Secondary glaucoma

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Secondary glaucoma is a progressive optic nerve disorder which results in complete loss of vision. Depiction of vision for a Glaucoma patient.png
Secondary glaucoma is a progressive optic nerve disorder which results in complete loss of vision.

Secondary glaucoma is a collection of progressive optic nerve disorders associated with a rise in intraocular pressure (IOP) which results in the loss of vision. In clinical settings, it is defined as the occurrence of IOP above 21 mmHg requiring the prescription of IOP-managing drugs. [1] It can be broadly divided into two subtypes: secondary open-angle glaucoma and secondary angle-closure glaucoma, depending on the closure of the angle between the cornea and the iris. Principal causes of secondary glaucoma include optic nerve trauma or damage, [2] eye disease, surgery, neovascularization, [3] tumours [4] and use of steroid and sulfa drugs. [2] Risk factors for secondary glaucoma include uveitis, [1] cataract surgery [5] and also intraocular tumours. [5] Common treatments are designed according to the type (open-angle or angle-closure) and the underlying causative condition, in addition to the consequent rise in IOP. These include drug therapy, the use of miotics, surgery or laser therapy. [6]

Contents

Pathophysiology

Secondary glaucoma has different forms based on the varying underlying ocular conditions. These conditions result in an increase in IOP that manifests as secondary glaucoma.

Paediatric congenital cataract associated glaucoma

The eye consist of several structures notable for the mechanisms of secondary glaucoma. Three Main Layers of the Eye.png
The eye consist of several structures notable for the mechanisms of secondary glaucoma.

Based on the onset of secondary glaucoma in paediatric patients, it can be classified into early-stage and late-stage glaucoma cases. Early-stage secondary glaucoma, observed as angle-closure glaucoma, results from the blockage and inflammation of the peripheral anterior synechiae structure. [5] However, early-stage secondary glaucoma rarely occurs with the readily available prescription of anti-inflammatory medications. On the other hand, late-stage glaucoma is commonly associated with open-angle glaucoma but the mechanisms are currently unconfirmed. Yet, it is believed to be closely related to the onset of trabeculitis or vitreous toxicity. [5]

In paediatric congenital cataract patients under the age of two, cataract surgery is considered and frequently employed as the primary treatment. There are two types of therapeutic combination, primary and secondary lens implantation (IOL). [5] In primary IOL, cataract surgery is performed alongside immediate implantation of IOL. However, in secondary IOL implantation, the patient is prescribed aphakic glasses or contact lenses till the implantation of IOL after a varied period of time between a few months or years. Primary IOL implantation is observed to significantly reduce and avoid the occurrence of secondary glaucoma in paediatric patients under the age of two. [5]

Herpetic anterior uveitis associated glaucoma

In patients diagnosed with herpetic anterior uveitis, elevated IOP and secondary glaucoma are often detected. This is due to two main reasons, the blockage of vitreous flow resulting from inflammation in the structures of the trabecular meshwork, and the sedimentation of inflamed cells. Specifically for viral anterior uveitis, patients with IOP levels above 30 mmHg are often suffer from secondary glaucoma caused by cytomegalovirus.  

Other forms of secondary glaucoma

Epidemiology

The overall prevalence of secondary glaucoma across China between 1990 and 2015 was reported to be 0.15%, lower than the overall estimates for East Asia (0.39%). [7]

Varying forms of secondary glaucoma

Pigmentary glaucoma has lower incidence in Black and Asian populations, due to their characteristically thicker irises that result in a lower likelihood of pigment release, as compared to the White populations. [2] Incidence of exfoliation syndrome-caused secondary glaucoma is estimated to be approximately 10% of the glaucoma patient population in the United States and over 20% of the patient population in Iceland and Finland. [2]

In populations above the age of 40, neovascular glaucoma has a prevalence of 0.4% worldwide. [8] The incidence of pigmentary glaucoma decreases with age while in exfoliation syndrome the incidence increases with age. [2]  However, given the derived nature of secondary glaucoma, there may be no significant association between age, ethnicity or gender and the prevalence of the condition. [7]

