What are the contraindications to prostaglandins?;"• Active uveitis • CME • Herpetic keratitis" What are the risk factors for failure of trabeculectomy?;"• Young age • Aphakia/pseudophakia • Disturbance of conjunctiva • African American • Active inflammation • Neovascularization" What are the last portions of the visual field (VF) to be affected in end-stage glaucoma?;"• Central VF • Inferotemporal VF" What are the functions of M cells?;"• Motion vision • Large diameter “Massive” • Sensitive to light in scotopic conditions" What is the function of P cells?;"• Concentrated in macula • Small diameter ”Petite” • 80% of RGCs • Responsible for color and fine detail" What is the most common complication after filtering surgery?;"• Visually significant cataract (20-40%)" What is phacolytic glaucoma?;"• Mature or hypermature cataract • Increased concentration of high molecular weight lens protein • Proteins released through MICROscopic openings in lens capsule • Protein clogs trabecular meshwork • Macrophages phagocytize large proteins clog trabecular meshwork • Cytology of aqueous = lens laden macrophages • LACK OF KERATIC PRECIPITATES • OPEN angle • Intact lens capsule" What is phacoanaphylaxis (AKA phacoantigenic glaucoma)?;"• Capsular bag violated (i.e. trauma, surgery) • Leads to granulomatous inflammation • Keratic precipitates" What is phacomorphic glaucoma?;"• Shallow anterior chamber • Lens becomes large, thick → pushes iris forward and closes angle • Treatment: cataract removal" What is lens particle glaucoma?;"• MACROscopic lens pieces in anterior chamber" What is the differential diagnosis for shallow anterior chamber with patent PI?;"• Aqueous misdirection, malignant glaucoma • Choroidal effusion • Suprachoriodal hemorrhage" What is the treatment of aqueous misdirection, malignant glaucoma?;"• Medical: intensive aqueous suppressant, cycloplegics, hyperosmotics. NEVER use miotics • Surgical (disruption of anterior vitreous face): YAG laser through patent iridotomy or pars plana vitrectomy (definitive)" What is the treatment for plateau iris?;"• Laser iridoplasty • Chronic cholinergics" What types of renal stones are caused by systemic carbonic anhydrase inhibitors?;"• Calcium oxalate • Calcium phosphate" What is the mechanism of action of latanoprostene bunod 0.024% (Vyzulta)?;"• Latanoprost component reduces IOP by long term remodeling of extracellular matrices in ciliary body (via uveoscleral pathway, ""nonconventional"") • Nitric oxide component reduces IOP by ""conventional"" pathway via relaxation of trabecular meshwork and Schlemm's canal" What is the purpose of dynamic gonio?;"Determines whether closed angle is due to appositional versus synechial closure" Which gonio lenses can and cannot be used for dynamic gonio?;"• Dynamic gonio: Zeiss, Posner, Sussman (posterior lens diameter < corneal diameter) • Cannot do dynamic gonio: Goldmann lens (posterior lens diameter > corneal diameter)" The TIGR/MYOC gene mutation leads to which conditions?;"• Mutations produce protein myocilin • Chromosome 1 • Seen in juvenile open angle glaucoma and adult onset POAG" The OPTN gene mutation leads to which condition?;"• Normal tension glaucoma" Which genes are associated with congenital glaucoma?;"• GLC3A gene mutation (most common) • CYP1B1 gene mutation (more severe form)" Which condition has a LOXL1 gene mutation?;"• Pseudoexfoliation glaucoma" What is the pathway of pressure sensitive trabecular outflow?;"Uveal TM → corneoscleral TM → juxtacanalicular TM (most outflow resistance) → Schlemm canal → collector channels (25-30) → deep and midscleral venous plexi → episcleral veins → anterior ciliary and superior ophthalmic veins → cavernous sinus " What is the pathway of pressure insensitive trabecular outflow?;"• Ciliary muscle → supraciliary and suprachoroidal spaces → intact sclera • 45% of total aqueous outflow • Increased by cycloplegia, adrenergic agents, prostaglandins • Decreased by age, glaucoma, miotics " What is tilted disc syndrome?;"• Situs inversus (vessels go nasally before turning temporally) • Superotemporal or bitemporal VF defects • Associated with myopic astigmatism and X-linked congenital stationary