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Critical analysis of the classification of glaucomas issued by the European Glaucoma Society in Clinical Ophthalmology, Constantin Bordeianu. A short summary of this paper. Download Download PDF. Translate PDF. Romania Methods: The paper tries to determine the extent to which this classification is clear being based on a coherent and consistently followed set of criteria , is comprehensive framing all For personal use only.

Results and conclusion: The paper shows that, compared with all the previous classifica- tions, the European Glaucoma Society classification is one step ahead in the way of classifying the group of secondary angle-closure glaucomas , two steps behind in rejecting two useful categories of congenital glaucoma , and similar in several respects: that it is based on criticizable fundamental and secondary criteria that cannot cover all forms of sickness gathered at a particular crossing; that it uses several equally weighted criteria for one single crossing division ; that it frames one clinical entity in several clinical categories; that it does not reflect reality in some aspects; and that it does not offer direct therapeutic suggestions: after framing a case in a scheme built on the basis of gonioscopic observation, it requires a second stage of pathogenic analysis, so that the ophthalmologist is able to decide the correct treatment only in the third stage.

All these considerations justify the efforts to find a new classification that will be able to correct the abovementioned shortcomings. Keywords: glaucoma, classification of glaucomas, shortcomings of the EGS classification Introduction The role of any classification is to highlight the essential and defining element in a group of related phenomena, in order to facilitate some practical decision making.

The major difficulty encountered in medical science is to find a criterion that can frame all forms of sickness in a coherent system, offering direct therapeutic suggestions. Several attempts have been made to elaborate glaucoma G classification, but only two have successfully survived Table 1. Both these classifications reflected the contemporary level of knowledge. Donders1 could use only the little information offered by clinical practice, in a period when there were few means of investigation specific for G.

The advent of gonioscopy threw light on a previously obscure domain, so that the gonioscopic classification2 was the first step toward understanding the Correspondence: Constantin-Dan Bordeianu pathogenic mechanism, explaining why some forms were silent and others so noisy.

The names of Ploiesti, , Prahova, Romania Email bordmail3 yahoo. S License. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. The purpose of this paper was to analyze the merits tive pathogenic mechanism. Without making considerable classification that avoids most of the drawbacks of the mental effort, its users got a much clearer explanation of EGSc and maintains all its merits.

In addition, it helped in and Guidelines for Glaucoma 11 Table 3. The method the spread of gonioscopy, and as a consequence, the whole involved a critical analysis of the EGSc to determine goniolens-producing industry supported the propagation the extent to which it is clear being based on a coherent and of this new classification.

In its form shown in Table 1, the consistently followed set of criteria , is comprehensive fram- gonioscopic classification remained almost unchanged for ing all forms of glaucoma , helps to understand the sickness 50 years, although the volume of knowledge continuously using a logical framing system , and facilitates therapeutic increased, and the following new information emerged: G was decision making offering direct therapeutic suggestions. As a conse- quence, the need for a new classification that could integrate The EGSc as one step ahead all this information became increasingly evident, and the first of the previous classifications attempts appeared in the seventh decennium Table 2.

This step is represented by the fact that the EGS finally tried From these, the classification suggested by Ourgaud and to clarify the group of ACG, which contained too many forms Etienne3 was too simple for a sickness with so many forms, characterized by angle closure AC despite the fact that the which is why it did not survive. Glad to have recognized the diagnostic category b. G associated with congenital anomalies of even a subtype eg, ACG in attack , some doctors could 2.

OAG a. Hypertensive adult G because the angle is closed. Normotensive adult G iv. Ocular hypertension forms according to the pathogenic mechanisms represents b. Secondary OAG an important step forward, even if this action is limited to the i. Nevertheless, when we analyze the manner hemorrhagic, traumatic, uveitic, caused by tumors, associated with retinal detachment in which the secondary ACG forms are classified, we find that ii.

Later, the paper a. Intermittent my passport, so I could not present my paper ; published iii. Chronic iv. Status after acute AC attack in Romania in in English ;12 presented several times v. With pupillary block During these years, my pathogenic classification did not stir ii. With pulling mechanism iii. With pushing mechanism any interest, and to some extent, this was understandable Note: Data from European Glaucoma Society.

This created serious confusion, rion. In this scenario, I hope that the ophthalmic community leading to therapeutic errors, since many times, the treatment will analyze, with a more positive mindset, the suggested for the most frequent form of ACG was automatically applied classification, to be detailed in my next paper. The errors occurred because in all of the previous clas- The EGSc as two steps sifications, the framing of a new case in a scheme defined behind the previous classifications by gonioscopic aspect or by clinical behavior did not have This is represented by the fact that, in congenital G, the direct therapeutic consequences for every case.

Or, the very late pathological manifestation. EGSc does not use the gonioscopic criterion in congeni- Secondly, this criterion might explain many difficulties tal G, in spite of the fact that the surgical techniques must encountered in classifying congenital G forms. Most authors target all pathogenic links, and that the angle narrowness consider that the major characteristic of what is nowadays may cause additional difficulties, imposing supplementary termed congenital G is the association of angle anomalies For personal use only.

