Manometric Studies

Congenital Glaucoma
This clinical condition provides a dramatic example of the absence

of a normal outflow system and the effects on intraocular pres-
sure (IOP), the outflow facility, and the effect of high IOP on the
cornea. The clinical signs of congenital glaucoma include thicken-
ing, edema, clouding, and increased diameter of the cornea. The
corneal edema and swelling precludes use of indentation and
Goldmann tonometers to measure the IOP. Under these conditions,
cannulation of the anterior chamber using a manometric technique
provides a direct way to evaluate the IOP and to investigate the
possibility of surgical therapy.
A needle with a double-cutting edge connected to a bottle of
sterile saline set at approximately 4050 mmHg and connected to a
sterilized pressure transducer is inserted from the area of the cor-
neal scleral junction and directed toward the middle of the anterior
chamber. The steady state IOP is determined by a short recording
of the IOP ( Fig. 10.1 ). The steady state IOP in this patient was 40
mmHg, the pulse amplitude was 2.2 mmHg, and the corresponding
rate of pulsatile blood flow was 365 l min
1
. An attempt was then
made to open up the trabecular meshwork with the cutting edge
of the recording needle; the needle was then brought into contact
with the trabecular meshwork and a cut of approximately 10 was
made into the Schlemms canal. In this patient success was immedi-
ate and the IOP started to fall (see Fig. 10.1 ) with a new state IOP
of 17 mmHg. In this patient it required only a very small opening
through the meshwork to achieve a normal outflow and IOP. Full
recovery ensued, and a normal IOP and transparency of the cornea
were confirmed at 1 year.
This clinical case gave a good example of the abnormal drain-
age of aqueous humor resulting in an abnormally high IOP from a
10
Manometric Studies
on the Intraocular Pressure
and Vascular Circulation in
Ophthalmic Disease
M.E. Langham, Ischemia and Loss of Vascular Autoregulation in Ocular and
Cerebral Diseases: A New Perspective, DOI: 10.1007/978-0-387-09716-9_10,
Springer Science + Business Media, LLC 2009
55
56 Chapter 10 Manometric Studies on the Intraocular Pressure and Vascular Circulation
mechanically induced high resistance in the trabecular meshwork,
while the flow resistance distal to the canal of Schlemm remained
essentially normal.
This patient formed one of a series of four similar cases on chil-
dren of less than 2 years of age with congenital glaucoma. In one
case, the IOP was 35 mmHg, but attempts to cut open the trabecu-
lar meshwork failed despite making a penetrating cut exceeding
180. It was concluded that the abnormal outflow was due to the
absence of a normal trabecular meshwork and Schlemms canal,
and the possible absence of a normal intrascleral drainage system.
In the remaining two cases, the initial IOPs were 26 and 30 mmHg,
respectively, and the operations were successful in normalizing
the IOP with several cuts into the trabecular meshwork, each of
approximately 20.
Normal Adult Eyes
An opportunity to examine the flow resistance in the trabecular
meshwork in normal eyes was found in living eyes of several
young adults who had developed small melanomas in the choroid.
In a typical case on a male of 22 years, the IOPs in the affected and
unaffected eyes were 18 and 18 mmHg , respectively, measured by
Goldman applanation tonometry, and the corresponding outflow
facilities measured by conventional indentation topography were
0.22 and 0 23 l min
1
mmHg, respectively. On the basis of the sym-
metry of the results, it was concluded that the IOPs and the aqueous
humor dynamics in the pairs of eyes were normal.
The affected eye was enucleated and measurements of the IOP
decay curves were made immediately. Analysis of the pressure
Figure 10.1. The IOP in a child of 2 months with congenital glaucoma
and the results of surgery. The first recording shows the IOP approach-
ing its steady state of 45 mmHg. The second recording shows the IOP
decay curve approaching the new steady state of 17 mmHg after a limited
section (approximately 10) of the occluded angle using the sharpened
cannulating needle (From Langham.
21
Reprinted from Glaucoma, Tutzing
Symposium . Used with permission from Basel-Karger.)
Adult Open Angle Glaucoma 57
decay curve in the enucleated eye indicated an outflow facility of
0.4 l min
1
mmHg. The trabecular meshwork was then opened
with the cutting edge of the recording needle and the IOP decay
curve was recorded. The new outflow facility following the trab-
eculectomy was 0.3 l min
1
mmHg. The results confirmed the
marked increase in the outflow facility following enucleation and
the major resistance to outflow to be distal to Schlemms canal in
the living eye.
Similar results were recorded on two further enucleated eyes, and
in both cases the major site of the outflow resistance was distal to
Schlemms canal.
Adult Open A ngle Glaucoma
A manometric investigation was made on a patient who had been
treated for open angle glaucoma for many years and then examined
within 3 h of death (in the morgue). Glaucomatous field loss had
been present in both eyes for more than 20 years and the patient
had been treated with increasing concentrations of pilocarpine and
epinephrine for many years. The IOP recordings over the years
ranged from 23 to 29 mmHg in both eyes and the outflow facilities
measured by conventional tonography were approximately 0.10
0.13 l min
1
mmHg in the two eyes. Perfusion studies were made
on one of the eyes in situ. The outflow facility based on analysis of
the pressure decay curve from an IOP of 35 mmHg was 0.3 l min
1

mmHg and, after opening the trabecular meshwork, increased to
0.4 l min
1
mmHg. Thus, in this glaucomatous eye, the abnormally
high outflow resistance was distal to Schlemms canal and not in
the area of the trabecular meshwork.
BookID 164770_ChapID 10_Proof# 1 - 30/12/2008
http://www.springer.com/978-0-387-09715-2

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Congenital Glaucoma

This clinical condition provides a dramatic example of the absence

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