Case Report Staphyloma & Secondary Glaucoma

Case ReportStaphyloma & Secondary GlaucomaDwi Permana PutraTanjungpura UniversityDefinition of StaphylomaStaphyloma refers to a localised bulging of weak and thin outer tunic of the eyeball (cornea or sclera) lined by uveal tissue which shines through the thinned out of fibrous coatTypesAnatomically: AnteriorIntercalaryCiliaryEquatorialposterior staphyloma

Anterior StaphylomaAn ectasia of psuedocornea (the scar formed from organised exudates and fibrous tissue covered with epithelium) It results after total sloughing of cornea, with iris plastered behind it

Intercalary StaphylomaIt is a bulge in limbal area lined by root of iris It results due to ectasia of weak scar tissue formed at the limbus, following healing of a perforating injury or a peripheral corneal ulcer.there may be associated secondary angle closure glaucoma due to the progression of bulge if not treatedTreatment consists of localised staphylectomy under heavy doses of oral steroids.

Ciliary staphylomait is the bulge of weak sclera lined by ciliary body occurs about 2-3 mm away from the limbus Its common causes thinning of sclera following perforating injury, scleritis and absolute glaucoma

Equatorial StaphylomaIt results due to bulge of sclera lined by the choroid in the equatorial region Its causes are scleritis and degeneration of sclera in pathological myopiaOccurs commonly at the regions of sclera which are perforated by vortex veins

Posterior staphylomaIt refers to bulge of weak sclera lined by the choroid behind the equator common causes are pathological myopia, posterior scleritis and perforating injuriesThe area is excavated with retinal vessels dipping in it (just like marked cupping of optic disc in glaucoma)it is diagnosed on ophthalmoscopy

GlaucomaGlaucoma refers to a group of conditions with heterogeneous causes that results in damage to the optic nerve head and loss of visual field It is usually associated with an increase in intraocular pressure (IOP) above the normal value usually estimated at 21 mmHgPrimary open angle glaucoma is the most common type of glaucoma, accounting for over 70 % of casesClassification1. Primary GlaucomaIn open-angle glaucoma, the channel where the flow of aqueous humor is open, but the flow of fluid from the anterior chamber is too slow.Pressure will gradually damage to the optic nerveprogressive decline in visual function

2. Primary Closure-Angle GlaucomaIf the iris by the pupil (by the center of the iris) touches the lens too much, the fluid is prevented from traveling through the pupilPressure from the flow of the aqueous trying to get through the pupil pushes the iris by the trabecular meshwork forward (called iris bombe) cause the iris to bow forward too much,resulting in acomplete blockage of the drainage meshwork

3. Secondary GlaucomaIs an increasing of intraocular pressure occurring as one manifestation of some other eye diseaseCaused by pigmentation, changes in lens, changes in uveal tract, tumor, trauma, surgery, neovascular and steroidTreatment involves controlling intraocular pressure by medical and surgical means but also dealing with the underlying disease if possible

Patient HistoryName: Mr. SSex: MaleAge: 28 years oldaddress: Parit Bugis St.Occupation: EmployeeEthnic: BugisReligion: MoslemMedical Record Number: -Hospital Entry Date: March 20th 2014

Chief ComplaintSore in the right eyeHistory of Current illnessesPast Medical HistoryPatient had an eye injury of his right eye when he was at 11 years old. Patient had suffered from typhoid 5 years agoHe ignored when he was asking from experiences of hypertension, diabetes mellitus and consumption of steroid drugsFamily HistoryHe admitted his family never suffered the disease like he experienced with. There was no history of hypertension and Diabetes Mellitus of his familyPhysical ExaminationAn interview was conducted on 20th March 2014, at 11.30 a.mGeneral Condition : GoodAwareness : Compos Mentis

Vital SignBlood Pressure: 140/80 mmHg HR: 64 x/minute RR: 24 x/minute Temperature: 36, 8 oC

Ophtalmologic StatusVisual Acuity :OD : 0OS : 6/7,5

ODOSexotrophiaEye ball PositionorthotrophiaMovement (+), spasm (+), pain (+)PalpebraMovement (+), spasm (-) NormalRedness (+), watery (+)ConjungtivaRedness (-). watery (-) NormalCloudy (+), edema (+), fibrous (+)corneaClear, edema (-), fibrous (-) normalCannot be describedAnterior ChamberClear, deepColor of iris : cannot be describedIris : cannot be describedPupil : cannot be describedLight reflex : cannot be describedIris/pupilColor of iris: BrowniesIris: regularPupil circular, 3 mm, isochor, Direct reflex (+), Indirect Reflex (+)Canno be describedLensclearCannot be describedVitreousclearCannot be describedFundusnormal

