(secondary glaucoma).

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‫پاتو فیزیو لوژی گلوکوم اطفال‬
‫دکتر علی صالحی‬
Types of Glaucoma
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•
•
•
•
•
•
•
Open-Angle Glaucoma
Angle-Closure Glaucoma
Normal-Tension Glaucoma (NTG)
Congenital Glaucoma
Secondary Glaucoma
Pigmentary Glaucoma
Pseudoexfoliative Glaucoma
Traumatic Glaucoma
Neovascular Glaucoma
Irido Corneal Endothelial Syndrome (ICE)
Congenital Or Infantile Glaucoma
• Primary congenital, or infantile, glaucoma is
elevated intraocular pressure with onset in the first
year of life.
• It occurs in about 1 out of 10,000 births and results
in blindness in approximately 10% of cases and
reduced vision (worse than 20/50) in about half of
all cases.
• approximately 70% of cases are bilateral.
• Although diagnosis is made in only 25% of
affected infants at birth, disease onset occurs
within the first year of life in more than 80% of
cases.
Pediatric glaucomas
• Constitute a heterogeneous group of diseases that may
result from an intrinsic disease or structural abnormality
of the aqueous outflow pathways
(primary glaucoma)
• Or from abnormalities affecting other regions of the eye
(secondary glaucoma).
• A variety of systemic abnormalities are also associated
with pediatric glaucoma.
Systemic diseases with Glaucoma
• Aniridia
• Marfan's syndrome
• Sturge-Weber syndrome
• Neurofibromatosis
• Down's syndrome
• Steroid therapy, including inhaled steroids for
asthma and nasal steroids for allergies .
causes
• Genetic (e.g. congenital glaucoma, infantile
glaucoma, juvenile glaucoma)
• Following cataract surgery (aphakic glaucoma)
• Due to ocular inflammation (iritis)
• Trauma
• Malformations of the eye (Axenfeld-Rieger,
aniridia , Peters anomaly)
• Diseases which affect the rest of the body
(Sturge-Weber Syndrome, Lowe Syndrome,
congenital rubella)
Aniridia
Axenfeld anomaly
Peters
anomaly
• Primary congenital glaucoma typically presents
in the neonatal or infantile period with the
classic triad of epiphora, photophobia, and
blepharospasm.
• Corneal clouding from microcystic edema can
occur, accompanied by gradual enlargement of
the corneal diameter. As the edema extends
through the corneal stroma, breaks called Haab
striae can occur in Descemet’s membrane.
Congenital Glaucoma (Primary Congenital Glaucoma)
Clinical
Findings
• Progressive corneal edema with breaks in
Descemet’s membrane (Haab striae)
• Elevated IOP, typically non-sedated between 30
and 40 mmHg
• Corneal enlargement
• The normal intraocular pressure is lower in
infants and young children than adults.
• A newborn has an average intraocular pressure
of 10-12 mm Hg, increasing to 14 mm Hg by age
7 or 8 years of age.
• An asymmetric measurement or an elevated
measurement in the presence of other clinical
signs helps make the diagnosis of glaucoma.
General
Pathology
• Primary congenital glaucoma may represent an
arrest of the normal development of the anterior
chamber.
• The iris and ciliary body have an anterior insertion
with an open angle.
• The trabecular meshwork is present and appears
patent, but the trabecular beams are thickened and
the deeper tissues appear compressed.
• The disease is more common in males, typically is
bilateral, and does not have a racial or geographic
preference.
• Most cases are sporadic, but there is an autosomal
recessive(AR) inheritance pattern either autosomal
dominant (AD) for some cases.
• (GLC3A locus on chromosome 2p21).
Risk Factors
• The only known risk factors are genetic
consanguinity and affected siblings.
• The risk of congenital glaucoma in the second
child is approximately 5%, and the risk increases
to 25% with two affected siblings.
Diagnosis
• The diagnosis of primary congenital glaucoma
can often be made clinically, even without an
accurate measurement of intraocular pressure.