night blindness" What is the mechanism of action of pilocarpine?;"● Contraction of longitudinal ciliary muscle where it inserts into scleral spur and TM → improves outflow ● Reduces IOP 15% to 20% ● Associated with: ○ Angle closure (forward shift of lens-iris diaphragm); myopic shift secondary to ciliary muscle contraction; headache, brow ache (ciliary muscle spasm); cataract formation; RD; breakdown of blood-aqueous barrier; iris pigment epithelial cysts; epiphora (lacrimal stimulation and punctal stenosis); ocular surface changes (drug-induced pseudopemphigoid)" What virus is associated with Posner Schlosmann and Fuchs iridocyclitis?;"• Posner Schlosmann: CMV • Fuchs: Rubella & CMV" What is hypotony maculopathy?;"• Common complication in young myopes (versus choroidal detachments which are more common in older pts) • Complication of over filtration • Fundus findings: optic disc edema, macular folds, CME • Hypotony maculopathy and choroidal detachments do not occur together" What are examples of direct gonioscopy (used in the operating room)?;"• Koeppe • Barkan • Wurst • Swan-Jacob • Richardson" What are examples of indirect gonioscopy?;"• Zeiss • Sussman • Posner • Goldmann (3 mirror)" What is the prognosis for primary congenital glaucoma?;"• Best if diagnosed between 3 months to 12 months of age • Worse when diagnosed within 1 month of life or >12 months of age • >50% of patients with newborn PCG develop legal blindness • Worse prognosis if corneal diameter >14 mm at diagnosis" What medications lower IOP and what is their mechanism of action?;"• Topical beta blockers: reduce aqueous production, inhibit cAMP production • Topical alpha agonists: reduce cAMP production by binding alpha 2 receptors. With long term use also increases uveoscleral outflow • Topical CAI: reduce aqueous production by inhibiting carbonic anhydrase • Topical pilocarpine, echothiophate, parasympathomimetics: increase outflow through TM by contraction of longitudinal ciliary muscle fibers • Topical prostaglandins analogs: increase uveoscleral outflow, activates MMP which remodels tissues along this pathway" What are the side effects of IOP-lowering medications?;"• Topical prostaglandins: conjunctival hyperemia, hypertrichosis, increased pigmentation of iris and periocular skin, CME, anterior uveitis, reactivation of herpes simplex virus keratitis. Rarely, flu-like symptoms and joint/muscle pains • Topical CAI: bitter taste, corneal edema secondary to effecting corneal endothelium pump • Topical beta blocker: decreased exercise tolerance. Use with caution in asthma and COPD • Topical alpha agonists: dry mouth, follicular conjunctivitis, contraindicated in children and while breastfeeding, safest medication during pregnancy but stop after birth of baby due to causing systemic hypotension and apnea" What is topiramate-induced angle closure?;"• Sulfamate-substituted monosaccharide medication • Causes bilateral acute myopia and angle closure • Ciliochoroidal swelling • Anterior rotation of ciliary body • First-line treatment: stop medication, start cycloplegia, hypotensive agents • Refractory cases: laser iridoplasty" What are the focal signs of glaucomatous cups?;"• Notching of rim • Vertical elongation of cup • Cupping to rim margin • RNFL hemorrhage • RNFL loss" What are less specific signs of glaucomatous cups?;"• Exposed lamina cribrosa • Nasal displacement of rim vessels • Baring of circumlinear vessels • Peripapillary atrophy" What is the classic triad of primary congenital glaucoma?;"• Epiphora • Photophobia • Blepharospasm" What is automated static perimetry?;"• Stimulus size constant • Varies stimulus intensity • Stationary stimulus at various locations" What is frequency doubling technology (FDT) perimetry?;"• Low spatial frequency sinusoidal grating that undergoes rapid phase-reversal flicker • Ability for patients to distinguish changes in contrast • Only useful for detecting early glaucomatous loss" What is SWAP (short wavelength automated perimetry)?;"• Isolates and tests the sensitivity of short-wavelength ganglion cells • Detection of early glaucoma is higher with SWAP compared to standard automated perimetry • VF defects predate