Ординатура / Офтальмология / Английские материалы / Clinical Pathways in Glaucoma_Zimmerman, Kooner_2001
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350 Drug-Induced Glaucoma
106.Monica ML, Hesse RJ, Messerli FH: The effect of a calcium channel blocking agent on intraocular pressure. Am J Ophthalmol 1983;96:814.
107.Beatty JF, Krupin T, Nichols PF, Becker B: Elevation of intraocular pressure by calcium channel blockers. Arch Ophthalmol 1984;102:1072.
108.Corridan P: Acute angle-closure glaucoma following botulinum toxin (letter). Br J Ophthalmol 1991;75:383.
109.Kupfer C: Selective block of synaptic transmission in ciliary ganglion by type A botulinum toxin in rabbits. Proc Soc Exp Biol Med 1958;99:474.
110.Sanford-Smith JH: Transient myopia after aspirin. Br J Ophthalmol 1974;58:698.
111.Clark AF, DeFaller J, Knepper PA, et al.: IOP lowering activity of anecortave acetate in rabbit and human gluticocorticoid induced ocular hypertension. Invest Ophthalmol Vis Sci 2000; 41:S511.
112.Do M, Firestone G, Chen P, et al.: Glucocorticoids did not regulate the TIGR promoterreporter gene and sustained steroid treatment down-regulated steroid regulatory components in TM cells. Invest Ophthalmol Vis Sci 2000; 41:S511.
16
Glaucoma Associated with Systemic Disease
Joern B. Soltau
Definition
What Systemic Diseases and Problems Are Associated with Elevated Intraocular Pressure or Glaucoma?
Several groups of systemic diseases can be associated with elevated intraocular pressure (IOP) and/or glaucomatous optic neuropathy: endocrine disorders, vascular disease, collagen vascular disease, renal disease and hemodialysis, hematologic disorders, primary familial amyloidosis, irradiation, systemic viral disease, parasitic disease, dermatologic disorders, and neurologic disorders. For management see Figure 16–1.
GLAUCOMA ASSOCIATED
WITH ENDOCRINE DISORDERS
Definition
What Are the Main Endocrine Disorders that Are Associated with Elevated IOP?
Glaucoma occurs in association with several endocrine disorders: pituitary disease, Cushing’s syndrome, diabetes mellitus, and thyroid disease. For management see Figure 16–2.
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Figure 16-1. Management of a patient with glaucoma and systemic disease(s).
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Figure 16-1. Continued.
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Figure 16-2. Management of a patient with glaucoma and endocrine disease.
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IOP, intraocular pressure
LPI, laser peripheral iridotomy
POAG, primary open-angle glaucoma
Figure 16-2. Continued.
GLAUCOMA ASSOCIATED WITH PITUITARY DISEASE
Definition
How Does Pituitary Disease Present Clinically?
The two most common types of pituitary adenomas are prolactinomas and somatotropic adenomas. Hyperprolactinemia is the most common form of pituitary hyperfunction. In women hyperprolactinemia causes galactorrhea, amenorrhea, and infertility. In men it causes impotence and diminished libido. Somatotropic adenomas are the second most common form of pituitary adenoma. These tumors produce excess growth hormone, resulting in skeletal growth changes in childhood leading to gigantism. In adults excess growth hormone secretion results in soft tissue swelling and hypertrophy involving the extremities and face, the hallmarks of acromegaly.
Why Is the IOP Elevated in Patients with Pituitary Disease?
There has been a suspicion that IOP can be regulated by neural and/or humoral influences on the rate of aqueous humor formation. However, it is difficult, if not impossible, to separate specific influences of the central nervous system on the IOP from vascular-induced or other secondary alterations. Although there is an association between chronic open-angle glaucoma and pituitary tumors, the exact mechanism by which this occurs is unknown.
356 Glaucoma Associated with Systemic Disease
Epidemiology and Importance
Is the IOP Elevated in Someone with Pituitary Disease?