Secondary glaucoma indicated after congenital cataract surgery is found between 6 and 24% of the cases noted, whereas, secondary glaucoma caused by primary IOL implantation was observed as 9.5%. [5] Additionally, for patients with aphakia and secondary IOL implantation, 15.1% of the cases were determined. [5] The incidence risk in primary IOL implantation in children with cataract in both eyes is lower than secondary IOL implantation and aphakic condition. However, this difference is not observed in the general population and populations with cataract in one eye. [5]

Due to lack of concrete and specific epidemiological evidence, further research is required to accurately estimate the prevalence of secondary glaucoma and its subtypes. [7]

Risk factors

In general, elevated IOP is a major risk factor in the development of secondary glaucoma. However, there are several risk factors contributing to the fluctuation in IOP levels.

Uveitis

Secondary glaucoma is commonly associated with uveitis. [9] Uveitis is the inflammation of the uvea, a middle layer tissue of the eye consisting of the ciliary body, choroid and iris. Various causes have been identified as potential risk factors contributing to the occurrence of secondary glaucoma. These include viral anterior uveitis due to cytomegalovirus infection, and herpetic anterior uveitis caused by herpes simplex virus. The observed pathophysiology of secondary glaucoma in uveitis is found to be linked to the increase and fluctuation of IOP. Inflammation of eye tissues contributes to the blockage of IOP produced in the ciliary body. This results in the accumulation of aqueous and thus elevated IOP, which is a common risk factor for the progression of secondary glaucoma. [1]

Paediatric congenital cataract surgery

Paediatric congenital cataract surgery is also identified as a risk factor for the progression of secondary glaucoma. [10] Cataract is an ocular disease, identified by the progressive clouding of the lens. Surgical procedures are often employed to replace the lens and allow for clear vision. However, there is an increased risk of secondary glaucoma development in children due to the secondary IOL implantation procedure. [10] The increased inflammatory sensitivity in the anterior chamber angle may contribute to the risks of secondary glaucoma. [5]

Intraocular tumour

Intraocular tumours (uveal and retinal tumours) are also found to be closely associated with the development of secondary glaucoma. The pathophysiology of secondary glaucoma in these cases is affected by the type of tumour, location and other tumour-associated factors. Among the many subtypes of uveal tumours, secondary glaucoma is the most prominent among patients with trabecular meshwork iris melanoma. [4] The blockage of vitreous flow due to inflammation in the structures of the trabecular meshwork is also observed in herpetic anterior uveitis patients. In addition to this, angle invasion [4] is a mechanism that is observed to contribute greatly to the development of secondary glaucoma in patients with iris tapioca melanoma, iris lymphoma, choroidal melanoma, and medulloepithelioma.  

Treatment and management

Pharmacological interventions

Miotic drugs are a class of cholinergic drugs that are frequently employed in the treatment and management of all types of glaucoma. [11] [12] These drugs stimulate the contraction of the pupil causing the iris to pull away from the trabecular meshwork. [2] [12] Consequently, the normal drainage of the aqueous humour is restored, relieving IOP. In addition to causing a direct effect on IOP, these drugs are applied to reduce pigment release (from the iris pigment epithelium) in the treatment of pigmentary glaucoma. [2] Despite the advantages, the widespread use of miotic drugs is limited by its associated side effects. There is an increased risk of development of posterior synechiae in glaucoma secondary to exfoliation syndrome and ocular trauma. [2] Other side effects include increased risk of miosis-induced headaches, blurred vision, retinal detachment and damage to the blood-aqueous barrier. [2]

