Glaucoma classification: Difference between revisions

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== Overview ==
The glaucoma is typically classified is as open angle or closed angle and as primary or secondary. There have been multiple schemes proposed for the classification for glaucoma. However the classification of the
The glaucoma is typically classified is as open angle or closed angle and as primary or secondary. There have been multiple schemes proposed for the classification for glaucoma. However the classification of the
glaucomas based on initial events and classification based on mechanisms of outflow obstruction are commonly used.
glaucomas based on initial events and classification based on mechanisms of outflow obstruction are commonly used.


==Classification based on angle==
==Classification Based Upon Angle==
{| class="wikitable"
{| class="wikitable"
!Open-angle Glaucoma
! colspan="2" |Open-angle Glaucoma
!
|-
|-
|Primary open-angle glaucoma (POAG)
|Primary open-angle glaucoma (POAG) (H40.11)
|
|
:* not associated  with  known  ocular  or  systemic  disorders  that  cause increased resistance to aqueous outflow or damage to optic nerve
:* Not associated  with  known  ocular  or  systemic  disorders  that  cause increased resistance to aqueous outflow or damage to optic nerve
:*  usually associated with elevated IOP
:*  Elevated IOP
|-
|-
|Normal-tension glaucoma
|Normal-tension glaucoma (H40.12)
|
|
:*    considered in continuum of POAG; often used when IOP is not elevated
:*    Continuum of POAG
:*    IOP is not elevated
|-
|-
|Juvenile open-angle glaucoma
|Juvenile open-angle glaucoma  
|
|
:* used when open-angle glaucoma diagnosed at young age (typically 10-30 years of age)
:* Open-angle glaucoma diagnosed at young age (typically 10-30 years of age)
|-
|-
|Glaucoma suspect
|Glaucoma suspect (H40.0)
|
|
:*  normal optic disc and visual field associated with elevated IOP
:*  Normal optic disc and visual field associated with elevated IOP
:*    suspicious optic disc and/or visual field with normal IOP
:*    Suspicious optic disc and/or visual field with normal IOP
|-
|-
|Secondary open-angle glaucoma
|Secondary open-angle glaucoma
:
:
|
|
:* increased resistance  to  trabecular  meshwork  outflow  associated  with other conditions (e.g. pigmentary-, phacolytic-, steroid-induced-)
:* Increased resistance  to  trabecular  meshwork  outflow  associated  with other conditions (e.g. pigmentary-, phacolytic-, steroid-induced-)
:* increased posttrabecular resistance  to  outflow  secondary  to  elevated episcleral venous pressure (e.g. carotid cavernous sinus fistula)
:* Increased post-trabecular resistance  to  outflow  secondary  to  elevated episcleral venous pressure (e.g. carotid cavernous sinus fistula)
|}
|}
{| class="wikitable"
{| class="wikitable"
!Angle-Closure Glaucoma
! colspan="2" |Angle-Closure Glaucoma
!
|-
|-
|Primary ACG with relative pupillary block
|Primary ACG with relative  
pupillary block
|
|
:*movement of aqueous humor from posterior chamber to anterior chamber restricted
:*Movement of aqueous humor from posterior chamber to anterior chamber restricted
:*peripheral iris in contact with trabecular meshwork
:*Peripheral iris in contact with trabecular meshwork
|-
|-
|Acute angle closure
|Acute angle closure
:
:
|
|
:*occurs when IOP rises rapidly as a result of relatively sudden blockage of the trabecular meshwork
:*Occurs when IOP rises rapidly as a result of relatively sudden blockage of the trabecular meshwork
|-
|-
|Subacute angle closure (intermittent angle closure)
|Subacute angle closure (intermittent angle closure)
:
:
|
|
:*repeated, brief episodes of angle closure with mild symptoms and elevated IOP, often a prelude to acute angle closure
:*Repeated, brief episodes of angle closure with mild symptoms and elevated IOP, often a prelude to acute angle closure
|-
|-
|Chronic angle closure
|Chronic angle closure
Line 63: Line 61:
|Secondary ACG with pupillary block
|Secondary ACG with pupillary block
|
|
:*e.g. swollen lens, secluded pupil
:*Swollen lens, secluded pupil
|-
|-
|Secondary ACG without pupillary block
|Secondary ACG without pupillary block
:
:
|
|
:* posterior pushing mechanism: lens-iris diaphragm pushed forward (e.g. posterior segment tumor, scleral buckling procedure, uveal effusion)
:* Posterior pushing mechanism: lens-iris diaphragm pushed forward (e.g. posterior segment tumor, scleral buckling procedure, uveal effusion)
:* anterior pulling mechanism: anterior segment process pulling iris forward to form PAS (e.g. iridocorneal endothelial syndrome, neovascular glaucoma, inflammation)
:* Anterior pulling mechanism: anterior segment process pulling iris forward to form PAS (e.g. iridocorneal endothelial syndrome, neovascular glaucoma, inflammation)
|-
|-
|Plateau iris syndrome
|Plateau iris syndrome
|
|
:*primary angle closure with or without component of pupillary block, but pupillary block is not predominant mechanism of angle closure
:*Primary angle closure with or without component of pupillary block, but pupillary block is not predominant mechanism of angle closure
|}
|}
#