same VF defects on standard automated perimetry • Disadvantage = long testing time and more sensitive to media opacities • SITA-SWAP = decrease in testing time" What is kinetic and tangent screen testing?;"• Target moved into an area just until it is seen (automated or manual)" What are the reliability indices of visual fields?;"• False positives(“trigger happy”): >15% is unreliable • False negatives: does not respond when stimulus is present, indicates inattentiveness or seen in areas of damage (if high, do not throw out the test) • Fixation loss: patient looks way from central target (“chasing lights”)" What is SLT and its efficacy compared to ALT?;"• SLT: selective photothermolysis targeting pigmented cell • Short, low-energy bursts absorbed selectively by pigmented trabecular meshwork • Little damage to surrounding tissue • Efficacy of SLT and ALT are equivalent" What is the process of aqueous production?;"• Produced by inner non pigmented epithelial cells • Ciliary process composed of outer pigmented and inner non-pigmented epithelial cells that face each other at their apical surface and joined by tight junctions • Tight junctions are part of blood-brain barrier • Inner non-pigmented epithelial cells have many mitochondria and microvilli • Inner non-pigmented epithelial cells protrude into posterior chamber" What is a beta-1 selective topical beta blocker?;"• Produced by inner non pigmented epithelial cells • Ciliary process composed of outer pigmented and inner non-pigmented epithelial cells that face each other at their apical surface and joined by tight junctions • Tight junctions are part of blood-brain barrier • Inner non-pigmented epithelial cells have many mitochondria and microvilli • Inner non-pigmented epithelial cells protrude into posterior chamber" What are the causes of falsely low IOP on applanation?;"• Thin CCT • BCL • Corneal edema • Corneal ectasia • Not enough fluorescein (thin meyers)" What are the causes of falsely high IOP on applanation?;"• Band keratopathy • Thick CCT • Corneal scar • Too much fluorescein (thick meyers)" What is the age range for JOAG?;"• Ages 4 to 35 years" Which anesthetics lower IOP?;"• Sevoflurane • Most others" Which anesthetics increase IOP?;"• Ketamine • Succinylcholine" Which anesthetic does not have an effect on IOP?;"• Chloral hydrate" Which illicit drugs lower IOP?;"• Heroin • Marijuana • Alcohol" What is an ideal time to check IOP in EUA?;"• Immediately after induction of general anesthesia and before intubation" What are the risk factors for aphakic glaucoma?;"● Cataract surgery in the first year of life ● Glaucoma develops in 15-50% of children who undergo surgery for congenital cataracts ● Small corneal diameters ● Post-op complications ● Aphakic patients are always at risk for developing glaucoma ○ Usually aphakic glaucoma develops within 3 years after cataract surgery" What are the relative contraindications to trabeculectomy?;"• Prior conjunctival surgery • Active anterior segment neovascularization • Active uveitis or scleritis • Younger age • African American" What are the findings in Axenfeld-Rieger syndrome?;"• Corectopia • Polycoria • Posterior embryotoxon • Iris strands to Schwalbe line • Iris hypoplasia • Maldeveloped anterior chamber angle • Craniofacial dysmorphism (maxillary hypoplasia, telecanthus, hypertelorism) • Dental abnormalities (microdontia/oligodontia/hypodontia) • Redundant umbilical skin • Hypospadias • Growth retardation • Cardiac valve abnormalities • Pituitary abnormalities" What is the aqueous humor formation rate?;"• 2 to 3 μL/min during waking hours • During sleep, 50% reduction in rate • Total aqueous volume: 250 μL • Turnover 1% per minute" What are the racial differences in risks in POAG?;"• POAG prevalence 3-4 times higher in African descent and Hispanic ethnicity • Blindness 4 times more common in Black patients; up to 15 times higher risk in older than 45 years • More likely to be diagnosed at younger age and more advanced stage in Black patients" What is the Goldmann equation?;"● Po = (F-U)/C + Pv ○ Po = IOP in mmHg ○ F = rate of aqueous formation ○ U = rate of aqueous drainage through pressure-insensitive uveoscleral