Shadow test : OD: NegativeOS: NegativeTonometryOD: Cannot be examinedOS: cannot be examinedVisual Field ExaminationOD: cannot be describedOS: Normal

ResumeThe patient, male 28 years old came to the clinic with sore, pain and watery of his right eye when he was seeing of light and he felt there was something that blocked in his right eye since a week agoWhen he was at 11 years old, he had an injury in his right eye and made him got swollen to his eye and was taken to the hospital for further treatment, because he had no longer to see clearly anymore. He had diagnosed by his doctor that he cannot see anymore, because of the severe damage of his injuryCont..3 years ago the patient has diagnosed suffered from glaucoma by his doctor. The doctor only able to remove his symptoms by medications. History of fever, nausea, vomiting, headache, smoking were ingnoredIn family history, he ignored that his family have never experienced with glaucoma, hypertension and diabetes mellitus. From physical examination, there were: OD : eye ball position is exotrophia, movement of palpebral was normal, palpebral was spasm, pain, conjunctiva was redness and watery, cornea was cloudy, iris/pupil was not clear enough because of cloudy. OS: palpebral was no pain and spasm, conjunctiva ws no redness, no edema and cloudy of the cornea, COA was clear and deep, iris and pupil were normal (direct or indirect reflex (+), isochor, 3mm)

DiagnoseOD : Secondary glaucoma due to staphylomaOS : Normal

Differential DiagnoseODLeucomaSecondary Glaucoma to trauma

Planning for additional examinationUltrasonographyTreatmentTimolol eye drops 0,25% 2x 1Sodium Hyaluronate 0,1% drops every hourIndometacin 100 mg tablets 2 x 1

Prognosis ODAd vitam : bonamAd functionam : malamAd sanactionam : malam

OSAd vitam : bonamAd functionam : bonamAd sanactionam : bonam

DiscussionThe diagnosis to the patient is secondary glaucoma due to staphylomaFirstly, the formation of the staphyloma, because of the trauma about 17 years ago, It results due to ectasia of weak scar tissue formed at the limbus, following healing of a perforating injury or a peripheral corneal ulcer or called as intercalary staphylomaSo that, in the right eye of the patient there is localised bulge in limbal area lined by root of iris. There may be associated secondary angle glaucoma, which may cause progression of bulge if not treated

Cont..The manifestation of secondary glaucoma is an increasing of intraocular pressure occurring as one manifestation of some other eyeTreatment involves controlling intraocular pressure by medical and surgical means but also dealing with the underlying disease if possibleDifferential DiagnosisFirstly is leucoma. Is the condition when the cornea is damaged by an infection the collagen laid down in the repair processes is not regularly arranged, with the result that an opaque patch called aleukoma, may occur

Secondly, secondary glaucoma to trauma is associated with the history of injury from the patient. Contusion injuries of the globe may be associated with an early rise in intraocular pressure due to bleeding into the anterior chamber (hyphema)Free blood blocks the trabecular meshwork, which is also causing edematous by the injury

MedicationTimolol eye drops 0,25% is useful to suppress of aqueous productionThe major contraindications to their use are chronic obstructive airway disease particularly asthma and cardiac conduction defectsSodium hyaluronate 0,1% eye drops functions as a tissuelubricant and is thought to play an important role in modulating the interactions between adjacent tissues. It forms a viscoelastic solution in water which makes it suitable foraqueousandvitreous humorMechanical protection for tissues (iris, retina) and cell layers (corneal, endothelium, and epithelium) are provided by the high viscosity of the solution. Elasticity of the solution assists in absorbing mechanical stress and providing a protectivebufferfor tissues.Indometacin 100 mg tablets is anon-steroidal anti-inflammatory drug(NSAID) commonly used as aprescription medicationto reducefever,pain, stiffness, andswelling. It works by inhibiting the production ofprostaglandins, molecules known to cause these symptoms

SummaryTo conclude, glaucoma is a condition in which the eye is characterized by the increase intraocular pressure, decreased visual acuity, visual field constriction, and optic nerve atrophyThe cause of glaucoma is poorly understood, it could be due to trauma / impact, or because of other eye diseases such as cataracts (cataract hipermatur), uveitis, and the influence of drugs This patient should need several treatments such as Timolol eye drops 0,25% 2x , Sodium Hyaluronate 0,1% drops every hour and Indometacin 100 mg tablets 2 x 1