clinical features of glaucoma

1. Clinical Features of glaucoma
Dr.Sidesh Hendavitharana(Registrar-
ophthalmology)

2. Etiological classification of glaucoma
• primary
– Children
• True congenital glaucoma
• Infantile glaucoma
• Juvenile glaucoma
– Adults
• Primary open angle glaucoma
• Primary angle closure glaucoma

3. secondary
• Children
– Aniridia
– Iridocorneal dysgenesis
– Ectopia lentis syndrome
– Lowe’s syndrome
– Rubella
• Adults
– Phacogenic glaucoma
– Pigmentary glaucoma
– Pseudoexfoliative glaucoma
– Inflammatory glaucoma
– Neovascular glaucoma
– Ghost cell glaucoma

4. Clinical features of congenital
glaucoma
• Symptoms
– Photophobia,blepharospasm and eye rubbing due
to irritation of corneal nerves because of elevated
IOP.
– Lacrimation due to corneal edema and erosion.
– Defective vision due to corneal edema leading to
hazy cornea ,enlarment of cornea and eye as a
whole.
– Irritable child.

5. signs
• Corneal edema(Hazy frosted glass cornea)
– 1st sign to arouse suspicion
– At first,epithelial,lateral stromal
– Results in permanent opacities
• Corneal enlargement
– Along with enlargement of eyeball
– Cornea more than 13mm(normal 10.5mm in infants)
• Tears and breaks in Descemet’s membrane(haab
striae)
– Because of less elasticity
– Appear as horizontal curvilinear lines representing healed
breaks of descemet membrane

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• Thin and blue sclera(due to stretching of
corneoscleral junction)
• Flattening of lens and backward displacement (due
to stretching of zonules of zinn) and even
subluxation of lens.
• Cupping and atrophy of optic disc especially after
3rd yr
• Raised IOP
• Axial myopia(due to increased in axial length)
anisometropic amblyopia

10. Clinical features of primary open
angle glaucoma
• Symptoms
– Painless,progressive loss of vision
– Mild headache and eyeache
– Defects in visual fields
– Difficulty in reading and close work(due to failure
in accomodation because of constant pressure on
cilliary muscles and its nerve supply)thus frequent
changes in presbyopic glasses
– Delayed dark adaptation

11. signs
• Anterior segment
– Normal depth and angle of anterior chamber
– Slightly hazy cornea(late stage)sluggish pupillary
reflex(late stages)
– IOP changes
– In initial stages ,rhythmic swing in diurnal variation of
IOP(morning rise 20%,afternoon rise 25%)
– Variation of >5mm of Hg of IOP is suspicious and
>8mm of Hg is diagnostic
– In late stages, IOP raised permenently above 21
mmHg, usually between 30-45mmHg

12. Optic disc changes
• Typically progressive and asymetric.
• Pathophysiology
– Mechanical effect
• Raised IOP , forces lamina cribrosa backward
squeezes nerve fibres within its meshes disturbance
in axoplasmic flow
– Vascular factors
• Contribute in ischemic atrophy of nerve fibres resulting
in large caverns or lacunae(cavernous optic atrophy)

13. Early changes
• Vertically oval cup(due to selective loss of neural rim
tissue in inferior and superior poles)
• Asymetry of cups in both eye(difference more than 0.2)
• Large cup,0.6 or more due to concentric expansion
• Splinter haemorrhage on or near optic disc margin
• Pallor areas on disc
• Atrophy of retinal nerve fiber layer(seen with red free
light)
• Barring of curcumlinear vessels at disc margin

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19. Advanced changes
• Marked cupping(cup size 0.7-0.9)-bean pot cupping
• Excavation reaching disc margin,steep and no shelving
• Thinning of neuroretinal rim seen as cresentic shadow
adjecent to disc margin on temporal side
• Nasal shifting of retinal vessels with broken off appearance
at margin(bayonetting sign)
• Pulsation of retinal arteries at disc margin
• Pores in lamina cribrosa slit-shaped and visible up to disc
margin(laminar dot sign)
• Glaucomatous optic atrophy
• Destructon of all neural tissue of disc
• Optic nerve head appears white and deeply excavated.

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24. Clinical features of ACG
• Symptoms
– Asymptomatic but during attack transient blurring
of vision,coloured halos and mild headache
• Signs
– Eclipse sign
• Shadow on nasal side elicited by shining penlight across
anterior chamber from temporal side
• Indicates decreased axial anterior chamber depth

25. Slit lamp examination
• Congested episcleral and conjunctival blood
vessels
• Corneal epithelial edema
• Shallow anterior chamber
• Mild amount of aqeous flare and cells
• Mid dilated,sluggish and irregularly shaped pupil
• Convex lens-iris diaphragm
• Glaukomflecken-characteristic small anterior
subcapsular lens opacities

26. Secondary glaucoma
• Clinical features of neovascular glaucoma
• Symptoms
– Severe pain
– Markedly reduced vision
• Signs
– Ciliary and episcleral congestion
– Corneal edema
– High IOP
– Rubeosis iridis

27. Causes for NVG
• CREDITS……
• C-CRVO
• R-RD
• E-eale’s disease
• D-diabetic retinopathy
• I-intraocular inflammations
• T-Tumors(intraocular)
• S-sickle cell retinopathy

28. Pseudoexfoliation syndrome
• Clinical features
– Effects elderly
– Presents like primary open angle glucoma
– Diposition of amorphous grey dandruff like
material on pupillary border,anterior lens
surface,posterior surface of iris,zonules and cilliary
processes
– Arrangement of pigments anterior to schwalbe’s
line-sampaolesi line.
– Subluxation of lens due to looseness of zonules

29. Clinical features of pigmentary
glaucoma
• Pigment diposition on the corneal endothelium in
a vertical spindle pattern-krukenberg
spindle(absolutely necessary to make the
diagnosis)
• Peripheral iris transillumination-characteristic
spokelike loss of the iris pigment epithelium
• When the pupil is dilated,pigment deposits can
be seen on the zonular fibres,anterior to hyaloid
and the lens capsule near the equator of the
lens(zentmayer line)

30. THANK YOU
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