eriora-
ube shun s (glaucoma drainage devices) and ion will progress no mat er wha level o IOP
endocyclopho ocoagula ion. T e ormer o is achieved.
194 12 PRIMARY O PEN-ANGLE GLAUCO MA
Stage
Disc 1
Damage
Likelihood Scale 2
3
Not definitely
damaged 4
5
Asymptomatic
glaucoma 6
damage
7
8
Glaucomatous
disease/ 9
disability
10
Birth Death
FIGURE 12-13 Glaucoma graph and explanation. T e glaucoma graph is a way o de ermining and
unders anding he clinical course o glaucoma in an individual pa ien .
Green Zone: When a person has a Disc Damage Likelihood Scale (DDLS) o 2, 3, or 4, one canno be sure ha
op ic nerve damage is no presen , even hough one knows ha visual f eld loss is no presen . I is possible ha
a an earlier da e he pa ien had a smaller DDLS, in which case, he presen larger DDLS would represen a
de eriora ion. I his were he case, he pa ien s ill would no have visual f eld loss and he need or rea men
would s ill be de ermined by he our ac ors ha always de ermine i rea men is necessary: he amoun o
damage ha is presen , he ra e o change, he dura ion ha he change will con inue, and socioeconomic
considera ions. Valid serial measuremen s allow es ablishing a rend, such as a ra e o de eriora ion o f eld or
disc. I he ra e o change is su cien ly rapid ha he person would ge in o he red zone prior o dea h, hen
rea men is clearly necessary. On he o her hand, i he ra e o change is so slow ha he person will probably no
ge in o he red zone prior o dea h, hen rea men is no likely jus if ed.
Yellow Zone: When a pa ien is in he yellow zone ( wi h a DDLS o 5 o 7) , he op ic nerve is def ni ely damaged,
bu he person is asymp oma ic. Even hough asymp oma ic, i is cer ain ha he eye is no normal. Nobody
s ar s wi h DDLS scores in hose ranges. T e person’s op ic nerve mus have become worse. In such a si ua ion i
is likely ha he pa ien will need rea men , hough his is no always he case. For example, a person could have
developed damage in he pas which hen became s abilized. Or, a person’s an icipa ed-number-o -years- o-live
could be so shor ha even wi hou rea men he/ she would no move rom he yellow o he red zone. Such
individuals would no need rea men .
Red Zone: When a person is already in he red zone, ha is, he person has a decreased quali y o li e or impaired
abili y o per orm he ac ivi ies o daily living (wi h a DDLS o 8, 9, or 10), hey already have a disabili y.
Consequen ly, he goal is preven ing any worsening o he disabili y, because any increase in damage makes he
pa ien symp oma ically worse. T ere ore, remaining years o li e is no longer a considera ion in pa ien s who
already have disabili y. In such a si ua ion, he only reason or no rea ing he pa ien is i he disabili y is o ally
s able wi hou rea men .
reatment 195
13
Secondary Open-angle Glaucoma
Jonathan S. Myers
PIG
PIGMEN
PI
IGGM
ME
MEEN
N DISPERSIO
DII SP E
D ERR SI
SIOON de ec s. T e libera ed pigmen may hen be
SYNN DRO
DR
ROO ME
ME deposi ed hroughou he an erior segmen .
Obs ruc ion o he rabecular meshwork
196
Pigment Dispersion Syndrome 197
Gonioscopy: Pa ien s ypically have back- risk o re inal de achmen while making mon-
ward bowing o he peripheral iris, increasing i oring o he re ina periphery more di cul .
lens–iris con ac . T e angle is very widely Laser peripheral irido omy also may
open, wi h modera e o heavy pigmen a ion, reduce pigmen shedding, because i allows
which is rela ively homogeneously spread he pos eriorly bowed iris o move an eriorly
over he en ire circum erence o he angle. as any buil -up uid pressure in he an erior
Pos erior pole: Charac eris ic glaucoma- chamber is hen normalized wi h he pos e-
ous op ic a rophy is seen wi h prolonged rior chamber (relie o so-called reverse pupil-
eleva ion o IOP or in ermit en pressure lary block). T is may help preven glaucoma
spikes. Myopic pa ien s, and possibly espe- in individuals a higher risk bu have no ye
cially hose wi h PDS, are prone o peripheral developed uncon rolled pressure.
re inal ears, necessi a ing close examina ion. Argon laser rabeculoplas y and f l ering
surgery are also e ec ive in individuals who
Treatment
are uncon rolled medically.
T e goal o herapy is o con rol IOP in
pa ien s wi h signif can ly eleva ed pressure or
glaucoma ous nerve changes, usually hrough BIBLIOGRAPH Y
aqueous suppressan s. Campbell DG. Pigmen ary dispersion and glaucoma: A
new heory. Arch Ophthalmol. 1997;97:1667.
Mio ics reduce pigmen shedding and Gandolf SA, Vecchi M. E ec o a YAG laser irido omy on
reduce IOP bu are o en poorly olera ed in in raocular pressure in pigmen dispersion syndrome.
his young popula ion and may increase he Ophthalmology. 1996;103:1693–1695.
FIGURE 13-1. Krukenberg’s spindle. A ver ical endo helial deposi ion o pigmen charac eris ic o PDS. May
slowly resolve when pigmen shedding s ops, bu may persis or many years or orever. Pat ern o deposi ion is
hough o be rela ed o convec ion curren s o aqueous wi hin he eye.
198 13 SECO NDARY O PEN-ANGLE GLAUCO MA
FIGURE 13-2. Transillumination defects in PDS. Marked peripheral and mid peripheral ransillumina ion
de ec s in PDS. Many pa ien s may presen wi h only several mild radial spoke like de ec s.
FIGURE 13-3. PDS, dense pigmentation, and Krukenberg’s spindle. Krukenberg’s spindle ( oreground), heavily
pigmen ed deep angle ( background). Charac eris ic homogeneous dense pigmen a ion o rabecular meshwork.
FIGURE 13-4. PDS, pigment deposition. Pa hology specimen showing pigmen deposi ion on rabecular
meshwork and an erior o meshwork.
Pigment Dispersion Syndrome 199
FIGURE 13-5. PDS, pigment deposition. Pa hology specimen showing pigmen deposi ion wi hin beams o
rabecular meshwork.
FIGURE 13-6. PDS, Zentmeyer ’s line. Deposi ion o pigmen near equa or o lens, a inser ion o lens zonular
f bers. Variously re erred o as Zen meyer’s line or Scheie’s s ripe.
A B
FIGURE 13-7. PDS, bowing of peripheral iris. A. UBM o pa ien wi h PDS, showing backward bowing
peripheral iris in con ac wi h lens sur ace. B. UBM o he same pa ien , ollowing irido omy, showing an erior
relaxa ion o iris wi h reduced con ac wi h lens.
200 13 SECO NDARY O PEN-ANGLE GLAUCO MA
Pos erior pole: Charac eris ic glaucoma- T e resul s o f l ra ion surgery are similar
ous op ic a rophy is seen wi h prolonged ele- o hose seen in primary open-angle glaucoma.
va ion o IOP or in ermit en pressure spikes. Ca arac surgery should be per ormed
wi h ex ra cau ion, given he known ragil-
Treatment
i y o he capsule and zonular f bers in hese
XFS-rela ed glaucoma o en leads pa ien s.
o higher pressures wi h grea er diurnal
uc ua ion.
BIBLIOGRAPH Y
opical medica ions are appropria e bu
Mi chell P, Wang JJ, Hourihan F. T e rela ionship be ween
have been repor ed o be less e ec ive. glaucoma and pseudoex olia ion: T e Blue Moun ains
Argon laser rabeculoplas y is e ec ive, Eye S udy. Arch Ophthalmol. 1999;117:1319–1324.
al hough here are repor s o increased pos - Ri ch R, Schlo zer-Schrehard U. Ex olia ion syndrome.
Surv Ophthalmol. 2001;45:265–315.
opera ive eleva ions in IOP. Lower energies
T orlei sson G, Magnusson KP, Sulem P, e al. Common
are indica ed o reduce he risk o pressure sequence varian s in he LOXL1 gene con er suscep i-
spikes, given he heavily pigmen ed rabecular bili y o ex olia ion glaucoma. Science. 2007;317(5843):
meshwork. 1397–1400.
FIGURE 13-8. XFS. Ex olia ion ma erial on an erior lens capsule wi h clear zone in he region be ween
undila ed pupil zone and more peripheral lens. Presumably, he movemen o he iris clears ex olia ive ma erial
rom his area.
202 13 SECO NDARY O PEN-ANGLE GLAUCO MA
FIGURE 13-9. XFS, exfoliation material. Ex olia ion ma erial on lens sur ace. No e ypical scrolled edges.
A B
FIGURE 13-11. XFS, angle structures. Heavy, dark, irregular pigmen a ion o angle s ruc ures in XFS.
FIGURE 13-12. XFS, dislocated lens. Spon aneously disloca ed lens in a pa ien wi h XFS highligh s ragili y
o zonular suppor .
204 13 SECO NDARY O PEN-ANGLE GLAUCO MA
History
prolonged. S eroid use o any ype is a crucial
aspec o he his ory. Prior use o s eroids
Epidemiology in he dis an pas wi h subsequen normal-
T e incidence o s eroid-induced glau- iza ion o IOP may presen as an apparen
coma in he general popula ion is unknown. normal- ension glaucoma (Figs. 13-13 to
Signif can eleva ions in IOP in response o 13-15).
opical s eroids have been repor ed in 50% o A his ory o as hma, skin disorders, aller-
over 90% o glaucoma pa ien s and 5% o 10% gies, au oimmune disorders, or he like may
o pa ien s wi h normal pressure. hus sugges possible pas or curren s eroid
T e incidence o he s eroid response is use.
rela ed o he ype, dose, and rou e o s eroid Occasionally, pa ien s no e changes in
adminis ra ion. vision rela ed o advanced visual f eld loss.
Eleva ed IOP has been observed wi h Table 13-1 gives a clinical example.
opical, in raocular, periocular, inhaled,
oral, in ravenous, and derma ologic admin- Clinical Examination
is ra ions o s eroids, as well as wi h endog-
Sli lamp: Usually unremarkable. Even
enous eleva ions o s eroids in Cushing’s
in cases wi h ex reme eleva ions o IOP, he
syndrome.
chronici y usually preven s corneal edema.
S eroid-induced pressure eleva ion is
Gonioscopy: Usually unremarkable.
no uncommon ollowing in ravi real injec-
ion o s eroids, or inser ion o depo s e- Pos erior pole: ypical glaucoma ous
roid devices in he pos erior segmen . op ic nerve changes are no ed i eleva ion o
IOP is su cien ly high and prolonged.
Following in ravi real injec ion, approx-
ima ely 50% experience an eleva ion o Special es s: Discon inua ion o he
IOP, bu a low percen age require surgical s eroids, i possible, may lead o a s eady
in erven ion. reduc ion o IOP. T e ime course is variable
and may be prolonged in cases o prolonged
Pathophysiology s eroid use. In cases in which here is concern
Increased glycosaminoglycans in he regarding hal ing an ocular s eroid (e.g., a cor-
rabecular meshwork in response o s eroids neal gra a high risk o rejec ion), con rala -
impede aqueous ou ow and lead o eleva ed eral s eroid challenge may demons ra e IOP
IOPs. S eroids may reduce he membrane eleva ion and conf rm he diagnosis.
permeabili y o he rabecular meshwork, as
well as reduce local phagocy ic ac ivi y by Treatment
cells and he breakdown o ex racellular and Discon inua ion o he s eroids, i possible,
in racellular s ruc ural pro eins, ur her con- or excision o depo s eroids may yield com-
ribu ing o reduced meshwork permeabili y. ple e resolu ion.
Steroid responsive Glaucoma 205
A B
FIGURE 13-14. Steroid-responsive glaucoma. Excised s eroid depo 5 mon hs ollowing vi rec omy or Eales’
disease on a Weck cell sponge.
FIGURE 13-15. Steroid responsive glaucoma. Fundus pho o aken immedia ely ollowing an in ravi real
injec ion o riamcinolone. Whi e colored crys als seen beginning o disperse in he vi reous o a pa ien wi h
diabe ic macular edema.
C H AP T ER
14
Uvei ic Glaucomas
Nicole Benitah, Ronald Buggage, and George N. Papaliodis
208
Etiology 209
eld de ec s. In mos cases o uvei ic glau- Abou 25% o all pa ien s wi h uvei is will
coma, he glaucoma ous op ic nerve injury is develop increased in raocular pressure a some
primarily a sequela o he eleva ed in raocular ime during he course o heir inf amma ory
pressure; here ore, he diagnosis o uvei ic disease.5 In general, uvei is-induced ocular
glaucoma should be ques ioned in a pa ien hyper ension and uvei ic glaucoma are more
wi h no known his ory o increased in ra- commonly complica ions o an erior uvei is
ocular pressure. Addi ionally, he diagnosis o and panuvei is because he inf amma ion in
glaucoma secondary o uvei is should be ques- he an erior segmen can in er ere direc ly
ioned in any pa ien wi h visual eld de ec s wi h he aqueous ou f ow rou e (Table 14-1).
a ypical or glaucoma and a normal-appearing Uvei ic glaucoma is also more common in
op ic nerve head. T is is because many ypes cases o granuloma ous han nongranuloma-
o uvei is, par icularly hose a ec ing he pos- ous uvei is. When all causes o uvei is are con-
erior segmen , are charac erized by choriore - sidered, he prevalence o glaucoma secondary
inal and op ic nerve lesions ha can produce o uvei is in adul s is es ima ed be ween 5.2%
visual eld de ec s ha do no represen glau- and 19%.6 T e overall prevalence o glaucoma
coma. T is dis inc ion is impor an , because in children wi h uvei is is similar o adul s,
he visual eld de ec s in pa ien s wi h ac ive ranging rom 5% o 13.5%; however, he
inf amma ory disease may resolve or improve repor ed visual prognosis or children wi h
wi h appropria e herapy, whereas rue glau- uvei ic glaucoma is worse.6,7
coma ous visual eld de ec s in pa ien s wi h
uvei is are irreversible.
ETIOLO GY
EPIDEMIOLOGY
T he in raocular pressure depends on he
balance o aqueous secre ion and aque-
con rolled medically is suspec ed in a pa ien ocular hyper ension is suspec ed in a pa ien
who main ains ac ive in raocular inf amma- wi h con rolled or quiescen uvei is, a reduc-
ion requiring sys emic cor icos eroids, his ion in he concen ra ion, dose, or re-
may be an indica ion or he ini ia ion o quency o he cor icos eroid used should be
a s eroid-sparing agen . I s eroid-induced at emp ed.
FIGU E 14-1. Periocular steroid injection in a steroid responder. Periocular s eroid injec ions, use ul in
rea ing bo h an erior and pos erior uvei is, can some imes induce a severe eleva ion in he in raocular pressure
in pa ien s wi h ocular hyper ension and known s eroid responders. T e an eriorly placed s eroid depo in his
16 year old pa ien wi h presumed sarcoidosis was removed when medical herapy ailed o con rol his eleva ed
in raocular pressure. Subsequen ly, his pressures normalized.
214 14 UVEITIC GLAUCO MAS
FIGU E 14-2. HLA B27–associated anterior uveitis. Bo h pos erior synechiae and a broad area o peripheral
an erior synechiae obli era ing he an erior chamber angle and ex ending on o he cornea superior are
seen in his pa ien wi h HLA B27 associa ed an erior uvei is ollowing a severe exacerba ion o in raocular
inf amma ion.
216 14 UVEITIC GLAUCO MAS
A B
FIGU E 14-3. Neovascular glaucoma. T is pa ien wi h granuloma ous panuvei is developed in rac able
neovascular glaucoma, one o he mos severe complica ions o uvei is. No e he di use, mut on a kera ic
precipi a es and iris bombé (A) and he neovasculariza ion in he broad peripheral an erior synechiae (B).
FIGU E 14-4. Posterior synechiae causing pupillar y block and iris bombé. T is pa ien wi h Vog
Koyanagi Harada syndrome presen ed wi h an erior segmen inf amma ion and increased in raocular pressure
as a resul o pos erior synechiae causing pupillary block wi h iris bombé. T e uvei is was managed wi h opical
and sys emic cor icos eroids, and he eleva ed in raocular pressure normalized ollowing a laser irido omy.
Diagnosis 217
A B
FIGU E 14-5. Sarcoidosis and active granulomatous panuveitis. A. T is pa ien wi h sarcoidosis presen ed
wi h an ac ive granuloma ous panuvei is, including Busacca nodules seen here in he iris s roma and secondary
glaucoma resul ing rom pos erior synechiae wi h pupillary block. Despi e managemen wi h opical and
sys emic cor icos eroids and opical an iglaucoma medica ions, his in raocular pressures were uncon rolled.
Examina ion o he op ic nerve head and visual eld es ing were consis en wi h glaucoma. B. wo mon hs
ollowing ube shun placemen or uvei ic glaucoma, he in raocular pressures were con rolled and he iris
nodules were resolved.
B
A
FIGU E 14-6. Multifocal choroiditis. T is pa ien wi h mul i ocal choroidi is demons ra es he need or
care ul examina ion o he op ic nerve or evidence o glaucoma in pa ien s wi h uvei is. Because o he ex ensive
pos erior pole lesions, visual eld es ing did no reliably demons ra e he developmen o glaucoma in he le
eye, evidenced by he progressive cupping o he op ic disc. A. Righ eye. B. Le eye.
Management 219
is because he induced miosis caused by hese more e ec ive han laser irido omy, he pro-
agen s may po en ia e orma ion o pos e- cedure can lead o severe surgically induced
rior synechiae, aggrava e ciliary body muscle pos opera ive inf amma ion ha may be
spasm, and con ribu e o a prolonga ion o he blun ed by he use o aggressive preopera ive
ocular inf amma ory response by enhancing and pos opera ive an i-inf amma ory herapy;
he breakdown o he blood–aqueous barrier. in ravenous cor icos eroids a he ime o he
procedure may also be bene cial. Compared
MANAGEMENT OF ANGLE- wi h a laser irido omy, a large-sec or surgical
iridec omy may delay ca arac progression.
CLOSURE GLAUCOMA
In uvei ic eyes in which he angle closure is
disc pa hology and because pa ien s wi h uve- required in he periopera ive period. For many
i is are rela ively young, here is a endency o pa ien s, we pre er a single in raopera ive dose
olera e hyper ension or longer periods and o 250 o 1,000 mg o in ravenous me hylpred-
o olera e higher levels o in raocular pressure nisolone, as a single pulse dose no requiring a
be ore using surgical in erven ion. However, gradual aper.
when he in raocular pressure remains uncon-
epor ed success ra es or rabeculec omy
rolled in pa ien s receiving maximal medical
in pa ien s wi h uvei is glaucoma range rom
herapy or here is evidence o op ic nerve
62% o 81%.27,17 However, depending o some
injury or visual eld de ec s, surgical in er-
ex en on he ollow-up in erval, he rue sig-
ven ion o con rol he in raocular pressure is
ni cance o such ndings is no en irely clear.
required.
In rabeculec omy cases per ormed in pa ien s
Surgical procedures per ormed in pa ien s wi h uvei is, he pos opera ive inf amma-
wi h uvei ic glaucoma include rabeculec- ory response is believed o accelera e he
omy wi h and wi hou he use o an ime ab- wound-healing process and cause ailure o
oli es and ube shun procedures such as he he l ering procedure.28 T e ou come o ra-
Ahmed, Baerveld , and Mol eno implan s5,6,25 beculec omies in pa ien s wi h uvei is may
(Fig. 14-8). T e bes surgical procedure or be improved by he use o aggressive periop-
pa ien s wi h uvei ic glaucoma has no been era ive an i-inf amma ory herapy and an i-
es ablished. me aboli es such as mi omycin C, which is
avored over 5-f uorouracil.6 T e higher suc-
All surgical procedures per ormed on pa ien s
cess ra es o l ering surgery wi h he use o
wi h uvei is carry he risk o a pos opera ive
wound-modula ing agen s, however, is associ-
f are, which ypically occurs in he rs pos -
a ed wi h an eleva ed risk or hypo ony, bleb
opera ive week. Pos opera ive inf amma ion
leaks, and endoph halmi is, which has been
or reac iva ion o uvei is has been repor ed
repor ed in up o 9.4% o eyes ollowing rab-
o occur in 5.2% o 31.1% cases o uvei ic
eculec omy.29 Ca arac progression is also very
glaucoma rea ed surgically.26 T e risk o a
common a er l ra ion surgery or uvei ic
pos opera ive f are is decreased in eyes ha
glaucoma.
are quiescen prior o he surgical procedure.
For elec ive surgeries, we require ha he eyes Implan drainage procedures have also been
remain quie or a leas 3 mon hs prior o he used or he rea men o uvei ic glaucoma,
opera ive procedure. o help o decrease he mos commonly in pa ien s who have ailed
risk o a pos opera ive f are, approxima ely previous l ering procedures.6,25 T ey have
1 week prior o he planned surgery day, he been repor ed o be more success ul han a
pa ien ’s opical or sys emic immunosuppres- repea rabeculec omy in pa ien s wi h uve-
sive regimen, or bo h, is increased and apered i is.27 Glaucoma drainage devices are also used
pos opera ively according o inf amma ory as a primary rea men or uvei ic glaucoma
response. In raopera ively, periocular, in raoc- wi h increasing requency, and ur her s udy is
ular, and/ or in ravenous s eroids are rou inely needed o de ni ively compare his approach
given. For emergen glaucoma procedures wi h rabeculec omy.17 Pos opera ive compli-
in pa ien s wi h ac ive disease, an exacerba- ca ions such as choroidal e usion, choroidal
ion o he exis ing inf amma ion should be hemorrhage, and shallow an erior chambers
expec ed; here ore, aggressive opical herapy may be grea er in eyes wi h uvei ic glaucoma
and he use o high-dose oral (0.5 o 1.5 mg/ as compared wi h eyes wi h primary open-
kg/ day) or in ravenous cor icos eroids may be angle glaucoma (Fig. 14-9).
Management o Angle-closure Glaucoma 223
Nonpene ra ing glaucoma surgery may also 7. Kanski JJ, Shun-Shin GA. Sys emic uvei is syn-
have a role in he surgical managemen o uve- dromes in childhood: An analysis o 340 cases.
Ophthalmology. 1984;91:1247–1252.
i ic glaucoma, hough i is no an op ion in eyes 8. Johnson DH. Human rabecular meshwork cell
wi h ex ensive an erior synechiae obs ruc ing survival is dependen on per usion ra e. Invest
he rabecular meshwork. Viscocanalos omy Ophthalmol Vis Sci. 1996;37(6):1204–1208.
has been shown o be e ec ive in pa ien s wi h 9. Ellio . A reatise on Glaucoma. London: Ox ord
open-angle glaucoma wi h a lower ra e o com- Medical Publica ions; 1918.
10. Pere z WL, omasi B. Aqueous humor pro eins in
plica ions han rabeculec omy. A small series uvei is. Immunoelec rophore ic and gel di usion
has repor ed success ul in raocular pressure s udies on normal and pa hological human aqueous
con rol using nonpene ra ing surgery in eyes humor. Arch Ophthalmol. 1961;65:20–23.
wi h uvei ic glaucoma. However, addi ional 11. Bei ch B , Easkins KE. T e e ec s o pros aglan-
s udy is needed o valida e he sa e y and dins on he in raocular pressure o he rabbi . Br J
Pharmacol. 1969;37:158–167.
e cacy o nonpene ra ing surgery in uvei ic 12. Bhat acherjee P. T e role o arachidona e me abo-
glaucoma.17 li es in ocular inf amma ion. Prog Clin Biol Res.
1989;312:211–227.
Ciliary body des ruc ive procedures should be 13. Jones 3rd, hee DJ. Cor icos eroid-induced ocu-
considered as a las resor or he rea men o lar hyper ension and glaucoma: a brie review and
uvei ic glaucoma in which in raocular pressure upda e o he li era ure. Curr Opin Ophthalmol. 2006;
is no amenable o any o her medical or surgi- 17:163–167.
cal glaucoma rea men . Cyclocryo herapy and 14. Weinreb N, Mi chell MD, Polansky J . Pros aglandin
produc ion by human rabecular cells: In vi ro inhibi-
con ac and noncon ac laser cycloabla ion ion by dexame hasone. Invest Ophthalmol Vis Sci.
procedures are generally similar in heir abili y 1983;24:1541–1545.
o success ully lower he in raocular pressures. 15. Golds ein DA, God rey DG, Hall A, e al. In raocular
T e primary disadvan age o cycloabla ive rea - pressure in pa ien s wi h uvei is rea ed wi h f uo-
men s is he induc ion o a severe in raocular cinolone ace onide implan s. Arch Ophthalmol. 2007;
125:1478–1485.
inf amma ory response and he developmen 16. Malone P, Herndon LW, Muir KW, e al. Combined
o ph hisis bulbi in abou 10% o rea ed eyes.30 f uocinolone ace onide in ravi real inser ion and
glaucoma drainage device placemen or chronic
uvei is and glaucoma. Am J Ophthalmol. 2010;
EFE ENCES 149:800–806.
