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Grand Ward Round. 31st January 2008 Boey Pui Yi Medical Officer. Case 1. Mr GKH 35/Chinese/male No past medical history Poor vision RE since childhood ?amblyopia Can only count fingers RE No trauma. Presented with…. RE pain & redness 1 day 1st episode No trauma. Van Herick

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grand ward round

Grand Ward Round

31st January 2008

Boey Pui Yi

Medical Officer

case 1
Case 1
  • Mr GKH 35/Chinese/male
  • No past medical history
  • Poor vision RE since childhood
    • ?amblyopia
    • Can only count fingers RE
    • No trauma
presented with
Presented with…
  • RE pain & redness 1 day
  • 1st episode
  • No trauma
slide5
Van Herick
  • 1 (<25%) - high
  • 2 (25%) - possible
  • 3 (25-50%) - unlikely
  • 4 (>50%) - rare
examination
RE

CF closely

Cornea hazy

Pupil mid-dilated

No RAPD

AC shallow

Glaucomflecken +

IOP 52

LE

6/6

Cornea clear

AC shallow

Lens clear

IOP 12

CD 0.4

Examination
slide9

Gonioscopy - correct conditions:

  • Dark room
  • High magnification
  • Small light beam 1-2mm height, as narrow as possible
  • Avoid pupil
  • +/- offset illumination column 10 deg
  • Superior and inferior angles first
acute glaucoma in young male ddx
Open angle

Primary OAG - rare

Secondary OAG

Pretrabecular

Neovascular

Trabecular

Uveitic - Any severe AAU, Fuch’s HI, Possner-Schlossman, Herpetic (HZV,VZV)

Pigment dispersion

Traumatic - hyphaema, angle recession

Post-trabecular

Raised episcleral pressure - CCF, Sturge-weber

Closed angle

Primary ACG - rare

Secondary ACG

Anterior pulling forces

Neovascular

Peripheral anterior synechiae

Posterior pushing forces

Posterior synechiae eg. Seclusio pupillae

Lens-related eg. Subluxation

Tumour eg. CB mass

Angle crowding

Plateau iris

Rare causes a/w ocular pathology

Ant segment dysgenesis

Aniridia

Iridocorneal-endothelial syndrome (ICE)

Phakomatoses (open or closed)

Sturge-Weber, NF

Acute glaucoma in young male – DDx?
anterior segment oct
Anterior segment OCT

RE

  • B scan RE
    • No RD
    • No mass displacing CB forward
  • Axial length
    • 24.67mm

LE

diagnosis
Diagnosis?
  • Acute primary angle closure (APAC) attack RE
  • PACS LE
  • Management…
key phrases for exams
Key phrases for exams…
  • Acute sight-threatening ocular emergency
  • Aim to break attack and lower IOP
    • Medical Rx
    • Other eg. Laser peripheral iridoplasty
  • Definitive treatment is laser PI
slide15

52(2130hr)

28 (1600hr)

Laser PI BE

21 (1800hr)

IV diamox 500mg

PO diamox 250mg tds

G T 0.5%

G pilo 4% q15min x 1hr

G alphagan

G xalatan

G PF hrly

G alphagan

G PF 2H

Attempted laser PI - failed

Repeat laser iridoplasty

40(2330hr)

48 (1220hr)

14(1000hr)

Laser iridoplasty

IV mannitol 130ml (20%) over 30min

30 (0200hr)

48 (1000hr)

Overnight…

review 1 52 post pi
RE

IOP 14

CD 0.3

Re-attached RD with pseudo-RP picture

LE

IOP 19

2-3

2-3

0

2-3

2

1-2

2

2

Review 1/52 post-PI

Plan: TCU 2/52, HVF

is our patient the typical apac pt
Patient factors

Elderly

Female

Race - Chinese, Eskimos

Family history

Ocular factors

Anatomical

Shallow AC, narrow angles

Anterior iris-lens diaphragm

Hypermetropia

Thick lens

Small corneal diameter

Physiological

Semi-dark lighting

Relative pupil block

Is our patient the typical APAC pt?
pathogenesis of apac
Pathogenesis of APAC
  • Incompletely understood
  • Physiological conditions
    • Iris rests posteriorly on anterior lens capsule
    • Some degree of resistance at pupil
    • Pressure in posterior chamber exceeds that in anterior chamber
  • Dilator muscle theory
    • Contraction of dilator pupillae exerts a posterior vector
      •  apposition between iris and lens,  pupil block
      • Dilated pupil  peripheral iris more flaccid  bombe
  • Sphincter muscle theory
    • Pupillary blocking force of sphincter greatest at 4mm
pathogenesis of apac20
Pathogenesis of APAC

