## Red cell glaucoma: secondary to hyphaema (usually traumatic)
- Around 50% of patients with traumatic hyphaema have posterior segment injury
- Raised IOP occurs in about 25%
- Corneal blood staining can occur despite normal IOP and may persist for years
- Black ball hyphaema indicates deoxygenation of blood and increased hypoxic risk to endothelium

## Ghost cell glaucoma: secondary to vitreous haemorrhage
- Tan-coloured cells seen in the angle having lost haemoglobin
- Medical therapy but consider AC washout

## Angle recession glaucoma
- Post-traumatic angle recession and trabecular damage carries 10% risk of glaucoma at 10 years
- A rupture in the face of the ciliary body that extends posteriorly between the longitudinal and circular fibres of the ciliary muscle
- Ciliary processes are displaced posteriorly and the overall shape of the ciliary body changes from triangular to fusiform
- Asymmetry of AC depth, pupil and angle seen
- Gonioscopy
    - Torn iris processes
    - Variation in ciliary body width within same quadrants
    - Increased visibility of scleral spur

- Patients should be screened at 6mo and yearly

## Schwartz-Matsuo syndrome
- AC inflammation and raised IOP associated with rhegmatogenous RD
- Photoreceptor outer segments block the TM
- Medical therapy until surgical repair of the RD

## Raised episcleral venous pressure
- Back-pressure reduces aqueous drainage
- Seen in
    - Sturge Weber syndrome: causes two types of glaucoma
        - Under age 10, mechanism is due to abnormal angle formation
        - Over age 10, mechanism is due to increased episcleral pressure

    - Orbital varices
        - Rare vascular lesions that intermingle with orbital contents
        - Engorge depending on posture, straining or coughing leading to **intermittent proptosis**
        - Intracranial extension is rare
        - May be complicated by orbital hemorrhage
        - Surgery is indicated for complicated lesions but carries great risk of optic nerve compromise through ischaemia

    - Carotid-cavernous fistulae
    - SVC obstruction/mediastinal tumours
    - Cavernous sinus thrombosis
    - Retrobulbar tumours
    - Dysthyroid orbitopathy
    - Familial episcleral pressure elevation

## Blood in Schlemm’s canal is seen in glaucomas affecting episcleral pressure

- Sturge Weber
- Carotid-cavernous fistula
- Hypotony

## Neoplastic/tumour related glaucoma
- 20% of malignant melanoma is associated with raised IOP

## Iridoschisis: splitting and atrophy of the iris leaf can cause angle closure
- Associated with nanophthalmos

## Iridocorneal endothelial syndrome (ICE)
- Rare unilateral** abnormality of corneal endothelium** migrating across the angle, TM and anterior iris
    - Abnormal endothelium behaves like epithelium in manner of proliferation

- Significant anterior segment distortion
- F>M, typically 20-40 years old
- 50% risk of glaucoma (a progressive **secondary closed angle glaucoma** due to high peripheral anterior synechiae)
    - Glaucoma is worse in those with mainly Cogan-Reese or iris atrophy

- Possibly related to HSV
- Subtypes
    - Chandler syndrome (most common): mainly corneal (including corneal decompensation)
    - Essential iris atrophy: mainly iris changes eg correctopia
    - Cogan-Reese syndrome: diffuse iris naevus or pigmented nodules

- Clinical features
    - Pain
    - Blurred vision
    - Corneal guttata
    - Corneal oedema
    - Corectopia: displaced pupil with iris atrophy
    - Pseudopolycoria
    - Broad PAS on gonioscopy

- Management as for POAG. There is no role for laser trabeculoplasty.

## Posterior polymorphous dystrophy
- Bilateral corneal endothelial adhesions with the iris causing **angle closure**
- Presents similarly to ICE but is inherited (ie. presents in childhood and is usually autosomal dominant) and bilateral (cp with ICE which is unilateral)
- 15% risk of glaucoma

## Epithelial downgrowth
- Migration of corneal epithelium through a wound (from trauma or surgery) which can then spread over the endothelium and TM
- Difficult to treat with poor visual prognosis.

## Aqueous misdirection syndrome aka malignant glaucoma aka ciliary block

- Misdirection of aqueous into the vitreous causes anterior displacement of the vitreous, ciliary processes and lens with secondary angle closure
- Risk factors
    - Short axial length
    - Chronic angle closure
    - **Previous AACG**
    - Nanophthalmos
    - Uveal effusion syndrome
    - Post-operative especially cataract or glaucoma surgery
    - Post-laser PI
    - Rarely after miotic therapy

- Clinical features
    - Blurred vision
    - Raised IOP
    - Shallow/flat AC both centrally and peripherally
    - No pupillary block (cp. PACG): therefore can occur **despite PI**
    - No posterior choroidal/suprachoroidal cause
    - May occur post-trabeculectomy: flat bleb, high IOP, shallow AC, patent PI