#
{| class="wikitable"
===Childhood Glaucoma===
|+
#Primary congenital/infantile glaucoma
!Childhood Glaucoma
#:*primary glaucoma present from birth to first few years of life
!
#Glaucoma associated with congenital anomalies
|-
#:*associated with  ocular  disorders  (e.g.  anterior  segment  dysgenesis, aniridia)
|Primary congenital/infantile glaucoma
#:* associated with systemic disorders (e.g. rubella, Lowe syndrome)
:
#Secondary glaucoma in infants and children
|
#:*e.g. glaucoma secondary to retinoblastoma or trauma
:*Primary glaucoma present from birth to first few years of life
|-
|Glaucoma associated with congenital anomalies
:
|
:*Associated with  ocular  disorders  (e.g.  anterior  segment  dysgenesis, aniridia)
:* Associated with systemic disorders (e.g. rubella, Lowe syndrome)
|-
|Secondary glaucoma in infants and children
:
|
:*Glaucoma secondary to retinoblastoma or trauma                                                                    
|}


==Classification on based on initial event==
==Classification based upon initial event==


=== Congenital and Developmental Glaucoma (Q15.0)===
=== Congenital and Developmental Glaucoma (Q15.0)===
Line 139: Line 148:
*Absolute glaucoma
*Absolute glaucoma


