Ophthalmology
TOPIC:
ANGLE OF ANTERIOR CHAMBER
DYNAMICS OF AQUEOUS HUMOUR
TYPES OF GLAUCOMA
ANGLE OF ANTERIOR CHAMBER
Angle of anterior chamber plays an important role in
the process of aqueous drainage.
> It is formed by root of iris, anterior-most part of ciliary body, scleral spur,
trabecular meshwork and Schwalbe’s line (prominent end of Descemet’s
membrane of cornea)
> The angle width varies in different individuals and plays a vital role in the
pathomechanism of different types of glaucoma.
> Gonioscopic grading of the angle width. Various systems have been suggested to
grade angle width.
> The most commonly used Shaffer’s system of grading the angle is
given in Table.
TYPES OF GLAUCOMA
Glaucoma :
Definition :
Glaucoma is not a single disease process but a group
of disorders characterized by a progressive optic neuropathy resulting in a
characterstic appearance of the optic disc and a specific pattern of irreversible
visual field defects that are associated frequently but not invariably with raised
intraocular pressure (IOP).
CLASSIFICATION
Clinico-etiologically glaucoma may be classified as follows:
A. Congenital/developmental glaucomas
1. Primary congenital glaucoma (without associated anomalies).
2. Developmental glaucoma (with associated anomalies).
B. Primary adult glaucomas
1. Primary open-angle glaucomas (POAG)
2. Primary angle-closure glaucoma (PACG)
3. Primary mixed mechanism glaucoma
C. Secondary glaucomas
A. Congenital/developmental glaucomas
The congenital glaucomas are a group of diverse disorders in which
abnormal high intraocular pressure results due to developmental
abnormalities of the angle of anterior chamber obstructing the drainage of
aqueous humour.
1. Newborn glaucoma : also called as true congenital glaucoma, is labelled when
IOP is raised during intrauterine life and child is born with ocular enlargement. It
accounts for about 40% of cases.
2. Infantile glaucoma is labelled when the disease manifests prior to the child’s
third birthday. It accounts for about 55% of cases.
3. Juvenile glaucoma is labelled in the rest 5% of cases who develop pressure rise
after 3 years but before adulthood. Also known as Juvenile primary open angle
glaucoma(POAG) usually occurs between
10 to 35 years of age. About 35% of patients with juvenile POAG are myopes. The
disease has a strong autosomal dominant inheritance
DEVELOPMENTAL GLAUCOMAS WITH ASSOCIATED OCULAR
ANOMALIES
A wide variety of systemic and/or ocular anomalies have an associated raised IOP,
usually due to developmental defects of the anterior chamber
angle. Some of the associations are as follows:
I. Glaucoma associated with iridodysgenosis
1. Glaucoma associated with aniridia (50%)
2. Glaucoma associated with familial iris hypoplasia
3. Glaucoma associated with congenital ectropion uvea
4. Glaucoma associated with congenital microcornea
5. Glaucoma associated with congenital nanop-hthalmos
II. Glaucoma associated with iridocorneal dysgenesis
These include:
1.Posterior embryotoxon
2. Axenfeld-Rieger syndrome
B. Primary adult glaucomas
PRIMARY OPEN-ANGLE GLAUCOMA
As the name implies, it is a type of primary glaucoma, where there is no obvious
systemic or ocular cause of rise in the intraocular pressure.
Primary open-angle glaucoma (POAG), also known as chronic simple glaucoma
of adult onset, is typically characterised by:
• Slowly progressive raised intraocular pressure
(>21 mm Hg recorded on at least few occasions) associated with,
• Open normal appearing anterior chamber angle,
• Characteristic optic disc cupping, and
• Specific visual field defects.
PRIMARY ANGLE-CLOSURE DISEASE
The word glaucoma is used only when the optic disc and visual field
changes are present, so the term ‘primary angle closure disease’ should
replace the term ‘primary angle closure glaucoma’.
Primary angle closure disease, is characterised by apposition of peripheral
iris against the trabecular meshwork (TM) resulting in obstruction of
aqueous outflow by closure of an already narrow angle of the anterior
chamber. The condition is not associated with any other ocular and systemic
abnormalities.
C. Secondary Glaucomas
Secondary glaucoma is not a disease entity, but a group of disorders in which rise of
intraocular pressure is associated with some primary ocular or systemic disease.
Therefore, clinical features comprise that of primary disease and that due to effects
of raised intraocular pressure.
Classification
A. Depending upon the mechanism of rise in IOP
1. Secondary open angle glaucomas in which aqueous outflow may be blocked
by:
• Pretrabecular membrane,
• Trabecular clogging,
• Oedema and scarring or
• Post-trabecular elevated episcleral venous pressure.
2. Secondary angle closure glaucomas which may or
may not be associated with pupil block.
