Ординатура / Офтальмология / Английские материалы / Clinical Pathways in Glaucoma_Zimmerman, Kooner_2001
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blood cell results in both free hemoglobin and ghost cells, it is likely that ghost cell glaucoma coexists with hemolytic glaucoma.
How Is Hemosiderotic Glaucoma Diagnosed?
Hemosiderotic glaucoma is a rare type of iron-induced glaucoma associated with a long-standing vitreous hemorrhage. Iron released from the hemoglobin of the red blood cell is toxic to ocular structures, which may result in cataract, iris discoloration, and reduced retinal function. Damage to the endothelial cells of the trabecular meshwork results in glaucoma. Most cases of hemosiderotic glaucoma result from iron-containing foreign bodies. The diagnosis is difficult to make clinically.
Treatment and Management
How Is Ghost Cell Glaucoma Treated?
The first step in treating ghost cell glaucoma is to medically reduce the pressure using aqueous suppressants. Topical steroid treatment may reduce inflammation caused by the elevated IOP; however, some authors feel that ghost cell glaucoma is not an inflammatory disease because the primary problem is obstruction of the trabeculum with ghost cells. If medical therapy is not successful, then a thorough vitrectomy is indicated to remove all the ghost cells as well as the remaining vitreous hemorrhage. During vitrectomy, it is important to trim the inferior vitreous base as much as possible, as this location harbors many red blood cells that may continue to produce ghost cells even after vitrectomy.
How Is Hemolytic and Hemosiderotic Glaucoma Managed?
The treatment of hemolytic glaucoma follows the standard medical therapy of glaucoma. If this therapy will be unsuccessful, a paracentesis with irrigation of the anterior chamber may be required.58
Treatment of hemosiderotic glaucoma follows the standard therapy of glaucoma as well. Filtering surgery may be required, as permanent damage to the trabecular meshwork may occur.
Future Considerations
What Future Therapies Are there
for Glaucoma Associated with Vitreous Hemorrhage?
Experimental nonsurgical treatment options involve improvement of physiologic clearance mechanisms to accelerate fibrinolysis, liquefaction, hemolysis, and phagocytosis.57
What Are the Future Concerns About These New Therapies?
There may be an increased incidence of ghost cell glaucoma with the advent of enzymatic vitreolysis of vitreous hemorrhage.
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MYOPIA
Definition
How Is Glaucoma Associated with Myopia Defined?
The relative risk of open-angle glaucoma was found to increase sequentially as the level of refractive error studied was shifted away from hyperopia toward higher levels of myopia, becoming three times greater for high myopia as compared to hyperopia.59 In addition, there is an increased frequency of myopia among patients who have POAG, ocular hypertension, and low-tension glaucoma.60
Are Myopes More Susceptible to Glaucoma?
Perkins and Phelps60 suggested that myopic eyes are more susceptible to the effects of raised IOP than are nonmyopic eyes and that myopes with ocular hypertension have a particularly high risk of the development of field defects. In the Blue Mountains Eye Study, glaucoma was present in 4.2% of eyes with low myopia and 4.4% of eyes with moderate to high myopia compared to 1.5% of eyes without myopia.61 This study has confirmed a strong relationship between myopia and glaucoma in that myopic subjects had a twofold to threefold increased risk of glaucoma compared to that of nonmyopic subjects. The risk was independent of other glaucoma risk factors and IOP.61
What Is the Mechanism of Glaucoma in Myopia?
Nesterov and Katnelson62 postulated that in myopic eyes, the ciliary body is in a relatively posterior position in relation to the canal of Schlemm so that it has less mechanical advantage in widening the spaces of the trabecular meshwork during accommodation. Tomlinson and Phillips63 found a statistically significant positive correlation between ocular tension and axial length. They proposed two possible explanations: Either the raised tension is an important factor in producing a large axial length, or the raised tension is produced by a large axial length. Although unlikely in the adult eye, the raised IOP in glaucoma may stretch the globe and cause myopia, especially in congenital and juvenile glaucoma.
The myopic eye tends to have a larger optic cup with a greater cup-to-disc ratio than emmetropic eyes, and it is possible that these anatomic features predispose the disc to pathologic changes from raised IOP.60 Fluorescein angiographic studies have suggested a reduced choroidal blood flow in myopia,64 and the amplitude of the ocular pulse is lower in myopes than in emmetropes or hypermetropes.65,66 The circulation to the optic disc may also be more susceptible to raised IOP.