pathway in μL/min → cannot be directly measured ○ C = facility of outflow through pressure-sensitive trabecular pathway in μL/min/mmHg ○ Pv = episcleral venous pressure in mmHg, normally 6-9 mmHg" What is the Imbert-Fick principle?;"• Used for Goldmann tonometer and Perkins tonometer • Assumes CCT = 520 μm • 3.06 mm tip diameter" What are the causes of increased episcleral venous pressure?;"• Sturge Weber • Carotid-cavernous fistula • Cavernous sinus thrombosis • TED" What are the contraindications and adverse effects of hyperosmotic agents?;"• Contraindication: renal failure • Adverse effects: headache, mental confusion, backache, acute CHF, myocardial infarct, subarachnoid/subdural hemorrhage" What anatomical changes are found in angle recession?;"• Tear between longitudinal and circular muscle fibers of ciliary body" What anatomical changes are found in cyclodialysis?;"• Separation of ciliary body from scleral spur • Causes hypotony" What anatomical changes are found in iridodialysis?;"• Disinsertion of iris root from ciliary body" What are the trabecular meshwork tear findings on gonio?;"• Small trabecular cleft on gonio" What are the risks for suprachoroidal hemorrhage after trabeculectomy?;"• High myopia • Aphakia • Pseudophakia • Hypotony • Prior vitrectomy • Advanced age • Systemic hypertension • Anticoagulant therapy • History of suprachoroidal hemorrhage in fellow eye • Large magnitude of IOP reduction from pre-op to post-op" Which glaucoma medication is category B in pregnancy?;"• Brimonidine" Which glaucoma medications are category C in pregnancy?;"• Prostaglandins (PGF 2a) → affects uterine smooth muscle and induces contraction/labor • Carbonic anhydrase inhibitors • Beta blockers" What are the preservative free (BAK free) glaucoma drops?;"• Tafluprost • Cosopt -PF • Timolol -PF • Travatan Z • Alphagan P" What are the optic nerve lengths in various locations?;"• Intraocular: 1 mm • Intraorbital: 25 mm • Intracanalicular: 10 mm • Intracranial: 10 mm" What are the number of axons in the optic nerve?;"• 1.2 -1.5 million axons" What are the risk factors for primary angle closure glaucoma?;"• Race: Inuit (20-40 times higher than whites) or East Asian • Small AC/short axial lengths • >40 years • Women > men • Positive family history • Hyperopes" Which topical steroids cause IOP elevation, ranked by decreasing severity?;"Decreasing order of effect on IOP elevation • Difluprednate (most) • Prednisolone • Rimexolone • Fluorometholone (FML) • Loteprednol" What are optic drusen?;"• Abnormal axonal metabolism → mitochondrial calcification and drusen formation • Histology: discrete basophilic zones of calcifications " What are the different secondary glaucomas and the respective cell types involved in blocking trabecular meshwork?;"• Hemolytic glaucoma → hemosiderin-laden macrophages • Ghost cell glaucoma → rigid hemolyzed erythrocytes • Uveal melanomas → pigmented epithelioid melanocytes • Phacolytic glaucoma → eosinophilic protein-laden macrophages" What is implicated in the excessive proliferation of tenon capsule fibroblasts?;"• Seen with scarring of glaucoma filtration bleb • Transforming growth factor beta and platelet-derived growth factor are implicated" What is this finding?;"• Haab striae " What were the findings in the Ocular Hypertension Treatment Study (OHTS)?;"● Determined the effectiveness of typical ocular hypotensive in preventing or delaying onset of glaucoma in patients with ocular HTN ● Risk factors for progression of POAG ○ Elevated IOP (for each mmHg above baseline IOP → risk of progression increased by 10%) ○ Advanced age (22% increased relative risk per decade) ○ Thin CCT (81% increase in relative risk for every 40 μm thinner CCT) ○ Large C/D ratio (for each 0.1 vertical CD ratio increase → risk of progression increased by 32%) ○ Worse pattern standard deviation on standard automated perimetry (22% increase in relative risk per 0.2 dB increase) ● Treated group: 22.5% IOP reduction; 4.4% developed optic nerve or VF damage over 5 years ● Untreated group: 4% IOP reduction; 9.5% developed optic nerve or VF damage in 5 years ● Patients with CCT > 588 had very low rates of conversation to OAG at 5 