==Classification based on mechanism of outflow obstruction==
==Classification based upon mechanism of outflow obstruction==
===Open Angle Glaucoma Mechanisms===
===Open Angle Glaucoma Mechanisms===
#Pre-trabecular (membrane overgrowth)
#Pre-trabecular (membrane overgrowth)
#:*fibrovascular membrane (neovascular glaucoma)
#:*Fibrovascular membrane (neovascular glaucoma)
#:*endothelial layer,  often  with  Descemet-like  membrane  (iridocorneal endothelial  syndrome,  posterior  polymorphous dystrophy,  penetrating and non-penetrating trauma)
#:*Endothelial layer,  often  with  Descemet-like  membrane  (iridocorneal endothelial  syndrome,  posterior  polymorphous dystrophy,  penetrating and non-penetrating trauma)
#:*epithelial downgrowth
#:*Epithelial downgrowth
#:*fibrous ingrowth
#:*Fibrous ingrowth
#:*inflammatory membrane  (Fuchs  heterochromic  iridocyclitis,luetic interstitial keratitis)
#:*Inflammatory membrane  (Fuchs  heterochromic  iridocyclitis,luetic interstitial keratitis)
#Trabecular
#Trabecular
#:*idiopathic (chronic open-angle glaucoma, juvenile open-angle glaucoma)
#:*Idiopathic (chronic open-angle glaucoma, juvenile open-angle glaucoma)
#:*“clogging” of trabecular meshwork
#:*"Clogging” of trabecular meshwork
#::*red blood cells (hemorrhagic-, ghost cell-, sickled red blood cells)
#::*Red blood cells (hemorrhagic-, ghost cell-, sickled red blood cells)
#::*macrophages (hemolytic-, phacolytic-, melanomalytic-)
#::*Macrophages (hemolytic-, phacolytic-, melanomalytic-)
#::*neoplastic cells (primary ocular tumors, neoplastic tumors, juvenile xanthogranuloma)
#::*Neoplastic cells (primary ocular tumors, neoplastic tumors, juvenile xanthogranuloma)
#::*pigment particles (pigmentary-, exfoliation syndrome /  glaucoma capsulare, malignant melanoma)
#::*Pigment particles (pigmentary-, exfoliation syndrome /  glaucoma capsulare, malignant melanoma)
#::*protein (uveitis, lens-induced glaucoma)
#::*Protein (uveitis, lens-induced glaucoma)
#::*viscoelastic agents
#::*Viscoelastic agents
#::*α-chymotrypsin-induced glaucoma
#::*α-chymotrypsin-induced glaucoma
#::*vitreous
#::*Vitreous
#:*alterations of the trabecular meshwork
#:*Alterations of the trabecular meshwork
#::*steroid-induced glaucoma
#::*Steroid-induced glaucoma
#::*edema (uveitis, scleritis, episcleritis, alkali burns)
#::*Edema (uveitis, scleritis, episcleritis, alkali burns)
#::*trauma (angle recession)
#::*Trauma (angle recession)
#::*intraocular foreign bodies (hemosiderin, chalcosis)
#::*Intraocular foreign bodies (hemosiderin, chalcosis)
#Post-trabecular
#Post-trabecular
#:*obstruction of Schlemm’s canal (e.g. collapse at canal)
#:*Obstruction of Schlemm’s canal (e.g. collapse at canal)
#:*elevated episcleral venous pressure
#:*Elevated episcleral venous pressure
#:*carotid cavernous fistula
#:*Carotid cavernous fistula
#:*cavernous sinus thrombosis
#:*Cavernous sinus thrombosis
#:*retrobulbar tumors
#:*Retrobulbar tumors
#:*thyroid ophthalmopathy
#:*Thyroid ophthalmopathy
#:*superior vena cava obstruction
#:*Superior vena cava obstruction
#:*mediastinal tumors
#:*Mediastinal tumors
#:*Sturge-Weber syndrome
#:*Sturge-Weber syndrome
#:*familial episcleral venous pressure elevation
#:*Familial episcleral venous pressure elevation
===Angle Closure Glaucoma Mechanisms===
===Angle Closure Glaucoma Mechanisms===
#Anterior (“pulling”)
#Anterior (“pulling”)
#:*contracture of membranes
#:*Contracture of membranes
#::*neovascular glaucoma
#::*Neovascular glaucoma
#::*iridocorneal endothelial syndrome
#::*Iridocorneal endothelial syndrome
#::*posterior polymorphous dystrophy  
#::*Posterior polymorphous dystrophy  
#::*penetrating and non-penetrating trauma
#::*Penetrating and non-penetrating trauma
#:*consolidation of inflammatory products
#:*Consolidation of inflammatory products
#Posterior (“pushing”)
#Posterior (“pushing”)
#:*with pupillary block
#:*With pupillary block
#::*pupillary block glaucoma
#::*Pupillary block glaucoma
#::*lens-induced mechanisms (phacomorphic lens, ectopia lentis)
#::*Lens-induced mechanisms (phacomorphic lens, ectopia lentis)
#::*posterior synechiae (iris-vitreous block, pseudophakia, uveitis)
#::*Posterior synechiae (iris-vitreous block, pseudophakia, uveitis)
#:*without pupillary block
#:*Without pupillary block
#::*ciliary block (malignant) glaucoma
#::*Ciliary block (malignant) glaucoma
#::*lens-induced mechanisms (phacomorphic lens, ectopia lentis)
#::*Lens-induced mechanisms (phacomorphic lens, ectopia lentis)
#::*following lens extraction (forward vitreous shift)
#::*Following lens extraction (forward vitreous shift)
#::*anterior rotation of ciliary body (following scleral buckling or panretinal photocoagulation, central retinal vein occlusion)
#::*Anterior rotation of ciliary body (following scleral buckling or panretinal photocoagulation, central retinal vein occlusion)
#::*intraocular tumors (retinoblastoma, malignant melanoma)
#::*Intraocular tumors (retinoblastoma, malignant melanoma)
#::*cysts of the iris and ciliary body
#::*Cysts of the iris and ciliary body
#::*retrolenticular tissue  contracture  (retinopathy  of  prematurity, persistent hyperplastic primary vitreous)
#::*Retrolenticular tissue  contracture  (retinopathy  of  prematurity, persistent hyperplastic primary vitreous)
===Developmental Anomalies of Angle===
===Developmental Anomalies of Angle===
#incomplete development of trabecular meshwork / Schlemm’s canal
#Incomplete development of trabecular meshwork / Schlemm’s canal
#:*congenital (infantile) glaucoma
#:*Congenital (infantile) glaucoma
#:*Axenfeld-Rieger syndrome
#:*Axenfeld-Rieger syndrome
#:*Peter’s anomaly
#:*Peter’s anomaly
#:*glaucomas associated with other developmental anomalies
#:*Glaucomas associated with other developmental anomalies
#iridocorneal adhesions
#Iridocorneal adhesions
#:*broad strands (Axenfeld-Rieger syndrome)
#:*Broad strands (Axenfeld-Rieger syndrome)
#:*fine strands that contract to close angle (aniridia)
#:*Fine strands that contract to close angle (aniridia)
===Combined Mechanism Glaucoma===
===Combined Mechanism Glaucoma===
#Combination of two or more forms of glaucoma present either sequentially or simultaneously
#Combination of two or more forms of glaucoma present either sequentially or simultaneously
#IOP elevation can occur as a result of either or both of the following:
#IOP elevation can occur as a result of either or both of the following:
#:*the intrinsic resistance of the trabecular meshwork to aqueous outflow in open-angle glaucoma
#:*The intrinsic resistance of the trabecular meshwork to aqueous outflow in open-angle glaucoma
#:*the direct anatomic obstruction of the filtering meshwork by synechiae in ACG
#:*The direct anatomic obstruction of the filtering meshwork by synechiae in ACG