Alternative drugs which can reduce the synthesis of aqueous humour, called aqueous suppressants, or increase the drainage of aqueous humour emerged as effective first-line treatments. [2] [6] Aqueous suppressants include beta-blockers, alpha-agonists and carbonic anhydrase inhibitors. They are particularly effective in treating corticosteroid, uveitic, aphakic, pseudophakic, ghost-cell and post-traumatic glaucoma. [2] Prostaglandin analogues increase aqueous drainage and are thus used in the reduction of IOP. [6] There are contradictory findings regarding the occurrence of prostaglandin analogue mediated side effects in the treatment of uveitic glaucoma. It was previously identified that the side effects comprise damage to the blood-aqueous barrier, cystoid macular oedema, risk of developing anterior uveitis and recurrence of keratitis caused by herpes simplex virus. [6]  However, current scientific evidence only supports the reactivation of herpes simplex keratitis among the other side effects. [6]

In uveitic and inflammatory glaucoma, reduction in inflammation is a critical step during the treatment and management process. This is commonly done using corticosteroids coupled with immunosuppressants. [6] Steroidal treatment is also used in management of aphakic, pseudophakic, and post-traumatic glaucoma. Inflammatory glaucoma may further be treated using cycloplegics, a class of drugs that treats pain, ciliary spasm, uveoscleral tract blockage and disrupted blood-aqueous barrier linked with this form of glaucoma. [2] While some studies recommend the use of anti-vascular endothelial growth factor drugs for inhibition of neovascularization in neovascular glaucoma, there is a lack of substantial evidence for the effectiveness of this treatment method. [3]  

Laser therapy

Among different laser therapies, laser peripheral iridotomy and laser trabeculoplasty are the most common procedures for secondary glaucoma. Both methods involve creating new outlets for the aqueous humour to flow out of, effectively reducing the IOP. In peripheral laser iridotomy, the opening is created in the iris tissue while in trabeculoplasty, this opening is made in the trabecular meshwork. [13] Further, there are two types of laser trabeculoplasty: argon laser trabeculoplasty and selective laser trabeculoplasty. [6]

Laser peripheral iridotomy has high efficacy in the treatment of pigmentary glaucoma. Argon laser trabeculoplasty is effective in the management of corticosteroid and pigmentary glaucoma. [2] However, this is often contraindicated due to high rates of failure in patients with uveitic glaucoma. [6] For uveitic glaucoma, treatment with selective laser trabeculoplasty is associated with fewer adverse effects and risks of failure. [6]

Surgical treatment

Surgical procedures are effective in cases where pharmacological management is not successful or suitable. Such methods work by facilitating aqueous outflow through the modification of the obstructing trabecular meshwork using trabeculectomy, goniotomy, non-penetrating deep sclerectomy or canaloplasty. Alternatively, introduction of new drainage pathways may also be achieved by the implantation of glaucoma shunts or glaucoma drainage devices. [6]

Trabeculectomy is held as the gold standard for surgical management of glaucoma. Studies indicate that treatment of uveitic glaucoma using trabeculectomy with antimetabolites administration has a high success rate of 62%-81%. [6] Thus, it is also commonly used in the treatment of pigmentary glaucoma.

Drainage tube implants are also implicated in treatment of uveitic and inflammatory glaucoma. [2] [6]

Minimally invasive glaucoma surgery is performed in order to overcome the risks and adverse effects associated with conventional surgical procedures. However, there are limited studies testing the efficacy of utilising this type of surgery for the treatment of uveitic glaucoma. [6]

In addition to the direct reduction of IOP, surgical procedures are used to remove blood, viscoelastic fluid and debris in glaucoma caused by cataract extraction and ocular trauma. They may also be utilized to remove depot steroids in corticosteroid glaucoma and ghost cells from the vitreous humour in ghost-cell glaucoma through a procedure known as vitrectomy. [2]

Related Research Articles

<span class="mw-page-title-main">Glaucoma</span> Group of eye diseases

Glaucoma is a group of eye diseases that lead to damage of the optic nerve, which is important for transmitting visual information from the eye to the brain. This damage is often caused by increased pressure within the eye, known as intraocular pressure (IOP) and may cause vision loss if left untreated. The word glaucoma originated from the Greek word ΓλαύV̇ξ (glaukos), which means "to glow". Glaucoma has been called the "silent thief of sight" because the loss of vision usually occurs slowly over a long period of time. It is associated with old age, a family history of glaucoma, and certain medical conditions or medications.