years" What was a shared conclusion of the Collaborative Normal Tension Glaucoma study (CNTGS) and the Early Manifest Glaucoma Trial (EMGT)?;"• Optic disc hemorrhage is a risk factor for glaucoma progression" What were the conclusions from the Collaborative Initial Glaucoma Treatment Study (CIGTS)?;"• Confirmed initial surgical (trab) therapy achieves better IOP than does initial medical therapy • Results do not translate to better visual field stabilization secondary to cataracts" What were the conclusions of the Early Manifest Glaucoma Trial (EMGT)?;"• Examined betaxolol plus laser trabeculoplasty or observation • Treated: 45% progressed at 6 years. Reduced IOP by 25% • Untreated: 62% progressed at 6 years" What are the different neuroradiologic findings in optic nerve glioma versus optic nerve meningioma?;"• Optic nerve glioma: fusiform lesion • Optic nerve meningioma: tram-track lesion; fusiform can also occur. Optic nerve should appear as lucency on imaging" What is congenital glaucoma?;"• Increased resistance to outflow through trabecular secondary to dysgenesis of neural crest cell derived angle structures • Males > females • Bilateral (70%) • 2% chance of having offspring with disease • Deep anterior chamber with high, flat anterior iris insertion • Hypoplastic peripheral iris" What are the findings in plateau iris?;"• Anteriorly rotated ciliary process • Anterior chamber deep central, narrow peripheral • Gonio: narrow angle, indentation shows peripheral hump where iris is draped over anteriorly placed ciliary process" What are the types of secondary lens-related open-angle glaucoma and their findings?;"• Phacolytic: leakage of high molecular weight lens protein through microscopic openings in capsule of hypermature cataract; wrinkling of capsule; lack KPs or synechiae; pseudohypopyon; lens-engorged macrophages settle in inferior trabecular meshwork • Phacoantigenic: after surgery or trauma; granulomatous inflammation; sensitized to their own lens protein; KPs; low grade vitrifies, posterior synechiae, PAS, residual lens material • Lens particle: due to fragments of cortical lens obstructing trabecular meshwork" What is the etiology of secondary lens-related closed angle glaucoma?;"• Phacomorphic: enlarging, intumescent cataract grows in anterior-posterior dimension → pushes iris forward" What are the anterior angle structures (posterior to anterior)?;"• Iris • Ciliary body • Scleral spur • Trabecular meshwork • Schwalbe's line" What is the significance of the corneal optical wedge?;"• Posterior termination of Descemet membrane and corneal endothelium" What is the differential diagnosis for ectopia lentis?;"• Marfans • Weill-Marchesani • Homocystinuria • Hyperlysinemia • Sulfite oxidase deficiency" What systemic abnormalities are associated with aniridia?;"● WAGR complex: Wilms tumor, aniridia, GU malformations, mental retardation ○ Common in sporadic aniridia (PAX6 mutation; chromosome 11p13) ● Gillespie syndrome: aniridia, cerebellar ataxia, hypotonia, mental deficiency" What ocular anomalies are associated with aniridia?;"• Cataract • Corneal pannus • Foveal hypoplasia • Limbal stem cell deficiency • Glaucoma • Nystagmus • Optic nerve coloboma • Optic nerve hypoplasia • Refractive errors • Ptosis" What fatal conditions are associated with albinism?;"• Chediak-Higashi • Hermansky-Pudlak" What is Chediak-Higashi syndrome?;"• Autosomal recessive • Mutation in lysosomal trafficking regulator protein that renders inadequate phagocytosis • Recurrent pyogenic infection • Patients rarely survive past 10 years of age, die from infection" What is Hermansky-Pudlak syndrome?;"● Autosomal recessive ● Associated with: ○ Low platelets ○ Interstitial lung disease ○ Granulomatous colitis ● Common among Swiss or Puerto Rican descent" What is the treatment for congenital glaucoma?;"• Topical IOP lowering medications until surgery • Surgery is definitive treatment • If cornea is clear → goniotomy • If cornea is cloudy → trabeculotomy" What are the clinical findings in pigmentary dispersion syndrome?;"• Krukenberg spindle: narrow or round pigment on corneal endothelium. Present in 90% of patients • Midperipheral transillumination