1. London NJS, a hinam S , Cunningham E . T e 17. Kuch ey W, Lowder CY, Smi h SD. Glaucoma
epidemiology o uvei is in developing coun ries. Int in pa ien s wi h ocular inf amma ory disease.
Ophthalmol Clin. 2010;50(2):1–17. Ophthalmol Clin North Am. 2005;18:421–430.
2. Gri z DC, Wong IG. Incidence and prevalence o uve- 18. Fos er CS, Davanzo , Flynn E, e al. Durezol
i is in nor hern Cali ornia: T e nor hern Cali ornia (dif upredna e oph halmic emulsion 0.05%) com-
epidemiology o uvei is s udy. Ophthalmology. pared wi h Pred For e 1% oph halmic suspension in
2004;111:491–500. he rea men o endogenous an erior uvei is. J Ocul
3. Darrell W, Wagener HP, Kurland L . Epidemiology Pharmacol T er. 2010;26(5):475–483.
o uvei is: Incidence and prevalence in a small urban 19. Jabs DA, osenbaum J , Fos er CS, e al. Guidelines or
communi y. Arch Ophthalmol. 1962;68:502–514. he use o immunosuppressive drugs in pa ien s wi h
4. Cunningham E Jr. Uvei is in children. Ocul Immunol ocular inf amma ory disorders: ecommenda ions
Inf amm. 2000;8:251–261. o an exper panel. Am J Ophthalmol. 2000;
5. ran V , Mermoud A, Herbor CP. Appraisal and 130:492–513.
managemen o ocular hypo ony and glaucoma asso- 20. Larkin G, Ligh man S. Mycophenola e mo e il. A use-
cia ed wi h uvei is. Int Ophthalmol Clin. 2000; ul immunosuppressive in inf amma ory eye disease.
40:175–203. Ophthalmology. 1999;106:370–374.
6. Moor hy S, Mermoud A, Baerveld G, e al. 21. Heiligenhaus A, T urau S, Hennig M, e al. An i-
Glaucoma associa ed wi h uvei is. Surv Ophthalmol. inf amma ory rea men o uvei is wi h biological:
1997;41:361–394. New rea men op ions ha ref ec pa hogene ic
224 14 UVEITIC GLAUCO MAS
knowledge o he disease. Grae es Arch Clin Exp 26. Pra a JA Jr, Neves R , Minckler DS, e al.
Ophthalmol. 2010;248:1531–1551. rabeculec omy wi h mi omycin C in glaucoma associ-
22. Akingbehin , Villada J . Me ipranolol-associa ed a ed wi h uvei is. Ophthalmic Surg. 1994;25:616–620.
granuloma ous an erior uvei is. Br J Ophthalmol. 27. Hill R , Nguyen QH, Baerveld G, e al.
1991;75:519–523. rabeculec omy and Mol eno implan a ion or glau-
23. Whi cup SM, Csaky KG, Podgor MJ, e al. A ran- comas associa ed wi h uvei is. Ophthalmology. 1993;
domized, masked, cross-over rial o ace azolamide 100:903–908.
or cys oid macular edema in pa ien s wi h uvei is. 28. Sku a GL, Parrish K 2nd. Wound healing in glaucoma
Ophthalmology. 1996;103:1054–1062. l ering surgery. Surv Ophthalmol. 1987;32:149–170.
24. Warwar E, Bullock JD, Ballal D. Cys oid macu- 29. Wolner B, Liebmann JM, Sassani JW, e al. La e
lar edema and an erior uvei is associa ed wi h bleb-rela ed endoph halmi is a er rabeculec omy
la anopros use. Experience and incidence in a re - wi h adjunc ive 5-f uorouracil. Ophthalmology.
rospec ive review o 94 pa ien s. Ophthalmology. 1991;98:1053–1060.
1998;105:263–268. 30. Schuman JS, Bellows A , Shingle on BJ, e al.
25. Da Ma a A, Burk SE, Ne land PA, e al. Managemen Con ac ransscleral Nd:YAG laser cyclopho oco-
o uvei ic glaucoma wi h Ahmed glaucoma valve agula ion. Mid erm resul s. Ophthalmology. 1992;
implan a ion. Ophthalmology. 1999;106:2168–2172. 99:1089–1094.
Management o Angle-closure Glaucoma 225
FIGU E 14-7. ecurrent iris bombé. T is pa ien presen ed wi h acu e eye pain and increased in raocular
pressure rom recurren iris bombé when he previous laser irido omy si e closed during a uvei ic f are associa ed
wi h he apering o her sys emic immunosuppression.
A B
FIGU E 14-8. Bilateral Baerveldt implants in patient with JR . T is 16 year old emale pa ien developed
bila eral an erior uvei is a he age o 3 years ha has been well managed wi h a combina ion o opical and
sys emic an i inf amma ory herapy. Because o uncon rolled in raocular pressure, she underwen bila eral
Baerveld implan s as a primary glaucoma procedure wi h excellen resul s. A. Righ eye showing he implan
ube in he an erior chamber. B. Righ eye looking down and nasally, revealing he conjunc ival bleb over he
implan .
226 14 UVEITIC GLAUCO MAS
A B
FIGU E 14-9. Complications of glaucoma surger y in uveitis patient. Hypo ony wi h choroidal e usion and
a shallow an erior chamber A, di use illumina ion; B, sli beam is a common complica ion o implan drainage
procedures in pa ien s wi h uvei is.
Specifc Entities 227
HISTORY
SPECIFIC
SP
P E CII FIC E
ENN I IES
I ES
S
Pa ien s wi h his condi ion are ypically
FUCHS’ HETEROCHROMIC asymp oma ic, al hough some pa ien s may
IRIDOCYCLITIS have mild ocular discom or and blurred
A B
FIGU E 14-10. Fuchs’ heterochromic iridocyclitis. A. Fuchs’ he erochromic iridocycli is is a unila eral,
nongranuloma ous an erior uvei is commonly charac erized by he riad o he erochromia, ca arac , and
glaucoma in he a ec ed eye. Pa ien s wi h his condi ion charac eris ically show s ella e kera ic precipi a es
dis ribu ed over he en ire corneal endo helium. B. T e iris he erochromia and ca arac in he le eye are a resul
o he chronic unila eral inf amma ion in he le eye.
230 14 UVEITIC GLAUCO MAS
GLAUCO
G LAUU C O MAM A O C YCLI
YCC LII IC
IC HISTORY
CRISIS
C RISII S ( P
POSN
O SN E
ER–
R– Pa ien s have a his ory o recurring symp-
SCH
S CH L
LOSSMAN
O SS SM ANNS SYN
YN
N DRO
DRR O ME)
MEE) oms o mild ocular pain or discom or and
blurred vision wi hou ocular injec ion.
o in raocular inf amma ion, ypically measur- o lower he in raocular pressure. Mydria ic
ing grea er han 30 mm Hg, o en in he 40 o and cycloplegic agen s are no commonly
60 mm Hg range. needed as ciliary muscle spasm is uncommon
T e undus examina ion is ypically and synechiae rarely orm. Oral indome ha-
normal. cin, 75 o 150 mg daily—a pros aglandin
an agonis —has been repor ed o lower he
Laboratory Studies in raocular pressure in pa ien s wi h glau-
Glaucoma ocycli ic crisis is a clinical diag- coma ocycli ic crises as er han s andard
nosis, and here are no labora ory s udies ha an iglaucoma medica ions.4 opical nons e-
are speci c or he diagnosis. roidal an i-inf amma ory medica ions migh
likewise be an e ec ive rea men op ion or
pa ien s wi h ocular hyper ension, bu evi-
COURSE dence is lacking o suppor his.
Mio ics and argon laser rabeculoplas y
Posner–Schlossman syndrome is a sel -
are generally no e ec ive. Be ween at acks,
limi ed ocular hyper ension ha resolves
prophylac ic an i-inf amma ory herapy is no
spon aneously regardless o rea men .
required.
T e recurren inf amma ory at acks end
Surgical l ra ion procedures are rarely
o occur a in ervals o a ew mon hs o years
required and, i per ormed, do no preven
and may las rom several hours o a ew
he recurren inf amma ory at acks.
weeks be ore spon aneously resolving.
T e developmen o op ic nerve damage
EFE ENCES
and visual eld de ec s in glaucoma ocycli ic
1. Moor hy S, Mermoud A, Baerveld G, e al.
crisis may occur as a resul o he repea ed Glaucoma associa ed wi h uvei is. Surv Ophthalmol.
bou s o ex remely eleva ed in raocular pres- 1997;41:361–394.
sure superimposed on an underlying primary 2. Chee SP, Bacsal K, Jap A, e al. Clinical ea ures o cy o-
open-angle glaucoma.5 megalovirus an erior uvei is in immunocompe en
pa ien s. Am J Ophthalmol. 2008;145(5):834–840.
3. Yamamo o S, Pavan-Langs on D, ada , e al.
MANAGEMENT Possible role o herpes simplex virus in he origin o
Posner-Schlossman syndrome. Am J Ophthalmol.
1995;119(6):796–798.
Posner–Schlossman syndrome is rea ed
4. Masuda K, Izawa Y, Mishima SS. Pros aglandins
ini ially wi h opical cor icos eroids o con rol and glaucoma o-cycli is crisis. Jpn J Ophthalmol.
he an erior uvei is. 1975;19:368.
I he in raocular pressure does no 5. Kass MA, Becker B, Kolker AE. Glaucoma ocycli ic
crisis and primary open-angle glaucoma. Am J
respond o opical an i-inf amma ory herapy, Ophthalmol. 1973;75:668–673.
an iglaucoma medica ions may be required
232 14 UVEITIC GLAUCO MAS
HEERPE
R P E IIC
C ETIOLO GY
KERA
K ERA O U UVEI
VEI IS
S I remains unclear whe her he uvei is
associa ed wi h herpes simplex kera i is is
I n he eye, in ec ion wi h he HSV can mani-
es as several dis inc , recurren , unila eral
ocular diseases such as blepharoconjunc ivi is,
a secondary inf amma ory response o he
corneal disease or whe her i is induced by
invasion o he virus in o he an erior uvea.
epi helial kera i is, s romal kera i is, and uve- T e eleva ed in raocular pressure in herpes
i is. Al hough ocular involvemen may occur simplex and herpes zos er uvei is is he resul
wi h primary herpes zos er in ec ion (chicken- o normal aqueous secre ion in eyes wi h
pox), i more commonly accompanies herpes impaired ou f ow resul ing rom rabecu-
zos er oph halmicus, a reac iva ion o herpes li is, direc inf amma ion o he rabecular
zos er in older adul s a ec ing he dis ribu ion meshwork. In herpes zos er uvei is, ischemia
o he oph halmic branch o cranial nerve V. resul ing rom an occlusive vasculi is may also
Uvei is associa ed wi h bo h HSV and herpes con ribu e o he increased in raocular pres-
zos er in ec ions ypically ollows previous sure.6 HSV has been cul ured rom he an e-
episodes o kera i is and accoun s or abou rior chamber o pa ien s wi h herpe ic uvei is,
5% o all uvei is cases seen in adul s.1 Eleva ed and i s presence is posi ively correla ed wi h
in raocular pressure ha can progress o a sec- ocular hyper ension.
ondary glaucoma is a prominen ea ure o
recurren herpe ic uvei is. Prolonged s eroid use may also con ribu e
o ocular pressure in pa ien s wi h herpe ic
uvei is.
EPIDEMIOLOGY
HISTORY
Approxima ely 0.15% o he Uni ed S a es
popula ion has a his ory o ex ernal HSV Pa ien s wi h herpe ic uvei is ypically
in ec ion.2 presen wi h a complain o unila eral ocu-
S romal kera i is and uvei is, which oge her lar redness, pain, pho ophobia, and, o en,
accoun or he grea es visual morbidi y rom decreased vision.
all orms o recurren herpes simplex ocular A prior his ory o recurren kera i is is
disease, develop in ewer han 10% o pa ien s commonly given.
wi h primary ocular herpes simplex in ec ion.1
Pa ien s wi h uvei is rela ed o herpes zos-
T e incidence o herpes zos er has been er are generally older and repor a his ory o
increasing, and ocular involvemen occurs herpes zos er oph halmicus. Ocular disease
in wo- hirds o all cases o herpes zos er rela ed o HSV is rarely bila eral, whereas
oph halmicus.3 Uvei is and ocular hyper en- herpes zos er oph halmicus only occurs
sion in pa ien s wi h zos er may be associa ed unila erally.
wi h ei her epi helial or s romal kera i is. T e
incidence o increased in raocular pressure in
pa ien s wi h herpe ic uvei is varies rom 28% DIFFERENTIAL DIAGNOSIS
o 40%.4
T e di eren ial diagnosis or herpe ic
T e incidence o secondary glaucoma
uvei is includes Fuchs’ he erochromic iri-
in pa ien s wi h herpes simplex uvei is and
docycli is, glaucoma ocycli ic crisis, and
herpes zos er uvei is is abou 10% and 16%,
sarcoidosis.
respec ively.4,5
Herpetic Keratouveitis 233
A B
FIGU E 14-11. Herpetic uveitis due to herpes simplex. In pa ien s presen ing wi h unila eral an erior uvei is
and eleva ed in raocular pressure, assessmen o corneal sensa ion and ransillumina ion o he pupil are help ul
in making a clinical diagnosis o herpe ic uvei is. Di use illumina ion o he iris (A) does no reveal he pa chy
a rophy o he iris s oma seen on ransillumina ion (B). A er he pa ien s ar ed oral acyclovir, he was able o
discon inue opical an iglaucoma herapy.
Syphilitic Interstitial Keratitis 235
JJUVEN
UVVE N ILE
I L E IDIO
O PA
PA H IC
C ETIOLO GY
AR
A R H RI
R I IS T e developmen o increased in raocular
pressure and glaucoma in pa ien s wi h JIA is
J uvenile idiopa hic ar hri is ( JIA), or-
merly known in he Uni ed S a es as juve-
nile rheuma oid ar hri is, is a common cause
mos o en caused by progressive angle clo-
sure as a resul o synechiae.
o pedia ric uvei is o en complica ed by Open-angle glaucoma also occurs and may
increased in raocular pressure and glaucoma. be he resul o chronic inf amma ory dam-
T ree sub ypes o JIA wi h di eren risks or age o he rabecular meshwork or s eroid-
he developmen o uvei is can be diagnosed induced glaucoma resul ing rom prolonged
based on he ex en o ar icular and sys emic opical s eroid rea men .
involvemen wi hin he rs 3 mon hs o pre-
sen a ion. Sys emic-onse JIA, or S ill’s dis- HISTORY
ease, is commonly seen in boys younger han
4 years o age and is an acu e sys emic disease Al hough ar hri is develops rs in he
consis ing o a cu aneous rash, ever, poly- majori y o cases, JIA-associa ed uvei is may
ar hri is, hepa osplenomegaly, leukocy osis, be he presen ing sign.
and polyserosi is. Young girls more commonly Because he an erior uvei is associa ed wi h
presen wi h he oligoar icular ( ewer han ve JIA is mild, asymp oma ic, and rarely causes
join s, also known as pauciar icular) and poly- ocular redness, he disease may go unno iced
ar icular ( ve or more join s) orms o JIA ha or a long period o ime un il visual loss, ca a-
lack he sys emic ea ures. rac , or an irregular pupil is no ed.
T e uvei is in pa ien s wi h JIA is bila eral
EPIDEMIOLOGY in almos all cases.
Kera ic precipi a es are generally dis rib- O en, periocular s eroid injec ions and
u ed over he in erior hal o he cornea. even sys emic s eroids are necessary o con-
Mio ic pupils resul ing rom pos erior rol an erior uvei is. Oral nons eroidal agen s
synechiae or pupillary membranes, iris are also used in JIA pa ien s. Me ho rexa e
bombé, and peripheral an erior synechiae are alone or in combina ion wi h o her immu-
requen ndings in a ec ed pa ien s ha can nosuppressive agen s such as prednisone or
con ribu e o he developmen o glaucoma. cyclosporine has been used o rea he ocular
and join mani es a ions o JIA. Newer bio-
An erior and pos erior subcapsular ca a-
logic agen s such as inf iximab ( emicade),
rac s are presen in up o one- hird o a ec ed
adalimumab (Humira), and aba acep
pa ien s. Pos erior segmen examina ion in
(Orencia), shown o be o bene or he join
pa ien s wi h JIA may show papilli is and cys-
disease in JIA, are curren ly being evalua ed
oid macular edema, which can con ribu e o
or heir e cacy in he rea men o uvei is in
visual loss.
hese pa ien s.
Laboratory Studies Eleva ed in raocular pressure in JIA
Up o 80% o pa ien s wi h an erior uvei is is rea ed ini ially wi h an iglaucoma
and JIA are an inuclear an ibody posi ive and medica ions. Medical managemen is
rheuma oid ac or nega ive. ini ially e ec ive in only abou 50% o JIA
pa ien s, wi h only 30% o pa ien s being
con rolled medically over he long erm.4
COURSE
Laser irido omy or surgical iridec omy
T e uvei is associa ed wi h JIA is a chronic may be necessary o relieve he pupillary
disease ha is di cul o con rol despi e block in pa ien s wi h pos erior synechiae.
rea men . Surgical managemen is required
In pa ien s wi h JIA, here is no direc or pa ien s who are unresponsive o
correla ion be ween he ac ivi y o he ocular medical herapy. o increase he likelihood
disease and he join disease. o a good ou come, i possible, surgical
in erven ion should be de erred un il he
T e incidence o secondary complica-
in raocular inf amma ion has been ade
ions, such as band kera opa hy, ca arac , and
qua ely con rolled or a period o a leas
glaucoma, increases wi h he dura ion o he
3 mon hs.
disease.
Opera ive procedures mos commonly
T e prognosis or children wi h uvei ic glau-
used in children wi h JIA include
coma, previously considered poor, is improv-
rabeculec omy and ube shun s (see
ing wi h more e ec ive surgical managemen .
Fig. 14-8).
Improved success has been repor ed wi h
MANAGEMENT he use o an ime aboli es in pa ien s under-
going rabeculec omy.1
T e ini ial rea men approach or he
managemen o in raocular inf amma ion in rabeculodialysis in a small case series has
pa ien s wi h JIA includes opical cor icos e- been shown o be sa e and e ec ive or con-
roids and cycloplegic agen s o preven he rolling he pressure in pa ien s wi h JIA or
orma ion o synechiae. up o 2 years.5
Juvenile Idiopathic Arthritis 239
In phacoan igenic uvei is, here is a commonly reveals conjunc ival injec ion and
granuloma ous inf amma ory response ciliary f ush. T ere may also be ex ernal evi-
o he elabora ed lens pro eins ha can dence o a prior ocular injury.
induce he orma ion o synechiae and I he pressure is signi can ly eleva ed, he
blockage o he rabecular meshwork. cornea is o en edema ous.
In phacoly ic glaucoma, he released T e an erior chamber ypically con-
lens pro eins and macrophages engorged ains an erior chamber cells and f are, wi h
wi h lens pro eins obs ruc he rabecular granuloma ous or nongranuloma ous kera ic
meshwork, whereas in lens par icle glau- precipi a es. Whi e, f occulen ma erial and
coma, i is he ac ual ragmen s o lens cor- ragmen s o lens cor ex may be seen circula -
ical ma erial ha are believed o injure he ing wi hin he aqueous and in he an erior
rabecular meshwork. chamber angle, which may be open, nar-
Unlike he o her lens-induced glaucomas, rowed, or closed. Peripheral an erior and pos-
in which he an erior chamber angle is ypi- erior synechiae are no uncommon.
cally open, in phacomorphic glaucoma he In cases o phacoan igenic uvei is and
in umescen lens can cause pupillary block lens par icle glaucoma, evidence o injury o
or disloca e he iris orward, resul ing in a he na ive lens or re ained lens ma erial can
shallowed an erior chamber or acu e angle usually be ound. In cases o phacoly ic and
closure. In pseudophakic eyes, in raocular phacomorphic glaucoma, examina ion reveals
inf amma ion may be he resul o a preexis - a hyperma ure or in umescen ca arac ,
ing uvei is, a delayed-onse pos surgical endo- respec ively, and in cases o pseudophakic
ph halmi is, or irri a ion o he uveal issue inf amma ory glaucoma, an in raocular lens is
by he in raocular lens. Glaucoma may arise presen .
because o damage o he rabecular mesh-
Pos erior segmen examina ion may show
work or orma ion o synechiae on he lens
vi reous cells and haze, lens ma erial in he
implan , causing pupillary block, and periph-
vi reous cavi y, and o her ndings rela ed o
eral an erior synechiae orma ion, resul ing in
he ocular injury.
angle closure.
Laboratory Studies
DIFFERENTIAL DIAGNOSIS T e diagnosis o lens-induced uvei is and
glaucoma is clinical and does no rely on labo-
T e main di eren ial diagnoses or phaco- ra ory es ing.
an igenic and lens par icle glaucoma are pos - His opa hologic examina ion o he lens in
rauma ic and pos surgical endoph halmi is. pa ien s wi h phacoan igenic uvei is reveals a
O her causes o acu e angle closure should zonal granuloma ous inf amma ion cen ered
be considered in pa ien s wi h phacomorphic a he si e o lens injury.
glaucoma.
COURSE
DIAGNOSTIC EVALUATION
T e clinical course o he lens-induced
Ophthalmic Examination glaucomas ends o be rela ively brie because
Ex ernal examina ion o pa ien s wi h hey are e ec ively managed wi h surgical
acu e lens-induced uvei is and glaucoma in erven ion.
242 14 UVEITIC GLAUCO MAS
S arcoidosis is a sys emic disease charac- An erior segmen neovasculariza ion and
erized by noncasea ing, granuloma ous, he prolonged use o s eroids can also con-
inf amma ory in l ra es a ec ing he lungs, ribu e o he impairmen o aqueous ou f ow.
skin, liver, spleen, cen ral nervous sys em,
and eyes. Ocular disease occurs in 10% o HISTORY
38% o pa ien s wi h sys emic sarcoidosis.3
Sarcoidosis, which can presen as an erior, Mos adul pa ien s wi h sarcoidosis
in ermedia e, pos erior, or panuvei is, is he presen wi h pulmonary involvemen ha
pro o ype or a chronic, granuloma ous uvei is. may mani es as cough, shor ness o brea h,
wheezing, or dyspnea on exer ion.
Ano her common presen a ion o sarcoid-
EPIDEMIOLOGY osis is wi h generalized symp oms such as
ever, a igue, and weigh loss.
Sarcoidosis is 8 o 10 imes more requen
among A rican Americans han whi es, having Many pa ien s are asymp oma ic a he
an es ima ed prevalence o 82 per 100,000 in ime o diagnosis.
his popula ion.1 Pa ien s wi h ocular involvemen ypically
Al hough sarcoidosis can develop a any presen wi h complain s o ocular pain, red-
age, he disease is ypically diagnosed in adul s ness, pho ophobia, f oa ers, and blurred or
be ween 20 and 50 years o age. Sarcoidosis decreased vision.
accoun s or 5% o all uvei is cases in adul s
bu abou 1% o uvei is cases in children.2 DIFFERENTIAL DIAGNOSIS
Sarcoidosis involves he an erior segmen
in up o 70% o cases wi h ocular involve- T e di eren ial diagnosis o sarcoidosis
men , whereas he pos erior segmen is includes he o her causes o granuloma ous
a ec ed in less han 33% o cases.3 panuvei is such as he Vog –Koyanagi–
Secondary glaucoma occurs in approxi- Harada syndrome, sympa he ic oph halmia,
ma ely 11% o 25% o all pa ien s wi h and uberculosis.
sarcoidosis and is more commonly a compli- Syphilis, Lyme disease, primary in raocu-
ca ion o he an erior segmen disease.4 lar lymphoma, and pars plani is should also
A rican-American pa ien s wi h sarcoid- be considered.
osis have a higher incidence o uvei ic glau-
coma and blindness. DIAGNOSTIC EVALUATION
Ophthalmic Examination
ETIOLO GY
T e ocular disease o sarcoidosis is ypi-
Ocular hyper ension and glaucoma cally bila eral, al hough i may be unila eral or
in pa ien s wi h sarcoidosis resul s rom very asymme ric.
obs ruc ion o he rabecular meshwork by Mos requen ly a cause o granuloma ous
he chronic granuloma ous inf amma ion uvei is, sarcoidosis may also cause a nongran-
and angle closure caused by he orma ion o uloma ous uvei is.