<span class="mw-page-title-main">Pilocarpine</span> Medication used to treat glaucoma and dry mouth

Pilocarpine is a medication used to reduce pressure inside the eye and treat dry mouth. As an eye drop it is used to manage angle closure glaucoma until surgery can be performed, ocular hypertension, primary open angle glaucoma, and to constrict the pupil after dilation. However, due to its side effects it is no longer typically used for long-term management. Onset of effects with the drops is typically within an hour and lasts for up to a day. By mouth it is used for dry mouth as a result of Sjögren syndrome or radiation therapy.

<span class="mw-page-title-main">Anterior chamber of eyeball</span> Space in the eye

The anterior chamber (AC) is the aqueous humor-filled space inside the eye between the iris and the cornea's innermost surface, the endothelium. Hyphema, anterior uveitis and glaucoma are three main pathologies in this area. In hyphema, blood fills the anterior chamber as a result of a hemorrhage, most commonly after a blunt eye injury. Anterior uveitis is an inflammatory process affecting the iris and ciliary body, with resulting inflammatory signs in the anterior chamber. In glaucoma, blockage of the trabecular meshwork prevents the normal outflow of aqueous humour, resulting in increased intraocular pressure, progressive damage to the optic nerve head, and eventually blindness.

<span class="mw-page-title-main">Schlemm's canal</span> Lymphatic-like vessel in the eye

Schlemm's canal is a circular lymphatic-like vessel in the eye. It collects aqueous humor from the anterior chamber and delivers it into the episcleral blood vessels. Canaloplasty may be used to widen it.

Ocular hypertension is the presence of elevated fluid pressure inside the eye, usually with no optic nerve damage or visual field loss.

<span class="mw-page-title-main">Pigment dispersion syndrome</span> Medical condition

Pigment dispersion syndrome (PDS) is an eye disorder that can lead to a form of glaucoma known as pigmentary glaucoma. It takes place when pigment cells slough off from the back of the iris and float around in the aqueous humor. Over time, these pigment cells can accumulate in the anterior chamber in such a way that they begin to clog the trabecular meshwork, which can in turn prevent the aqueous humour from draining and therefore increases the pressure inside the eye. A common finding in PDS are central, vertical corneal endothelial pigment deposits, known as Krukenberg spindle. With PDS, the intraocular pressure tends to spike at times and then can return to normal. Exercise has been shown to contribute to spikes in pressure as well. When the pressure is great enough to cause damage to the optic nerve, this is called pigmentary glaucoma. As with all types of glaucoma, when damage happens to the optic nerve fibers, the vision loss that occurs is irreversible and painless.

<span class="mw-page-title-main">Iridectomy</span> Surgical removal of part of the iris

An iridectomy, also known as a surgical iridectomy or corectomy, is the surgical removal of part of the iris. These procedures are most frequently performed in the treatment of closed-angle glaucoma and iris melanoma.

<span class="mw-page-title-main">Posterior chamber of eyeball</span> Region of the eyeball between the iris and lens

The posterior chamber is a narrow space behind the peripheral part of the iris, and in front of the suspensory ligament of the lens and the ciliary processes. The posterior chamber consists of small space directly posterior to the iris but anterior to the lens. The posterior chamber is part of the anterior segment and should not be confused with the vitreous chamber.