Moreover, even if gonioscopy is not with ocular hypertension, manifested at an early age, on the only guiding technique for therapy and even if its find- a distensible sclera, which explains the increase in ocular ings must be corroborated with the information gathered by dimensions, Descemet membrane rupture, and fundus pecu- other investigation means, the gonioscopic indicator cannot liarities.

The isolated presence of angle anomalies at birth be excluded without affecting the clarity and finality of a with no ocular hypertonia or its effects does not indicate classification. The exact manner in the group of secondary acquired ACG. Moreover, the will be suggested in my next paper. Furthermore, without maternal rubella. Confused with other genetic contemporary science has proved that there is a cause for anomalies, a young ophthalmologist could indicate avoid- almost any form of G, even for the genetic anomalies.

As the role of any classification is to prevent damental criterion will produce a clinical classification, with erroneous decisions by simplifying the way of thinking, these all its drawbacks. This statement raises the questions: How exists?

What have if, on the one hand, we are advised to consider the justifies the choice of this value? After solving this dichotomy, he would relatives] , although they know that this treatment cannot expect it to be easier to reach a therapeutic decision; instead, prevent closure.

As the treatment must target the essential pathogenic medical treatment. The only problem lies in the fact that link and not the angle conformation, he may consider that the treatment was recommended on the basis of erroneous all his previous efforts to frame the case in one gonioscopic conceptions that were accepted uncritically, which the category did not yield practical results.

The immediate EGSc further strengthens, instead of amending. Clinical Ophthalmology submit your manuscript www. This rule is Moreover, the described stages are not specific for PACG: not followed by the EGSc, which uses many secondary some secondary ACGs may pass through some of these criteria in a criticizable manner.

We are allowed to consider that the exogenous G been eliminated. The result is a better understanding of the may appear at any degree of angle aperture and that angle sickness, both in general and in any particular case a doctor closure may appear in a case with exogenous G. After that, is that it allows the use of the pathogenic criterion both in the secondary criteria pick up the relay, until each form finds primary and secondary forms, thus avoiding the shortcomings its natural place.

The signs of inconsistency observed in EGSc are resolved as follows: 1 the gonioscopic and etiologic criteria The new classification frames each For personal use only. The perinatal—adult dichotomy is logical and more Table 1, line C-IV-3 ; 4 the clinical forms of perinatal G are permissive. Its use will not stir debate, because it does not distributed into the same pathogenic categories as the ones combine genetic with etiologic connotations, such as those used for adult G Table 1, line C-IV Nevertheless, we must found in the congenital—acquired dichotomy.

It refers only admit that the distribution suggested in this paper is only a to age, and it is not against logic to accept that one sickness first attempt that needs further investigation and debate. With all these improvements, confusion is less likely The clinical entities listed in the corresponding section of to occur. We are allowed to think of neuroprotection in any which buphthalmia is usually associated. When the but also in hypertensive cases, and not only in adults but mechanism is unclear at the moment, the entity may enter also in infants.

At the same time, one must try glaucoma drainage devices, as the last resource the term avoids the confusion generated by the contradictory before cycloanemisation. If moment. These structures tend to rec- decision for both the patient and his blood relatives. More reate the iris deformation with anterior contact and anterior importantly, the doctor will do this as soon as he or she synechia relapse, in spite of the fact that the PI has equalized For personal use only.

Natu- goniosynechialysis separates the synechia under gonioscopic rally, he or she will reach the stage of therapeutic decision mak- control either by passing a spatula25 or by injecting cohesive ing sooner; more importantly, the decision will be correct. G with primary trabecular G. After this short period of trabecular therapeutic suggestions structure rearrangement, the IOP usually decreases, allow- In simple pathogeny G, a specific treatment exists for each ing progressive tapering of medication.

In the end, the case pathogenic group. The results after angle repermeation,29 The primary forms are shown in a new manner of presentation30 that conveys all The pathogenic treatment in case of trabecular G aims for necessary data for statistical interpretation at five significant outflow increase: in the reversible stage of the sickness, the evolution moments: Clinical Ophthalmology submit your manuscript www.

Taking all complete success rates C ; a column for the qualified success these arguments into consideration, the only logical conclu- rates q , detailed according to the number of medications sion is that the trabecular surgery should be reserved only that ensured the compensation between parenthesis ; and for trabecular G or for the forms of mixed G in which the a column for failure rates F , in order to ease the under- trabecular block is associated.

In case of neglected pupillary standing of the success-failure rapport. In the first 3 postoperative months, any durable IOP because the formulation in words of the results takes with rise above 21 mmHg with tolerable medication or above the accompanying phrasing more typographic space, in spite of target pressure established according to the stage of sickness the fact it does not transmit anything about the preoperative represents a similar indication. That is why frequent controls aspect, about the success criterion, about the number of cases are needed in the first 3 postoperative months day 1, 5, 15, that passed each significant control, about the IOP mean 30, 45, 60, Generally, the results at 3 months are long value and SD at each control, about the number of medica- duration ones.