- Management
    - Half can be managed medically
    - Mydriasis (cp. PACG): cycloplegia pulls the lens-iris diaphragm posteriorly
    - Systemic and topical IOP-lowering therapy
    - Ensure patent PI
    - Laser disruption of the anterior vitreous face (hyaloidotomy)
    - Argon laser to the ciliary processes through the patent (usually surgical) PI
    - Trans-scleral cyclodiode
    - Surgery: peripheral zonulo-hyaloidectomy to create a single-chamber eye
        - Cataract extraction with PPV to debulk the vitreous

## Post-operative raised IOP

- Post-cataract surgery: consider a post-operative short course of diamox prophylactically
    - Retained viscoelastic
    - Retained lens fragment
    - Post-op inflammation
    - Suprachoroidal hemorrhage
    - Phacoanaphylaxis (see above)

- Post-vitreoretinal surgery
    - Gas overfill: short-term medical therapy may suffice but some gas may need removal 
    - Scleral buckle: secondary angle closure typically resolves spontaneously
        - Mechanism: obstruction of venous outflow produces choroidal effusions which cause anterior rotation of the ciliary body and secondary angle closure.
        - Alternatively: neovascular glaucoma caused by buckle-induced ischaemia

    - Silicone oil: can obstruct the TM. Managed with medical therapy first. Early oil removal (&lt;6 months) can help but beyond that, removal makes little difference
    - Vitrectomy: may cause ghost cell glaucoma and increase risk of rubeosis

## Plateau iris

- Anteriorly positioned and larger ciliary processes push iris anteriorly in the periphery
- AC may have normal depth centrally but can be much narrower peripherally
- Iris has a flat contour
- On dilation, the peripheral iris bunches up and occludes the TM
- Demographics
    - Younger patients
    - Less hyperopic than primary ACG
    - Asian or caucasian 

- Plateau iris configuration refers to those who have normal IOP
- Angle does not respond to indentation on gonioscopy as easily
    - “Double hump” sign on indentation gonioscopy: posterior displacement of the mid-peripheral iris depicts persistently anterior peripheral iris
    - Plateau configuration can persist **despite PI**
    - Peripheral anterior synechiae develop from Schwalbe’s line and then extend posteriorly (cp. With pupil block wherein PAS develop in a posterior to anterior direction)

- Laser PI **must be done** but is not adequate
    - NB: a diagnosis of plateau iris cannot be made until a patent PI is performed to eliminate any component of pupillary block
    - Laser peripheral iridoplasty is more definitive
    - Chronic miotic therapy

## Tilted disc syndrome

- Superotemporal disc is elevated
- Inferonasal disc is posteriorly displaced
- Associated with superotemporal field loss
    - Does not respect vertical midline
    - Improves with myopic correction (‘refractive scotoma’)

- May mimic a bitemporal hemianopia if bilateral


Red cell glaucoma: secondary to hyphaema (usually traumatic) Around 50% of patients with traumatic hyphaema have posterior segment injury Raised IOP…

Glaucoma

Miscellaneous Glaucoma

Intro

FRCOphth Part 2 Study Notes

Tumours, masses and neoplasia

Tumours overview

Uveitis

Uveitis background

Anterior uveitis

Intermediate uveitis

Uveitis in JIA

Uveitis with JIA

Retinal vasculitis

Sarcoidosis

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Strabismus

Overview

Esotropia

Fungal uveitis

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Spirochaetal uveitis (including Syphilis)

Exotropia

Melanoma

Nematode uveitis

Retinoblastoma

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Incomitent

Voyt-Koyanagi-Harada syndrome

Conjunctival intraepithelial neoplasia

Vertical deviations

Sympathetic ophthalmia

Orbit and ocular adnexae

Orbit

AV Malformations and hamartomas

Arteriovenous malformations and hamartomas

Restriction syndromes

Paediatrics

Leucocoria

Congenital Cataract

Paediatric Glaucoma

Retinopathy of prematurity

Retinopathy of Prematurity

ROP-like disorders

Congenital nasolacrimal duct obstruction

White dot syndromes

Aniridia: Short Arm 11 Deletion (11p13)

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Management Of Amblyopia

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Scleritis

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Strabismus surgery

Optic nerve glioma

Lymphoma

Extraocular Muscles

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Idiopathic orbital inflammation

Orbital neuroblastoma

Anterior Persistent Foetal Vasculature

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Metastatic lesions

Surgical Retina

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Vitreoretinal Interface And Macular Hole

Epiretinal Membrane

Medical Retina

Diabetic Eye Disease

Orbital Blood Vessels

Retinal Vascular Disease

Macular Degeneration

Central Serous Chorioretinopathy (CSCR)

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Atropine And Myopia Progression

Pharmacology

Side Effects Of Systemic Drugs

Foetal Alcohol Syndrome

Neuro-ophthalmology

Optic Neuropathy

Papilloedema

Idiopathic Intracranial Hypertension

Chiasmal Disorders

Retrochiasmal Disorders

Migraine

Paranasal Sinuses

Supranuclear Motility Disorders

Third Nerve Palsies

Fourth Nerve Palsies

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Tear Film

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Anterior segment - ocular surface

Conjunctiva

Conjunctivitis

Sclera

Pigmented Conjunctival Lesions

Squamous Cell Carcinoma Of The Conjunctiva

Ocular Cicatricial Pemphigoid

Cornea

Corneal Structure And Development