1. ONH exam, clinical characteristics of glaucoma and risk factors

is glaucoma elevated IOP?

no

POAG is a CHRONIC, progressive ____ _____ in which there is an acquired atrophy of the optic nerve and irreversible loss of _____ ____ ____ and their ______

optic neuropathy retinal ganglion cells axons

in POAG, the anterior chamber is ____ by gonio, and secondary causes of IOP elevation are _____

open absent

POAG is a diagnosis of ______

exclusion

POAG is a potentially ______ eye disease, but early diagnosis and treatment can generally prevent visual disability

blinding

glaucoma is the leading cause of blindness in ____ america

black

ganglion cells synapse in the _____ ____ _____ in the brain (long pathway)

lateral geniculate body

the optic nerve that is visible is about ____mm in diabeter

1.75

there are ____ million axons that make up the optic nerve

1.2

in the NFL, there is a large number of axons dedicated to the ________ _____

papillomacular bundle

NFL organization causes ______ fibers

arching

do NFL fibers cross the horizontal raphe?

no

peripheral retinal axons exit more ________ part of ONH

peripheral

central retinal axons exit more _____ in ONH

central

what is a normal CD ratio?

0.1 to 0.4

what color is normal rim tissue?

pink

what color is normal and observed after cat sx?

psuedopallor

how much of a difference between CDs is okay?

0.05

larger than ____ CD ratio difference is not normal

0.1

in a normal disc, veins are slightly ____ and _____ than arteries

darker larger

_____ ____ _____ - a rhythmic pulsing of the central retinal veins at the optic disc

spontaneous venous pulsation

spontaneous venous pulsation is a ____ finding indicating the pressure gradient between the ___-____ pressure and ____-_____ pressur

normal intra ocular intra cranial

spontaneous venous pulsation is because there is ____ IOP than CSF pressure

higher

can you see SVP on all patients?

no

when does SVP matter?

when it is present and then it is not

what can cause SVP to be present and then absent later?

increased ICP

glaucoma occurs when there is reduced ____ ____ to axons

blood flow

trauma can cause glaucoma due to direct ______ on the axons, and ______ _____ at the lamina cribosa

pressure mechanical compression

_____ glaucoma theory - high IOP or lamina cribosa weakness

mechanical

______ glaucoma theory - low perfusion pressure leads to ONH ischemia

ischemic

______ glaucoma theory - retinal ganglion cells are under stress due to mechanical and vascular damage

excitotoxicity

glaucoma damage may still progress when IOP is low due to _______

apoptosis

is POAG bilateral or unilateral?

bilateral

what are 5 things you need to be able to diagnose POAG?

ONH damage, VF defect, adult onset, open angles, no secondary cause

_____ ____ of POAG - optic disc RNFL damage/loss

structural defect

______ ____ of POAG - corresponding to a reliable and reproducable VF defect

functional defect

what rule is followed when observing narrowing or notching of the rim?

ISNT

visible ONH damage:

_____ of the disc

cupping

visible ONH damage:

_____ of RNFL and/or macular GCA

thinning

visible ONH damage:

optic disc _____

hemes

visible ONH damage:

_______ of the rim between the two eyes

asymmetry

visible ONH damage:

____ zone parapapillary atrophy

beta

RNFL/GCA thinning on OCT

RNFL/GCA thinning on OCT

what are two ways you can document RNFL loss?

disc photos (red free) and OCT

thinning of peripapillary RNFL

look for diffuse or focal narrowing or notching of the optic disc rim especially at the _____ or _____ poles

inferior superior

the neuroretinal rim should be widest at the ____ rim, then _____ rim, then ___ rim and lastly ____ rim

inferior superior nasal temporal

in approx ____% of patients with glaucoma, cupping does not follow ISNT rule

80

normal eyes follow ISNT rule ____% of the time

45

progressive narrowing of the neuroretinal rim can cause an ______ in cup size

increase

does cupping or pallor occur first in glaucoma?

cupping

_____ cupping is specific to glaucoma, specifically in the _____ meridian

progressive vertical

what does the beta zone represent?

less RPE

what does the alpha zone represent

thickened RPE

the beta zone represents atrophy of what 3 areas?

RPE, PRs and choriocapillaris

the beta zone is present in ___% of normal patients

25

beta zone atrophy can worsen overtime, which may indicate worsening ______ glaucoma

structural

what are four vessels changes that all indicate glaucoma progression?

baring of circumlunar vessels, bayoneting of vessels, nasalization of vessels and hemes

______ of circumlinear vessels - vessel lining of the cup becomes exposed as the rim thins

baring

baring

_______ of vessels - vessels crossing the rim disappear into a deep cup

nasalization of the vessels indicates _____ galcuoma

late

does pallor always indicate glaucoma?

no

when does pallor indicate glaucoma?

no rim tissue

pallor without ______ is not glaucoma

cupping

does visible lamina cribosa indicate glaucoma?

no

when does visible lamina cribrosa become indicative of glaucoma?

when lamina was not visible and then it is

____ hemes indicate focal disc damage

drance

drance hemes signify ____ damage in patients with glaucoma

ON

the _____ ____ ____ _____ revealed that the incidence of POAG in eyes with a disc heme was 13.6% compared with 5.2% in eyes without disc hemes over 8 years

ocular hypertension treatment study

drance heme

what are the 5 rules in the FORGE template?

NRR size, NRR shape RNFL thickness, scleral ring with PPA, ONH heme

high IOP compresses ganglion cell axons as they pass through the _____ ______

lamina cribosa

high IOP compressing ganglion cell axons leads to _____ flow stasis

axoplasmic

_____ _____ _____ - perfusion pressure is too low, leading to ONH ischemia

ischemic perfusion insufficiency

what produces aqueous?

CB

the CB forms what barrier?

blood aqueous

on average __ml/minute of aqueous is being produced

2

aqueous production ______ with age

decreases

aqueous production _______ with inflammation

decreases

________ - passive, pressure-dependent movement

ultrafiltration

________ - pressure independent across membranes

diffusion

_____ ______ - ion transport creates osmotic gradient and water follows

active secretion

which kind of secretion produces most of the aqueous humor?

active secretion

TM outflow is pressure _______

dependent

____ outflow is pressure independent

uveoscleral

which outflow system is responsible for most aqueous outflow?

TM

which part of the TM pathway has the highest resistance to outflow?

juxtacanclicular

what are the four steps of TM outflow?

TM, schlemms canal, outlow channels and aqueous venous system

what are the three steps of the uveoscleral outflow?

CB, suprachoroidal space, venous circulation of CB, choroid and sclera

how is IOP calculated?

aqueous production/outflow + episcleral venous pressure

cannot lower IOP greater than ____ ____ pressure

episcleral

how much is episcleral venous pressure?

8-10

what are three drugs that can decrease aqueous production?

CAIs, BB and a2 agonists

what are two drugs that can increase uveoscleral outflow?

PGA and ROCKi

what are three things that can increase TM outflow?

SLT, ROCKi, pilo

what is the treatment for decreasing episcleral venous pressure?

sx

prevalence of POAG increases as the ____ increases

IOP

7% of white individuals and 25% of black individuals had POAG at an IOP of ___ or greater

30