4. History of presenting illness
Apparently alright 2 months back when she noticed
diminution of vision in left eye, gradual in onset and
progressive in nature.
Associated with pain in her left eye, pricking in
nature, present throughout the day.
Sometimes pain used to increase in the evening.
No aggravating and relieving factors and radiating to
left brow and forehead area.
5. Had shown to another ophthalmologist where she
was diagnosed to have anterior segment dysgenesis
and was prescribed following eye drops- left eye
1. Eyemist forte eye drops( Hydroxypropyl methyl
cellulose 3mg, Dextran 70, Glycerin) sos.
2. Travatan eye drops(Travoprost 0.004%) once at
night.
3. Dortas T eye drops( Dorzolamide hydrochloride 2%,
Timolol Maleate 0.5%) 2 times per day.
6. History of using glasses since 7-8 years.
Her present glasses were 5 months old.
No ho redness, watering.
No ho photophobia.
No ho coloured halos.
No ho trauma
No ho similar complaints in the other eye.
7. • PAST HISTORY
No history of similar complaints in the past.
• FAMILY HISTORY
Nothing significant.
8. GENERAL PHYSICAL EXAMINATION-
Normal
SYSTEMIC EXAMINATION-
Normal
10. Visual acuity
SPH CYL AXIS VA
DIST -2.50 -1.50 160 6/12
NEAR - - - N18
Extra ocular movements-All uniocular and binocular
extraocular movements are full and free.
SPH CYL AXIS VA
DIST -2.00 -2.00 20 6/6
NEAR - - - N6
11. Structure Right eye Left eye
lids Normal Normal
Conjunctiva Normal Mild superficial
conjunctival congestion
Cornea Clear Few iris pigments on
endothelium
Anterior chamber Quiet Irregular in depth, quiet
Anterior segment examination
12. Anterior segment examination
Iris Normal in colour and
pattern
Loss of pattern,
Iris holes
Pupil Round, regular and
reacting to light
single, eccentric pupil,
round,3mm in size,
sluggishly reactive,
pseudopolycoria
Lens Clear Clear, iris pigments on
anterior lens capsule.
18. Fundus
OD OS
Glow Present Present
Media Clear Clear
Disc Small Small
cup:disc 0.4:1 0.8:1, small inferior notch
Macula Foveal reflex present Foveal reflex present
Background Normal Normal
25. After the above investigations, patient was advised to
continue same eye drops-left eye
1. Eyemist forte eye drops( Hydroxypropyl methyl
cellulose 3mg, Dextran 70, Glycerin) sos.
2. Travatan eye drops(Travoprost 0.004%) once at
night.
3. Dortas T eye drops( Dorzolamide hydrochloride 2%,
Timolol Maleate 0.5%) 2 times per day.
Patient was given appointment for diurnal variation
test.
27. Time IOP B.P.
8:00 am 12 16 110/80
10:00 am 12 16 108/76
12:00 pm 14 16 120/72
3:00 pm 14 16 110/78
28. Right eye Left eye
Highest IOP 16 24
Lowest IOP 12 16
•Patient was asked to continue same eye drops and review
after 6 weeks.
•Also, Dortas T eye drops were asked to be added a little
later in the day to blunt off the spike.
29. Subsequently patient was followed up with intervals
of 2-3 months for IOP evaluation.
Her IOP was well controlled throughout.
30. 23-08-2013
Patient came for regular follow-up. She was in first
trimester of pregnancy.
On examination, BCVA in Right eye was 6/6, N6
Left eye was 6/12, N18
Anterior and posterior findings were same as before.
Patient was advised to stop Travoprost eye drops for
first trimester as it could be an abortifacient and
follow up 3 weeks.
31. On subsequent follow ups till Feb 2014, her pressures
were under control.
Then she directly came for follow up on 08-10-14.
She was using both Dortas T eye drops 2 times daily
and Travatan eye drops once daily in left eye.
IOP was 10mmHg in right eye and 16 mmHg in left
eye.