==References==
==References==
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{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[Category:Aging-associated diseases]]
[[Category:Aging-associated diseases]]
[[Category:Blindness]]
[[Category:Blindness]]
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[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Mature chapter]]
[[Category:Mature chapter]]
[[Category:Primary care]]
[[Category:Needs overview]]
[[Category:Needs overview]]

Latest revision as of 21:52, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Rohan Bir Singh, M.B.B.S.[2]

Overview

The glaucoma is typically classified is as open angle or closed angle and as primary or secondary. There have been multiple schemes proposed for the classification for glaucoma. However the classification of the glaucomas based on initial events and classification based on mechanisms of outflow obstruction are commonly used.

Classification Based Upon Angle

Open-angle Glaucoma
Primary open-angle glaucoma (POAG) (H40.11)
  • Not associated with known ocular or systemic disorders that cause increased resistance to aqueous outflow or damage to optic nerve
  • Elevated IOP
Normal-tension glaucoma (H40.12)
  • Continuum of POAG
  • IOP is not elevated
Juvenile open-angle glaucoma
  • Open-angle glaucoma diagnosed at young age (typically 10-30 years of age)
Glaucoma suspect (H40.0)
  • Normal optic disc and visual field associated with elevated IOP
  • Suspicious optic disc and/or visual field with normal IOP
Secondary open-angle glaucoma
  • Increased resistance to trabecular meshwork outflow associated with other conditions (e.g. pigmentary-, phacolytic-, steroid-induced-)
  • Increased post-trabecular resistance to outflow secondary to elevated episcleral venous pressure (e.g. carotid cavernous sinus fistula)
Angle-Closure Glaucoma
Primary ACG with relative

pupillary block

  • Movement of aqueous humor from posterior chamber to anterior chamber restricted
  • Peripheral iris in contact with trabecular meshwork
Acute angle closure
  • Occurs when IOP rises rapidly as a result of relatively sudden blockage of the trabecular meshwork
Subacute angle closure (intermittent angle closure)
  • Repeated, brief episodes of angle closure with mild symptoms and elevated IOP, often a prelude to acute angle closure
Chronic angle closure
  • IOP elevation caused by variable portions of anterior chamber angle being permanently closed by PAS
Secondary ACG with pupillary block
  • Swollen lens, secluded pupil
Secondary ACG without pupillary block
  • Posterior pushing mechanism: lens-iris diaphragm pushed forward (e.g. posterior segment tumor, scleral buckling procedure, uveal effusion)
  • Anterior pulling mechanism: anterior segment process pulling iris forward to form PAS (e.g. iridocorneal endothelial syndrome, neovascular glaucoma, inflammation)
Plateau iris syndrome
  • Primary angle closure with or without component of pupillary block, but pupillary block is not predominant mechanism of angle closure
Childhood Glaucoma
Primary congenital/infantile glaucoma
  • Primary glaucoma present from birth to first few years of life
Glaucoma associated with congenital anomalies
  • Associated with ocular disorders (e.g. anterior segment dysgenesis, aniridia)
  • Associated with systemic disorders (e.g. rubella, Lowe syndrome)
Secondary glaucoma in infants and children
  • Glaucoma secondary to retinoblastoma or trauma

Classification based upon initial event

Congenital and Developmental Glaucoma (Q15.0)

  • Developmental glaucoma

Primary Glaucoma and its Variants (H40.1-H40.2)

  • Primary glaucoma
  • Primary open-angle glaucoma, also known as chronic open-angle glaucoma, chronic simple glaucoma, glaucoma simplex
  • Low-tension glaucoma
  • Primary angle-closure glaucoma, also known as primary closed-angle glaucoma, narrow-angle glaucoma, iris- block glaucoma, acute congestive glaucoma
  • Variants of primary glaucoma