Epidemiology and Importance
How Common Is Glaucoma in Association with Myopia?
In a population based survey of 2,403 individuals in Israel, increased IOP was observed in high myopes compared to emmetropes and hypermetropes.67 In
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one study, compared with the normal population, the glaucoma population contained about half as many hypermetropic eyes but four times as many myopic eyes.60 In one series of 68 patients between the ages of 10 and 35 years, myopia was present in 59% of the ocular hypertensives and 73% of the POAG patients.68 In a population-based study of an Australian white community, the overall glaucoma prevalence was reported to be 3.0%.69
Diagnosis and Differential Diagnosis
How Is Myopia Defined?
Myopia, or nearsightedness, is generally classified as axial or refractive. Axial myopia occurs because the eye has a longer axial length, whereas refractive myopia occurs because of the higher refractive properties of the cornea and lens. The vast majority of myopes are axial in nature. In the general population, the prevalence of myopia is approximately 25%.68
What Is the Differential Diagnosis for Glaucoma in Association with Myopia?
Friedman70 showed that an eye of large volume with thin scleral walls will experience greater stress on its scleral walls than a normal eye at the same IOP. During ocular tension measurements, the plunger reading would seemingly indicate a lower IOP in the myopic eye and a higher IOP in the hyperopic eye than actually exists.70 The optic disc in myopia is larger with a larger cup-to- disc ratio, making evaluation of the optic disc difficult when attempting to make a diagnosis of glaucoma. In addition, tilted discs, which are more common in myopia, may give visual field defects that mimic glaucomatous scotomas. Myopic retinal degeneration is common in patients with high myopia. Myopic retinal degeneration may produce visual field defects that mimic glaucoma.
Treatment and Management
How Is Glaucoma in Association with Myopia Treated?
Because the optic nerve head in myopic eyes may be structurally more susceptible to the effects of raised IOP, appropriate treatment should be initiated once the diagnosis is made.60,68,71 Similar to patients with POAG, medical therapy should be instituted first and should consist of topical aqueous suppressants and oral carbonic anhydrase inhibitors. Miotics should be avoided due to the higher risk of retinal detachment in these eyes. If the pressure continues to be elevated despite maximal medical therapy, then argon laser trabeculoplasty or filtering surgery should be considered. Young myopic males are also at risk for pigmentary glaucoma, which may respond to peripheral iridotomy.
Because of many confounding variables in making a diagnosis of glaucoma in patients with myopia, factors such as optic disc appearance, visual field, and IOP should be carefully monitored for progression.
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Future Considerations
What Are the Future Considerations in Glaucoma in Association with Myopia?
There is ongoing research in finding a genetic link between glaucoma and myopia, which may help us better understand the relationship between these two common disorders.
Acknowledgment
This work was supported in part by grants from Research to Prevent Blindness.
References
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12
Glaucoma Associated
with Ocular Surgery
Eve J. Higginbotham
Definition of the Problem
Based on current teaching regarding glaucoma, glaucoma associated with ocular surgery can be defined as any evidence of optic nerve deterioration and visual field loss that follows either extraocular or intraocular surgery. However, given that such complicated instances have traditionally included problems that occur acutely, prior to the onset of changes in either the optic nerve or visual field, for the purposes of this chapter we will include those instances in which the intraocular pressure (IOP) is simply elevated. However, elevated IOP is simply a risk factor and should not be defined solely in one’s definition of glaucoma.
Epidemiology and Importance
Elevated IOP is important to recognize following any surgery given its significant role as a risk factor in some patients as a key “driver” for developing glaucoma. A transient increase in IOP is certainly less worrisome than a 20% or greater sustained increase that may occur in a patient with moderate or severe cupping of the optic nerve. Over time, patients may develop the characteristic changes in the optic nerve and/or the visual field if the unsuspecting clinician fails to closely monitor the patient’s course.
There is a range of glaucomas that can follow ocular surgery, from a steroidinduced glaucoma, which may occur following any extraocular or intraocular procedure, to angle closure, which may follow a scleral buckling procedure.
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Because all of these glaucomas are due to another reason, they are considered “secondary.” However, these complications, which may follow ocular surgery, can be either open angle or angle closure in nature.