34. Patient was asked to continue same treatment and
review every 3 months for IOP evaluation.
On 27-07-15, patient came for follow up.
IOP was 14 mmHg in both eyes.
42. There seems to be a progresion happening.
Hence an AGV counselling was done.
Till then, advised to continue same eye drops and
review after 1 month.
44. Disorders of the cornea associated
with glaucoma
• Peters’ anomaly
• Aniridia
• Axenfeld-Rieger syndrome
Developmental
disorders
• Keratouveitis
• Full thickness or endothelial
keratoplasty
• Trauma
Acquired
conditions
45. Glaucomas associated with primary disorders of
corneal endothelium
1. Iridocorneal endothelial syndrome (Unilateral)
2. Posterior polymorphous dystrophy (Bilateral)
3. Fuch’s endothelial dystrophy (Bilateral)
Allingham RR, Damji KF, Freedman SF et al. Editors. SHEILDS.
Textbook of Glaucoma.6th ed. Lippincott Williams & Wilkins: 2012
46. Glaucoma with secondary corneal
abnormalities
A. Pressure induced
corneal changes
1. Epithelial and stromal
oedema
2. Endothelial changes
3. Haab’s
striae(childhood
glaucoma)
B. Exfoliation induced
corneal endothelial
changes
47. C. Drug induced changes in the cornea
1. Endothelial decompensation with topical
carbonic anhydrase inhibitors.
2. Toxic effects to cornea epithelium(eg:
benzalkonium chloride, β- blockers, miotics.)
48. Iridocorneal endothelial syndrome
Characterised by primary corneal endothelial
abnormality.
Associated with-
1. corneal oedema
2. Anterior chamber angle changes
3. Alterations in iris
4. Glaucoma
Hirst LW, Quigley HA, Stark WJ, et al. Specular microscopy if
iridocorneal endothelia syndrome. AM J Ophthalmol. 1990;89(1):11-21.
49. General features
Clinically unilateral
Age- early to middle adulthood
Sex- females more commonly affected
Familial cases rare
No consistent association with any systemic disease
Most common clinical manifestations-
Abnormalities of iris
Reduced vision
Pain
50. Major clinical variations
Progressive iris
atrophy
• Iris features
predominate
• Corectopia
• Atrophy and hole
formation
Allingham RR, Damji KF, Freedman SF et al. Editors. SHEILDS.
Textbook of Glaucoma.6th ed. Lippincott Williams & Wilkins: 2012
53. Specular microscopy
Fine hammered
silver appearance of
posterior cornea.
Pleomorphism in size
and shape.
Dark areas within the
cells.
Loss of clear hexagonal
margins
Hirst LW, Quigley HA, Stark WJ, et al. Specular microscopy if
iridocorneal endothelia syndrome. AM J Ophthalmol. 1990;89(1):11-21.
54. ICE cells
These endothelial cells appear dark by specular
microscopy except for light central spot and a light
peripheral zone.
When clustered as continuous cells, known as ICE
TISSUE.
Give appearance of negative of a tissue.
55. Variations of ICE tissue
• Disseminated ICE –
1. ICE cells scattered among large
endothelial cells.
2. elevated IOP
• Total ICE-
1. Whole posterior corneal surface
composed of ICE tissue.
Hirst LW, Quigley HA, Stark WJ, et al. Specular microscopy if
iridocorneal endothelia syndrome. AM J Ophthalmol. 1990;89(1):11-21.
56. • Subtotal ICE(+)-
1. clearly defined ICE tissue
2. remaining cells-distinct small cells
3. normal IOP
• Subtotal ICE (-)-
1. ICE tissue
2. larger than normal remaining
endothelial cells.
57. Anterior chamber angle alterations
Peripheral anterior synechia, usually extending
to or beyond Schwalbe’s line is common to all
variations of ICE syndrome.
Histology reveals a cellular membrane consisting of a
single layer of endothelial cells and Descemet’s like
membrane extending down from the peripheral
cornea.
