Updated: 4/6/2018

Glaucoma

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Snapshot
  • A 55-year-old male presents with severe light-sided pain around the eye. He experiences blurred vision and nausea. His symptoms began while at the movie theatre. On physical exam, decreased visual acuity is appreciated. Inspection of the eye is shown.
Introduction

  • Optic neuropathy characterized by optic nerve damage and visual abnormalities
    • majority of patients have increased intraocular pressure (IOP)
      • important causative risk factor
      • associated with increased resistance to aqueous outflow
      • compresses retinal blood supply or retinal ganglion cells
        • optic disc atrophy with cupping → visual loss
  • Aqueous humor inflow and outflow maintains intraocular pressure
    • ciliary body produces aqueous humor
    • humor gets resorbed by the trabecular meshwork and uveoscleral outflow pathway
  • Glaucoma can be characterized into
    • open-angle or angle-closure 
  • Epidemiology
    • second leading cause of blindness
      • cataracts is first
    • open-angle glaucoma is more common
    • risk factor examples
      • family history
      • age
      • race
Open-Angle Glaucoma
  • Open-angle glaucoma is most common among Europeans and African Americans
  • Presentation
    • usually asymptomatic
  • Etiology
    • primary open-angle glaucoma
      • unclear
    • secondary open-angle glaucoma
      • neovascularization
        • e.g., diabetes mellitus,
      • debri
        • e.g., RBCs, WBCs, pseudoexfoliation
      • corticosteroids
      • retinal detachment
  • Evaluation
    • visual acuity
    • visual field testing
    • intraocular pressure
    • pachymetry
  • Treatment
    • pharmacologic 
      • increases aqueous outflow
        • prostaglandins (becoming first-line)
        • α-agonists
        • cholinomimetics
      • decreases aqueous production
        • carbonic anhydrase inhibitors
        • α-agonists
        • β-blockers
    • laser therapy
      • trabeculoplasty
    • surgical
      • filtration bleb
  • Prognosis, prevention, and complications
    • prognosis
      • does not substantially reverse
    • prevention
      • may involve lower IOP
    • complications
      • blindness
Angle-Closure Glaucoma
  • Angle-closure glaucoma is more common in people of Asian decent
  • Presentation
    • symptoms
      • very painful
      • frontal headache
      • ↓ vision (photophobia/blurry vision)
      • halos around lights
      • eye very firm
    • physical symptoms
      • fixed-dilated pupil
      • corneal clouding
      • conjunctival injection
  • Etiology
    • obstruction of flow between the iris and cornea
      • can have primary (anatomy) or secondary (pulling or pushing the iris to shorten the angle) causes
        • angle-closure crisis is an ophthalmic emergency
      • can be caused by mydriatic agents such as atropine (pupil dilation reduces aqueous humor outflow), infection, or lens dislocation 
  • Evaluation
    • visual acuity
    • visual field testing
    • intraocular pressure
    • evaluation of anterior chamber via slit-lamp
    • gonioscopy (gold standard)
  • Treatment
    • iridotomy
    • topical β-blockers, α2-agonists
      • epinephrine contraindicated!
        • α1-agonism causes mydriasis
    • oral carboanhydrase inhibitors
  • Prognosis, prevention, and complications
    • prognosis
      • progressive vision loss that may lead to blindness
        • if not detected early and not properly managed
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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