Pupil block

Iris bombe

Irido-trabecular block

Acute  IOP

revised classification of primary angle closure pac
Revised classification of Primary Angle Closure (PAC)
  • Foster PJ et al. The definition and classification of glaucoma in prevalence surverys. BJO 2002;86;238-242
  • Acute, symptomatic form of angle closure may not have end-organ damage
    • 65-70% recover without OD or VF damage
  • Chronic, asymptomatic form of angle closure may have more end-organ damage
    • Comparison of 18 AACG vs 11 CACG eyes
      • NFL defect 39% vs 82%
      • Disc cupping 0% vs 45%
      • Disc pallor 39% vs 82%
  • Douglas GR et al. The visual field and nerve head in angle-closure glaucoma. A comparison of the effects of acute and chronic angle closure. Arch Ophthalmol 975;93:409-11
revised classification of primary angle closure pac24
Revised classification of Primary Angle Closure (PAC)
  • PAC suspect or narrow angles
    • Appositional contact between peripheral iris and posterior trabecular meshwork is considered possible
    • Arbitrary defined: 270º of posterior pigmented TM cannot be seen
  • PAC
    • Occludable angles, with:
    • Features indicating that TM obstruction by peripheral iris has occurred
      • PAS
      • IOP
      • Iris whorling (distortion of radially oriented iris fibres)
      • Glaucomflecken
      • Excessive TM pigmentation
  • PACG
    • PAC, with Glaucomatous disc or VF defect
laser settings iridoplasty
Laser settings - Iridoplasty
  • Indications
    • APAC when corneal oedema precludes laser peripheral iridotomy
    • Plateau iris
  • Therapeutic goal
    • Shrink and flatten peripheral iris
    • Peripheral iridoplasty
      • Peripheral iris
    • Radial iridoplasty
      • Double row of burns radially on oblique meridians
      • Dilate pupil to break pupil block
laser settings iridoplasty26
Laser settings - Iridoplasty
  • Type of laser
    • Argon
      • 4-10 per quad, 1 spot size apart
      • Large, long, low-powered burns
      • 200-500microns
      • 0.2-0.5s
      • 0.2-0.4W
  • End-point
    • Non-penetrating contraction burns
peripheral iridotomy
Peripheral iridotomy
  • Indications
    • Therapeutic
      • PACG
      • POAG with narrow angles
      • Secondary ACG
    • Prophylactic
      • Narrow occludable angles
peripheral iridotomy28
Peripheral iridotomy
  • Technique
    • Lens
      • Abraham
    • Site
      • 1, 11 o’clock
      • Peripheral 1/3, Iris crypt
    • Type of laser
      • Argon
        • Small, short, high-powered burns
        • 50microns
        • 0.02-0.05s
        • 0.8-1.1W
      • Nd:YAG
        • 2-3.5mJ
    • End-point
        • Plume of pigments
        • Visualise lens capsule
        • Transillumination
case 2
Case 2
  • Mdm LGS, 74/Chinese/lady
  • DM - OHGA
  • Seen previously in TTSH Eye 2004-05
    • VR 6/7.5 +1.75/-0.75x88
    • VL 6/7.5 +2.25/-1.25x105
    • NS + cataracts
    • AC D/Q
    • No NVI
    • Dilated fundal exam - No DR, CDR 0.2 OU
    • Discharged to OPS for yearly DRP
urgent referral
Urgent referral…
  • LE pain, redness 1 day
  • Giddy, vomiting
  • 1st episode
  • RE no complaints
examination32
RE

6/24 -> 6/12

Cornea clear

AC shallow

NS 2-3 +

IOP 26

CD 0.2

LE

HM

Hazy cornea

AC shallow

NS 2-3 +

IOP 46

No RAPD

0

0

0

0

0

0

0

0

Examination
diagnosis33
Diagnosis
  • LE APAC attack
  • RE PAC
slide34

D1

  • 46 (1510hr)
  • 46 (1730hr)
  • 31 (2030hr)
  • 27 (0000hr)
  • IV diamox 500mg
  • PO diamox 250mg tds
  • T 0.5, PF 3H, Pilo 4% LE, Pilo 2% RE
  • IV mannitol, G alphagan

D2

  • 16 (0900hr)
  • 10 (1030hr)
  • 13 (1630hr)
  • RE laser PI - through
  • LE laser PI (1st) - failed - cornea haze +
  • LE laser PI (2nd) - failed
  • LE laser PI (3rd) - failed

D3

  • 18
  • LE laser PI (4th) - failed
  • Options? Laser Iridoplasty? Surgical PI? Watch?

D4

  • 16

D5

  • 16

Discharged with AAC advice

  • LE laser PI (5th) - through

D6

  • 12
slide36
46 (1510hr)

46 (1730hr)

31 (2030hr)

27 (0000hr)

16 (0900hr)

10 (1030hr)

13 (1630hr)

18

16

16

12

IV diamox 500mg

PO diamox 250mg tds

T 0.5, PF 3H, Pilo 4% LE, Pilo 2% RE

IV mannitol, G alphagan

RE laser PI - through

LE laser PI (1st) - failed - cornea haze +

LE laser PI (2nd) - failed

LE laser PI (3rd) - failed

LE laser PI (4th) - failed

Discharged with AAC advice

LE laser PI (5th) - through

D1

D2

D3

D4

Options?

  • Laser iridoplasty
    • But attack broken
  • Surgical PI

D5

D8