<span class="mw-page-title-main">Trabeculectomy</span> Surgical procedure used in the treatment of glaucoma

Trabeculectomy is a surgical procedure used in the treatment of glaucoma to relieve intraocular pressure by removing part of the eye's trabecular meshwork and adjacent structures. It is the most common glaucoma surgery performed and allows drainage of aqueous humor from within the eye to underneath the conjunctiva where it is absorbed. This outpatient procedure was most commonly performed under monitored anesthesia care using a retrobulbar block or peribulbar block or a combination of topical and subtenon anesthesia. Due to the higher risks associated with bulbar blocks, topical analgesia with mild sedation is becoming more common. Rarely general anesthesia will be used, in patients with an inability to cooperate during surgery.

<span class="mw-page-title-main">Glaucoma surgery</span> Type of eye surgery

Glaucoma is a group of diseases affecting the optic nerve that results in vision loss and is frequently characterized by raised intraocular pressure (IOP). There are many glaucoma surgeries, and variations or combinations of those surgeries, that facilitate the escape of excess aqueous humor from the eye to lower intraocular pressure, and a few that lower IOP by decreasing the production of aqueous humor.

Pseudoexfoliation syndrome, often abbreviated as PEX and sometimes as PES or PXS, is an aging-related systemic disease manifesting itself primarily in the eyes which is characterized by the accumulation of microscopic granular amyloid-like protein fibers. Its cause is unknown, although there is speculation that there may be a genetic basis. It is more prevalent in women than men, and in persons past the age of seventy. Its prevalence in different human populations varies; for example, it is prevalent in Scandinavia. The buildup of protein clumps can block normal drainage of the eye fluid called the aqueous humor and can cause, in turn, a buildup of pressure leading to glaucoma and loss of vision. As worldwide populations become older because of shifts in demography, PEX may become a matter of greater concern.

Trabeculoplasty is a laser treatment for glaucoma. It is done on an argon laser equipped slit lamp, using a Goldmann gonioscope lens mirror. Specifically, an argon laser is used to improve drainage through the eye's trabecular meshwork, from which the aqueous humour drains. This helps reduce intraocular pressure caused by open-angle glaucoma.

The Trabectome is a surgical device that can be used for ab interno trabeculotomy, a minimally invasive glaucoma surgery for the surgical management of adult, juvenile, and infantile glaucoma. The trabecular meshwork is a major site of resistance to aqueous humor outflow. As angle surgeries such as Trabectome follow the physiologic outflow pathway, the risk of complications is significantly lower than filtering surgeries. Hypotony with damage to the macula, can occur with pressures below 5 mmHg, for instance, after traditional trabeculectomy, because of the episcleral venous pressure limit. The Trabectome handpiece is inserted into the anterior chamber, its tip positioned into Schlemm's canal, and advanced to the left and to the right. Different from cautery, the tip generates plasma to molecularize the trabecular meshwork and remove it drag-free and with minimal thermal effect. Active irrigation of the trabectome surgery system helps to keep the anterior chamber formed during the procedure and precludes the need for ophthalmic viscoelastic devices. Viscoelastic devices tend to trap debris or gas bubbles and diminish visualization. The Trabectome decreases the intra-ocular pressure typically to a mid-teen range and reduces the patient's requirement to take glaucoma eye drops and glaucoma medications. The theoretically lowest pressure that can be achieved is equal to 8 mmHg in the episcleral veins. This procedure is performed through a small incision and can be done on an outpatient basis.

Micro-invasive glaucoma surgery (MIGS) is the latest advance in surgical treatment for glaucoma, which aims to reduce intraocular pressure by either increasing outflow of aqueous humor or reducing its production. MIGS comprises a group of surgical procedures which share common features. MIGS procedures involve a minimally invasive approach, often with small cuts or micro-incisions through the cornea that causes the least amount of trauma to surrounding scleral and conjunctival tissues. The techniques minimize tissue scarring, allowing for the possibility of traditional glaucoma procedures such as trabeculectomy or glaucoma valve implantation to be performed in the future if needed.

<span class="mw-page-title-main">Phacolytic glaucoma</span> Medical condition

Phacolytic glaucoma (PG) is a form of glaucoma which is caused due to a leaking mature or immature cataract. Inflammatory glaucoma which occurs in phacolysis is a condition which is a result of the leakage of protein within the lens into the capsule of a mature or hyper mature cataract and involves a simple procedure to be cured that is referred to as cataract extraction.