244 14 UVEITIC GLAUCO MAS
Oph halmic ndings in he an erior seg- uberculosis and ungal in ec ions, have been
men include orbi al and cu aneous granulo- excluded.
mas, enlarged lacrimal glands, and palpebral An ini ial diagnos ic evalua ion or sar-
and bulbar conjunc ival nodules. coidosis should include a ches x-ray and
T e cornea mos commonly shows serum angio ensin-conver ing enzyme (ACE)
large, mut on a kera ic precipi a es, wi h level. Serum lysozyme levels may also be
nummular corneal in l ra es and in erior eleva ed in pa ien s wi h sarcoidosis; his es
areas o endo helial opaci ca ion being may have a bet er combina ion o sensi ivi y,
no ed less requen ly. speci ci y, posi ive predic ive value, and nega-
Pos erior and peripheral an erior syn- ive predic ive value han ACE level.5
echiae, when ex ensive, resul in eleva ed Addi ional s udies ha may be use ul in
in raocular pressure or secondary uvei ic con rming he diagnosis include anergy es -
glaucoma caused by angle closure or iris ing, pulmonary unc ion es ing, gallium scan,
bombé. compu ed omographic scan o he horax,
Koeppe and Busacca- ype iris nodules bronchoalveolar lavage, and ransbronchial
are o en seen in he more severe cases o biopsy.
an erior segmen disease (see Fig. 14-5). Because ACE levels may be high in normal
Pos erior segmen involvemen in sarcoid- children, serum ACE level is a less use ul
osis occurs less requen ly han an erior seg- diagnos ic es or sarcoidosis in children.
men disease. Eleva ed ACE levels have been repor ed in
he aqueous humor and cerebrospinal f uids
T e vi reous requen ly shows a vi ri-
o pa ien s wi h ocular and cen ral nervous
is wi h vi reous snowballs and in erior
sys em sarcoid uvei is and neurosarcoidosis,
inf amma ory debris.
respec ively.
Examina ion o he pos erior pole
may reveal a varie y o ndings, including
COURSE
peripheral re inal vasculi is, peripheral exu-
da es similar o snowbanks, hemorrhages,
T e clinical course o ocular sarcoidosis
re inal exuda es, and perivascular nodular
can be acu e and sel -limi ed or chronic,
granuloma ous lesions, Dalen–Fuchs’ nod-
recurren , and relen less.
ules, and re inal, subre inal, or disc neo-
vasculariza ion. Granulomas in he re ina, T e chronic orm o sarcoid uvei is has
choroid, and op ic nerve may also be seen. he worse prognosis because o he onse o
complica ions such as glaucoma, ca arac , and
Visual loss in sarcoidosis is mos o en a
macular edema.
resul o cys oid macular edema, op ic neuri-
is caused by granuloma ous in l ra ion o he
op ic nerve, and secondary glaucoma. MANAGEMENT
Lens-associa ed Open-angle
Glaucomas
Michele C. Lim and Ashley G. Lesley
246
Lens Protein or Phacolytic Glaucoma 247
LEN
L ENSS PROO EIN
EII N O R History
PH
P H AC
ACO
C O LY
LY IC
CG GLAUCO
LA
AUCO
O MA
A Pa ien s repor gradually diminishing
vision rom he ma ure or hyperma ure ca a-
only be ob ained by removal o he ca arac . 4. Eps ein D, Jedziniak J, Gran W. Obs ruc ion o aque-
In developing coun ries, small-incision ex ra- ous ou ow by lens par icles and by heavy-molecular-
capsular ca arac surgery has been shown in a weigh soluble lens pro eins. Invest Ophthalmol Vis Sci.
1978;17(3):272–277.
case series o be a sa e and e ec ive me hod o
5. Rosenbaum J. Chemo ac ic ac ivi y o lens pro eins
surgical herapy wi h minimal morbidi y.7 and he pa hogenesis o phacoly ic glaucoma. Arch
Ophthalmol. 1987;105:1582.
6. Uemura A, Sameshima M, Nakao K. Complica ions
REFERENCES o hyperma ure ca arac : Spon aneous absorp ion
1. Hogan M, Zimmerman L. Ophthalmic Pathology: An o lens ma erial and phacoly ic glaucoma-associa ed
Atlas and Textbook. 2nd ed. Philadelphia, PA: WB re inal perivasculi is. Jpn J Ophthalmol. 1988;32(1):
Saunders; 1962:797. 35–40.
2. Irvine S, Irvine A. Lens-induced uvei is and glaucoma. 7. Venka esh R, an CS, Kumar , e al. Sa e y and
Am J Ophthalmol. 1952;35:489. e cacy o manual small incision ca arac surgery
3. Eps ein D, Jedziniak J, Gran W. Iden if ca ion o heavy- or phacoly ic glaucoma. Br J Ophthalmol. 2007;91:
molecular-weigh soluble pro ein in aqueous humor in 279–281.
human phacoly ic glaucoma. Invest Ophthalmol Vis Sci.
1978;17(5):398–402.
FIGURE 15-1. Mature cataract. Mature cataract with olds in the anterior capsule. Courtesy o Donald L.
Budenz, MD, Bascom Palmer Eye Institute, Miami, FL.
FIGURE 15-2. Lens protein glaucoma. Macrophages in the trabecular meshwork in lens protein glaucoma.
Courtesy o Donald L. Budenz, MD, Bascom Palmer Eye Institute, Miami, FL.
Lens Protein or Phacolytic Glaucoma 249
FIGURE 15-3. Lens protein glaucoma. Intense anterior chamber inf ammation with mature cataract in lens
protein glaucoma. Courtesy o Donald L. Budenz, MD, Bascom Palmer Eye Institute, Miami, FL.
250 15 LENS-ASSO CIATED O PEN-ANGLE GLAUCO MAS
FIGURE 15-4. Pseudoex oliation. Subluxed PCIOL in a patient with pseudoex oliation. T is patient
developed lens particle glaucoma as a result o released lens cortex a er the PCIOL dislocation.
FIGURE 15-5. Lens f ber. Lens ber recovered rom aqueous aspirate o the eye shown in Figure 15-4.
Lens associated Uveitis (Phacoanaphylaxis) 253
TREATMENT
FIGURE 15-6. LAU. Zonal granulomatous ormation in a patient with LAU. Courtesy o Donald L. Budenz,
MD, Bascom Palmer Eye Institute, Miami, FL.
FIGURE 15-7. LAU. Severe anterior chamber inf ammation, hypopyon, and corneal edema in a patient with
LAU. Courtesy o Donald L. Budenz, MD, Bascom Palmer Eye Institute, Miami, FL.
256 15 LENS-ASSO CIATED O PEN-ANGLE GLAUCO MAS
PH
HAACO
COMMOOR
RPH
P H IC
C CLINICAL EXAMINATION
GLAUCO
GL
L AU
U CO
O MA
MA T e crux o he problem is he ma ure or
hyperma ure ca arac causing a shallow an e-
P hacomorphic glaucoma resul s rom angle
closure secondary o a ma ure or hyper-
ma ure lens. I may be dis inguished rom he
rior chamber (Fig. 15-8). T e pupil may be
mid-dila ed wi h or wi hou iris bombé, and
gonioscopy reveals angle closure.
previous en i ies by he clinical appearance o
an in umescen lens, shallow an erior cham- T e IOP is high rom obs ruc ion o aque-
ber, and angle closure. ous ou ow, and as a resul he cornea may be
edema ous (Fig. 15-9).
PATHOPHYSIOLOGY TREATMENT
Phacomorphic glaucoma is a direc Medical herapy o suppress aqueous or-
sequela o a ma ure or hyperma ure lens ha ma ion is he f rs line o rea men . Mio ics
has become in umescen , causing crowd- may increase con ac be ween he lens and
ing o he an erior segmen s ruc ures.1 In iris and should no be used.1 Laser irido omy
he early s age, pupillary block may cause should be per ormed o allevia e any com-
high IOP. La er, he growing size o he lens ponen o pupillary block. Irido omy may
presses orward on he iris in he periphery, open up he angle, lower he IOP, and allow
blocking o ou ow hrough he rabecular he eye o quie be ore ca arac removal. I
meshwork. may also give he clinician an oppor uni y
Phacomorphic glaucoma is a common o examine he angle or peripheral an erior
condi ion in developing coun ries in which synechiae.4
ca arac surgery is delayed. T e degree o scarring in he angle
T e visual prognosis is poor, wi h may signal he need or glaucoma surgery
one s udy repor ing ha only 57% o 49 ei her a he ime o ca arac removal or in
pa ien s wi h phacomorphic glaucoma he u ure. One s udy ound a 20% ra e o
at ained visual acui y o 6/ 12 or bet er, glaucoma progression over 2 years indica -
al hough ano her s udy repor ed ha over ing ha hese pa ien s need o be ollowed
80% o pa ien s had some long- erm visual or long erm.3 T e def ni ive rea men or
improvemen and IOP normaliza ion a er phacomorphic glaucoma is removal o he
ca arac ex rac ion. Bet er visual ou come in umescen lens. One case series repor ed
appears o be rela ed o a shor er dura ion manual small-incision ca arac surgery as a
o eleva ed IOP.2,3 sa e and e ec ive rea men in developing
coun ries where his en i y is more common,
bu phacoemulsif ca ion has also proven an
HISTORY e ec ive echnique.5,6
Capsulorhexis in he set ing o a dense lens
Pa ien s have chronic or acu e decrease may be acili a ed by he use o indocyanine
in vision, ocular pain, headache, and green or rypan blue s aining o he an erior
pho ophobia.4 capsule.
Phacomorphic Glaucoma 257
FIGURE 15-8. Phacomorphic glaucoma. A hyperdense crystalline lens causing a shallow anterior chamber. T e
lens is dislocated in eriorly. Courtesy o Richard K. Lee, MD, PhD, Bascom Palmer Eye Institute, Miami, FL.
A B
FIGURE 15-9. Phacomorphic glaucoma. A. Slit lamp photograph o an eye with phacomorphic glaucoma.
Descemet’s olds rom an edematous cornea and darkly brunescent cataract are seen. B. Slit beam photograph o
the same eye shows the corneal swelling and narrow anterior chamber. Courtesy o Douglas J. Rhee, MD, Wills
Eye Hospital, Philadelphia, PA.
C H AP T ER
rauma ic Glaucoma
Angela V. Turalba and Mary Jude Cox
258
Traumatic Hyphema 259
body vessels. ears in he ciliary body resul chamber. When here is eleva ed in raocular
in damage o he major ar erial circle o he pressure associa ed wi h a large hyphema,
iris. Pene ra ing injuries can cause direc corneal blood s aining can occur (Fig. 16-6).
damage o blood vessels. Clo s plug hese T ere may be evidence o rauma o o her
damaged blood vessels and rebleeding ocular s ruc ures such as ca arac (Fig. 16-7A,
occurs as hese clo s re rac and lyse B), phacodonesis, subconjunc ival hemor-
(Fig. 16-2B). rhage, oreign bodies, lacera ions, or iris dam-
In raocular pressure rises acu ely as red age such as sphinc er ears, iridodialysis, or
blood cells, in amma ory cells, and debris rauma ic aniridia (Figs. 16-7A and 16-8).
obs ruc he rabecular meshwork (Fig. Gonioscopy: Gonioscopy should be
16-1C). Eleva ed in raocular pressure can delayed un il he risk o rebleeding has passed.
also be he resul o pupillary block caused by When per ormed 3 o 4 weeks af er he ini ial
he clo in he an erior chamber. Eigh -ball injury, he angle may appear undamaged or
hyphemas of en cause his orm o pupillary may show residual blood (see Fig. 16-1C)
block and can impair aqueous circula ion or angle recession (Fig. 16-9). Occasionally,
(Fig. 16-5). T e impaired aqueous circula- peripheral an erior synechiae or a cyclodialy-
ion causes a decrease in oxygen concen ra- sis clef (Fig. 16-10A) may be presen .
ion in he an erior chamber resul ing in he Pos erior pole: T e pos erior pole may
black appearance o he clo . show evidence o blun or pene ra ing rauma.
In pa ien s wi h sickle cell disease or rai , Commo io re inae, choroidal rup ures, re inal
sickling causes he red blood cells o be rigid de achmen s, in raocular oreign bodies, or
and easily rapped in he rabecular mesh- vi reous hemorrhage may be presen . Scleral
work, leading o eleva ed in raocular pressure depression should be delayed un il he risk o
even in he presence o a small hyphema. rebleeding has passed. A persis en vi reous
Sickle cell pa ien s are subjec o vascular hemorrhage can also cause eleva ed in raocu-
occlusion and op ic nerve damage a lower lar pressures in he orm o ghos cell glau-
in raocular pressures as he resul o microvas- coma. Unlike he ypical red blood cells seen
cular compromise. in hyphemas, an-colored ghos cells can be
observed in he an erior chamber. Ghos cells
History and Clinical Examination are degenera ed ery hrocy es ha clog he
For pa ien s presen ing wi h a rauma ic rabecular meshwork as hey make heir way
hyphema, a horough evalua ion o he im- rom he pos erior segmen o he an erior
ing and na ure o he rauma is impor an chamber presumably hrough a break in he
o de ermine he likelihood o addi ional an erior hyaloid ace.
injuries and he need or close observa ion
and rea men . Pa ien s may be asymp oma ic Special Tests
or have decreased vision, pho ophobia, and B-scan ul rasonography should be per-
pain. Nausea and vomi ing may accompany ormed in any pa ien in whom here is
a rise in in raocular pressure. T ere may be no view o he pos erior pole. Compu ed
evidence o orbi al rauma or damage o o her omographic scan o he orbi s should be per-
ocular issues. ormed i here is clinical suspicion or orbi al
Sli lamp: Sli -lamp examina ion may show rac ures or in raocular oreign bodies.
circula ing red blood cells alone or in combi- Any black or Hispanic pa ien or any
na ion wi h a layered hyphema in he an erior pa ien wi h a posi ive amily his ory should
260 16 TRAUMATIC GLAUCO MA
undergo sickle prep or hemoglobin elec ro- sickling hemoglobinopa hies because CAIs
phoresis o de ermine he presence o sickling increase he pH o he aqueous and hyperos-
hemoglobinopa hies. mo ic agen s can cause hemoconcen ra ion,
resul ing in increased sickling.
Treatment Surgical in erven ion is indica ed in
T e a ec ed eye is shielded and he pa ien pa ien s a risk or corneal blood s aining
is ypically placed on ac ivi y res ric ions. T e (Fig. 16-6), uncon rolled in raocular pres-
pa ien is asked o keep he head o he bed sure, or persis en pain. T e iming o surgical
eleva ed o allow he blood o set le below in erven ion or in raocular pressure con rol
he visual axis (Fig. 16-3). T e pa ien is depends on he individual pa ien . In a pa ien
ins ruc ed o avoid aspirin and nons eroidal wi h a heal hy op ic nerve, an in raocular
agen s. opical cycloplegics and s eroids pressure o 60 mm Hg or 2 days, 50 mm Hg
are given o rea in amma ion and preven or 5 days, or 35 mm Hg or 7 days requires
orma ion o synechiae. Aminocaproic acid, surgical in erven ion. Pa ien s wi h compro-
an an i brinoly ic, can be given sys emically mised op ic nerves or corneal endo helium
o preven rebleeding. Aminocaproic acid require earlier in erven ion, as do pa ien s
may cause pos ural hypo ension, nausea, and wi h sickle cell disease or rai . Surgical in er-
vomi ing, and should be avoided in pregnan ven ion is indica ed in sickle cell pa ien s wi h
pa ien s and hose wi h cardiac, hepa ic, or an in raocular pressure grea er han 24 mm
renal disease. Hg or more han 24 hours.
Eleva ed in raocular pressure is rea ed Surgical op ions o remove he hyphema
opically wi h be a-blockers, alpha-agonis s, include an erior chamber washou , clo
or carbonic anhydrase inhibi ors (CAIs). expression a he limbus, or removal wi h
Mio ics and pros aglandin analogs may an erior vi rec omy ins rumen a ion. I pos-
increase in amma ion and are avoided i sible, clo removal should be per ormed 4 o
possible. Oral or in ravenous CAIs or hyper- 7 days pos - rauma in order o preven new
osmo ic agen s may also be given o lower bleeding. In some cases, a guarded l ra ion
in raocular pressure. However, hese sys emic procedure is per ormed concurren ly o con-
agen s should be avoided in pa ien s wi h rol in raocular pressure.
Traumatic Hyphema 261
A B
C
FIGURE 16-1. Small hyphema. A. T is small hyphema is layering in eriorly in he an erior chamber. Mos
hyphemas resorb gradually. B. T e same eye 4 days la er has a much smaller clo in he an erior chamber. C. T is
is ano her eye wi h persis en ly eleva ed pressures 3 weeks af er an injury when he layered hyphema was no
longer eviden on sli -lamp examina ion. Gonioscopy reveals residual blood in he angle.
A B
FIGURE 16-2. Traumatic hyphema with rebleed. A. Blood layers in he an erior chamber o his eye wi h a
rauma ic hyphema. B.T e same eye rebleeds 24 hours la er, demons ra ing an increase in he amoun o blood
in he an erior chamber.
262 16 TRAUMATIC GLAUCO MA
FIGURE 16-3. Layering hyphema. T e hemorrhage in his new hyphema obscures he visual axis, bu is
beginning o set le in o he in erior an erior chamber. Pa ien s are ins ruc ed o keep heir head eleva ed o assis
his process.
FIGURE 16-4. Total hyphema. A o al hyphema is presen ollowing a baseball injury. T e an erior chamber is
lled wi h brigh red blood.
Traumatic Hyphema 263
FIGURE 16-5. Eight ball hyphema. An eigh -ball hyphema is a o al clo o he an erior chamber ha ge s i s
black appearance rom decreased oxygena ion as a resul o impaired aqueous circula ion.
A B
FIGURE 16-6. Corneal blood staining. A. Corneal blood s aining persis s in his eye ollowing surgical
evacua ion o he hyphema. B. A ew mon hs af er a pene ra ing eye injury and a o al hyphema, his eye has
persis en cen ral corneal blood s aining wi h peripheral clearing.
264 16 TRAUMATIC GLAUCO MA
A B
FIGURE 16-7. Traumatic cataracts. A. rauma ic ca arac s can occur immedia ely or mon hs af er blun or
pene ra ing eye injuries. T is eye has a comple e rauma ic ca arac ha developed immedia ely af er a blun
injury. T e ca arac and mul iple iris sphinc er ears became more eviden as he o al hyphema cleared. B. T is
pa ien had a pene ra ing injury resul ing in a ull- hickness corneal lacera ion ( solid arrows) wi h a corresponding
de ec in he lens (dashed arrow) and a di use rauma ic ca arac . T e pa ien developed lens par icle glaucoma
rom he disrup ion o he lens capsule.
Traumatic Hyphema 265
A B
A B
FIGURE 16-9. Angle recession. A. T is eye wi h angle recession shows irregular widening o he ciliary body
band on gonioscopy. B. T is eye has angle recession adjacen o an area o iridodialysis as seen on gonioscopy.
T e ciliary body processes can be seen hrough he de ec in he iris.
268 16 TRAUMATIC GLAUCO MA
A B
270
Background 271
(an erior o he iris) and pos erior chamber angle closure. I is impor an o per orm
(pos erior o he iris) (Fig. 17-1). T e iris gonioscopy in a comple ely darkened room
has a charac eris ic orward-bowing con- using he smalles square o ligh or a sli
f gura ion leading o narrowing o he angle beam ha se s o he pupil as sli -lamp illu-
(primary angle–closure suspec s). T e adhe- mina ion can s imula e pupillary ligh re ex
sion o he peripheral iris o he rabecular and widen he angle (Fig. 17-2). A narrow
meshwork may obs ruc he angle and resul angle is usually def ned as an angle in which
in eleva ion o in raocular pressure and or- ≥270 degrees o he pos erior rabecular
ma ion o peripheral an erior synechiae (pri- meshwork canno be seen. Inden a ion goni-
mary angle closure). I he degree o rela ive oscopy is use ul o di eren ia e synechial
pupillary block is ex ensive and he angle is closure rom apposi ional closure. Synechial
already very narrow, comple e obs ruc ion o closure is recognized when here are consid-
he angle occurs, and he rise in in raocular erable acquired adhesions be ween he iris
pressure would be precipi ous, leading o an and he corneoscleral junc ion a he angle.
acu e at ack (primary acu e angle closure). I Peripheral an erior synechiae may ex end cir-
he degree o rela ive pupillary block is small cum eren ially resul ing in synechial closure
and he rabecular meshwork is blocked only and progressive increase in in raocular pres-
in small por ions, he in raocular pressure may sure (Fig. 17-3). T e ex en o peripheral
increase gradually over he years resul ing in an erior synechiae correla es wi h he risk o
chronic progressive degenera ion o he op ic developing glaucoma.
nerve wi hou developmen o any symp om
(chronic angle–closure glaucoma). Ultrasound Biomicroscopy and Optical
Coherence Tomography
Epidemiology While assessmen o he angle wi h goni-
Al hough angle-closure glaucoma represen s oscopy is largely quali a ive and subjec ive,
approxima ely 25% o glaucoma worldwide, objec ive and reproducible measuremen
i accoun s or nearly hal o glaucoma blind- o he an erior chamber angle can only
ness.3 I is more prevalen in China, India, be ob ained wi h cross-sec ional imaging
and Sou h-eas Asia han in Europe and La in devices like he ul rasound biomicroscopy
America. A shallow an erior chamber, shor (UBM) and he op ical coherence omogra-
axial leng h, and small corneal diame er are phy (OC ) (Fig. 17-4). OC has a number
biome ric risk ac ors or primary angle clo- o advan ages over UBM or an erior cham-
sure. T e incidence o acu e angle closure ber angle imaging. I is a noncon ac ech-
has been es ima ed a approxima ely 4 o 16 nique, has a higher image resolu ion, and
per 100,000 per year in he popula ion aged is more precise in loca ing he posi ion o
30 years and older.4 In addi ion o he biome - in eres or evalua ion compared wi h UBM.
ric risk ac ors or primary angle closure, age UBM, however, has a unique role in visualiz-
≥60 years, emale gender, a posi ive amily his- ing he ciliary body. Commercially available
ory, and a hick and bulky lens impose addi- ime-domain and spec ral-domain models
ional risks or acu e at ack. have been developed or an erior cham-
ber angle imaging5 (Table 17-1). Wi h he
Clinical Examination
developmen o high-resolu ion OC imag-
Gonioscopy ing sys ems, angle s ruc ures including he
Gonioscopy is an indispensable echnique scleral spur, Schwalbe’s line, Schlemm’s canal,
o visualize he angle s ruc ures and de ec and collec ing channels can be examined
272 17 PRIMARYACUTE ANGLE– CLOSURE AND CHRONIC ANGLE– CLOSURE GLAUCOMA
C
FIGURE 17-1. Pathophysiology o primar y angle closure. Drawing o (A) apposi ion o pupillary margin o
he an erior sur ace o he lens, (B) aqueous pressure developing behind he iris ( arrows) and pushing he iris
orward, and (C) iris bombé (arrows) causing obs ruc ion o he rabecular meshwork.
A B
FIGURE 17-2. Ef ect o illumination on the anterior chamber angle. An erior segmen OC images ob ained
wi h he Visan e OC (Carl Zeiss Medi ec, Dublin, CA) demons ra ing narrowing o he angle rom ligh (A) o
dark (B). Apposi ional closure is de ec ed only in he dark.
274 17 PRIMARYACUTE ANGLE– CLOSURE AND CHRONIC ANGLE– CLOSURE GLAUCOMA
A B
FIGURE 17-3. Peripheral anterior synechiae. A. Gonioscopic view o an eye wi h ex ensive peripheral
an erior synechiae. B. T ree-dimensional recons ruc ion o mul iple OC images collec ed rom he same eye
wi h a swep -source OC (Casia OC , omey, Nagoya, Japan) .