The hallmark of the disease, however, is an
elevated intraocular pressure in the absence of
other conditions that can cause glaucoma,
such as Axenfeld-Reiger syndrome or aphakia.
• . A newborn’s cornea is typically 9.5-10.5 mm in
diameter and increases to 10.0-11.5 mm by age
1.
• Any diameter above 12.5 mm suggests an
abnormality, especially if there is asymmetry
between the two eyes.
Differential diagnosis
• The differential diagnosis depends on the major
presenting symptom.
•
For the classic triad of epiphora, photophobia, and
blepharospasm, the differential diagnosis includes:
nasolacrimal duct obstruction
• conjunctivitis
• corneal abrasion
• and uveitis.
• For corneal clouding and edema, the differential
diagnosis includes :
• congenital corneal dystrophies
• birth trauma with tears in Descemet’s membrane
keratitis
• congenital ocular anomalies like sclerocornea or Peters
anomaly or
• storage
cystinosis
disesases
like
mucopolysaccharidoses
or
• For corneal enlargement, the differential diagnosis includes :
• high axial myopia and megalocornea.
• For optic nerve cupping the differential diagnosis includes:
• physiologic cupping
• optic nerve coloboma
• optic nerve atrophy
• optic nerve hypoplasia
• an optic nerve malformation
Prognosis
• Glaucoma that presents from 3-12 months of age has a
favorable prognosis, with 80-90% of cases achieving
good control of intraocular pressure with angle
surgery.
• The vision loss in children is multifactorial and does
not depend exclusively on the health of the optic
nerve.
• Affected children can develop significant myopia
from axial elongation of the globe,
• astigmatism from unequal enlargement of the
cornea, corneal scarring
• Even dislocation of the lens from excessive anterior
segment enlargement.
• Correction of the refractive error and aggressive
treatment
of
associated
amblyopia
and/or
strabismus is required to maximize visual outcome.
• Visual acuity is worse than 20/50 in at least 50%
of cases.
• This condition is bilateral in about two-thirds of
patients
• occurs more frequently in males (65%) than in
females (35%).
Pathophysiology
• The basic pathologic defect in PCG remains
controversial.
• Barkan originally proposed a Thin, imperforate
membrane that covered the anterior chamber
angle and blocked aqueous outflow.
• By age 1 year, normal corneal diameter is
10-11.5 mm
• a diameter greater than 12.5 mm suggests
abnormality.
•
Glaucoma should be suspected in any child
with a corneal diameter greater than 13 mm.
Medical therapy
• Medical therapy for primary congenital glaucoma is
typically used as an adjunct to surgery.
• Oral
carbonic
anhydrase
inhibitors
include
acetazolamide (Diamox 10-20 mg/kg/day divided
into 3 or 4 doses) and methazolamide (Neptazane
5-10 mg/kg QID).
• Side affects include weight loss, lethargy, and
metabolic acidosis.
• Topical carbonic anhydrase inhibitors include
dorzolamide 2% (Trusopt) and brinzolamde 1%
(Azopt) drops TID.
• These medications may produce less reduction in
intraocular pressure than oral carbonic anhydrase
inhibitors, but also appear to have fewer systemic
side affects.
• Beta-blockers (timolol or equivalent) can also be
given topically, usually using a lower starting
concentration of 0.25% drops BID. Side affects
include:
• respiratory distress, caused by apnea or
bronchospasm, and bradycardia.
• A combined beta-blocker/carbonic anhydrase
inhibitor (Cosopt) drop BID has been shown to
be effective in reducing intraocular pressure in
children requiring more than one topical
medication.
• Prostaglandin analogs latanoprost 0.005%
(Xalatan), travoprost 0.004% (Travatan), and
bimatoprost 0.03% (Lumigan) have been
effective in reducing intraocular pressure,
although use is discouraged in the presence
of inflammatory condition
• Miotic agents (pilocarpine, echothiophate) and
adrenergic agents (epinephrine, dipivefrin) are
not usually effective.