Schwartz–Matsuo syndrome is a human eye disease characterised by rhegmatogenous retinal detachment, elevated intraocular pressure (IOP) and open angle of anterior chamber.

Uveitis–glaucoma–hyphaema (UGH) syndrome, also known as Ellingson syndrome, is a complication of cataract surgery, caused by intraocular lens subluxation or dislocation. The chafing of mispositioned intraocular lens over iris, ciliary body or iridocorneal angle cause elevated intraocular pressure (IOP) anterior uveitis and hyphema. It is most commonly caused by anterior chamber IOLs and sulcus IOLs but, the condition can be seen with any type of IOL, including posterior chamber lenses and cosmetic iris implants.

<span class="mw-page-title-main">Uveitic glaucoma</span> Glaucoma caused by uveitis or its treatments

Uveitic glaucoma is most commonly a progression stage of noninfectious anterior uveitis or iritis.

<span class="mw-page-title-main">Phacomorphic glaucoma</span> Disorder of the human eye

Phacomorphic glaucoma is an eye disease that can occur due to a neglected advanced cataract. In this, the mature cataractous lens cause secondary angle closure glaucoma. The presence of an asymmetric mature cataractous lens, shallow or closed anterior chamber angle, raised intraocular pressure (IOP) and other typical signs and symptoms of angle-closure glaucoma in the eye may lead to a diagnosis of phacomorphic glaucoma. Cataract surgery after initial IOP control with medication is the only treatment.

<span class="mw-page-title-main">Lens induced glaucomas</span> Disorder of the human eye

The crystalline lens inside the human eye has been implicated as a causative factor in many forms of glaucoma. Lens induced glaucomas or Lens related glaucomas are either open-angle or closed-angle glaucomas that can occur due to a neglected advanced cataract or a dislocated lens. It is a type of secondary glaucoma. The angle-closure glaucoma can be caused by a swollen or dislocated lens. The open-angle glaucoma can be caused by leakage of lens proteins through the capsule of a mature or hyper mature cataract or by a hypersensitivity reaction to own lens protein following surgery or penetrating trauma.

References

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  8. ↑ Chen, Monica F; Kim, Carole H; Coleman, Anne L (2019-03-10). "Cyclodestructive procedures for refractory glaucoma". Cochrane Database of Systematic Reviews. 2019 (3): CD012223. doi:10.1002/14651858.cd012223.pub2. ISSN   1465-1858. PMC   6409080 . PMID   30852841.
  9. ↑ Pohlmann, Dominika; Pahlitzsch, Milena; Schlickeiser, Stephan; Metzner, Sylvia; Lenglinger, Matthias; Bertelmann, Eckart; Maier, Anna-Karina B.; Winterhalter, Sibylle; Pleyer, Uwe (2020-02-24). Awadein, Ahmed (ed.). "Virus-associated anterior uveitis and secondary glaucoma: Diagnostics, clinical characteristics, and surgical options". PLOS ONE. 15 (2): e0229260. Bibcode:2020PLoSO..1529260P. doi: 10.1371/journal.pone.0229260 . ISSN   1932-6203. PMC   7039515 . PMID   32092116.
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  11. ↑ Clinical glaucoma care : the essentials. John R. Samples, Paul N. Schacknow. New York. 2014. ISBN   978-1-4614-4172-4. OCLC   868922426.{{cite book}}: CS1 maint: location missing publisher (link) CS1 maint: others (link)
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  13. ↑ Michelessi, Manuele; Lindsley, Kristina (2016-02-12). "Peripheral iridotomy for pigmentary glaucoma". The Cochrane Database of Systematic Reviews. 2 (9): CD005655. doi:10.1002/14651858.CD005655.pub2. ISSN   1469-493X. PMC   5032906 . PMID   26871761.
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