A B
FIGURE 17-4. Anterior chamber angle imaging with UBM and the OC . While he ciliary body is bet er
visualized wi h UBM (A), OC (Casia OC , omey, Nagoya, Japan) (B) provides a higher image resolu ion.
T e UBM and OC images were ob ained wi h model 840 (Paradigm Medical Indus ries, Sal Lake Ci y, U )
and a swep -source OC (Casia OC , omey, Nagoya, Japan) , respec ively.
Background 275
FIGURE 17-5. Anterior chamber angle Imaging with spectral domain OC . De ailed angle s ruc ures
including he scleral spur, Schwalbe’s line, and Schlemm’s canal ( *) can be visualized wi h a spec ral-domain
OC (Cirrus HD OC , Carl Zeiss Medi ec, Dublin, CA) .
A B
FIGURE 17-6. T ree dimensional visualization o the anterior chamber angle. T e Casia OC ( omey,
Nagoya, Japan) is a swep -source OC wi h a scan speed o 30,000 A-scans per second. T e whole an erior
segmen can be radially imaged in 64 cross sec ions in 1.2 seconds. An open (A) and a closed angle (B) in
hree-dimensional display are illus ra ed.
276 17 PRIMARYACUTE ANGLE– CLOSURE AND CHRONIC ANGLE– CLOSURE GLAUCOMA
DIAGNOSTIC EVALUATION
TREATMENT
Symp oms o primary acu e angle closure
range rom unila eral blurring and ocular T e goals o rea men are o reduce he
pain o ex reme ocular or periocular pain, in raocular pressure and preven recurren
headache, nausea, vomi ing, and diaphoresis. at ack.
Pa ien s may have a his ory o subacu e angle opical be a-blocker, cholinergic agen ,
closure including in ermit en at acks o pain and carbonic anhydrase inhibi or, and sys-
and possibly mildly blurry vision, which may emic ace azolamide (i.v. 250 o 500 mg) are
be con used wi h migraine headache. Acu e usually e ec ive in lowering he in raocular
at acks may be precipi a ed by pharmacologi- pressure and abor ing he at ack. An osmo ic
cal mydriasis, dim illumina ion, s ress, or pro- agen (e.g., i.v. manni ol 1 o 2 g per kg over
longed near work. 45 minu es) may be considered i in raocular
Clinical examina ion shows conjunc ival pressure con rol is subop imal.
injec ion, corneal epi helial edema, mid- In pa ien s no responsive o medical
dila ed pupil, a shallow an erior chamber, and rea men , argon laser peripheral iridoplas y
o en imes, he iris in a classic bombé pat ern (ALPI) can be applied rom 180 degrees o
(Figs. 17-7 to 17-9). T e in raocular pres- 360degrees a he ar peripheral iris o pull
sure may be as high as 80 mm Hg. Mild cell open he closed angle mechanically. T e spo
and are are o en presen . size is usually se a 500 µm wi h dura ion o
Gonioscopy can be di cul in he pres- 0.5 seconds and energy o 200 o 400 mJ or
ence o he corneal edema. Early in he at ack, each applica ion. T e op imal energy should
he op ic nerve head can show edema and be i ra ed wi h an end poin o visualizing he
hyperemia. con rac ion o he peripheral iris. Charring
T e ellow eye should be examined closely o he iris wi h excessive laser energy should
because i will almos always have a shallow be avoided. ALPI alone is a sa e and e ec ive
an erior chamber wi h a narrow angle. al erna ive in abor ing acu e angle closure.
Once he corneal edema has cleared, a laser
PROGNOSIS peripheral irido omy (LPI) can be per ormed
o preven recurren at ack. By providing a
Depending on he level o in raocular communica ing channel, LPI reduces he
pressure and he dura ion o at ack, variable pressure gradien be ween he an erior and he
degree o irreversible ischemic damages can pos erior chambers and at ens he iris (Fig.
be incurred on he iris, he lens, and he op ic 17-11). LPI should be considered in he el-
nerve resul ing in iris a rophy, glaukom ecken low eye because o an associa ed increased risk
( ecks o an erior subcapsular opaci ies rep- o developing acu e angle closure.
resen ing in arc ion o an erior lens epi helial Pa ien s should be moni ored or develop-
cells) (Fig. 17-10), and a pale op ic nerve men o peripheral an erior synechiae, chronic
head wi h visual f eld loss dispropor iona e o eleva ion o in raocular pressure, and angle-
he disc cupping. closure glaucoma in he ollow-up visi s.
Primary Acute Angle Closure 277
I n pla eau iris conf guration, he iris is dis- rela ive pupillary block.
placed an eriorly a i s roo by large or In pla eau iris syndrome, ALPI is use ul
abnormally posi ioned ciliary processes. A o open apposi ionally closed angle. ypical
componen o rela ive pupillary block may rea men includes approxima ely 20 o 30
also be presen , par icularly in older individu- spo s o argon laser placed in he ar periphery
als. T e rabecular meshwork may be occluded over 360 degrees. Fil ra ion surgery may ul i-
i he displacemen is an erior enough. Pla eau ma ely become necessary in some pa ien s.
278 17 PRIMARYACUTE ANGLE– CLOSURE AND CHRONIC ANGLE– CLOSURE GLAUCOMA
FIGURE 17-7. Iris bombé. Sli -beam pho ograph showing he appearance o iris bombé. T is eye has iris bombé
rom uvei is causing 360 degrees o pos erior synechiae (scarring be ween he pupillary margin and he an erior
sur ace o he in raocular lens) , causing secondary pupillary block by mechanically blocking aqueous f ow
hrough he pupil.
A B
FIGURE 17-8. Primar y acute angle closure. A pa ien wi h primary acu e angle closure and a rela ively clear
cornea. A. T e sli -beam pho ograph o he gonioscopic view shows he s eep approach o he iris in his case o
acu e angle closure (iris bombé). B. T e di use illumina ion o he gonioscopic view o he same eye shows no
angle s ruc ures (i.e., an occluded angle) .
Primary Acute Angle Closure 279
A B
FIGURE 17-9. Narrow anterior chamber angle. A. Sli -beam pho ograph showing a narrow an erior
chamber angle. B.T e gonioscopic view o he same eye showing he absence o angle s ruc ures in an eye wi h
normal in raocular pressure. T is angle is occludable. (Cour esy o Douglas J. Rhee, MD, Wills Eye Hospi al,
Philadelphia, PA.)
FIGURE 17-10. Glaukom ecken. Sli -lamp pho ograph o an eye 2 mon hs a er acu e angle–closure at ack
shows f ecks o an erior subcapsular opaci ies.
280 17 PRIMARYACUTE ANGLE– CLOSURE AND CHRONIC ANGLE– CLOSURE GLAUCOMA
A B
FIGURE 17-11. Ef ect o LPI on the anterior chamber angle. OC imaging ( Visan e OC , Carl Zeiss
Medi ec, Dublin, CA) o an eye wi h narrow angle be ore (A) and a er (B) LPI. A er LPI, he angle is widened
and he iris is f at ened.
A B
FIGURE 17-12. Ef ect o lens extraction on the anterior chamber angle. OC imaging (Casia OC , omey,
Nagoya, Japan) o an eye wi h chronic angle–closure glaucoma be ore (A) and a er (B) ca arac ex rac ion. T e
angle is widened and he iris is f at ened a er ca arac ex rac ion.
Primary Acute Angle Closure 281
A B
C
FIGURE 17-13. Plateau iris con guration. A. Sli -beam pho ograph showing a rela ively deep an erior chamber.
T ere is a pa en peripheral irido omy superiorly. B. Gonioscopy wi h no pressure on he cornea; no angle
s ruc ures are visible. T e black arrow shows a prominen las iris old. C. Inden a ion gonioscopy. T e arrows pointing
up shows he same iris old seen in B; he arrowheads showing he rabecular meshwork now revealed behind he
prominen iris old. T e image is dis or ed because o he corneal s riae induced by he inden a ion. (Cour esy o
Douglas J. Rhee, MD, Wills Eye Hospi al, Philadelphia, PA.)
FIGURE 17-14. UBM o the same eye shown in Figure 17-13. T e arrow shows he an eriorly displaced ciliary
body causing a prominen iris roll direc ly above i in his pic ure. (Cour esy o Douglas J. Rhee, MD, Wills Eye
Hospi al, Philadelphia, PA.)
C H AP T ER
18
Secondary Angle-closure Glaucoma
Douglas J. Rhee and Jamie E. Nicholl
282
Neovascular Glaucoma 283
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peripheral an erior synechiae occluding some re inal vascular occlusion II. Occurrence in cen ral
and branch re inal ar ery occlusion. Arch Ophthalmol.
or all o he angles may be seen. 1982;100:1585.
Pos erior pole: Re inal f ndings are consis- Laa ikainen L, Kohner EM, Khoury D, e al. Panre inal
en wi h he underlying pa hology. pho ocoagula ion in cen ral re inal vein occlusion: A
randomized con rolled clinical s udy. Br J Ophthalmol.
Management 1977;61:741.
Magargal LE, Brown GC, Augsburger JJ, e al. E cacy o
ypically, medical managemen is no ade- panre inal pho ocoagula ion in preven ing neovascu-
qua e in con rolling he in raocular pressure. lar glaucoma ollowing ischemic cen ral re inal vein
Surgical in erven ion is usually required. obs ruc ion. Ophthalmology. 1982;89:780.
Miki A, Oshima Y, O ori Y, e al. One-year resul s o in ra-
Op ions include rabeculec omy wi h an vi real bevacizumab as an adjunc o rabeculec omy
an if bro ic agen , a glaucoma drainage implan or neovascular glaucoma in eyes wi h previous vi rec-
device, and cyclodes ruc ive procedures. omy. Eye (Lond). 2011;25:658–659.
Ne land PA, Ishida K, Boyle JW. T e Ahmed Glaucoma
Valve in pa ien s wi h and wi hou neovascular glau-
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284 18 SECO NDARY ANGLE– CLO SURE GLAUCO MA
FIGURE 18-1. Neovascularization of the iris. Neovasculariza ion o he iris f ne, noncircular vessels is seen
near he papillary border ex ending on o he iris.
FIGURE 18-2. Neovascularization of the iris. Gonioscopic pho o showing neovasculariza ion f ne, nonradial
vessels over he rabecular meshwork be ore he f brovascular membrane has con rac ed causing peripheral
an erior synechiae.
Iridocorneal Syndromes 285
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2001;20:134–140. phakic eyes. Arch Ophthalmol. 2009;127:33–36.
Anderson NJ, Badawi DY, Grossniklaus HE, e al. Kup er C, Kaiser-Kup er MI, Da iles M, e al. T e con ral-
Pos erior polymorphous membranous dys rophy wi h a eral eye in he iridocorneal endo helial (ICE) syn-
overlapping ea ures o iridocorneal endo helial syn- drome. Ophthalmology. 1983;90:1343–1350.
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Doe EA, Budenz DL, Gedde SJ, e al. Long- erm surgical rabeculec omy wi h mi omycin-C in he irido-
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endo helial syndrome. Clin Experiment Ophthalmol. Price MO, Price FW Jr. Desceme s ripping wi h endo he-
2004;32:275–283. lial kera oplas y or rea men o iridocorneal endo he-
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Cornea. 1995;14:331. Shields MB. Progressive essen ial iris a rophy, Chandler’s
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1995;113:1226–1228. 24:3–20.
A B
FIGURE 18-3. Essential iris atrophy. A. Essen ial iris a rophy showing pulling and dis or ion o he pupil.
B. Sli -beam pho ograph o he same eye.
Iridocorneal Syndromes 287
A B
FIGURE 18-4. Essential iris atrophy. A. Ano her example o essen ial iris a rophy. B. Gonioscopic view o he
same eye, showing peripheral an erior synechiae.
A B
FIGURE 18-5. Essential iris atrophy. A. Ex reme example o essen ial iris a rophy. B. Gonioscopic view o he
same eye, showing peripheral an erior synechiae.
288 18 SECO NDARY ANGLE– CLO SURE GLAUCO MA
A B
FIGURE 18-6. Chandler’s syndrome. A. T e iris f ndings are similar o essen ial iris a rophy excep ha he
corneal f ndings are more prominen . B. Sli -beam pho ograph o he same eye.
FIGURE 18-7. Advanced iris nevus syndrome. Sli -lamp pho ograph o an individual wi h an advanced case
o iris nevus syndrome. T e emporal aspec o he iris clock hours 8 o 9 shows loss o he normal cryp s o
he iris. T e small brown do s are u s o normal iris issue poking hrough he abnormal corneal endo helial
membrane. From clock hours 9 o 11, he membrane has re rac ed, causing s re ch ears in he iris. T e
subconjunc ival hemorrhage is a resul o his pa ien ’s recen guarded f l ra ion surgery.
Aqueous Misdirection Syndrome (Malignant Glaucoma) 289
A B
C D
FIGURE 18-8. Aqueous misdirection following glaucoma drainage device implantation. A–C. Ul rasound
biomicroscopy o a pa ien wi h aqueous misdirec ion syndrome ollowing a glaucoma drainage device
implan a ion procedure. In panels A and B, he s ar indica es he cornea. A. T e arrow shows he an erior lens
capsule; his cen ral view shows a shallow an erior chamber wi h ICE ouch o he papillary margin. B. T e
arrow shows he at ened ciliary body processes diagnos ic o aqueous misdirec ion syndrome; his view o he
angle also shows he ICE ouch. C. A magnif ed view o he at ened ciliary processes. Appearance a er limi ed
vi rec omy. D and E. T e same pa ien ollowing limi ed vi rec omy wi h disrup ion o he an erior hyaloid
ace. T e star indica es he cornea while he arrow indica es he an erior capsule o he lens. D. Deepening o
he an erior chamber angle; he ube can be seen lying a on he iris.
(continued)
Aqueous Misdirection Syndrome (Malignant Glaucoma) 291
19
Glaucoma Secondary o Eleva ed
Venous Pressure
Douglas J. Rhee, Ribhi Hazin, and Louis R. Pasquale
292
Carotid-Cavernous Fistula 293
FIGURE 19-1. Arterialization o conjunctival vessels in a 78-year-old patient with a spontaneous indirect CCF
prior to endovascular embolization with detachable coil. (Courtesy o Dr. Peter Veldman.)
FIGURE 19-2. Magnetic resonance angiography o the patient in Figure 19-1 revealing an enlarged right
superior ophthalmic vein. (Courtesy o Dr. Peter Veldman.)
Carotid-Cavernous Fistula 295
FIGURE 19-3. Improved clinical appearance o the patient in Figure 19-1 with marked reduction o conjunctival
arterialization ollowing endovascular embolization with detachable coil. (Courtesy o Dr. Peter Veldman.)
296 19 GLAUCO MA SECO NDARY TO ELEVATED VENO US PRESSURE
A B
FIGURE 19-4. Slit-lamp view o the episcleral vascular mal ormation o a 49-year-old man with SWS and
late-onset glaucoma. Note that the episcleral mal ormation can be subtle and construed as episcleritis i it were
unaccompanied by a port-wine stain. A. Lower magnif cation slit lamp view. B. Higher magnif cation view o the
in eronasal limbal area showing terminal end bulbs at the limbus di erentiating these as abnormal vessels.
298 19 GLAUCO MA SECO NDARY TO ELEVATED VENO US PRESSURE
FIGURE 19-5. A. ypical appearance o the drainage angle in SWS with decreased visibility o scleral spur
and ciliary body band. Note the decreased visibility o the ciliary body band, scleral spur, and irregular border
o the peripheral iris. B. Gonioscopy o the anterior chamber angle o the contralateral eye o the same patient
showing the normal landmarks. (From Aggarwal NK, Gandham SB, Weinstein R, et al. Heterochromia iridis and
pertinent clinical f ndings in patients with glaucoma associated with Sturge-Weber syndrome. J Pediatr Ophthalmol
Strabismus. 2010;47:361–365, permission pending.)
FIGURE 19-6. Angiomatosis involving periocular skin and episclera in the same patient as in Figure 19 4.
Note that the periocular involvement does not ollow a strict dermatomal distribution.
Idiopathic Elevated Episcleral Venous Pressure 299
IIDIO
DIOO PA
A H ICC ELEVA
E L E VA EDD o li e. T e dila ed vessels can be unila eral
EPISCLERAL
E PIS
SC LE
E R AL
L VEN
VE N O UUS
S or bila eral, usually wi h asymme ry even in
bila eral cases (Fig. 19-7).1
PRESSURE
P RE
E SSU
U RE
Pa ien s may have blood in Schlemm’s
Idiopa hic eleva ed episcleral venous pres- canal which is a generalized sign o eleva ed
sure (IEEVP) is a diagnosis o exclusion. An episcleral venous pressure (Fig. 19-8), bu
ex ensive his ory, clinical exam, and comple e his f nding is no necessary o es ablish he
diagnos ic evalua ion including radiologic diagnosis.
es ing should be under aken o de ec any
primary causes such as hose lis ed in he REFERENCE
in roduc ion o his chap er. 1. Rhee DJ, Gup a M, Moncavage M, e al. Idiopa hic
eleva ed episcleral venous pressure and open angle
Pa ien s wi h IEEVP have dila ed, or uous
glaucoma. Br J Ophthalmol. 2009;93:231–234; Epub
episcleral vessels wi h onse occurring sub- 2008 Jun 20.
acu ely ypically in he hird or our h decade
FIGURE 19-7. Bilateral case o IEEVP with greater involvement o the le eye. Images o the individual eyes.
300 19 GLAUCO MA SECO NDARY TO ELEVATED VENO US PRESSURE
C
FIGURE 19-9. AV malformation. T is patient had bilateral AV mal ormations involving the trochlear arteries
that were discovered using C angiography. T e le side had greater involvement and received a trabeculectomy.
A. external photograph showing involvement o both eyes but with greater involvement o the le eye. B. view o
the right eye with C. the lid raised showing engorgement o episcleral veins. D–G. Images o the le eye ollowing
trabeculectomy surgery with ExPress shunt (Alcon, Ft. Worth, X) and Ologen (Aeon Astron, Netherlands)
implants.
( continued)
Idiopathic Elevated Episcleral Venous Pressure 301
D E
F G
20
In roduc ion o Glaucoma
Managemen
Douglas J. Rhee
W e curren ly unders and he pa hophysi- no used or rea men un il la er. Adol Weber
ology o glaucoma o be a progressive (1829 o 1915) f rs in roduced hem as medi-
loss o ganglion cells resul ing in visual f eld cal rea men s o glaucoma in 1876. T e f rs
damage ha is rela ed o in raocular pres- s udy comparing he wo available orms o
sure. T e goal o rea men is o re ard or hal glaucoma rea men , eserine and iridec omy,
he ganglion cell loss and preven symp om- was per ormed a Wills Eye Hospi al in 1895
a ic visual loss while at emp ing no o cause by Zen mayer e al. T is s udy showed ha
un oward side e ec s. bo h rea men s are equivalen and ha a
pa ien ’s visual s a us could be main ained or
Al hough many clinicians now eel ha here periods ranging rom 5 o 15 years on chronic
are several ac ors involved in he pa hogen- medical rea men .
esis o glaucoma, he only rigorously proven
me hod o rea men is he lowering o in raoc- T e deba e over he bes ini ial herapy con in-
ular pressure. T ere con inues o be a moun - ues oday. In Europe, many clinicians per orm
ing body o evidence ha suppor s his ac . surgery as he ini ial rea men or glaucoma.
Mos clinicians in he Uni ed S a es con-
inue o use medica ions as he ini ial rea -
HOW DO WE TREAT men or glaucoma. In he Uni ed S a es, wo
GLAUCOMA? large s udies were per ormed o compare
medical rea men wi h laser rabeculoplas y
302
HowDo We Treat Glaucoma? 303
21
Medical Managemen
Malik Y. Kahook and Douglas J. Rhee
U nless here are ex reme circums ances, ma ous op ic neuropa hy is diagnosed and a rm
such as an IOP higher han 40 mm Hg or unders anding o he limi ed number o glau-
an impending risk o cen ral xa ion, rea men coma herapeu ics is necessary o choose he
is s ar ed using a so-called one-eyed herapeu- bes herapy or each individual pa ien .
ic rial. ypically, one ype o drop is s ar ed T ere are several dif eren classes o medi-
in only one eye wi h reexamina ion in 3 o 6 ca ions. All medica ions work o lower IOP
weeks o check or ef ec iveness. Ef ec iveness hrough varying pharmacologic mechanisms.
is de ermined by comparing he dif erence in IOP is de ermined by he balance be ween
IOP in he wo eyes prior o herapy wi h he secre ion and drainage o aqueous humor.
dif erence in IOP a er ini ia ing herapy. For All medica ions ei her decrease secre ion or
example, i IOP is 30 mm Hg OD (oculus dex- increase ou ow. In he subsequen sec ions,
ter; in he righ eye) and 33 mm Hg OS (oculus he mechanism o ac ion, common side ef ec s,
sinister; in he le eye) prior o rea men , and, and con raindica ions or he dif eren classes
ollowing rea men o he righ eye, IOP is o medica ions are presen ed. Table 21-1
304
Description and Physiology 305
FIGURE 21-1. Alpha agonists. All rade-name alpha agonis s available in he Uni ed S a es a he ime o
publica ion. From lef o righ : Alphagan (Allergan; Irvine, CA), Alphagan-P (Allergan; Irvine, CA) , and
Iopidine 0.5% (Alcon; For Wor h, X) . No e: Iopidine 1% is no shown.
Alpha Agonists 307
FIGURE 21-2. Allergic reaction from chronic brimonidine. ypical allergic reac ion rom brimonidine is
a ollicular conjunc ivi is ha occurs mon hs o years af er chronic use. T e prevalence is dose rela ed o he
concen ra ion o brimonidine wi h lower concen ra ions having lower prevalence o allergic reac ions. T is is an
ex reme case in which an ec ropion occurred as a resul o periorbi al skin excoria ion and brosis. T ese ndings
resolved spon aneously over a ew weeks o discon inuing he medica ion.
308 21 MEDICAL MANAGEMENT
FIGURE 21-3. Beta blockers. Nearly all single-agen , rade-name be a-blockers available in he Uni ed S a es
a he ime o publica ion; Be agan 0.25% and Be op ic are missing. From lef o righ : Be agan 0.5% (Allergan;
Irvine, CA), Be imol 0.25% and 0.5%, respec ively (San en; ampere, Finland) , Be op ic-S (Alcon; For Wor h,
X) , Op iPranolol (Bausch & Lomb; Claremon , CA) , Ocupress (Novar is; A lan a, GA) , and imop ic XE
0.25% and 0.5%, respec ively ( Merck; Whi ehouse S a ion, NJ) .
Carbonic Anhydrase Inhibitors 309
FIGURE 21-4. Oral CAIs. T e oral CAIs available in he Uni ed S a es a he ime o publica ion. From lef o
righ : Diamox (Lederle; PA) and me hazolamide ( generic made by Copley Pharmaceu ical; Can on, MA) . O her
companies have manu ac ured hese medica ions in heir generic orms in recen years.
FIGURE 21-5. Topical CAIs. All single-agen , rade-name opical CAIs available in he Uni ed S a es a he
ime o publica ion. From lef o righ : rusop , old and new bot le, respec ively ( Merck; Whi ehouse S a ion,
NJ) , and Azop (Alcon; For Wor h, X).
Miotics 311
FIGURE 21-6. Pilocarpine strengths. T e various s reng hs o pilocarpine, rom 0.5% o 6%.
Prostaglandins 313
A B
FIGURE 21-7. Prostaglandin agonists. A. All pros aglandin agonis s available in he Uni ed S a es a he ime
o publica ion. From lef o righ : Xala an 0.005% (P zer; New York, NY) , Rescula (Sucampo Pharmaceu icals,
Inc., Be hesda, MD) is no longer in he US marke , and rava an 0.004% (Alcon; For Wor h, X) . Separa ed
rom he res o he group is he medica ion Lumigan 0.03% (Allergan; Irvine, CA) , which is chemically similar
o he o her drugs bu is considered a pros amide. B. A more recen version o Lumigan (Allergan; Irvine, CA)
con ains a lower dose o bima opros ( 0.01%) han he original ormula ion.
FIGURE 21-8. Prostaglandin analog induced heterochromia. T is pa ien had been rea ed monocularly in
he lef eye wi h a pros aglandin analog which resul ed in a darker iris in he rea ed eye.