In one study, patients with open-angle glaucoma were found to have on average growth hormone levels twice as high as controls after intravenous administration of arginine,1 and patients with hyperprolactinemia were found to have a sustained increase in IOP after water load compared to normal individuals.2 However, in a group of patients with acromegaly the elevated IOP was felt to be secondary to a thicker cornea in this group of patients.3
Diagnosis and Differential Diagnosis
It is still unclear if there is a direct link between increased growth hormone or prolactin levels and IOP. Therefore, it is paramount to make sure that in patients with the above-named conditions other etiologies for the elevated IOP are excluded and that existing or progressing visual field defects are not caused by the pituitary tumor itself.
Treatment and Management
Treatment of glaucoma in patients with pituitary tumors is the same as that for patients with chronic open-angle glaucoma. Progression in visual field changes may be due to either the glaucoma or the tumor itself. Therefore, special care must be taken when visual field changes are not consistent with optic nerve head changes or are not typical for glaucoma. For example, prominent bitemporal visual field depression should alert the physician to exclude pituitary pathology even in the presence of typical glaucoma related visual field changes.
Future Considerations
Further exploration of the central regulation of IOP may help to understand the pathophysiology of open-angle glaucoma.
GLAUCOMA ASSOCIATED WITH CUSHING’S SYNDROME
Definition
What Is Cushing’s Syndrome?
Cushing’s syndrome may be associated with corticotropic adenomas of the pituitary gland, adrenal gland adenomas, or exogenous hormone administration. Excessive adrenocorticotropic hormone (ACTH) results in centripetal obesity, hypertension, diabetes, amenorrhea, osteoporosis, and muscle atrophy.
Why Is the IOP Elevated in Patients with Cushing’s Syndrome?
The facility of outflow is up to 50% decreased in patients with Cushing’s syn- drome.4–6 Excessive ACTH production from a pituitary corticotropic adenoma
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causes the adrenal gland to increase secretion of cortisol, which in turn decreases the outflow facility (see Chapter 15).
Is There a Connection Between Chronic Open-Angle Glaucoma and Cushing’s Syndrome?
Increased plasma cortisol levels7–9 and a disturbance of the hypothalamo- hypophyseal-adrenal gland system10,11 have been found in patients with ocular hypertension and glaucoma.
Epidemiology and Importance
In one study, IOP greater than 21 mm Hg was found in only four eyes of 62 patients with Cushing’s syndrome.12 In another series, 7 out of 29 patients with Cushing’s syndrome had IOPs above 23 mm Hg.13
Diagnosis and Differential Diagnosis
Cushing’s syndrome might be caused by a pituitary adenoma. Therefore, it is of paramount importance to make sure that progression in visual field changes is not caused by compressive optic neuropathy by the tumor itself. Special care must be taken when visual field changes are not consistent with optic nerve head changes or are not typical for glaucoma.
Treatment and Mangement
Glaucoma in patients with Cushing’s syndrome is treated the same as chronic open-angle glaucoma. Adrenalectomy with resulting normalization of hormone levels may allow IOP and reduced outflow facility to return to normal.4–6,12,14
Future Considerations
Further research into the influence of glucocorticoids on aqueous outflow, on the expression of trabecular meshwork inducible glucocorticoid response (TIGR) protein in particular, will help understand the mechanism of openangle glaucoma.15–17
GLAUCOMA ASSOCIATED WITH DIABETES MELLITUS
Definition
Two main types of diabetes exist: type I, insulin-dependent diabetes mellitus, and type II, non–insulin-dependent diabetes mellitus. Chronic open-angle glaucoma, angle-closure glaucoma, and neovascular glaucoma have all been associated with both forms of diabetes mellitus.
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Epidemiology and Importance
Is There a Connection Between Chronic Open-Angle Glaucoma and Diabetes Mellitus?