Secondary Glaucoma (H40.3-H40.6)

  • Secondary glaucoma
  • Phacogenic glaucoma
  • Angle-closure glaucoma with mature cataract
  • Phacoanaphylactic glaucoma secondary to rupture of lens capsule
  • Phacolytic glaucoma due to phacotoxic meshwork blockage
  • Subluxation of lens
  • Traumatic glaucoma
  • Angle recession glaucoma: Traumatic recession on anterior chamber angle
  • Postsurgical glaucoma
  • Glaucoma of miscellaneous origin

Absolute Glaucoma (H44.5)

  • Absolute glaucoma

Classification based upon mechanism of outflow obstruction

Open Angle Glaucoma Mechanisms

  1. Pre-trabecular (membrane overgrowth)
    • Fibrovascular membrane (neovascular glaucoma)
    • Endothelial layer, often with Descemet-like membrane (iridocorneal endothelial syndrome, posterior polymorphous dystrophy, penetrating and non-penetrating trauma)
    • Epithelial downgrowth
    • Fibrous ingrowth
    • Inflammatory membrane (Fuchs heterochromic iridocyclitis,luetic interstitial keratitis)
  2. Trabecular
    • Idiopathic (chronic open-angle glaucoma, juvenile open-angle glaucoma)
    • "Clogging” of trabecular meshwork
    • Red blood cells (hemorrhagic-, ghost cell-, sickled red blood cells)
    • Macrophages (hemolytic-, phacolytic-, melanomalytic-)
    • Neoplastic cells (primary ocular tumors, neoplastic tumors, juvenile xanthogranuloma)
    • Pigment particles (pigmentary-, exfoliation syndrome / glaucoma capsulare, malignant melanoma)
    • Protein (uveitis, lens-induced glaucoma)
    • Viscoelastic agents
    • α-chymotrypsin-induced glaucoma
    • Vitreous
    • Alterations of the trabecular meshwork
    • Steroid-induced glaucoma
    • Edema (uveitis, scleritis, episcleritis, alkali burns)
    • Trauma (angle recession)
    • Intraocular foreign bodies (hemosiderin, chalcosis)
  3. Post-trabecular
    • Obstruction of Schlemm’s canal (e.g. collapse at canal)
    • Elevated episcleral venous pressure
    • Carotid cavernous fistula
    • Cavernous sinus thrombosis
    • Retrobulbar tumors
    • Thyroid ophthalmopathy
    • Superior vena cava obstruction
    • Mediastinal tumors
    • Sturge-Weber syndrome
    • Familial episcleral venous pressure elevation

Angle Closure Glaucoma Mechanisms

  1. Anterior (“pulling”)
    • Contracture of membranes
    • Neovascular glaucoma
    • Iridocorneal endothelial syndrome
    • Posterior polymorphous dystrophy
    • Penetrating and non-penetrating trauma
    • Consolidation of inflammatory products
  2. Posterior (“pushing”)
    • With pupillary block
    • Pupillary block glaucoma
    • Lens-induced mechanisms (phacomorphic lens, ectopia lentis)
    • Posterior synechiae (iris-vitreous block, pseudophakia, uveitis)
    • Without pupillary block
    • Ciliary block (malignant) glaucoma
    • Lens-induced mechanisms (phacomorphic lens, ectopia lentis)
    • Following lens extraction (forward vitreous shift)
    • Anterior rotation of ciliary body (following scleral buckling or panretinal photocoagulation, central retinal vein occlusion)
    • Intraocular tumors (retinoblastoma, malignant melanoma)
    • Cysts of the iris and ciliary body
    • Retrolenticular tissue contracture (retinopathy of prematurity, persistent hyperplastic primary vitreous)

Developmental Anomalies of Angle

  1. Incomplete development of trabecular meshwork / Schlemm’s canal
    • Congenital (infantile) glaucoma
    • Axenfeld-Rieger syndrome
    • Peter’s anomaly
    • Glaucomas associated with other developmental anomalies
  2. Iridocorneal adhesions
    • Broad strands (Axenfeld-Rieger syndrome)
    • Fine strands that contract to close angle (aniridia)

Combined Mechanism Glaucoma

  1. Combination of two or more forms of glaucoma present either sequentially or simultaneously
  2. IOP elevation can occur as a result of either or both of the following:
    • The intrinsic resistance of the trabecular meshwork to aqueous outflow in open-angle glaucoma
    • The direct anatomic obstruction of the filtering meshwork by synechiae in ACG

References

Template:WH Template:WS

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