B. Depending upon the causative primary disease
secondary glaucomas are named as follows:
1. Lens-induced (phacogenic) glaucomas.
2. Inflammatory glaucoma (glaucoma due to intraocular inflammation).
3. Pigmentary glaucoma.
4. Neovascular glaucoma.
5. Glaucomas associated with iridocorneal endothelial syndromes.
6. Pseudoexfoliative glaucoma.
7. Glaucomas ass ociate d w ith intraocular haemorrhage.
8. Steroid-induced glaucoma.
9. Traumatic glaucoma.
10. Glaucoma-in-aphakia.
11. Glaucoma associated with intraocular tumours.
LENS-INDUCED (PHACOGENIC) GLAUCOMAS
In this group IOP is raised secondary to some disorder of the crystalline lens.
Lens induced glaucoma can be classified as below:
Lens-induced secondary angle closure glaucoma
• Phacomorphic glaucoma (due to swollen lens)
• Phacotopic glaucoma (due to anterior lens displacement).
Lens-induced secondary open angle glaucoma
• Phacolytic glaucoma
• Lens particle glaucoma
• Phacoanaphylactic glaucoma.
GLAUCOMAS DUE TO UVEITIS
The IOP can be raised by varied mechanisms in inflammations of the
uveal tissue (iridocyclitis). Even in other ocular inflammations such as keratitis
and scleritis, the rise in IOP is usually due to secondary
involvement of the anterior uveal tract.
Types:
I. Non-specific inflammatory glaucomas, and
II. Specific hypertensive uveitis syndromes.
PIGMENTARY GLAUCOMA
It is a type of secondary open-angle glaucoma wherein clogging up of the
trabecular meshwork occurs by the pigment particles. About 50% of patients
with the Pigment dispersion syndrome (PDS) develop glaucoma.
NEOVASCULAR GLAUCOMA (NVG)
It is an intractable glaucoma which results due to formation of neovascular
membrane involvingthe angle of anterior chamber. It is usually associated with
neov-ascularization of iris (rubeosis iridis). Neov-ascularization develops
following retinal ischaemia, which is a common feature of:
• Proliferative diabetic retinopathy,
• Central retinal vein occlusion,
• Sickle-cell retinopathy, and
• Eales’ disease.
• Other rare causes are chronic intraocular inflammations, intraocular
tumours, long-standing retinal detachment and central retinal artery occlusion.
GLAUCOMA ASSOCIATED WITH INTRAOCULAR TUMOURS
Secondary glaucoma due to intraocular tumours such as malignant melanoma (of
iris, choroid, ciliary body) and retinoblastoma may occur by one or more of the
following mechanisms:
• Trabecular block due to clogging by tumour cells or direct invasion by
tumour seedlings.
• Neovascularization of the angle.
• Venous stasis following obstruction of the vortex veins.
• Angle closure due to forward displacement of iris-
lens diaphragm by increasing tumour mass.
TRAUMATIC GLAUCOMA
A secondary glaucoma may complicate perforating as well as blunt injuries.
Mechanisms : Traumatic glaucoma may develop by one or more of the
following mechanisms:
• Inflammatory glaucoma due to iridocyclitis .
• Glaucoma due to intraocular haemorrhage .
• Lens-induced glaucoma due to ruptured, swollen
or dislocated lens .
• Angle-closure due to peripheral anterior synechiae formation
following perforating corneal injury producing adherant leucoma.
• Epithelial or fibrous in growth, may involve trabeculum.
• Angle recession (cleavage) glaucoma.
GLAUCOMAS ASSOCIATED WITH INTRAOCULAR HAEMORRHAGES
Intraocular haemorrhages include hyphaema and/or vitreous haemorrhage due to
multiple causes. These may be associated with following types of glaucomas:
1. Red cell glaucoma. It is associated with fresh traumatic hyphaema. It is caused
by blockage of trabeculae by RBCs in patients with massive hyphaema (anterior
chamber full of blood). It may be associated with pupil block due to blood clot.
Blood staining of the cornea may develop, if the IOP is not lowered within a few
days.
2. Haemolytic glaucoma. It is an acute secondary open angle glaucoma due to
the obstruction (clogging) of the trabecular meshwork caused by macrophages
laden with lysed RBC debris.
3. Ghost cell glaucoma. It is a type of secondary open angle glaucoma which
occurs in aphakic or pseudophakic eyes with vitreous haemorrhage. After
about 2 weeks of haemorrhage the RBCs degenerate, lose their pliability and
become khaki-coloured cells (ghost cells) which pass from the vitreous into
the anterior chamber, and block the pores of trabeculae leading to rise in IOP.
4. Hemosiderotic glaucoma. It is a rare variety of secondary glaucoma
occurring due to sclerotic changes in trabecular meshwork caused by the iron
from the phagocytosed haemoglobin by the endothelial cells of trabeculum.
Some other secondary glaucomas are:
● Pseudoexfoliative glaucoma
● Glaucomas in aphasia / psudophakia
● Steroid-induced glaucoma
● Ciliary block glaucoma
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