• The alpha2-adrenergic agonist brimonidine
(Alphagan) is contraindicated in children under
age 2 because of potentially serious lethargy,
hypotonia, hypothermia, and CNS depression.
Medical follow up
• Primary congenital glaucoma requires lifelong
serial measurements of intraocular pressure,
corneal diameter, refractive error, and optic
nerve cupping.
• Any change in medical regimen should be
followed in 1-2 weeks to assess the efficacy of
the new treatment regimen.
Surgical follow up
• In the short term, these patients require frequent
follow up to monitor for infection or excessive
inflammation. Long term, just like patients on
medical therapy, these patients require serial
measurements of intraocular pressure, corneal
diameter, refractive error, and optic nerve cupping.
If an adequate assessment of the clinical response
is not possible in the outpatient clinic, an
examination under anesthesia can be performed.
Complications
• The most common complication after surgery is
poor control of intraocular pressure.
• The success rate for angle surgery is approximately
80% after 1 or 2 procedures, while the other
procedures report a success rate of 33-80%.
‫انجمن خیریه چشم پزشکان اصفهان‬
‫خداوند در سوره بقره آیه ‪ 274‬به ستایش کسانی پرداخته که در شب و‬
‫روز و نهان و آشکار انفاق می کنند و برخی آن را «آیه انفاق» گفته‬
‫اند‪.‬‬
‫«الذین ینفقون اموالهم بالیل والنهار سرا وعالنیه فلهم‬
‫اجرهم عند ربهم والخوف علیهم و الهم یحزنون‬
‫کسانی که دارایی های خود را در شب و روز‪ ،‬و نهان و آشکارا‪،‬‬
‫انفاق می کنند‪ ،‬پاداش آنان نزد پروردگارشان برای آنان خواهد‬
‫بود‪ ،‬و نه بیمی بر آنان است و نه اندوهگین می شوند»‪.‬‬
‫در آیه ‪ 261‬سوره بقره می فرماید‬
‫َّ‬
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‫َ‬
‫ن‬
‫س‬
‫ع‬
‫ب‬
‫س‬
‫ت‬
‫ت‬
‫ب‬
‫ن‬
‫أ‬
‫ة‬
‫ب‬
‫ح‬
‫ل‬
‫ث‬
‫م‬
‫ك‬
‫ّللا‬
‫یل‬
‫سب‬
‫فى‬
‫م‬
‫ه‬
‫ل‬
‫و‬
‫م‬
‫« َّم َثل ا َّل ِذینَ ینفِقونَ أ‬
‫ِ‬
‫َ‬
‫ْ‬
‫َ‬
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‫َ‬
‫ْ‬
‫ِ‬
‫ِ‬
‫ابل َ‬
‫ْ‬
‫ِ‬
‫ِ‬
‫ّللا یضعِف لِ َمن َیشاء َو َّ‬
‫فى كل سنب َلة ما َئة َح َّبة َو َّ‬
‫ّللا َوسِ ع َعلِیم؛‬
‫كسانى كه اموال خود را در راه خدا انفاق مى كنند‪ ،‬همانند بذرى‬
‫هستند كه هفت خوشه برویاند‪ ،‬كه در هر خوشه‪ ،‬یكصد دانه باشد‪،‬‬
‫و خداوند آن را براى هر كس بخواهد (و شایستگى داشته باشد)‪،‬‬
‫دو یا چند برابر مى كند‪ ،‬و خدا (از نظر قدرت و رحمت) وسیع‪ ،‬و‬
‫(به همه چیز) داناست» (بقره ‪.)261 ،‬‬
