Grand Ward Round

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Grand Ward Round

• 31st January 2008
• Boey Pui Yi
• Medical Officer

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Case 1

• Mr GKH 35/Chinese/male
• No past medical history
• Poor vision RE since childhood
• ?amblyopia
• Can only count fingers RE
• No trauma

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Presented with

• RE pain redness 1 day
• 1st episode
• No trauma

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• Van Herick
• 1 (lt25) - high
• 2 (25) - possible
• 3 (25-50) - unlikely
• 4 (gt50) - rare

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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

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Gonioscopy

• RE - No view

• LE

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• 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

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Acute glaucoma in young male DDx?

• Open angle
• Primary OAG - rare
• Secondary OAG
• Pretrabecular
• Neovascular
• Trabecular
• Uveitic - Any severe AAU, Fuchs 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

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Anterior segment OCT
RE
LE

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

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Diagnosis?

• Acute primary angle closure (APAC) attack RE
• PACS LE
• Management

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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

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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
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Review 1/52 post-PI

• RE
• IOP 14
• CD 0.3
• Re-attached RD with pseudo-RP picture

• LE
• IOP 19

Plan TCU 2/52, HVF
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Mechanism of APAC
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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

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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

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Pathogenesis of APAC
Pupil block
Iris bombe
Irido-trabecular block
Acute ? IOP
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Classification of PACG
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Classification of PACG
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Revised classification of Primary Angle Closure
(PAC)

• Foster PJ et al. The definition and
  classification of glaucoma in prevalence
  surverys. BJO 200286238-242
• 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 97593409-11

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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

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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

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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

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Peripheral iridotomy

• Indications
• Therapeutic
• PACG
• POAG with narrow angles
• Secondary ACG
• Prophylactic
• Narrow occludable angles

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Peripheral iridotomy

• Technique
• Lens
• Abraham
• Site
• 1, 11 oclock
• Peripheral 1/3, Iris crypt
• Type of laser
• Argon
• Small, short, high-powered burns
• 50microns
• 0.02-0.05s
• 0.8-1.1W
• NdYAG
• 2-3.5mJ
• End-point
• Plume of pigments
• Visualise lens capsule
• Transillumination

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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

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Urgent referral

• LE pain, redness 1 day
• Giddy, vomiting
• 1st episode
• RE no complaints

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Examination

• RE
• 6/24 -gt 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

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Diagnosis

• LE APAC attack
• RE PAC

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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

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Thank you
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• 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