Sympathomimetic Agents 315
FIGURE 21-9. Sympathomimetic agents. His orically u ilized sympa homime ic agen s rom lef o righ :
Epi rin (Allergan; Irvine, CA) and Propine (Allergan; Irvine, CA) .
316 21 MEDICAL MANAGEMENT
A B
FIGURE 21-10. Combination agents. A. T e combina ion agen Cosop ( Merck; Whi ehouse S a ion, NJ) .
B. T e combina ion agen Combigan (Allergan, Irvine, CA) .
Technique of Drop Instillation 317
A B
FIGURE 21-11. Self administration of drops: two handed method. wo-handed me hod or sel -
adminis ra ion o opical drop. A. Fron al view. B. La eral view.
318 21 MEDICAL MANAGEMENT
A B
FIGURE 21-12. Self administration of drops: one handed method. Using he bridge o he nose o aid wi h
s eadiness o he hand or sel -adminis ra ion o opical drop. A. Fron al view. B. La eral view.
Technique of Drop Instillation 319
A B
FIGURE 21-13. Punctal occlusion. Punc al occlusion o minimize sys emic absorp ion o opically
adminis ered medica ions hrough he nasolacrimal sys em. A. Fron al view. B. La eral view.
C H AP T ER
Laser rabeculoplas y
L. Jay Katz and Kathryn B. Freidl
320
Argon Laser Trabeculoplasty 321
AR
ARGO
R G O N LASER
LAASE R he success o laser rabeculoplas y. Heavier
RABECULO
R ABEE C ULO
O PLAS
P LA
AS Y pigmen a ion is a posi ive predic or o suc-
cess. T e hermal burn wi h he argon laser
has been shown his ologically o cause mel -
TECHNIQUE
ing and dis or ion o he rabecular beams.
Since he in roduc ion o argon laser T e f rs heory sugges ed ha hese con-
rabeculoplas y (AL ) in 1979 by Wit er rac ion burns over he angle mechanically
and Wise, here has been remarkably lit le helped adjacen rabecular beams open wider,
al era ion o he echnique. A 50-µm spo size hus allowing easier aqueous ou ow. T e
is applied o he rabecular meshwork wi h second heory sugges ed ha he laser irradia-
up o 1000 mW o energy, enough o cause ion s imula ed rabecular endo helial cells
minimal blanching o he pigmen . T e leas o replica e (Fig. 22-3). Because hese cells
amoun o energy is employed o at ain he serve a phagocy ic role in he angle, i was
issue endpoin (Fig. 22-1). hough ha he endo helial cells keep he
in ra rabecular spaces ree o debris ha may
T e laser spo is aimed a he junc ion o
be implica ed in he increased resis ance o
he pigmen ed and nonpigmen ed rabecular
ou ow seen in glaucoma ous eyes.
meshwork. Ei her a single rea men session o
he en ire 360 degrees wi h up o 100 applica-
ions, or wo sessions o 180 degrees each wi h
EFFICACY
50 sho s, may be per ormed. A single- or hree-
In raocular pressure is ypically reduced
mirrored Goldmann lens or Ri ch goniolens is
20% o 30% below baseline levels wi h AL .
used o apply he laser sho s o he arge issue.
No all eyes are responsive o laser rabecu-
A opical alpha-agonis (apraclonidine or loplas y. Posi ive predic ors o a avorable
brimonidine) is given pre- and pos laser rea - response include heavy pigmen a ion o he
men o minimize he possibili y o a ransien rabecular meshwork, age (older pa ien s),
in raocular pressure spike (Fig. 22-2). A opi- and diagnosis (pigmen ary glaucoma, pri-
cal cor icos eroid is prescribed our imes daily mary open-angle glaucoma, and ex olia ion
or a week o preven pos laser in amma ion. syndrome).
A er he rea men , he pa ien is exam- T ere is an apparen waning o he e ec
ined 1 hour la er o measure he eye pressure. o AL over ime. In long- erm s udies o 5
I a pressure spike occurs, i is rea ed wi h o 10 years, AL ailure ranged rom 65% o
glaucoma medica ions such as oral carbonic 90%. Re rea men a er a previous comple e
anhydrase inhibi ors or oral hyperosmo ic 360-degree applica ion o AL is a bes a
agen s. T e pa ien is reexamined a 1 week shor - erm benef wi h ailure a 1 year up
and again 1 mon h a er he rea men . A o 80%. Because here is s ruc ural al era ion
he las visi , a de ermina ion is made as o o he ou ow sys em wi h AL , repea rea -
whe her he laser herapy was benef cial. men may lead o a paradoxical persis en
eleva ion o in raocular pressure. Repea
MECH ANISM OF ACTION argon laser applica ion o he angle s ruc ures
in animals was used by Gaas erland o cre-
T eories have been o ered, bu none veri- a e an experimen al open-angle glaucoma
f ed, as o how laser herapy lowers he eye model. I a promp reduc ion in in raocular
pressure. T e ex en o pigmen a ion o he pressure is needed, or a rela ively large reduc-
rabecular meshwork seems o be cri ical or ion in pressure is desired (e.g., more han a
322 22 LASER TRABECULO PLAST Y
30% lowering below baseline pre rea men me hodological aws in he s udy design
in raocular pressure), hen AL may no be a or his s udy, here was in riguing suppor
good choice. Medica ion or f l ering surgery is o a leas consider AL as ini ial herapy
more likely o achieve hose objec ives. or cer ain pa ien s.
T e curren rea men paradigm or glau-
coma in he Uni ed S a es is medica ion f rs , BIBLIOGRAPH Y
hen AL , and, f nally, f l ering surgery. T is Damji F, Shah C, Rock WJ, e al. Selec ive laser ra-
s epping regimen is only a guideline, and beculoplas y argon laser rabeculoplas y: A pro-
spec ive randomised clinical rial. Br J Ophthalmol.
rea men needs o be individualized or each
1999;83:718–722.
pa ien o provide op imum care. Feldman RM, a z LJ, Spae h GL, e al. Long- erm e cacy
T ere have been s udies ha have reex- o repea argon laser rabeculoplas y. Ophthalmology.
amined he sequencing o rea men s or 1991;98:1061–1065.
Glaucoma rial Research Group. T e Glaucoma Laser rial
open-angle glaucoma. In he Glaucoma 2. Resul s o argon laser rabeculoplas y versus opical
Laser rial, AL was compared wi h medi- medicines. Ophthalmology. 1990;97:1403–1413.
ca ion as he f rs s ep in he rea men o Glaucoma rial Research Group. T e Glaucoma Laser
newly diagnosed primary open-angle glau- rial (GL ) and glaucoma laser rial ollow-up s udy:
coma. A er 2 years, 44% o eyes wi h AL 7. Resul s. Am J Ophthalmol. 1995;120:718–731.
a z LJ. Argon laser rabeculoplas y. Annu Ophthalmic
alone were con rolled as opposed o only Laser Surg. 1992;1:103–110.
20% wi h imolol alone being adequa ely ramer R, Noecker RJ. Comparison o he morpho-
rea ed. In a subsequen paper, wi h a logic changes a er selec ive laser rabeculoplas y and
mean ollow-up o 7 years, AL alone was argon laser rabeculoplas y in human eye bank eyes.
adequa e con rol or 20% o eyes and imo- Ophthalmology. 2001;108:773–779.
Wise JB. Long- erm con rol o adul open angle glaucoma by
lol alone or 15%. Al hough here were argon laser rea men . Ophthalmology. 1981;88: 197–202.
Corne a
S chwa lbe ’s
line
S chle mm’s
ca na l Tra be cula r
me s hwork
S cle ra l s pur
Cilia ry body
ba nd
Iris
Force
ve ctor
FIGURE 22-1. Tissue response to laser treatment. T e “ideal” tissue response is minimal bubble ormation
and mild blanching o the trabecular meshwork. T e laser is aimed at the junction o the pigmented and
nonpigmented trabecular meshwork. (Reprinted with permission rom Katz LJ. Argon laser trabeculoplasty.
Annu Ophthalmic Laser Surg. 1992;1:103–110.)
Argon Laser Trabeculoplasty 323
FIGURE 22-2. Ef ects o postlaser medication administration. Blunting o the postlaser intraocular pressure
spike af er AL with apraclonidine is compared with other glaucoma medications.
2 Day 14 Day
FIGURE 22-3. ALT: One proposed mechanism o action. Cellular theory that AL stimulates the replication
o trabecular endothelial cells that promote aqueous out ow. (Reprinted with permission rom Van Buskirk EM.
Pathophysiology o laser trabeculoplasty. Surv Ophthalmol. 1989;33:264–272.)
324 22 LASER TRABECULO PLAST Y
SEL
SELEC
L EC
C IVE
IV
VE LASER
LA
ASER R o rabecular meshwork cells were irradi-
RABECULO
R ABE
E C UL
L O PLAS
P LA
AS Y a ed by La ina wi h ei her argon or selec-
ive laser. Argon laser applica ion damaged
bo h pigmen ed and nonpigmen ed cells.
TECHNIQUE
In con ras , he selec ive laser arge ed only
he pigmen ed cells. Recrui men o mac-
A pulsed- requency doubled neodymium
rophages in o he ou ow sys em has been
(Nd):YAG laser was in roduced in 1998 by
demons ra ed in animal models and in human
La ina or rabeculoplas y. I was developed o
eyes. T ese macrophages may release chemi-
selec ively arge pigmen ed issue and mini-
cal media ors ha regula e he ou ow ra e.
mize any colla eral e ec . In con ras wi h he
Eleva ed in erleukin levels de ec ed ollow-
con inuous-wave argon laser, he selec ive
ing laser applica ion have been pos ula ed o
laser does no cause any hermal injury o
improve aqueous ou ow.
he rabecular region. T e f xed spo size o
400 µm dwar s he ypical 50-µm spo size Recen ly, Alvarado described a junc-
used wi h AL (Fig. 22-4). T ere ore, he ion disassembly in Schlemm’s canal cells
spacing be ween laser spo s wi h he selec ive when hey were exposed o laser-irradia ed
laser rabeculoplas y (SL ) is much more Schlemm’s canal cells and rabecular mesh-
compac and almos con uen (Fig. 22-5). work cells. T is same junc ion disassembly
T e spo size wi h SL is so large ha he was demons rable wi h pros aglandin analog
en ire angle is covered wi h he aiming beam. rea men as well. In bo h cases, endo helial
T e only variables in applying he laser are cell junc ion disassembly was associa ed
he number o sho s (50 o 60), ex en o he wi h a congruous increase in he conduc iv-
angle rea ed (180 o 360 degrees), and he i y. Alvarado concluded ha he in raocular
power (up o 0.8 J). pressure–lowering e ec s o SL and pros a-
glandin analogs share a common mechanism
T e power endpoin is de ermined by he
o ac ion a ec ing he barrier proper ies o
issue reac ion wi h he ini ial laser applica-
Schlemm’s canal cells.
ion. Blanching o he pigmen ed rabecular
meshwork wi h sligh bubble vaporiza ion is
ideal. I here is a grea deal o bubble orma- EFFICACY
ion, hen he power is adjus ed downward.
T e use o low power is s rongly recom- Compara ive rials have conf rmed ha
mended in heavily pigmen ed angles as seen AL and SL have equivalen e cacy in
in pigmen ary glaucoma. lowering he in raocular pressure in eyes ha
have ailed medical herapy. S udies sugges
ha ini ial herapy wi h SL prior o any glau-
MECH ANISM OF ACTION
coma medica ion use lowers he in raocular
pressure by 24% o 35% below baseline levels.
Scanning elec ron microscopy highligh s
Posi ive predic ors o success include higher
he di erence be ween argon laser applica-
baseline in raocular pressure and he 2-week
ion, wi h he “mel ing” o rabecular beams,
pos laser pressure response. Like AL , SL ’s
and he selec ive laser, wi h lit le, i any,
e cacy wanes over ime, on average ailing
observable s ruc ural al era ion (Fig. 22-6).
somewhere be ween 6 mon hs and 3 years.
T ere ore, he mechanical s re ching heory
is no applicable or he selec ive laser e ec Because here is no apparen s ruc ural
on he in raocular pressure. In vi ro cul ures damage wi h SL , repea SL is generally
Selective Laser Trabeculoplasty 325
hough o be sa e. Early s udies show ha HongB , Winer JC, Mar one JF, e al. Repea selec ive laser
re rea men yields success ul (≥20%) in ra- rabeculoplas y. J Glaucoma. 2009;18(3):180–183.
Jindra LF. SL as primary rea men . Ophthalmol
ocular pressure reduc ion. Also, in eyes ha Management. 2004;8(11):77–78.
have ailed previous AL , success has been Johnson PB, a z LJ, Rhee DJ. Selec ive laser rabecu-
repor ed in using SL o lower he in raocular loplas y: Predic ive value o early in raocular pres-
pressure. SL has also been shown o work sure measuremen s or success a 3 mon hs. Br J
well wi h PXF glaucoma, pigmen ary glau- Ophthalmol. 2006;90:741–743.
ramer R, Noecker RJ. Comparison o he morpho-
coma, juvenile open-angle glaucoma, and logic changes a er selec ive laser rabeculoplas y and
secondary pseudophakic glaucoma. argon laser rabeculoplas y in human eye bank eyes.
Ophthalmology. 2001;108:773–779.
BIBLIOGRAPH Y Lai JSM, Chua J , T am CCY, e al. Five-year ollow up
Alvarado JA, Iguchi R, Jus er R, e al. From he bedside o selec ive laser rabeculoplas y in Chinese eyes. Clin
o he bench and back again: Predic ing and improv- Exp Ophthalmol. 2004;32(4):369–372.
ing he ou comes o SL glaucoma herapy. Trans Am La ina MA, Sibayan SA, Shin DH, e al. Q-Swi ched 532-
Ophthalmol Soc. 2009;107:167–181. nm Nd:YAG laser rabeculoplas y (selec ive laser ra-
Alvarado JA, Iguchi R, Mar inez J, e al. Similar e ec s o beculoplas y). Ophthalmology. 1998;105:2082–2090.
selec ive laser rabeculoplas y and pros aglandin ana- Lee R, Hu nik CM. Projec ed cos comparison o selec ive
logs on he permeabili y o cul ured Schlemm canal laser rabeculoplas y versus glaucoma medica ion in
cells. Am J Ophthalmology. 2010;150(2):254–264. he On ario Heal h Insurance Plan. Can J Ophthalmol.
Damji F, Shah C, Rock WJ, e al. Selec ive laser ra- 2006;1(4):449–456.
beculoplas y argon laser rabeculoplas y: A pro- Nagar M, Shah N, apoor B. Selec ive laser rabeculo-
spec ive randomised clinical rial. Br J Ophthalmol. plas y in pseudophakic glaucoma. Ophthalmic Surg
1999;83:718–722. Lasers Imaging. 2010;9:1–2.
Hodge WG, Damji F, Rock W, e al. Baseline IOP pre- Spae h GL, Baez K . Argon laser rabeculoplas y con-
dic s selec ive laser rabeculoplas y success a 1 year rols one hird o cases o progressive, uncon rolled,
pos - rea men : Resul s rom a randomized clinical open angle glaucoma or 5 years. Arch Ophthalmol.
rial. Br J Ophthalmol. 2005;89:1157–1160. 1992;110:491–494.
FIGURE 22-4. Comparison o argon and selective laser spots. Comparative size o the argon laser spot
(50 µm) versus the Nd:YAG selective laser spot ( 400 µm) . (Courtesy o Michael S. Berlin, MD, Associate
Clinical Pro essor, University o Cali ornia–Los Angeles; Jules Stein.)
326 22 LASER TRABECULO PLAST Y
FIGURE 22-5. Comparison o spacing o laser spots. Spacing o the argon laser versus the close application o
the selective laser. riangle indicates approximate 50-µm spot size with AL versus the 400-µm spot size o SL
(right arrow) . (Courtesy o Michael S. Berlin, MD, Associate Clinical Pro essor, University o Cali ornia–Los
Angeles, Jules Stein.)
A B
FIGURE 22-6. Scanning electron microscopy o cadaver eyes treated with argon or selective laser.
A. Argon burn resulted in coagulative melting o the trabecular beam. Le panel: a lower-magni cation view
showing the crater; right panel: a higher-magni cation view showing the curling o the collagen caused by the
thermal damage. B. T e selective laser did not cause any signi cant structural alteration. Le panel: a lower-
magni cation view showing the absence o a crater; right panel: a higher-magni cation view showing a racture
o one o the sheets o collagen. (Reprinted with permission rom Kramer R, Noecker RJ. Comparison o the
morphologic changes af er selective laser trabeculoplasty and argon laser trabeculoplasty in human eye bank eyes.
Ophthalmology. 2001;108:773–779.)
Economics 327
ECO
E CONOM
MICS
IC
CS $4,838 compared wi h $6,571 or pa ien s
rea ed wi h medica ion alone. Fur her, laser
Mos prac i ioners oday s ill adhere o he rabeculoplas y o ered a cos savings o
rea men paradigm o medica ions as f rs - approxima ely $1,700 per pa ien rea ed by
line herapy, ollowed by laser rabeculoplas y, up i ra ion in medica ion rom wo o our
and hen possibly surgery. Ye , comparisons in over 5 years.
he li era ure be ween medica ions and laser T e au hor does no recommend ha
rabeculoplas y demons ra e equivalen e - prac i ioners base rea men decisions solely
cacy in reducing in raocular pressure. On he on economic considera ions. Curren ly, ac-
o her hand, economic s udies indica e ha ors such as age, access o medica ion, abili y
laser rabeculoplas y is more cos -e ec ive o adminis er and/ or olera e medica ion,
han rea men wi h medica ion. disease s age, and ra e o progression are s ill
In Aus ralia, aylor e al. ound ha a he primary considera ions ha will guide
change in rea men paradigm o f rs -line care. Ye , i is inevi able ha in he ace o
laser rabeculoplas y ollowed by opical oday’s rising heal h care expendi ures and
medica ion and hen rabeculec omy saved shrinking heal hcare budge s, cos is a ac-
$2.50 or every $1.00 spen . In pa ien s who or ha will be increasingly brough o he
received mono-, bi- or ri-medica ion herapy, ore ron .
a Canadian s udy o 6-year cumula ive cos s
ound ha primary SL repea ed every BIBLIOGRAPH Y
2 years produced cos savings o $206, Can or LB, a z LJ, Cheng JW, e al. Economic evalua-
$1,669, and $2,993 per pa ien . Similarly, ion o medica ion, laser rabeculoplas y and f l ering
in he Uni ed S a es, he baseline 5-year surgeries in rea ing pa ien s wi h glaucoma in he US.
Curr Med Res Opin. 2008;24(10):2905–2918.
cumula ive cos or pa ien s rea ed wi h
aylor HR. Glaucoma: Where o now? Ophthalmology.
laser rabeculoplas y was es ima ed o be 2009;116(5):821–822.
C H AP T ER
328
Studies 329
complica ions were more prevalen wi h rab- and ca arac orma ion. Wi h rabeculec-
eculec omy.3 In El Sayyad’s s udy, bo h groups omy, complica ions occur in 10% o 18%
were rea ed wi h pos opera ive 5-f uorouracil o pa ien s. T e well-guarded dissec ion in
(5-FU) subconjunc ival injec ions a he dis- deep sclerec omy reduces he complica-
cre ion o he inves iga ors. ions rela ed o over l ra ions.8
T e resul s o deep sclerec omy An impor an cavea exis s when
are improved when combined wi h an analyzing he resul s o nonpene ra ing
implan . T e implan is designed o main ain surgery. Deep sclerec omy is highly depen-
he suprachoroidal space (i.e., in rascleral den upon he echnical skills o he surgeon
bleb) avoiding he closure o he sclerec- which can bring large di erences when
omy. T e implan s can be absorbable or resul s rom di eren au hors are compared.
nonabsorbable. Deep sclerec omy has a long learning curve
In a case series o 105 eyes wi h an during which he surgical ime is longer
average ollow-up o 64 mon hs, Shaarawy and he ini ial ou comes migh no be very
e al., using absorbable implan s o col- sa is ac ory.
lagen, repor ed a success ra e o 91% (IOP Dahan and Drusedau repor ed he
< 21 mm Hg wi h or wi hou medica ions) resul s including pa ien s rom he learn-
a 96 mon hs; hal o he eyes underwen ing curve, during which ime per ora ions
laser goniopunc ure wi h a mean ime in o he an erior chamber were 1 in 3,
o goniopunc ure a 21 mon hs and 23% necessi a ing conver ing o a s andard rab-
received pos opera ive 5-FU injec ions.4 eculec omy. T ey also men ion ha as he
T ey repor ed no incidence o f a an erior manual echnique improves, he per ora-
chamber or endoph halmi is.4 ion ra e drops o 1 in 20.9
Using he nonabsorbable -Flux In our personal experience, he rs 20
implan (IOL ECH Labora ories, cases were conver ed o pene ra ing rab-
France), Jungkim e al.5 repor ed a case eculec omies or di eren reasons. Deep
series o 35 eyes wi h 12 mon hs o ollow- sclerec omy is no a simple surgery; on he
up demons ra ing a lowering o IOP rom con rary, ime is needed o learn i properly
33 mm Hg o an IOP o approxima ely bu once mas ered, i is elegan , secure, and
15 mm Hg wi h an average o 0.1 an iglau- com or able or he pa ien s in mos o he
coma medica ions. A es e al.6 repor ed cases.
similar resul s in a small case series o 25
eyes. REFERENCES
T e advan ages o o her me hods using 1. Baudouin C, Rouland JF, Le Pen C. Change in medical
cheaper ma erials, like viscoelas ic, show and surgical rea men s o glaucoma be ween 1997 and
2000 in France. Eur J Ophthalmol. 2003;13(suppl 4):
some long- erm validi y.7 I has been over
S53–S60.
50 years since rabeculec omy was popular- 2. Zimmerman J, Kooner KS, Ford VJ, e al.
ized; we are amiliar wi h i s advan ages, rabeculec omy vs nonpene ra ing rabeculec omy:
disadvan ages, and success ra e bu rab- A re rospec ive s udy o wo procedures in pha-
eculec omy has a price, he complica ions. kic pa ien s wi h glaucoma. Ophthalmic Surg. 1984;
15:734–740.
Mos o he complica ions are rela ed o
3. El Sayyad F, Helal M, El-Kholi y H, e al. Non-
excessive l ra ion, especially in he early pene ra ing deep sclerec omy versus rabeculec-
pos opera ive period, such as f a an erior omy in bila eral primary open angle glaucoma.
chamber, hypo ony, choroidal de achmen , Ophthalmology. 2000;107:1671–1674.
330 23 DEEP SCLERECTO MY SURGERY FO R GLAUCO MA
4. Shaarawy , Mansouri K, Schnyder C, e al. Long- erm 7. Ravine E, Bovey E, Mermoud A. -f ux implan
resul s o deep sclerec omy wi h collagen implan . J versus Healon GV in deep sclerec omy. J Glaucoma.
Cataract Ref act Surg. 2004;30:1225–1231. 2004;13:46–50.
5. Jungkim S, Gibran SK, Khan K, e al. Ex ernal rab- 8. Drolsum L. Conversion rom rabeculec omy o deep
eculec omy wi h -Flux implan . Eur J Ophthalmol. sclerec omy. Prospec ive S udy o he rs 44 cases. J
2006;16:416–421. Cataract Ref act Surg. 2003;29:1378–1384.
6. A es H, Ure men O, Andaç K, e al. Deep sclerec omy 9. Dahan E, Drusedau M. Non pene ra ing l ra ion sur-
wi h nonabsorbable implan ( -Flux): Preliminary gery or glaucoma: Con rol by surgery only. J Cataract
resul s. Can J Ophthalmol. 2003;38:482–488. Ref act Surg. 2000;26:696–701.