‫به امید روزی که درمان هیچ بیمار چشمی به دلیل عدم‬
‫بضاعت مالی به تاخیر نیافتد‪.‬‬
‫رباعی زیبا از خیام‪:‬‬
‫تا کی غم آن خورم که دارم یا نه‬
‫وین عمر به خوشدلی گذارم یا نه‬
‫پر کن قدح باده که معلوم نیست‬
‫کاین دم که فرو برم بر آرم یا نه‬
‫مغز گردو شبیه مغز انسان هستش‪ .‬نیم کره راست و نیم کره چپ ‪.‬‬
‫قسمت باالی مغز و پایین مغز‪ .‬حتی چین خوردگی های و‬
‫پیچیدگی های اون هم شبیه نئو کورتکس میباشد ‪.‬‬
‫در حال حاضر میدانیم که گردو ‪ ۳۶‬مرتبه نورونهای پیام رسان‬
‫به مغز را گسترش میدهد‪.‬‬
‫اگر شما یک غذای بد طعم را •‬
‫خورده باشید‬
‫میتوانید طعم یک غذای خوب را‬
‫درک کنید‬
‫پس‪ ،‬از تلخیهای زندگی درس‬
‫بگیرید تا بتوانید آنرا درک کنید‬
‫حبه های انگور روی خوشه شبیه قلب هستش و هر دونه‬
‫اون‬
‫شبیه سلولهای خونی‪ .‬امروزه تحقیقات نشون داده که‬
‫انگور برای حیات قلب بسیار مفیده‪.‬‬
‫وقتی گوجه فرنگی رو از وسط دو نیم میکنید چهار تا خونه میبینید که‬
‫قرمزه و‬
‫دقیقا مثل قلب هستش که اون هم قرمزه و چهار تا بخش مجزا داره ‪.‬‬
‫تحقیقات نشون داده که گوجه فرنگی خون رو تصفیه میکنه ‪.‬‬
‫هویج حلقه شده شبیه چشم انسان است‪ .‬مردمک و عنبیه و خط نوری که‬
‫به چشم میرسد درست مانند چشم انسان میباشد‪ .‬تحقیقات نشان میدهد‬
‫که مصرف هویج باعث افزایش جریان خون در عملکرد چشم میشود‪.‬‬
‫تا حاال به لوبیا قرمز دقت کردین؟ درسته ‪ ...‬شبیه کلیه انسان هست ‪.‬‬
‫تحقیقات نشون داده که لوبیا قرمز در بهبود عملکرد کلیه نقش‬
‫بسزایی داره‬
‫ساقه کرفس شبیه به استخوان است و این نوع از سبزیجات‬
‫در استحکام استخوان بسیار موثر میباشد‪ .‬استخوانها تشکیل شده‬
‫از ‪ ۲۳٪‬سدیم و کرقس هم ‪ ۲۳٪‬سدیم داره ‪ .‬چنانچه‬
‫در رژیم غذایی شما سدیم وجود نداره کرفس میتونه این کمبود رو‬
‫جبران کنه‬
‫آوکادو و گالبی و بادمجان برای سالمت سرویکس و رحم در خانمها‬
‫بسیار موثر میباشد‪ .‬امروزه تحقیقات نشان میدهد که اگر خانمها‬
‫در هفته یک عدد آوکادو مصرف نمایند هورمونهای آنها متعادل میشود‬
‫و از بروز سرطان رحم جلوگیری میکند ‪ .‬جالبه که بدونید ‪ ۹‬ماه‬
‫از شکوفه کردن آوکادو تا رسیدن میوه آن طول میکشه ‪.‬‬
‫انجیر پر از دونه هستش که باعث افزایش تعداد و‬
‫حرکت اسپرم مرد و همچنین جلوگیری از عقیم شدن میشود ‪.‬‬
‫زیتون به سالمت و عملکرد تخمدان کمک میکند‪.‬‬
‫کریپ فروت و پرتقال و انواع مرکبات شبیه غده های شیری هستند‬
‫و‬
‫در سالمت سینه و جنبش غدد لنفاوی در سینه موثر است ‪.‬‬
‫پیاز شبیه سلولهای بدن میباشد‪ .‬امروزه تحقیقات نشان داده است‬
‫که پیاز نقش مهمی در خروج مواد زائد در بدن را داراست و‬
‫باعث ریزش اشک و شستشوی الیه مخاطی چشم میگردد‪.‬‬
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