defects of iris → iris with concave contour, rubs against zonules → pigment release. Present in 90% of patients • Scheie’s line or Zentmayer’s line: pigment on anterior surface along zonule and posterior surface • Gonioscopy: open angle, trabecular meshwork densely pigments and pigment on Schwalbe’s line (Sampaolesi line)" What are the risk factors for pigmentary dispersion syndrome?;"• Male • Age (usually 30’s) • Myopia • Concave iris and posterior iris insertion • Flat corneas • Family history" What is the alcohol content of alcohol wipes?;"• 70% isopropyl alcohol" What is the site of presumed damage to the optic nerve in glaucoma?;"• Lamina cribrosa" What is Lowe syndrome?;"• Oculocerebrorenal syndrome • X-linked recessive; mutation of OCRL gene • Poor visual prognosis • Bilateral cataracts • Glaucoma -50% of patients • Nystagmus • Keloids -corneal or conjunctival • Hypotonia • Fanconi syndrome/chronic renal failure" What are the ocular findings in albinism?;"• Foveal hypoplasia (poor vision and poor prognosis) • Nystagmus due to poor vision from foveal hypoplasia • Over-decussation of optic nerve fiber, 90% fiber decussates to contralateral side (normally 53%) • Loss of stereopsis due abnormal decussation • Transillumination defects of iris • Strabismus • Photophobia • Refractive errors" What is aniridia?;"• Iris hypoplasia, various degrees Genetic etiology: • PAX6 mutation; chromosome 11p13 • Autosomal dominant (⅔) or sporadic (⅓) • Autosomal recessive in 2% -seen with Gillespie syndrome Management: • Obtain renal ultrasound in sporadic aniridia to rule out WAGR" What is neurofibromatosis type 1?;"• Autosomal dominant • Chromosome 17 • AKA von Recklinghausen disease • Associated with with cafe au lait spots, iris Lisch nodules (hamartoma), neurofibromas, plexiform neurofibromas (increased risk of glaucoma; described as “bag of worms,” S shaped eyelid), optic nerve gliomas, sphenoid wing dysplasia" What is tuberous sclerosis?;"• Autosomal dominant • Mutation of TSC1 (hamartin; more common for retinal lesions) and TSC2 (tuberin) • Chromosome 9, 16 • AKA Bourneville-Pringle disease • Triad: facial sebaceous adenomas (angiofibromas), mental deficiency, seizures (intracranial calcified astrocytic hamartomas) • Other findings, ungual fibromas, hypomelanotic macules, Shagreen patch, multiple retinal hamartomas" What is von Hippel-Lindau Disease?;"• Autosomal dominant • Chromosome 3 • Tumor suppressor gene mutation • AKA cerebello-retinal-angiomatosis • Associated with retinal capillary hemangioblastomas; angiomatous lesions of CNS; cerebellar hemangioblastoma; pancreatic cysts; renal cell carcinoma; pheochromocytoma" What is ataxia telangiectasia?;"• Autosomal recessive • AT gene mutation → DNA damage repair • Chromosome 11 • AKA Louis Bar syndrome • Ocular manifestations include conjunctival telangiectasias, nystagmus, oculomotor apraxia, convergence and accommodation abnormalities, strabismus • Increased risk of cancer and immunodeficiency" What are the laser settings for diode cyclophotocoagulation?;"• Power: 750 mW to 2000 mW • Duration: 2 to 4 seconds • Avoid 3 o’clock and 9 o’clock positions (ciliary nerves) • 6 spots per quadrant • Total of 18 spots (recommend 3 quadrants to avoid anterior segment necrosis)" What medication has shown to decrease secondary hemorrhage in hyphema patients?;"• Aminocaproic acid" What is the medical management of traumatic hyphema?;"• If sickle cell screen positive: beta blockers and alpha-2 agonists; avoid systemic and topical CAI’s • If sickle cell screen negative: beta blockers, alpha-2 agonists, and CAI’s (topical and systemic)" What are surgical indications for traumatic hyphema?;"• If sickle cell screen positive: corneal blood staining; IOP > 25 for 24 hours; recurrent IOP spike > 30 • If sickle cell screen negative: corneal blood staining; IOP > 60 for 48 hours; IOP > 50 x 5 days; IOP > 25 for 6 days, hyphema > 50% after 8 days" What are mechanisms of action of Mitomycin C (MMC) and 5-fluorouracil (5-FU)?;"• Both are chemotherapeutic agents • MMC: DNA crosslinker • 5-FU: inhibits thymidylate synthase, ultimately inhibits DNA synthesis and repair. Cell cycle specific (G1)"