Surgical Technique 331
During he dissec ion when we s ar canal a er hey have been dila ed. T e body
observing he change in color be ween he will res in he scleral bed and can be xa ed
sclera and he clear cornea, i is bet er o wi h 10–0 nylon su ure.
do small cu s a he sides o he f ap (Fig. We recen ly worked on a modi ca ion o
23-7A). We need o ge ar an erior in o he he Esnoper V-2000 (AJL Oph halmic S.A.,
clear cornea be ore we ampu a e he deep Álava, Spain) (Fig. 23-10A). T is implan has
scleral f ap (Fig. 23-7B). I he surgeon is a rapezoidal shape wi h longi udinal s ria-
working alone, a ip is o use an addi ional ions (Fig. 23-10B) ha we believe enhance
s i ch o x he superior scleral f ap and o he f ow o he aqueous humor in o he supra-
ge a bet er view o he surgical eld (Fig. choroidal space; i can also be xa ed wi h
23-7C). su ure or by in roducing he pos erior par
T e rabeculodesceme ic membrane in o he suprachoroidal pocke as described
(Fig. 23-8A–B) is he key poin o he sur- by Muñoz.1 He repor ed a ur her decrease in
gery and special care mus be aken o pre- IOP o 2 mm Hg a more han 1 year a er he
pare i . T e rs and mos impor an s ep surgery.
is o ge he righ dep h. T e second s ep is T is echnique involves making an inci-
o peel Schlemm’s canal (Fig. 23-8C), and sion in he scleral bed abou 2 or 3 mm
some imes when we have done a very deep pos erior o he rabeculodesceme ic mem-
dissec ion i will be already removed, a er brane wi h very small cu s o expose he
his we can dila e he emporal and nasal suprachoroidal space (Fig. 23-11A, B); his
sides o Schlemm’s canal, his maneuver space is dila ed wi h a spa ula (Fig. 23-11C)
can be done wi h a spa ula (Fig. 23-8D). I and we place par o he implan inside ha
pre er he Mermoud predesceme ic spa ula pocke (Fig. 23-11D). A ip wi h he use o
(Huco Vision SA) or a scraper; he one hese implan s, as hey are colorless (Fig.
shown in he gure is he Dahan rabecular 23-11E), is o in hem wi h f uorescein
meshwork scraper (Fig. 23-8E). When (personal echnique) (Fig. 23-11F); his is
he canal is properly dila ed, he aqueous especially help ul during he learning process.
humor will f ow abundan ly. I every hing is success ul – good dissec ion
T e las aspec are he implan s (no avail- wi h he correc hickness and dep h, implan
able in he Uni ed S a es). T ey are used o in place, and appropria e aqueous humor
keep he scleral lake open, he posi ion where l ra ion (Fig. 23-11G) – we should be able
hey all are going o be is in he space crea ed o observe a ormed an erior chamber i no
a er making he deep f ap and will be covered rup ures o he membrane has occurred. We
by he remaining superior f ap. T ere are wo can now close he super cial f ap wi hou
ypes, he absorbable like he Aquaf ow colla- su ure (Muñoz echnique) 1 (Fig. 23-11H)
gen glaucoma drainage device (S aar Surgical, or using a 10–0 nylon su ure (Fig. 23-11I).
Monrovia, CA) (Fig. 23-9A) which has a T e conjunc iva can be closed wi h a running
comple e resorp ion wi hin 6 o 9 mon hs su ure o 8–0 Vicryl (E hicon) (Fig. 23-11J)
and he SKGEL (Corneal, Paris, France) (Fig. par icularly i i is a limbus-based conjunc ival
23-9B) made o re icula ed sodium hyaluro- f ap or wi h 10–0 nylon i i is ornix based.
na e. T e nonabsorbable implan s, like -Flux We also like o use an ime aboli es like
(Carl Zeiss Medi ec Company, La Rochelle, Mi omycin-C 0.05 mg per mL or 1.0 o 1.5
France) (Fig. 23-9C), have a shape and he minu es or 5-FU a 50 mg per mL or 3 min-
superior hap ics are inser ed in o Schlemm’s u es. We apply i by cut ing wo small pieces
Surgical Technique 333
A B
A B
FIGURE 23-2. A. Silk su ure 7–0 placed in clear cornea a 12 hours. B. Ro a ion o he globe or bet er
presen a ion o he eld.
A B
C D
FIGURE 23-3. A. Limbus-based incision. B. Fornix-based incision, rs s ep. C. Fornix-based incision, second
s ep. D. L shape inverses. Dahan describes he L incision, ornix based.
Surgical Technique 335
A B
FIGURE 23-4. A. Cau eriza ion o he eld, dia hermy very ligh . B. Scari ca or, ins rumen used o break he
unions a he sclera and conjunc iva.
A B
C D
FIGURE 23-5. A. Dimension o he f ap can be measured wi h a compass, horizon al. B. Dimension o he f ap
can be measured wi h a compass, ver ical. C. Fix rapezoidal-shaped marker. D. Area marked.
( continued)
336 23 DEEP SCLERECTO MY SURGERY FO R GLAUCO MA
E F
G H
FIGURE 23-5. (Continued) E. Super cial f ap, rec angular shape, rs s ep. F. Super cial f ap, rec angular
shape. G. Super cial f ap, rapezoidal shape, rs s ep. H. Super cial f ap, rapezoidal shape, 5 × 5 × 2 mm.
A B
A B
A B
C D
A B
A B
FIGURE 23-10. A. Esnoper V-2000 (AJL Oph halmic S.A., Álava. Spain) schema ic design. B. Esnoper V-2000,
rapezoidal shape wi h longi udinal s ria ions.
A B
C D
FIGURE 23-11. A. Crea ing he scleral pocke in a square f ap. B. Crea ing he scleral pocke in a rapezoidal
f ap. C. Widen he pocke wi h a spa ula. D. Esnoper V-2000 nonabsorbable implan in he scleral bed wi h he
pos erior par in he suprachoroidal pocke .
( continued)
Surgical Technique 341
E F
G H
I J
FIGURE 23-11. (Continued) E. -Flux nonabsorbable colorless implan . F. -Flux a er using f uorescein.
G. Aqueous humor ou f ow. H. Closing he scleral f ap, no su ure. I. Closing he scleral f ap wi h nylon 10–0.
J. Conjunc ival closing wi h Vicryl 8–0 running su ure.
342 23 DEEP SCLERECTO MY SURGERY FO R GLAUCO MA
A B
A B
FIGURE 23-13. A. Eye 24 hours a er a deep sclerec omy and phacoemulsi ca ion. B. Bel su ure over he
scleral f ap made wi h Vicryl 8–0.
A B
C D
FIGURE 23-14. A. Eye 24 hours a er a deep sclerec omy. B. Eye 1 mon h a er deep sclerec omy. C. Eye
6 weeks a er deep sclerec omy. D. Eye 3 mon hs a er deep sclerec omy.
346 23 DEEP SCLERECTO MY SURGERY FO R GLAUCO MA
A B
A B
A B
C D
A B
C D
E F
FIGURE 23-18. A. An erior-segmen OC de ails o he rabeculodesceme ic membrane, implan , and
posi ion o he iris can be observed. B. Coronal view rom an erior-segmen OC , -Flux in posi ion, end o
he hap ics can be seen and measured. C. Visan e OC o a deep-sclerec omy big bleb over he implan can be
seen. D. An erior-segmen OC wi h a suprachoroidal view rom he implan . E. An erior-segmen OC in a
non unc ioning deep sclerec omy, showing he collapse o he issue over he surgery. No l ra ion. F. Esnoper
V-2000 nonabsorbable implan coronal view wi h an iris incarcera ion a er a per ora ion.
C H AP T ER
24
rabeculec omy and Ex-PRESS
Mini Glaucoma Shun
Marlene R. Moster and Augusto Azuara-Blanco
RABECULEC
R AB E C
CUU L EC
ULEC
UL E O MY
MY presen ing wi h more advanced disease had
slower visual f eld progression i heir primary
350
Trabeculec omy 351
A B
FIGURE 24-1. Sli lamp view o an eye ha underwen rabeculec omy 3 mon hs earlier (A and B) . No e he
non localized eleva ion o he conjunc iva.
352 24 TRABECULECTO MY AND EX-PRESS MINI GLAUCO MA SHUNT
FIGURE 24-2. Topical anes he ic agen s. Xylocaine 2% gel or opical applica ion and lidocaine 1%
nonpreserved or sub enon’s or subconjunc ival injec ion.
354 24 TRABECULECTO MY AND EX-PRESS MINI GLAUCO MA SHUNT
FIGURE 24-3. Ballooning o conjunc iva. Ballooning o he conjunc iva wi h nonpreserved lidocaine 1%
( 0.5 mL) using a 30 gauge sharp needle in he direc ion o he superior rec us muscle.
FIGURE 24-4. Trac ion su ure placemen . Placemen o a superior rec us rac ion su ure prior o a limbus
based rabeculec omy.
Trabeculec omy 355
A B
FIGURE 24-5. Limbus based f ap. Developing a limbus based conjunc ival– enon’s f ap. A. T e conjunc iva
is grasped wi h orceps and eleva ed be ore he ini ial cu , placed approxima ely 8 o 10 mm pos erior o he
limbus. B. T e incision is ex ended la erally exposing he episclera.
A B
FIGURE 24-6. Fornix based f ap. Developing a ornix based conjunc ival– enon’s f ap. A. T e conjunc iva
is grasped wi h orceps and eleva ed be ore he ini ial cu . B. T e conjunc ival incision is done as an eriorly as
possible a he limbus, ex ending 2 o 3 clock hours.
356 24 TRABECULECTO MY AND EX-PRESS MINI GLAUCO MA SHUNT
A B
FIGURE 24-8. Corneal paracen esis. A corneal paracen esis is done emporally or nasally be ore crea ing he
s ula. A sharp kni e is used, and a long rack is crea ed.
Trabeculec omy 357
A B
FIGURE 24-9. Removing he in ernal issue block. A er an ini ial incision wi h a sharp kni e o en er in o
he an erior chamber, he s ula can be crea ed wi h a punch or wi h Vannas scissors (A). T e block excised can
be corneal and/ or limbal (B). No e he preplaced scleral f ap su ures, used o expedi e closure and minimize he
ime when he eye is hypo onous ( A and B) .
A B
FIGURE 24-10. Surgical iridec omy. Surgical iridec omy wi h Vannas scissors ( A and B) a er rabeculec omy
block removal. I is impor an o avoid he iris roo when grasping he peripheral iris.
A B
FIGURE 24-11. Su uring he scleral f ap. T ere are many di eren echniques or su uring he scleral f ap. In
his echnique he surgeon is ying he preplaced in errup ed su ures a each corner o he scleral f ap ( A). A
slipkno is help ul o adjus he igh ness and he amoun o drainage hrough he f ap (B) .
358 24 TRABECULECTO MY AND EX-PRESS MINI GLAUCO MA SHUNT
A B
C D
E F
FIGURE 24-12. Releasable su ures. Releasable su ure echnique in a limbus based conjunc ival incision
described by Richard P. Wilson, MD. A 10–0 nylon su ure is used. A and B. S ep 1: T e su ure en ers in o
he cornea 1 mm an erior o he limbus (dep h: mids romal) and exi s hrough he sclera adjacen o he f ap
(going undernea h he corneoscleral limbus and he inser ion o he conjunc iva) . C. S ep 2: T e needle is
passed hrough he scleral f ap and sclera adjacen o he f ap. D. S ep 3: T e needle en ers he sclera and exi s
hrough he cornea (direc ion parallel o s ep 1) . E. S ep 4: T e su ure is hen ied up securely. F. Illus ra ion
o he dep h o he su ure. (Illus ra ions by Chris ine Gralapp; adap ed wi h permission o American Academy
o Oph halmology rom Mos er MR, Azuara Blanco A. Focal Points Volume XVIII, number 6. San Francisco, CA:
American Academy o Oph halmology, 2000.)
Trabeculec omy 359
A B
A B
C D
FIGURE 24-14. Conjunc ival closure: ornix based f ap. Closure o a ornix based conjunc ival– enon’s f ap
wi h 10–0 nylon mat ress su ures a each corner ( A–D) .
Trabeculec omy 361
FIGURE 24-15. MMC solu ion. MMC ( 0.4 mg per mL) as delivered o he opera ing room.
A B
FIGURE 24-16. Applica ion o MMC. Delivery o MMC on a Weck cell sponge under he conjunc iva and
enon’s capsule ( A and B) . In his case large sponges are used. O her surgeons pre er o use mul iple small
sponges.
362 24 TRABECULECTO MY AND EX-PRESS MINI GLAUCO MA SHUNT
A B
FIGURE 24-17. Handling o MMC sponges. A. Collec ion o sponges o MMC and con amina ed f uid
a er irriga ion. T e number o sponges used and collec ed should be coun ed. B. Proper disposal o MMC
con amina ed ma erials is manda ory.
Trabeculec omy 363
FIGURE 24-18. Su ure lysis. A Hoskins lens is used o compress he conjunc iva and acili a e he view o he
nylon su ure. (Cour esy o Richard P. Wilson, MD, Wills Eye Hospi al, Philadelphia, PA.)
Trabeculec omy 365
hemorrhage (Fig. 24-21), ca arac , macular done hrough he conjunc iva, as repor ed
and op ic disc edema, and chorio-re inal olds by Shira o e al.1 A er anes he ic eye drops
(predominan ly in young myopic pa ien s). are ins illed, he f l ering bleb on he scleral
Hyphema is no rare (Fig. 24-22), bu o en ap is compressed by a cot on ip and
resolves wi h conserva ive managemen . released o conf rm he si e o excess f l ra-
T e ini ial managemen o early pos - ion a he scleral ap. T en, using a round,
opera ive hypo ony wi h a ormed an e- apered needle wi h 10–0 nylon su ure,
rior chamber is conserva ive wi h opical he scleral ap is su ured igh ly direc ly
s eroids and cycloplegics. In erven ion is hrough he conjunc iva. I necessary, an
indica ed in cases when hypo ony is associ- addi ional su ure can be placed and igh -
a ed wi h o her complica ions such as per- ened o achieve a wa er igh closure.
sis en low IOP wi h loss o visual acui y When i is di cul o see he margin
and hypo ony maculopa hy (Fig. 24-23, o he scleral ap, compression and su ur-
see below). rea men should be aimed a ing while observing wi h a Hoskins lens
correc ing he specif c cause o hypo ony. are help ul. Usually, small leakage a he
Mos commonly, hypo ony is due o over- su ured poin s occurs, especially when he
f l ra ion o a f l ering bleb. When here is bleb wall is hin. However, i s ops spon a-
a a an erior chamber wi h lens–corneal neously a ew hours or days la er because
ouch, immedia e surgical in erven ion is o he decrease in f l ra ion and/ or down-
necessary o preven endo helial damage sizing o he f l ering bleb. A er he proce-
and ca arac orma ion. Re orma ion o he dure, a opical an ibio ic is prescribed. T e
an erior chamber wi h viscoelas ic can be su ure is buried in he conjunc iva spon a-
done a he sli lamp or under he opera ing neously in 1 week in all cases.
microscope hrough he paracen esis made Occasionally, bleb revision or overf l-
in raopera ively. When here are large ra ion mus be associa ed wi h pa ch gra -
apposi ional choroidal e usions, drainage ing (i.e., in cases o incompe en scleral
o he uid is recommended. ap, when resu uring is no possible).
When overf l ra ion persis s (Fig. 24-24), La e bleb-rela ed in ec ion can be a very
several rea men s can be used o induce an severe complica ion, po en ially leading o
in amma ory or healing reac ion in he f l er- endoph halmi is (Fig. 24-26). I is more
ing bleb which modif es he morphology o he common in surgeries supplemen ed wi h
f l ering blebs and increase he IOP. Surgical MMC and in leaking (Figs. 24-27 to 24-29),
revision is he mos e cacious op ion. avascular, hin, localized f l ering blebs.
Palmberg ransconjunc ival su ures are
o en help ul o reduce overf l ra ion (Fig. REFERENCE
24-25). Resu uring he scleral ap hrough 1. Shira o S, Maruyama K, Haneda M. Resu uring he
he conjunc iva is curren ly our avored scleral ap hrough conjunc iva or rea men o excess
op ion. Su uring he scleral ap can be f l ra ion. Am J Ophthalmol. 2004;137:173–174.
Trabeculec omy 367
FIGURE 24-19. Fla an erior chamber. T e an erior chamber is f a (Spae h’s Grade II), wi h iris–cornea
ouch, bu no lens–cornea ouch.
FIGURE 24-20. Choroidal de achmen . Fundus pho ograph showing serous choroidal de achmen obscuring
he op ic nerve.
368 24 TRABECULECTO MY AND EX-PRESS MINI GLAUCO MA SHUNT
FIGURE 24-21. Suprachoroidal hemorrhage. Sli lamp pho ograph o an eye wi h suprachoroidal hemorrhage;
he re ina can be seen hrough he pupil.
FIGURE 24-23. Chronic hypo ony. Fundus pho ograph showing re inal olds and or uosi y o he vessels—
so called hypo ony maculopa hy.
FIGURE 24-24. Over l ra ion. Over l ra ion caused by an exuberan bleb. No e he avasculari y o he bleb.
370 24 TRABECULECTO MY AND EX-PRESS MINI GLAUCO MA SHUNT
FIGURE 24-25. Palmberg su ures. ransconjunc ival su ures can be used o reduce he size o he bleb and
rea over l ra ion.
A B
FIGURE 24-26. Bleb rela ed ocular in ec ion. A. Sli lamp pho ograph o a case o blebi is; purulen discharge
can be seen on he bleb. B. Hypopyon in a pa ien wi h blebi is.
Trabeculec omy 371
FIGURE 24-27. Conjunc ival but onhole. Conjunc ival but onhole iden i ed several weeks ollowing
rabeculec omy wi h MMC. T e arrowheads deno e he edges o he hole.
FIGURE 24-28. La e bleb leak. La e bleb leak 3 years ollowing rabeculec omy surgery. Under cobal blue
ligh , he Seidel es shows aqueous f ow rom he leak. T e bleb is small, localized, and avascular.
372 24 TRABECULECTO MY AND EX-PRESS MINI GLAUCO MA SHUNT
FIGURE 24-29. Encapsula ed bleb. ypically encapsula ed blebs are localized and vascularized.
Ex Press Mini Glaucoma Shun 373
A B
25
Glaucoma Drainage Devices
JoAnn A. Giaconi and Marlene R. Moster
376
Description 377
FIGURE 25-1. Nonrestrictive GDD. Models commercially available. A–D. Mol eno devices. T e newer
Mol eno3 shun s (A and B) are charac erized by a larger, more f exible episcleral pla e han he older models
(C and D). Numbers adjacen o models indica e sur ace area o episcleral pla e. E and F. Baerveld devices, he
pla es o which are made o barium-impregna ed silicone.
378 25 GLAUCO MA DRAINAGE DEVICES
FIGURE 25-2. Restrictive devices. Ahmed valves come wi h a f exible pla e (FP models) or rigid
polypropylene pla e (S models) . T e smaller sizes are in ended or pedia ric eyes. T e double-pla e model
consis s o a valved pla e connec ed o a nonvalved pla e by an in ervening silicone ube ha crosses over a rec us
muscle (in his gure, he in ervening ube is no connec ing he wo pla es on he bot om righ ) .
Surgical Technique 379
SURGICAL
S UR
R G IC
C AL E
ECH
CH
H N IQ
Q UE
E ube may or may no be f xed o he sclera
wi h su ures o 10–0 nylon or prolene (Fig.
Local anes hesia is recommended, as some 25-10). T is an erior su ure is wrapped
o he surgical s eps can be pain ul wi hou igh ly around he ube o preven movemen
adequa e anes hesia. A re robulbar, peribul- in o or ou o he an erior chamber, bu no
bar, or sub- enon’s injec ion can be u ilized. so igh ly ha i occludes he ube lumen.
T e supero emporal quadran (Fig. 25-3) o avoid conjunc ival erosion by he ube,
is he pre erred loca ion or implan a ion processed pericardium, donor sclera or cor-
o a f rs GDD (addi ional shun s can be nea, and less commonly ascia la a or dura,
implan ed in o her quadran s). For bet er are used o cover he an erior scleral por ion
exposure o he surgical si e, a corneal rac- o he ube (Fig. 25-11). T e pa ch gra is
ion (Fig. 25-4) or superior rec us bridle su ured in place using in errup ed su ures.
su ure is help ul. T e ube should be ushed Al erna ively, a par ial- hickness limbal-based
wi h balanced sal solu ion o ensure pa ency scleral ap can be ashioned, and he ube
using a 30-gauge cannula. en ry is made undernea h his ap so ha he
su ured ap covers he ube.
Generally, a ornix-based peri omy is used.
A 90- o 110-degree conjunc ival incision is T e ube can also be placed hrough he
adequa e or single-pla e implan s. S evens pars plana (Figs. 25-8 to 25-26) in cases
eno omy scissors are used o blun ly dissec where placemen in o he an erior chamber
pos eriorly in he quadran o make room is di cul or undesirable. T is approach
or he pla e. T e episcleral pla e is placed requires a pars plana vi rec omy by a re ina
be ween adjacen rec us muscles wi h i s surgeon wi h care ul at en ion o remove he
an erior edge a leas 8 mm pos erior o he vi reous skir in he quadran where he ube
limbus (Fig. 25-5). Nonabsorbable su ures will be inser ed.
(6–0 o 8–0 nylon, prolene, mersilene) are During he inser ion o nonrestrictive
passed hrough he f xa ion holes o he epi- devices, an addi ional s ep is needed o pre-
scleral pla e and su ured o he sclera. ven immedia e and prolonged pos opera-
T e op imal leng h o ubing is es ima ed ive hypo ony—occlusion o he ube. T is
by laying he ube across he cornea. T e ube s ep can be per ormed be ore su uring down
is hen rimmed, bevel up, o ex end 2 o he episcleral pla e in a number o ways.
3 mm in o he an erior chamber (Fig. 25-6). Absorbable 6–0 o 8–0 Vicryl su ure can be
A corneal paracen esis is made o provide ied around he ube so ha here is no ow
access o he an erior chamber in case o col- o he pla e. Vicryl o his size will dissolve in
lapse (Fig. 25-7). A 22- or 23-gauge needle 4 o 8 weeks, by which ime a ow-res ric ive
is used o crea e a rack in o he an erior capsule will have ormed around he pla e.
chamber, parallel o he plane o he iris, s ar - Because he ube is comple ely liga ed, several
ing approxima ely 1 o 2 mm pos erior o he ven ing sli s in he an erior ex rascleral por-
corneoscleral limbus (Fig. 25-8). T e ube is ion o he ube can be made wi h a needle
hen inser ed hrough his rack in o he or 15-degree blade o allow some aqueous
an erior chamber wi h smoo h orceps ou ow in he early pos opera ive period. T e
(Fig. 25-9). amoun o aqueous egress can be checked
wi h a 27-gauge cannula on a syringe wi h
Proper posi ioning o he ube in he saline inser ed in o he end o he ube. I he
an erior chamber is essen ial, ensuring ha i pressure canno be con rolled wi h
does no ouch he iris, lens, or cornea. T e
380 25 GLAUCO MA DRAINAGE DEVICES
medica ion during he period be ore he hrough he conjunc iva and pulled weeks
liga ure dissolves, abla ing he Vicryl su ure a er surgery, i IOP needs o be lowered.
wi h an argon laser can open he ube T e ripcord su ure has he advan age o no
( he su ure needs o be pos erior enough o requiring rea men wi h an argon laser i
he pa ch gra in order o be seen). Ano her early opening o he ube is needed. T e hird
op ion is a ripcord su ure o 5–0 nylon op ion is o ie o he in racameral por ion
su ure, 3–0 prolene, or 3–0 mersilene placed o he ube be ore inser ing i in o he an e-
in o he ube, en ering rom he pla e end rior chamber (Fig. 25-15). T is is generally
(Fig. 25-13). An absorbable su ure is hen done wi h nylon or prolene su ure, which
ied around he ube and he ripcord su ure can be lysed wi h he laser i IOP needs o be
(Fig. 25-14). T e dis al end o he ripcord brough down in he pos opera ive period. A
is placed subconjunc ivally in he in erior wa er igh conjunc ival closure comple es he
quadran , where i can be accessed by cut ing procedures.
FIGURE 25-3. Superotemporal quadrant. Placemen o an Ahmed ube shun in he supero emporal quadran
o he eye receiving he rs GDD.
Surgical Technique 381
FIGURE 25-4. Traction suture. A superior rac ion su ure o 6–0 silk placed hrough corneal s roma allows
in raduc ion o he eye or bet er exposure o he supero emporal quadran .
FIGURE 25-5. Scleral f xation. Ahmed ube shun sewn down o sclera 8–10 mm pos erior o he limbus using
nonabsorbable su ure.
382 25 GLAUCO MA DRAINAGE DEVICES
FIGURE 25-6. Tube trimming. Prior o inser ion in he eye, he ube is rimmed o an appropria e leng h wi h
Wes cot scissors so ha i will res 2 o 3 mm long wi hin he an erior chamber. When cu , he bevel should ace
upwards o decrease he risk o iris incarcera ion in o he ube.
FIGURE 25-7. Corneal paracentesis. T is is no considered o be a manda ory s ep, bu in he case o an erior
chamber collapse in raopera ively or f a chamber pos opera ively, i allows access o re orm he an erior
chamber.