Weber PA, Gibb G. Iridocorneal endothelial syndrome glaucoma
without peripheral anterior synchias. Glaucoma. 1994;6:128.
58. Membrane theory of Campbell
Campbell DG, Shields MB, Smith TR. The corneal endothelium and the
spectrum of essential iris atrophy. AM J Ophthalmos. 1978;86(3):317-324.
60. Dissolution of the iris
Axenfeld Rieger syndrome
• Congenital
• Bilaterality
• Prominant anteriorly
displaced Schwalbe’s line
• Associated ocular and
systemic abnormalities.
Iridoschisis
Separation of superficial
layers of iris stroma
May be associated with
glaucoma
Typically seen in elderly
62. Management Of ICE Syndrome
In early stages, drugs that reduce aquoeus
production are used.
Aqueous facilitators are of no use, as the TM is
affected . However other pathways may still be
targeted.
Prostaglandins may not be advocated, as there is a
school of thought that believes the HSV / Epstein Barr
virus to be an aetiological factor.
There have been no reported cases of reactivation of
the viral infection.
63. When the IOP can no longer be controlled medically,
surgical intervention is indicated.
Laser trabeculoplasty is not effective for this
disease, as the angle is affected.
64. Filtering surgery is reasonably successful, though
late failures have occured because of
endotheliazation of the filtering bleb & the fact
that the surgery is done on relatively young
adults, where fibroblastic proliferation is
common. .
Glaucoma drainage device surgery, is the surgery
of choice & has proven to be more effective.
Kim DK, Aslanides IM, Schmidt CM Jr, et al. Long term outcome of
aqueous shunt surgery in ten patients with iridocorneal endothelial
syndrome. Ophthalmology. 2000;106(5):1030-1034.
65. Corneal oedema may be controlled improved by
lowering the IOP.
Hypertonic saline solutions can be used.
Penetrating keratoplasty or DSAEK if there is
marked dysfunction of corneal endothelium and
oedema is not getting cleared.
Alwin PT, Cohen EJ, Rapuano CJ, et al. Penetrating keratoplasty in
iridocorneal endothelial syndrome. Cornea. 2001;20(2):134-140.
67. Beta-blockers-FDA rating class C
Drugs like timolol, levobunolol, betaxolol, carteolol-
should be avoided in the first trimester of pregnancy
and discontinued 2-3 days prior to delivery to avoid
beta-blockade in the infant.
Beta-blockers being concentrated in breast milk,
avoided in mothers who are breastfeeding.
Timolol - reported to be compatible with lactation
according to the American Academy of Pediatrics.
Michael J. Trad. Some ophthalmic drugs not safe for use in
lactating or pregnant women
Primary Care Optometry News, September 2008
68. Carbonic anhydrase inhibitors- FDA
rating Class C
Contraindicated during pregnancy because of
potential teratogenic effects.
Avoided in mothers who are breastfeeding because of
the potential hepatic and renal effects to the infant.
However, acetazolamide has been reported to be
compatible with lactation according to the American
Academy of Pediatrics.
69. Miotics-Class C
Drugs like pilocarpine, echothiophate, carbachol
appear to be safe during pregnancy.
The toxicity during lactation is unknown.
One exception is demecarium, which is toxic and is
contraindicated in pregnancy and mothers who are
breastfeeding.
70. Prostaglandin analogs-Class C
Prostaglandins are used systemically for labor
induction and termination, and as such, the topical
use for glaucoma during pregnancy raises natural
concern.
Therefore, caution should be exercised when
latanoprost is administered in women who are
pregnant or breastfeeding.
71. Adrenergic agonists- Class C
Brimonidine has not demonstrated any fetal risk.
Although no studies were conducted in pregnant
patients, it may be used if necessary.
Whether brimonidine is excreted in human milk is
not known. Therefore, caution should be exercised
since topical brimonidine given to human infants
aged younger than 2 months has been reported to
cause bradycardia, hypertension, hypothermia,
and apnea.