The issue of whether open-angle glaucoma is more prevalent in patients with diabetes mellitus appears to be controversial.18 Although many studies do show a positive correlation between those two conditions,6,19–27 other studies do not confirm this association.28–34 However, some studies have shown that IOP in patients with type I and II diabetes mellitus seems to be higher than in the general population.23,24,35,36
Can Diabetes Mellitus Cause an Angle-Closure Attack?
Lens swelling through influx of free water from acute hyperglycemia may precipitate an angle-closure attack in susceptible individuals.37,38
Is Neovascular Glaucoma Still an Issue
in Diabetic Patients?
Neovascular glaucoma is the final complication of diabetic proliferative retinopathies. Its incidence has significantly decreased due to the improvement of the management of diabetic patients and systematic panretinal photocoagulation.39
Diagnosis and Differential Diagnosis
In every patient with diabetes mellitus, the clinician’s suspicion needs to be raised to detect ocular complications. For the glaucoma specialist this includes detection of visual field changes that are not secondary to defects caused by retinal photocoagulation for diabetic retinopathy, but rather secondary to glaucomatous optic neuropathy. The evaluation of optic nerve head changes might also be difficult in a patient with active or regressed neovascularization of the disc. Regular gonioscopy is also important to detect early neovascularization of the angle and neovascular glaucoma early in its course.
Treatment and Management
Treatment of glaucoma in association with diabetes mellitus is aimed at the underlying etiology—open-angle glaucoma, angle-closure glaucoma, or neovascular glaucoma. Treating a patient with open-angle glaucoma and diabetes can be very challenging, because visual field changes might be secondary to diabetic retinopathy or laser treatment of the disease. Diabetics with glaucoma seem to have more inferior visual field defects than patients without diabetes.18
Future Considerations
It is hoped that future studies will further elucidate the association of diabetes mellitus with open-angle glaucoma. Inhibition of angiogenic factors like vascu-
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lar endothelial growth factor (VEGF) that lead to iris and angle neovascularization in diabetic retinopathy will be a new tool to treat neovascular glaucoma.40
GLAUCOMA ASSOCIATED WITH THYROID DISEASE
Definition
How Does Graves’ Disease Present Clinically?
Graves’ disease presents with hyperthyroidism with one or more of the triad of diffuse goiter, dermopathy, and ophthalmopathy. Graves’ disease usually occurs between the ages of 30 and 50, with women more often affected than men.
How Does Graves’ Disease Cause IOP Elevation?
Glaucoma can occur by several mechanisms including elevated episcleral venous pressure through infiltration of the orbital tissues, impaired outflow facility, and fibrosis of the extraocular muscles compressing the globe in the different positions of gaze and thus elevating the IOP.
The association between hypothyroidism and open-angle glaucoma is controversial.41,42 Systemic thyroid medication did lower IOP in patients with hypothyroidism.43–46 Thyroid disease might also be a risk factor for normaltension glaucoma.47
Epidemiology and Importance
In one series 24% of patients with thyroid-associated orbitopathy (TAO) were noted to have an IOP greater than 22 mm Hg but less than 30 mm Hg.48 In another series of 482 patients, 4.8% of patients had open-angle glaucoma or IOP greater than 22 mm Hg.49 Only a prolonged duration of active TAO in association with ocular hypertension correlated with progression to glaucomatous damage.48,50
Diagnosis and Differential Diagnosis
It is important to differentiate visual field and optic nerve head changes in an individual with Graves’ disease from changes caused by compressive optic neuropathy related to the infiltrative thyroid orbitopathy.
Treatment and Management
Glaucoma due to thyroid eye disease is treated the same as chronic open-angle glaucoma. In patients with infiltrative ophthalmopathy, high-dose corticosteroids, radiotherapy, extraocular muscle surgery,49 and orbital decompression49,51,52 may be indicated for various reasons and may help in the management of the glaucoma.