Surgical Technique 383
FIGURE 25-8. Track creation. A 23-gauge needle en ering he an erior chamber prior o placemen o he ube.
T is rack should be crea ed a he pos erior surgical limbus or ideal ube posi ion.
FIGURE 25-10. Tube f xation. Su uring he ube shun o he sclera wi h 10–0 nylon. T is ype o su ure can
help direc he ube oward a rack ha is no direc ly in ron o i (i.e., i can change he course o he rack so
ha i will hold a bend where he su ure is placed) , or i can be used o help preven movemen o he ube. T is
is an op ional s ep.
FIGURE 25-11. Patch gra . A pericardial pa ch gra is placed over he ube be ore su uring i o episclera a
wo o our corners.
FIGURE 25-12. Pars plana tube shunt. T e ube en ers hrough he scleros omy used or pars plana vi rec omy.
Surgical Technique 385
FIGURE 25-13. Latina or ripcord suture. T e Baerveld 350-mm2 ube shun wi h prepared ripcord placed in
he an erior chamber.
A B
FIGURE 25-14. Ripcord suture. A. Ripcord su ure easily seen wi hin lumen o ube. T e absorbable Vicryl
su ure is ied igh ly around he ube wi h ripcord o preven ou f ow. B. Subconjunc ival end o a ripcord is
visible in he pos opera ive eye.
FIGURE 25-15. Ligature suture. Nonabsorbable su ure liga ing in racameral ube.
386 25 GLAUCO MA DRAINAGE DEVICES
he shun may need o be removed or pla e go ull hickness hrough sclera and
reloca ed. re ina.
Re inal de achmen : T is can occur i Endoph halmi is
he needle passes o secure he episcleral
FIGURE 25-16. Chronic hypotony. Chronic hypo ony wi h maculopa hy and choroidal olds.
FIGURE 25-17. Shallow anterior chamber. Shallow an erior chamber ollowing ube shun wi h chamber-
main aining su ure holding back he lens implan .
388 25 GLAUCO MA DRAINAGE DEVICES
FIGURE 25-18. Choroidal e usion. Fundus pho ograph showing serous choroidal de achmen impinging on
he op ic nerve.
FIGURE 25-20. Suprachoroidal hemorrhage. Sli -lamp pho ograph o an eye wi h suprachoroidal
hemorrhage; he re ina can be seen hrough he pupil.
Surgical Technique 389
FIGURE 25-21. Aqueous misdirection. Sli -lamp pho ograph o an eye wi h aqueous misdirec ion. T ere is a
f a an erior chamber and an eleva ed IOP.
FIGURE 25-23. Conjunctival erosion. Erosion o he conjunc iva over he an erior scleral por ion o a GDD
near he limbus. T ere is an increased risk o endoph halmi is wi h his complica ion. (Cour esy o Simon Law,
MD.)
FIGURE 25-24. Corneal decompensation. Pericardial pa ch gra overlying ube visible a limbus in
decompensa ed cornea.
Surgical Technique 391
FIGURE 25-25. Tube malposition. ube erosion hrough cornea and res ing on he sur ace o cornea.
(Cour esy o Simon Law, MD.)
FIGURE 25-26. Implant migration. Migra ion o he ube shun an eriorly in o he an erior chamber in a
14-year-old pa ien wi h congeni al ca arac and glaucoma.
C H AP T ER
26
Schlemm’s Canal-based Surgery
Richard A. Lewis
T
subconjunc ival space, he search or a sa e and he concep o nonpene ra ing glaucoma
e ec ive canal-based surgery did no s op. T e surgery has evolved as an al erna ive o
curren in eres in procedures in and around he ull- or par ial- hickness procedures ha rely
canal is a resul o a number o ac ors includ- on subconjunc ival f ow and a bleb. T e com-
ing he complica ions ha arise in he early and plex and uniquely individual variabili y o
la e pos opera ive period a er rabeculec omy hese procedures due o wound healing lead o
bu also as a resul o he developmen o more a search or a more direc surgical rea men o
sophis ica ed surgical ins rumen s and devices glaucoma. T e rs nonpene ra ing procedure
allowing easier access o he canal; such is he o u ilize a microca he er (i rack, iScience
case or canaloplas y, rabec ome, and iS en . In erven ional Inc., Menlo Park, CA) o ake
advan age o he ull ex en o he canal was
INDICATIONS canaloplas y, rs described in 2007.
392
Canaloplasty 393
A B
FIGURE 26-1. Canaloplasty ef ect. Ul rasound image o canal pre-op (A) and 2 years pos op (B). A. T e
collapsed canal in open-angle glaucoma sugges s limi ed f ow. B. Canaloplas y viscodila es he canal during
surgery and acili a es drainage in o he collec ors.
A B
FIGURE 26-2. Scleral dissection. A guarded blade is used o crea e a 300-µm par ial- hickness groove (A and
B), ollowed by sharp dissec ion o crea e a sclerocorneal f ap (C). D. A deeper f ap is dissec ed a approxima ely
99% dep h. E. Once Schlemm’s canal is unroo ed, a modi ed Drysdale spa ula is used o blun ly dissec he
inner corneoscleral f ap rom Desceme ’s membrane wi h care ul at en ion no o rup ure and en er he an erior
chamber. F. T e appearance o bo h dissec ed f aps; here is some blood ref ux rom each end o he exposed
Schlemm’s canal.
( continued)
Canaloplasty 395
C D
E F
FIGURE 26-4. Prolene suture in canal adjacent to Descemet’s window. Wi h removal o he microcannula,
he wo ends o he at ached prolene su ure are ied igh . No e he large clear Desceme ’s window a er excising
he deep scleral f ap.
Trabectome 397
RABEC
R ABE
E C O ME
ME OUTCOMES
Minckler DS, Baerveld G, Al aro M , e al. Clinical Minckler DS, Baerveld G, amirez MA, e al. Clinical
resul s wi h he rabec ome or rea men o open- resul s wi h he rabec ome, a novel surgical device
angle glaucoma. Ophthalmology. 2005;112:962–967. or he rea men o open-angle glaucoma. Trans Am
Ophthalmol Soc. 2006;104:40–50.
Irrigation Port
Protective
Footplate
Aspiration Port
Return Electrode
Active Electrode
a. Handpiece
b. Power, IA Line
c. Irrigation/Aspiration Unit
d. High Frequency Generator
e. Clean Tray
f. Main Stand
g. Foot Control
FIGURE 26-5. Trabectome handpiece and setup. T e irriga ion sleeve ends 5 mm above he ip. T e oo pla e
is 800 µm heel o ip, wi h a maximum wid h o 230 µm and maximum hickness o 110 µm. T e gap be ween
he elec rocau ery pole and he oo pla e is 150 µm. (Cour esy o NeoMedix Corpora ion, us in, Cali ornia)
A B
FIGURE 26-6 Trabectome. A. Canal view ollowing rabec ome procedure exposing he rabecular meshwork
and collec ors. (Cour esy o NeoMedix Corpora ion, us in, Cali ornia.) B. In raopera ive view o rabec ome
procedure. T e ip is wi hin Schlemm’s canal and moving o he le . Behind he probe, he opalescen colored
ou er wall o Schlemm’s canal can be seen ex ending rom he righ o he probe o he edge o he mirror.
iStent 399
iS E
ENN OUTCOMES
FIGURE 26-7. iStent. Surgical-grade i anium wi h wo openings and ridged ube o provide grea er re en ion
in he canal. (Cour esy o Glaukos, Laguna Hills, Cali ornia.)
A B
FIGURE 26-9. iStent positioning. A. Op imal posi ion o he s en . B. iS en placed hrough he M posi ioned
in he canal. No e he proximi y o he iS en in rela ion o he landmarks o he angle. (Cour esy o Glaukos,
Laguna Hills, Cali ornia.)
C H AP ER
27
Cyclodes ruc ive Procedures
or Glaucoma
Shan Lin, Geof rey P. Schwartz, and Louis W. Schwartz
402
Contraindications 403
removal o he eye as long as visualiza ion or A phakic pa ien wi h good vision has his-
ul rasound reveals no in raocular umor. orically been he primary con raindica ion;
ypes o glaucoma ha have been rea ed however, recen s udies have used ransscleral
wi h varying degrees o success include end- CPC and ECP in such cases.1,2
s age open-angle glaucoma; neovascular Marked uvei is is a rela ive con raindica-
glaucoma; glaucoma pos pene ra ing kera- ion because pa ien s have increased inf am-
oplas y; advanced angle closure, bo h pri- ma ion and risk or CME ollowing he
mary and secondary; rauma ic glaucoma; rea men ; care should be aken o ry o quie
malignan glaucoma; silicone oil glaucoma; he eye as much as possible be ore he proce-
congeni al glaucoma; pseudophakic and dure. However, uvei ic glaucoma is one o he
aphakic open-angle glaucoma; and second- secondary glaucomas ha have been rea ed
ary open-angle glaucoma. success ully wi h ECP and ransscleral CPC.
Al erna ive rea men s ha are usually For all o he nonpene ra ing orms o
considered in his group o pa ien s include CPC, he procedure is usually per ormed
l ering surgery wi h an ime aboli e or in he o ce, and pa ien coopera ion is
ube shun s. required; inabili y o coopera e may be a con-
Bo h ransscleral CPC and endoscopic raindica ion in such cases.
cyclopho ocoagula ion (ECP) have been used For ECP, very poor visual po en ial (no
in cases o rela ively good po en ial vision.1,2 ligh percep ion or hand mo ions) are con ra-
In he case o ECP, his is o en in he set ing indica ions since here are po en ial risks or
o combined cases wi h ca arac surgery.2 endoph halmi is and choroidal hemorrhage
Inf amma ion and cys oid macular edema wi h his in raocular surgery.
(CME) are no in requen complica ions and
should be an icipa ed and preven ed wi h EFE ENCES
appropria e s eroid herapy. 1. Egber P , Fiadoyor S, Budenz DL, e al. Diode laser
ransscleral cyclopho ocoagula ion as a primary surgi-
cal rea men or primary open-angle glaucoma. Arch
CONTRAINDICATIONS Ophthalmol. 2001;119(3):345–350.
2. Chen J, Cohn R , Lin SC, e al. Endoscopic pho oco-
T ere are rela ively ew s ric con raindica- agula ion o he ciliary body or rea men o re rac ory
ions o he various orms o CPC. glaucomas. Am J Ophthalmol. 1997;124(6):787–796.
404 27 CYCLO DES RUC IVE PRO CEDURES FO R GLAUCO MA
A B
FIGURE 27-1. A. Shields lens. Shields lens or noncontact transscleral CPC. B. Placement o laser burns 1.5 mm
rom the limbus. Note blanching o inf amed conjunctiva.
FIGURE 27-2. Noncontact transscleral CPC. Diagram o noncontact transscleral CPC showing that the laser
energy is actually ocused within the ciliary body.
406 27 CYCLO DES RUC IVE PRO CEDURES FO R GLAUCO MA
A B
FIGURE 27-3. Contact transscleral CPC. A. G probe or diode laser treatment. B. Diagram showing the
placement o the G probe relative to the limbus so that laser application is at the ciliary body.
Cyclocryotherapy 407
EFE ENCE
C YC
YCLO
C LO
OCCRYO
RY
YO H ERAP
ERA
AP Y 1. Biet i G. Surgical in erven ion on he ciliary body:
New rends or he relie o glaucoma. JAMA. 1950;
A ni rous oxide cryosurgical uni is used 142:889–897.
o cool he 2.5-mm probe o −80 °C, which is
placed approxima ely 1 mm pos erior o he
limbus or 60 seconds.
wo o hree quadran s are rea ed wi h
our spo s per quadran , avoiding he 3 and
9 o’clock posi ions (Fig. 27-4).1
FIGURE 27-4. CCT. Photograph demonstrating CC . T e probe is placed approximately 1 mm posterior to the
limbus.
408 27 CYCLO DES RUC IVE PRO CEDURES FO R GLAUCO MA
FIGURE 27-5. Transpupillar y CPC. Diagram showing transpupillary CPC. T e laser energy is being ocused
by a mirrored lens onto the ciliary body, which has been moved into view by scleral depression.
Endoscopic Cyclophotocoagulation 409
A B
FIGURE 27-6. ECP. A. Diagram showing an endolaser probe delivering energy to the ciliary body. (Courtesy o
Martin Uram, MD.) B. View through the endoscopic camera o the whitened, shrunken ciliary processes on the
le ollowing delivery o the laser energy. T e processes on the right have not received treatment but one process
has the red He–Ne beam ocused on its tip.
Postprocedure Care 411
La e Complica ions o
Glaucoma Surgery
Gabriel Chong, Francisco Fantes, and Paul F. Palmberg
TABLE 28-1. Fac ors ha can Inf uence Inadequate Healing Response
Wound Healing Hypotony
Choroidal e usion
Impeccable and precise surgical techniques Macular olds
Use o antimetabolites Flat chambers
Etiologyo glaucoma,such as uveitic or neovascular cause Bleb leaks
Use o postoperative anti-infammatory medications Bleb-related in ections
Other biologic actors, such as genetics, age, and race Giant blebs
412
Hypotony 413
B
A
FIGURE 28-1. Transcorneal sutures. A. Diagram o he echnique. (From Eha J, Ho man E, P ei er N. Graefes
Arch Clin Exp Ophthalmol. 2008;246:869–874.) B. Pho o mon age o he e ec o ranscorneal su ures over ime.
416 28 LA E CO MPLICA IONS O F GLAUCO MA SURGERY
A B
C D
FIGURE 28-2. Hypotony. A. Drama ic example o hypo ony causing olds in he choroid and re ina involving
he oveal region. B. Example o race cys ic changes and sub le olds in he in ernal limi ing membrane in a
pa ien wi h hypo ony maculopa hy as shown in op ical coherence omography (OC ) . C. In raopera ive video
s ill- rame showing a cu piece o donor cornea being used o cover a f ap. D. In raopera ive video s ill- rame
showing a compression su ure o 10-0 nylon being used over he piece o donor cornea o increase he scleral
resis ance o aqueous ou f ow.
Hypotony 417
FIGURE 28-3. Shallow an erior chamber sli -beam pho ograph showing a shallow an erior chamber. T ere is
signi can iridocorneal ouch; however, nei her he pupillary border nor in raocular lens is in con ac wi h he
cornea.
FIGURE 28-4. Peripheral choroidal ef usions. Fundus pho ograph showing peripheral choroidal e usions
( le ) .
418 28 LA E CO MPLICA IONS O F GLAUCO MA SURGERY
A B
C D
FIGURE 28-5. Repair o choroidal ef usion. In raopera ive video s ill pho ographs o a repair o choroidal e usion.
A. Paracen esis side-por using a sharp poin number 75 blade is made a he corneoscleral limbus. B. A sharp
blade is used o gen ly en er he suprachoroidal space a he base o he par ial- hickness radial scleral incision.
C. Once he suprachoroidal space is en ered, he incision is widened using a Kelly punch; a he base o he
incision, a hole crea ed by he punch can be seen. D. T e conjunc ival incision is closed using 7-0 Vicryl su ures;
he sclero omy is le open.
Bleb Leaks 419
reduc ion. However, pa ien s should be A varia ion o his echnique could be
aware o he possibili y o requiring pos - applied o ree conjunc ival gra s as well,
opera ive medical or surgical in erven ion adding he s eps o cut ing he issue rom he
or in raocular pressure con rol a er he selec ed si e, and wi hou olding he ree gra .
revision.
Results and Prognosis
Amnio ic membrane (AM) 14—in cases
in which he conjunc ival issue available T e s udy o AM ransplan a ion by
is considered by he surgeon o be very Budenz e al.14 does no o er an e ec ive
limi ed (e.g., as a resul o hinning or scar- al erna ive o conjunc ival advancemen or
ring), or here is already some degree o repair o leaking glaucoma-f l ering blebs. T e
p osis presen , an AM gra could be an cumula ive survival ra e or AM ransplan
al erna ive. T e echnique described nex is was 81% a 6 mon hs, 74% a 1 year, and 46%
sligh ly di eren rom he one described by a 2 years. T e cumula ive survival ra e was
Budenz e al.14 In his echnique, he gra 100% or conjunc ival advancemen hrough-
is olded upon i sel , leaving he basemen ou ollow-up.
layer ou ward, and he s romal layer on he Al hough Budenz e al.’s s udy showed ha
inside (Fig. 28-6). AM gra s were less success ul han resul s
T e echnique o su uring AM is as o he s andard conjunc ival advancemen ,
ollows: heir s udy showed ha hey could be suc-
cess ul in cer ain si ua ions, providing an
T e conjunc iva surrounding he isch-
al erna ive rea men or bleb leaks in special
emic bleb is reed (Fig. 28-7A, B).
circums ances.
T e old ischemic bleb is excised
T e long- erm resul s o he s udy o
(Fig. 28-7C).
Budenz e al. were published in 2007 wi h a
T e donor AM is removed and olded median ollow-up o 80 mon hs.20 Almos hal
upon i sel (see Fig. 28-6). o 15 pa ien s who received AM ransplan a-
T e an erior edges o he gra are ion developed ailures, our required reop-
su ured a he corners o corneal limbus era ion or bleb leakage, and hree required
using 9-0 nylon. reopera ion or uncon rolled in raocular
T e pos erior edge o he AM under- pressure.20 Four o 15 pa ien s wi h conjunc-
nea h he ree undermined an erior con- ival advancemen experienced ailure wi h
junc iva (Fig. 28-7D). one requiring ano her opera ion or a bleb
leak and hree pa ien s required glaucoma
T e gra is igh ly su ured o he an e-
in erven ion.20 Al hough no s a is ically sig-
rior edge o he pa ien ’s ree conjunc iva
nif can , he Kaplan–Meier long- erm survival
using a running 8-0 Vicryl su ure
curves rended oward earlier ailure wi h he
(Fig. 28-7E).
AM ransplan group.20
A 9-0 nylon compression su ure is
O her groups have had more success
placed a he an erior edge o he gra , a
wi h AMs including a group in Japan (Nagai-
he level o he limbus (Fig. 28-7F).
Kusuhara e al.) which repor ed six pa ien s
T e si e is checked or wound leaks wi h who underwen AM ransplan a ion-assis ed
uorescein s rips. bleb revision or leaking blebs and all six
T e an erior compression su ure can be pa ien s had heir leaks resolved wi hou
removed a er 1 mon h (Fig. 28-8). complica ions.21
Bleb Leaks 421
However, ano her group also in Japan 9. Gehring J , Ciccarelli EC. richlorace ic acid rea -
concluded ha he use o AM ransplan men o f l ering blebs ollowing ca arac ex rac ion.
Am J Ophthalmol. 1972;74(4):622–624.
did no improve he overall surgical ou - 10. Douvas NG. Cys oid bleb cryo herapy. Am J
come or heir pa ien s.22 T eir Kaplan– Ophthalmol. 1972;74(1):69–71.
Meier survival curves showed a success 11. Bet in P, Carassa G, Fiori M, e al. rea men o
ra e o 58.3% a 6 mon hs and 21.9% a er hyperf l ering blebs wi h Nd:YAG laser-induced
1 year or he AM ransplan group com- subconjunc ival bleeding. J Glaucoma 1999;8(6):
380–383.
pared o 74.8% success in heir con rol 12. Fink AJ, Boys-Smi h JW, Brear . Managemen
group rom 6 o 12 mon hs.22 o large f l ering blebs wi h he argon laser. Am J
In addi ion, i an AM gra ails, conjunc- Ophthalmol. 1986;101(6):695–699.
13. Fukuchi , Ma suda H, Ueda J, e al. Corneal lamel-
ival advancemen is s ill a possibili y. I may
lar gra ing o repair la e complica ions o mi omy-
even be possible o make modif ca ions in he cin C rabeculec omy. Clin Ophthalmol. 2010;4:
surgical echnique ha could al er he ou - 197–202.
comes. T is las poin is only specula ive; i 14. Budenz DL, Bar on K, seng SC. Amnio ic mem-
will need o be proven by a randomized clini- brane ransplan a ion or repair o leaking glaucoma
f l ering blebs. Am J Ophthalmol. 2000;130(5):
cal rial comparable o he Budenz e al. rial
580–588.
and, o course, by he f nal es o ime. 15. Budenz DL, Chen PP, Weaver YK. Conjunc ival
advancemen or la e-onse f l ering bleb leaks:
EFE ENCES indica ions and ou comes. Arch Ophthalmol. 1999;
117(8):1014–1019.
1. Jampel HD, Quigley HA, Kerrigan-Baumrind LA,
16. Burns ein AL, WuDunn D, Knot s SL, e al.
e al. isk ac ors or la e-onse in ec ion ollow-
Conjunc ival advancemen versus nonincisional
ing glaucoma f l ra ion surgery. Arch Ophthalmol.
rea men or la e-onse glaucoma f l ering bleb
2001;119(7):1001–1008.
leaks. Ophthalmology. 2002;109(1):71–75.
2. Lehmann OJ, Bunce C, Ma heson MM, e al.
17. O’Connor DJ, ressler CS, Caprioli J. A surgical
isk ac ors or developmen o pos - rabeculec-
me hod o repair leaking f l ering blebs. Ophthalmic
omy endoph halmi is. Br J Ophthalmol. 2000;
Surg. 1992;23(5):336–338.
84(12):1349–1353.
18. Wadhwani R , Bellows A , Hu chinson B . Sur-
3. Liebmann JM, i ch . Bleb rela ed ocular in ec-
gical repair o leaking f l ering blebs. Ophthalmology.
ion: A ea ure o he HELP syndrome. Hypo ony,
2000;107(9):1681–1687.
endoph halmi is, leak, pain. Br J Ophthalmol. 2000;
19. Schnyder CC, Shaarawy , avine E, e al. Free
84(12):1338–1339.
conjunc ival au ologous gra or bleb repair and
4. Sol au JB, o hman F, Budenz DL, e al. isk
bleb reduc ion a er rabeculec omy and nonpen-
ac ors or glaucoma f l ering bleb in ec ions. Arch
e ra ing f l ering surgery. J Glaucoma. 2002;11(1):
Ophthalmol. 2000;118(3):338–342.
10–16.
5. Sharan S, rope GE, Chipman M, e al. La e-onse
20. auscher FM, Bar on K, Budenz DL, e al. Long-
bleb in ec ions: Prevalence and risk ac ors. Can J
erm ou comes o amnio ic membrane ransplan a-
Ophthalmol. 2009;44(3):279–283.
ion or repair o leaking glaucoma f l ering blebs.
6. Song A, Scot IU, Flynn HW Jr, e al. Delayed-onse
Am J Ophthalmol. 2007;143(6):1052–1054.
bleb-associa ed endoph halmi is: Clinical ea ures
21. Nagai-Kusuhara A, Nakamura M, Fujioka M, e al.
and visual acui y ou comes. Ophthalmology. 2002;
Long- erm resul s o amnio ic membrane rans-
109(5):985–991.
plan a ion-assis ed bleb revision or leaking blebs.
7. Palmberg P. Surgery or complica ions. In: Alber
Grae es Arch Clin Exp Ophthalmol. 2008;246(4):
D, ed. Ophthalmic Surgery: Principles and echniques.
567–571.
London: Blackwell Science; 1999:v. 1.
22. Kiuchi Y, Yanagi M, Nakamura . E cacy o amni-
8. Okada K, sukamo o H, Masumo o M, e al.
o ic membrane-assis ed bleb revision or eleva ed
Au ologous blood injec ion or marked overf l ra-
in raocular pressure a er f l ering surgery. Clin
ion early a er rabeculec omy wi h mi omycin C.
Ophthalmol. 2010;4:839–843.
Acta Ophthalmol Scand. 2001;79(3):305–308.
422 28 LA E CO MPLICA IONS O F GLAUCO MA SURGERY
FIGURE 28-6. A single layer o amnio ic membrane being peeled rom he suppor ing membrane. T e s romal
layer is agains he paper and s icky. T e basemen membrane layer is shiny and non-s icky.
A B
C D
FIGURE 28-7. Amniotic membrane gra technique. A. T e conjunc ival issue surrounding he ischemic bleb
has been cu along he margins o he bleb; a superiorly placed 7-0 Vicryl corneal rac ion su ure is also seen.
B. T e conjunc ival- enon’s f ap has been blun ly undermined o mobilize he issue. C. T e ischemic bleb is
excised using a number 67 blade. D. T e pos erior layer o he amnio ic membrane sandwich is pushed and now
lying undernea h he conjunc ival- enon’s f ap.