These glaucomas may be further broken down according to a mechanistic classification. The secondary glaucomas can be classified into three subcategories: (1) pretrabecular, (2) trabecular, and (3) posttrabecular. Examples of pretrabecular glaucomas are represented by glaucomas such as neovascular glaucoma, in which a fibrovascular membrane is present, or by the occurrence of epithelial down-growth following a complicated procedure. When red blood cells obstruct the trabecular meshwork, such as ghost cell glaucoma or hemorrhagic glaucoma, the trabecular meshwork becomes the primary factor that contributes to elevated IOP. Sometimes, however, the site of resistance is beyond the trabecular meshwork. When there is an elevation in episcleral venous pressure, as in Sturge-Weber syndrome, or there is a carotid-cavernous fistula, the intraocular pressure can be significantly affected. For those patients who present with a secondary angle-closure glaucoma, one can consider either an anterior or “pulling” mechanism or a posterior or “pushing” mechanism. The anterior secondary angle closure would be typified by neovascular glaucoma or iridocorneal endothelial syndrome. The posterior or pushing mechanism can be further subdivided into pupillary block, such as an intumescent lens, or an elevation in pressure that occurs in the absence of pupillary block, such as ciliary block glaucoma.1 whichever classification one uses, it is important to recognize and address the underlying cause prior to undertaking aggressive intervention, which can worsen the problem.
What Are the Demographic Characteristics of Patients
Who May Develop Glaucoma After Ocular Surgery?
There is no age, gender, race, or ethnic group predilection for any of these glaucomas. However, there are certain ocular characteristics that may make some problems more likely to occur. For example, an eye that may be significantly hyperopic will be more likely to develop malignant glaucoma following laser iridotomy. Similarly, a patient on chronic miotic therapy may also develop malignant glaucoma following filtration surgery. An eye that has evidenced an elevation in IOP prior to cataract surgery would be more likely to develop an elevation in IOP following surgery. Moreover, known steroid responders need careful monitoring in the postoperative period.
What Are the Biological Characteristics of Patients Who
May Develop Glaucoma After Ocular Surgery?
There are no biologic characteristics, such as blood levels of antibodies, chemicals, and enzymes, cellular constituents of the blood, and measurements of physiologic functions of different organ systems, that are characteristic for glaucomas associated with ocular surgery.
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What Are the Social and Financial Factors of Patients
Who May Develop Glaucoma After Ocular Surgery?
Physicians need to assess the patient’s ability to pay for the surgical expenses and postoperative medications before undertaking any surgery. Referral to appropriate social agencies and counseling is essential.
What Are the Personal Habits of Patients
Who May Develop Glaucoma?
There are no personal habits, such as tobacco or drug abuse, diet, and physical exercise, which are likely to contribute to the development of these glaucomas. Patients who are noncompliant with their medications and those with no family or social support warrant careful postoperative observation.
What Are the Genetic Characteristics of Patients Who
May Develop Glaucoma After Ocular Surgery?
A patient who may have a genetic predilection for glaucoma has a higher risk of developing a glaucoma associated with ocular surgery. Any surgical trauma may trigger the condition. See Chapters 1, 2, and 5 for discussions regarding the genetics of these diseases.
Diagnosis and Differential Diagnosis
How Is Glaucoma Associated with Ocular Surgery Diagnosed?
Glaucoma associated with ocular surgery is diagnosed as in other glaucomas. A comprehensive history is necessary, and should include reports of previous trauma, previous reports of elevated pressure, or the ingestion or topical use of steroids or other medications that can confound the clinical picture. A discussion with the referring physician would also be helpful to determine if there were unusual occurrences during prior surgery.
An evaluation of the optic nerve and the visual field are key steps to assessing the level of damage. However, it is important to determine if there are any anatomic changes that can be addressed to alleviate any significant increase in IOP. The ongoing medical or surgical management of the eye will be dependent on the outcome of gonioscopy, disc evaluation, and perimetry.
Can Glaucoma Occur with Any Type of Surgery?
Generally, yes. Patients who undergo even extraocular procedures such as strabismus or refractive surgery can develop steroid-induced glaucoma, for example. Patients who are susceptible may develop an elevation in IOP after 2 weeks or more of continuous use of steroids. It is estimated that 5% of nondiabetic and 20% of diabetics may potentially evidence an increase in IOP.2 If closely moni-