(continued)
Bleb Leaks 423
E F
FIGURE 28-7. ( Continued) Amniotic membrane gra technique. E. T e conjunc ival- enon’s f ap and
amnio ic membrane sandwich are su ured oge her using a running 8-0 Vicryl su ure. F. A he corneal edge o
he gra , a 9-0 nylon compression su ure is used o obs ruc f ow rom undernea h he amnio ic membrane gra
a he limbus.
FIGURE 28-8. Appearance a er bleb revision. Pos opera ive appearance o he same eye shown in
Figure 28-7 ollowing bleb revision using a double-layer amnio ic membrane gra .
424 28 LA E CO MPLICA IONS O F GLAUCO MA SURGERY
(pos ca arac endoph halmi is was s udied) he s i ches in place un il hey become
have been applied by clinicians as a paradigm loose, or or 6 o 8 weeks i hey are reason-
o rea bleb-rela ed endoph halmi is, here ably well olera ed.
is growing evidence ha hose resul s can- In one case, a pa ien developed necro iz-
no be direc ly applied due o di erences ing blebi is (see Fig. 28-10), which required
in he virulence o he pa hogens involved use o a corneal pa ch gra , covered by an AM
be ween pos ca arac endoph halmi is and gra . A he same ime, a GDD was placed
bleb-rela ed endoph halmi is, in par icular superiorly (Fig. 28-12).
he Streptococcus species.
egardless o promp rea men ( ap and Bleb Dysesthesia
injec versus vi rec omy), visual prognosis On occasion, blebs can be associa ed wi h
is poor wi h f nal visual acui ies >20/ 400 in a cer ain degree o discom or . T e e iology
only 22% o 53% o pa ien s.4 Several s ud- o he pain is at ribu ed o he heigh and
ies also repor con ic ing resul s regarding shape o he bleb, which dis urbs he spread
rea men modali y wi h Song e al. repor ing o he ear f lm, producing dellen.7,8 T is con-
worse visual ou comes wi h vi rec omy rea - di ion has been associa ed wi h he presence
men and Busbee e al. repor ing he oppo- o bubbles a he sli -lamp examina ion, by
si e.4,5 Smiddy e al. repor ed 34 cases rom he cap ure o air bubbles wi hin he ears as
Bascom Palmer wi h nei her ap-injec ion he upper eyelid moves over he irregular bleb
nor ap-injec ion wi h vi rec omy proving (Fig. 28-13).
superior in he managemen o bleb-rela ed
endoph halmi is.6 Eyes wi h glaucoma-f l ering blebs expe-
rience more dyses hesia han eyes wi hou
Corneal Patching f l ering blebs. Budenz e al. iden if ed young
Corneal issue ha is no o ransplan age, supranasal bleb loca ion, poor lid cover-
quali y can be preserved in glycerin and used age, and bubble orma ion as being associa ed
or pa ching, as ollows: wi h glaucoma-f l ering–bleb discom or .7
T e donor cornea is cu o he needed Some blebs ha produce dyses hesia have
size. been described as ischemic, hin-walled,
and associa ed wi h low-normal pressures.
Desceme ’s membrane is peeled o Palmberg described a echnique in which, by
wi h wo large oo hed orceps. using compressing s i ches or 3 weeks over
T e bed is cleaned o necro ic issue. he bleb, here is a change in he o ending
T e cornea pa ch is su ured wi h 9-0 prof le o he bleb, hereby reducing discom-
nylon su ures and compressive su ures, as or or up o 83% o pa ien s es ed wi h his
needed. echnique.9 T e echnique is as ollows:
T e pa ch is covered by conjunc iva. I I he bleb is very hin, and he su ures
lit le conjunc iva is available, he surgeon could rauma ize he sur ace, he surgeon
may consider covering i wi h AM, wi h may consider aspira ing a small amoun o
he s romal layer inside, in direc con ac aqueous wi h a 30-gauge needle rom he
wi h pa ch. an erior chamber o decompress he bleb
o close he f l ra ion permanen ly, he (Fig. 28-14A).
surgeon can consider placing more han One or more 9-0 nylon mat ress su ures
one igh compression s i ch, and leaving are anchored in he cornea.
426 28 LA E CO MPLICA IONS O F GLAUCO MA SURGERY
Su ures are passed pos eriorly over he 4. Song A, Scot IU, Flynn HW Jr, e al. Delayed-onse
por ion o he bleb o be compressed, and bleb-associa ed endoph halmi is: Clinical ea ures
and visual acui y ou comes. Ophthalmology. 2002;
passed again over he bleb o ie he kno 109(5):985–991.
(Fig. 28-14B). 5. Busbee BG, ecchia FM, Kaiser , e al. Bleb-associa ed
T e kno is ied igh ly and ro a ed in o endoph halmi is: Clinical charac eris ics and visual
ou comes. Ophthalmology. 2004;111(8):1495–1503;
he cornea, making sure ha he area ar-
discussion 503.
ge ed is well compressed. 6. Ba’arah B , Smiddy WE. Bleb-rela ed endoph halmi-
Su ures are le in place rom 1 o is: Clinical presen a ion, isola es, rea men and visual
4 weeks, and hen removed (Fig. 28-14C). ou come o cul ure-proven cases. Middle East Af J
Ophthalmol. 2009;16(1):20–24.
7. Suner IV, Greenf eld DS, Miller MP, Nicolela M ,
EFE ENCES Palmberg PF. Hypo ony maculopa hy ollowing f l er-
1. Greenf eld DS, Suner IJ, Miller MP, e al. ing surgery wi h mi omycin C: Incidence and rea -
Endoph halmi is a er f l ering surgery wi h mi omy- men . Ophthalmology. 1977;104:207–214.
cin. Arch Ophthalmol. 1996;114(8):943–949. 8. Soong HK, Quigley HA. Dellen associa ed wi h f l er-
2. Higginbo ham EJ, S evens K, Musch DC, e al. Bleb- ing blebs. Arch Ophthalmol. 1983;101(3):385–387.
rela ed endoph halmi is a er rabeculec omy wi h 9. Palmberg P. Surgery or complica ions. In: Alber
mi omycin C. Ophthalmology. 1996;103(4):650–656. D, ed. Ophthalmic Surgery: Principles and echniques.
3. Wolner B, Liebmann JM, Sassani JW, e al. La e London: Blackwell Science; 1999:v. 1.
bleb-rela ed endoph halmi is a er rabeculec omy
wi h adjunc ive 5- uorouracil. Ophthalmology. 1991;
98(7):1053–1060.
A B
FIGURE 28-9. Giant bleb. A. An ischemic, gian cys ic bleb can be seen overhanging on o he cornea. A dell
can be seen a he an erior edge o he overhanging bleb. B. Pos opera ive appearance o he eye ollowing bleb
revision.
Giant Blebs 427
FIGURE 28-10. Bleb related in ection. An in eriorly loca ed bleb wi h blebi is. T e overlying conjunc ival
issue is clear, showing hazy bleb f uid benea h.
FIGURE 28-11. Bleb related in ection. An in eriorly loca ed bleb, which is ischemic, and a necro ic bleb wi h
opaque conjunc ival issue overlying he bleb.
428 28 LA E CO MPLICA IONS O F GLAUCO MA SURGERY
A B
FIGURE 28-13. Bleb dysesthesia. An air bubble can be seen ex ending rom he bleb and he upper lid.
Giant Blebs 429
A B
FIGURE 28-15. Encapsulated bleb. An encapsula ed bleb; he ense appearance and hickened appearance o
he wall o he “cys ” can be seen. Also no e he increased vasculariza ion o he overlying conjunc iva.
A B
C D
FIGURE 28-16. Transcorneal ap revision. A. A 30-gauge needle is ben in o a “Z” con gura ion. B. T e
needle is hen guided hrough clear cornea in o he an erior chamber. C. T e needle ip is seen pro ruding ou
undernea h he sclera f ap, visible under clear conjunc iva. D. T ere is a nice eleva ion o he bleb a er he needle
has been used o sever any brous adhesions, reeing he f ap.
432 28 LA E CO MPLICA IONS O F GLAUCO MA SURGERY
A B
A B
FIGURE 28-18. Ultrasound imaging o glaucoma drainage device. A. A Baerveld glaucoma drainage device
prior o capsule orma ion. T e pla e is indica ed by he yellow arrow. B. A Baerveld glaucoma drainage device
a er ube opening wi h f uid (red arrow) overlying he pla e ( yellow arrow) .
FIGURE 28-19. Tube exposure. An exposed glaucoma drainage device ube as indica ed by he yellow arrow.
A B
FIGURE 28-20. Patch gra . A. Scleral pa ch gra . B. Clear corneal pa ch gra .
Index
Note: Locators ollowed by ‘ ’ and ‘t’ re er to f gures and tables respectively.
437
4 3 8 INDEX
Blood ow, in glaucoma, 136–149 Circum erential bleb, 432, 433 Cornea
Brimonidine, 220, 306, 316 treatment o , 432 measurement o , 51
allergic reaction rom chronic, 307 Cirrus SD-OCT progression analysis mesodermal dysgenesis o , 164
Brinzolamide, 305t so ware, 81 Corneal blood staining, 263
B-scan ultrasonography, 217, 415 Cirrus SD-OCT RNFL imaging scan, 80 Corneal decompensation, 390
or cyclodialysis cle , 268 Closed-angle mechanisms, in uveitic Corneal edema, 386
or traumatic hyphema, 259 glaucoma, 214–215. See also Corneal paracentesis, 356 , 382
Buphthalmos, 154, 157 Uveitic glaucoma Corneal patches, usage o , 424–425. See
Bupivacaine, in deep sclerectomy ciliary body, 215 also Giant blebs
surgery, 331 peripheral anterior synechiae, 214, Corneal traction suture, 331
215 Corneotrabeculodysgenesis, 152
C posterior synechiae, 214–215, 216 Corticosteroids
Cadaver eye, dissection o , 7 Cogan–Reese syndrome, 284 oral, 219
Canaloplasty, 392–393 Cogan’s syndrome, 235 and uveitis treatment, 209–210, 212
e ect, 394 Collaborative Initial Glaucoma Cosopt, 316
mechanism o action, 392–393 Treatment Study (CIGTS), Cushing’s syndrome, 204
outcomes o , 393 302 Cyclocryotherapy (CCT), 223, 404,
technique, 393 Collagen def ciency syndromes, 292 407, 407
Capsulorhexis, 256 Color Doppler imaging (CDI), 142, 143 Cyclodestructive procedures, 402–411
Carbonic anhydrase inhibitors (CAI), description o , 142 complications o , 411, 411t
220, 260, 276, 321 limitations o , 142 contact transscleral, 406, 406
or glaucoma, 309–310, 310 purpose o , 142 contraindications to, 403
Carotid angiography, 293 Color stereophotographs, 64 cyclocryotherapy, 407, 407
Carotid-cavernous f stula (CCF), 32, Combigan, 316 endoscopic, 409, 410
292–293 Con ocal scanning laser doppler indications or, 402–403
classif cation o , 292 owmetry, 146 noncontact transscleral, 404, 405
clinical presentation o , 293 description o , 146 postprocedure care or, 411
diagnostic evaluation o , 293, 294 limitations o , 146 techniques, 404
management o , 293, 295 purpose o , 146 transpupillary, 408, 408
pathophysiology o , 292–293 Con ocal scanning laser Cyclodialysis cle , 58, 58 , 268, 269
Carteolol, 220, 305t, 308t ophthalmoscopy (CSLO), B-scan ultrasonography or, 268
Cataract 67–68, 105, 106 –107 clinical examination o , 268
and Fuchs’ heterochromic limitations o , 105 def ned, 268
iridocyclitis, 228 role o , 105 epidemiology o , 268
mature, 248 usage o , 105 gonioscopy and, 268
subcapsular, 228 Congenital anomalies, glaucoma history o , 268
traumatic, 264 associated, 162–166 occurrence o , 268
Cavernous sinus (CS), 292 aniridia, 162, 162 , 163 pathophysiology o , 268
Central retinal vascular occlusions Axen eld’s, 164, 165 slit-lamp examination o , 268
(CRVO), 282 Peter’s, 164, 166 special tests or, 268
Chandler’s syndrome, 284, 286 Rieger’s, 164 treatment o , 268
Choroidal detachment, 367 Rieger’s syndrome, 164, 165 , 166 Cyclodialysis, gonioscopy in, 46, 47
Choroidal e usion Congenital glaucoma, 152–173 Cyclophotocoagulation (CPC), 402
draining, 414 in gonioscopy, 153, 156 –157 Cyclosporine, 238, 245
repair o , 418 during goniotomy, 158 Cystoid macular edema (CME), 220, 403
Choroidal per usion and ocular pulse primary, 153–154, 155 –161
amplitude, 21 round cupping in, 153, 156 D
Chronic angle-closure glaucoma, Congenital syphilis, 235 Dahan Diamond Schlemm’s canal
270–281, 277 Congestive heart ailure (CHF), 308 opener kni e, 331
diagnostic evaluation o , 277 Conjunctiva, ballooning o , 354 Dahan incision, 331
gonioscopy and, 277 Conjunctival advancement, 419 Dahan trabecular meshwork scraper, 332
treatment o , 277 Conjunctival bu onhole, 365t, 371 Dalen–Fuchs’ nodules, 244
Chronic hypotony, 369 , 387 , 413 Conjunctival erosion, 386, 390 Deep sclerectomy surgery
Chronic obstructive pulmonary disease Conjunctival gra , 419–420 or glaucoma, 328–349
(COPD), 308 Contact transscleral advantages o , 343
Ciliary body cyclophotocoagulation postoperative care, 343–344,
rotation o , 215 (See also Uveitic (CPC), 402 345 –349
glaucoma) Continuous-wave argon laser, 408 studies, 328–329
tumors, 58, 59 Contusion trauma, gonioscopy in, surgical technique, 331–333,
Cipro oxacin, 343 46, 46 334 –342
INDEX 4 3 9
Glaucoma (continued) Glaucoma hemif eld testing, 84, 84 o Schiemm’s canal, 32, 33
drainage device, 222, 376–391 (See Glaucoma Laser Trial (GLT), 302 o Schwalbe’s line, 30, 34, 35
also Drainage device) Glaucoma probability score (GPS), technique o , 30, 30 –31
drop instillation or, 317, 317 –318 105, 109 in trauma, 46, 46 –47
FDT or, 92 Glaucoma progression analysis (GPA), and traumatic hyphema, 259
and Fuchs’ heterochromic 88, 88 Goniosynechialysis, 221
iridocyclitis, 228 limitations o , 88 Goniotomy, 154
hyperosmolar agents or, 311 role o , 88 procedures, 159
ipsilateral, 172 usage o , 88 Goniotomy kni e, usage o , 221
laser trial, 322 Glaucoma surgery, late complications Granulomatous uveitis, signs o , 217
lens-associated open-angle, 246–257 o , 412–435 Guarded f ltration surgery, 350
and lens-induced uveitis, 240–242 Glaucomatocyclitic crisis, 230–231 Guided progression analysis, 72, 74
(See also Lens-induced course o , 231 def ned, 88
uveitis) diagnostic evaluation o , 230–231
lens particle, 240, 250–251 di erential diagnosis o , 230 H
lens protein, 247–248, 248 , 249 epidemiology o , 230 Haab’s striae, 153, 155
management o , 302–303 etiology o , 230 Haag-Streit 900 series slit-lamp
medical treatment o , 304–319, 305t history o , 230 biomicroscope, 182
miotics or, 311, 311t laboratory studies o , 231 Heavy-molecular-weight (HMW)
neovascular, 40, 43 , 216 , 228 management o , 231 protein, 247
occurrence o , 82 ophthalmic examination o , 230–231 Heidelberg retinal owmeter (HRF),
and optic nerve, 13 Glaucomatous disc, 153 146, 146 –147
pathogenesis o , 4 Glaucomatous optic nerve injury, 209 Heidelberg retina tomography (HRT),
phacolytic, 240, 247 Glaucomatous optic neuropathy 67, 69 , 105
phacomorphic, 240, 256, 257 (GON), 64, 82 advantages o , 67–68
pigmentary, 40, 41 Glaucomatous visual f eld de ects, 82, 83 disadvantage o , 68
primary, 150, 174 Glaukom ecken, 279 usage o , 67
primary angle-closure, 270–281 Glycerin, 311 Hematoxylin and eosin (H&E), 7
primary open-angle, 150, 174–195 in uveitis treatment, 220 Hemodynamics measurement,
(See also Primary open- Goldmann applanation tonometer, 14, 15 instruments or, 137
angle glaucoma) usage o , 14 HeNe laser slit beam, 119
prostaglandins or, 313–314, 314 Goldmann equation, 5 Herpes simplex uveitis, 232
punctal occlusion or, 317, 319 modif cation o , 5 Herpes simplex virus (HSV), 230
risk actor or, 4, 82, 180t–181t, 402 Goldmann goniolens, 30 Herpes zoster uveitis, 232
and RTA, 119 Goldmann lens, 25, 321 Herpetic keratouveitis, 232–233
Schlemm’s canal-based surgery, Goldmann visual f eld, 122, 124 course o , 233
392–401 Goniolenses diagnostic evaluation o , 233
scientif c history o , 2 characteristics o , 25t di erential diagnosis o , 232–233
secondary, 150, 152, 174 types o , 26 epidemiology o , 232
secondary angle-closure, 282–289 Gonioscopy, 22–47, 36 , 182 etiology o , 232
secondary open-angle, 196–207 angle anatomy, elements o , 32, 32 –33 f ltration surgery, 233
secondary to elevated venous angle classif cation, 38, 38 –39 history o , 232
pressure, 292–301 angle structure in, 32, 32 laboratory studies o , 233
surgery in uveitis patient, 226 in angular recession, 46, 47 management o , 233
SWAP testing in, 90 in contusion trauma, 46, 46 ophthalmic examination o , 233
sympathomimetic agents or, 315, 315 in cyclodialysis, 46, 47 Herpetic uveitis, 234
tissue damage development in, 179t def ned, 22 Heterochromia, 227
trabeculectomy in, 350, 351 (See direct, 22–24 “Hill o vision,” 122, 123
also Trabeculectomy) dynamic, 44, 45 HLA-B27-associated anterior uveitis,
traumatic, 258–269 (See also error actors in, 44, 44 –45 215 , 230
Traumatic glaucoma) in ICE syndrome, 284 Hoskin anatomic classif cation, 152
uveitic, 208–245 (See also Uveitic indirect, 25–27 Hoskins lens, 366
glaucoma) in iridodialysis, 46, 47 Humphrey f eld analyzer (HFA), 84, 133
Glaucoma diagnosis (GDx) test, 71 o iris cyst, 32, 33 Humphrey machine, 122
strengths o , 72 iris plane, 32 and AASVF test, 131
Glaucoma drainage device (GDD), 350, o iris processes, 34, 36 –37 Humphrey visual f eld, 190
376, 419 iris root, 32 pa ern deviation, 88
ultrasound imaging o , 435 objectives o , 38 Hyperosmolar agents, or glaucoma,
Glaucoma drainage implants, 61, 63 pigment deposition and, 40, 41 –43 311
Glaucoma graph, 192, 194 purpose o , 22 Hyperosmotic agents, 321
INDEX 4 4 1
Peter’s anomaly, 164, 166 Posner-Schlossman Syndrome. See Pseudophakic malignant glaucoma,
Phacoanaphylactic endophthalmitis, 240 Glaucomatocyclitic crisis 51, 55
Phacoanaphylactic uveitis, 240, 253 Posterior chamber intraocular lens Pseudophakic pupillary block, 51, 55
Phacoanaphylaxis. See Lens-associated (PCIOL), 250 Psychophysical test, 120–135
uveitis (LAU) Posterior embryotoxon, 164 def ned, 120
Phacoantigenic uveitis, 240 Posterior synechiae, 214–215, 216 description o , 122–124
Phacolytic glaucoma, 240, 247 Prednisolone acetate (Pred Forte), 219 requency-doubling perimetry, 132,
clinical examination o , 247 Prednisone, 238 132 –135
history o , 247 Primary acute angle closure, 276–281, optic nerve visual f elds, 125, 126 –131
pathophysiology o , 247 278 purpose o , 121
special tests o , 247 clinical examination o , 276 short-wave automated perimetry,
treatment o , 247–248 diagnostic evaluation o , 276 132, 132 –135
Phacomorphic glaucoma, 50, 54 , 240, prognosis o , 276 Pulsatile ocular blood ow (POBF),
256, 257 symptoms o , 276 144, 145
clinical examination o , 256 treatment o , 276 Pulsed dye laser photocoagulation, 296
history o , 256 Primary angle-closure glaucoma, Punctal occlusion, or glaucoma, 317,
pathophysiology o , 256 270–281, 272t 319
treatment o , 256 background o , 270 Pupillary block, 214
Phacotoxic uveitis, 240 clinical examination o , 271–272
Photography, 99 epidemiology o , 271 R
NFL, 99, 100 –101 gonioscopy and, 271 Ranibizumab, 363
stereoscopic, 99, 100 management o , 277 Rapid plasma reagin (RPR), 236
Photophobia, 154 OCT and, 271–272 Re erence plane, def ned, 67
Physostigmine, 305t, 311t pathophysiology o , 270–271, 273 Relative pupillary block, 49–50, 52 –53
Pigmentary glaucoma, 40, 41 , 56. See with relative pupillary block, 277 def ned, 50
also Open-angle glaucoma risk actors or, 271 Resistive index (RI), 142
Pigment deposition and gonioscopy, 40, UBM and, 271–272 Retardation, 71
41 –43 Primary congenital glaucoma (PCG), Retinal ganglion cell, 82
angle-closure glaucoma, 40, 42 153–154, 155 –161 Retinal nerve f ber layer (RNFL), 64,
lens pseudoex oliation, 40, 41 angle visualization, 158 125, 178
neovascular glaucoma, 40, 43 characteristics o , 153 analysis scanning, ast, 75, 77
pigmentary glaucoma, 40, 41 clinical examination o , 153–154 deviation map, 71, 73
uveitis, 40, 42 di erential diagnosis o , 154 thickness map, 71, 73
Pigment dispersion syndrome (PDS), epidemiology o , 153 and TSNIT graph, 71, 74
56, 57 , 182, 196–197 history o , 153 Retinal pigment epithelium (RPE), 75
clinical examination o , 196–197 management o , 154 Retinal sensitivity, 122
epidemiology o , 196 unilateral, 153, 155 Retinal thickness analyzer (RTA), 119
history o , 196 Primary open-angle glaucoma, limitations o , 119
and Krukenberg’s spindle, 198 174–195 role o , 119
pathophysiology o , 196 clinical examination o , 182–184 usage o , 119
peripheral iris, 199 def nition o , 174–175, 176 Retinal thickness mapping, 119, 119
pigment deposition, 198 –199 epidemiology o , 177 Retrobulbar anesthesia, in Contact
transillumination de ects in, 198 external and biomicroscopic transscleral CPC, 406
treatment o , 197 examination, 182, 184 Retroillumination, with Koeppe lens, 23
Zentmeyer’s line, 199 gonioscopy, 182 Reverse pupillary block, 197
Pigment storm, 196 history o , 180 Rieger’s anomaly, 164
Pilocarpine, 304 management o , 191 Rieger’s syndrome, 164, 165 –166
hydrochloride, 305t, 311t pathophysiology o , 178, 178 Ritch goniolen, 321
nitrate, 305t, 311t posterior pole, 182–184, 185 –189 Round cupping, 156
strengths, 312 risk actors o , 180t–181t Rubella virus, 227, 228
Plateau iris, 50, 53 –54 , 277 special tests, 190
diagnostic evaluation o , 277 treatment o , 191–195, 191t–193t S
slit-lamp examination and, 277 Primary open angle glaucoma (POAG), Sampaolesi’s line, 200
treatment o , 277 2, 136, 392 Sampaolesi’s sign, 40, 41
Plateau iris conf guration, 281 Propionibacterium acnes, 253 Sarcoidosis, 235, 243–245
Plateau iris syndrome, 53 –54 Prostaglandin, 230 course o , 244
Plexi orm neurof bromas, 172 analogs, 220 diagnostic evaluation o , 243–244
Pneumotonometer, 5, 20, 20 or glaucoma, 313–314, 314 di erential diagnosis o , 243
Port wine stain, 296. See also Sturge- role o , 211 epidemiology o , 243
Weber syndrome (SWS) Pseudoex oliation, 252 etiology o , 243
4 4 4 INDEX