In a After closing this long discussion about the pathogenic world based on an extensive use of abstracts for reviewing treatment in case of pupillary G, the other forms need less information, the suggested manner of reporting results would discussions. In the irreversible stage, the treatment is to deepen or political barriers.

In such cases, the nonperforant formula above prove that the neglected pupillary G may be filtering procedures cannot prevent AC. For those In the case of perinatal angular G, the treatment is who have noticed, the increase in complete success rate goniotomy or trabeculotomy, with or without medical after 3 months is explained by the fact that cataract surgery therapy.

In the reversible stage of both malignant G and was recovered in at least 2 quadrants. In the irreversible stage of of the cornea. The essential difference as incision with the excision of the flap tip ,31 which in my compared with the neovascular type 1 G consists in the fact hands has never failed.

When the aqueous humor is misdi- that there is no need to dry the neovessels before G surgery: rected toward a deep intravitreal or retrovitreal space, the if successful, the G surgery will annul the retinal ischemia, treatment is puncture in pars planum and vitreal aspiration, the cause of the vasoformative factor.

In case of relapsing hyphema with normal IOP, this attitude will cure relapse, when the dense vitreous rapidly closes the tunnel, both the glaucoma and its neovascular complication. In on aphakic or pseudophakic eyes. In secondary push 2 Gs case of uveal effusion not responding to medical therapy, organic , each causal type responds to a specific treatment. For excessive maneuvers in retinal detachment surgery, the The secondary forms treatment would be the release of the encircling suture or par- For personal use only.

In case of the shortcomings listed as miscellanea idiopathic elevated episcleral vein pressure, the perforant The absence of a definition and the terminologic confusions filtration surgery or, better, the nonperforant one may listed in Table 1, lines C-IX-1 and C-IXa have been have good results, although it is frequently complicated by resolved by the replacement of the congenital—acquired choroidal effusion or hemorrhage.

In the case of type 1 longer exist, because my classification recognizes only neovascular G organic , and its OA, reversible phase, the three mechanisms of pretrabecular block: pupillary block, treatment is to inhibit the vasoformative factor, by laser or angular block, and the posterior push. These mechanisms are cryogenic ablation of peripheral retina, or by intravitreal active in both primary and secondary, as well as in perinatal injection of an anti-VEGF agent: these procedures can cure and adult forms.

As a consequence, the torrent of questions the neovascular G itself. In the AC, irreversible phase of this at the end of my previous paper3 remains without object. In this classification, everything Clinical Ophthalmology submit your manuscript www.

The doctor, both pathogenic classification, which clearly defines the mechanism, the experienced and the inexperienced, will know which indicates the correct treatment, and avoids therapeutic errors. It corrects the drawbacks of all previous gation gathered in the category of unknown or uncertain classifications. Then, secondary criteria pick up the relay until changes after all.

Naturally, the categories have received new each form finds its logical place in the scheme. To avoid pathogenic names, but the clinical forms in each category unclear aspects, the genetic criterion is no longer used, hav- remain mostly the same. Some categories have been upgraded ing been replaced by one of the clinical criteria age.

The and received the right of independent existence TRAG, exog- suggested classification brings only benefits to all categories enous G but only because their natural place was not among of ophthalmologists: the beginners will have a tool to better POAGs. Although the scheme seems more complex, one must understand the sickness and to ease their decision making, consider that for the great majority of patients, one will use whereas the experienced doctors will have their practice For personal use only.

For all doctors, errors leading to therapeutic gonioscopic classification. All one needs to know is that 1 disasters will be less likely to occur.

Finally, researchers more mechanisms may act on the same case, 2 exogenous G will have the object of their work gathered in the group of may appear on any degree of angle aperture, and 3 somewhere, glaucoma with unknown or uncertain pathogenesis, while at a higher level, TRA exists and may complicate the evolution the result of their work will easily find a logical place in the of any gonioscopic form, primary or secondary.

To reflect this scheme, because the suggested classification remains open reality, the exogenous G and the TRAG have received the right to any new to development. The author reports no conflicts of interest in this work. On the other hand, if one examines the benefits, one cannot deny the fact that although the scheme seems more References complex, it eases the decision making.

Once the pathogenic 1. European Glaucoma Society. Terminology and Guidelines for Glaucoma. Savona: Editrice Dogma; — Donders FC. Bordeianu CD. Critical analysis of the classification of glaucomas issued by the European Glaucoma Society in Clin Ophthalmol.

This pathogenic treatment offers time for etiologic analysis, ;— In Shields Textbook of Glaucoma. Rapport de la SFO [The functional investigation of glaucoma eye. Report of the French Society of Ophthalmology]. Paris: Masson; modalities or about particular responses to the pathogenic French. With such classification having 6. Krasnov MM. Vestn Oftalmol. Goldmann H. Doc Ophthalmol. As I wrote 22 years ago,9 if every doctor stands to benefit 8.

The pathogenic classification of glaucomas. The gonioscopic classification versus a pathogenic Poster SPpage Stockholm, Sweden.

Page Again, about iris vicious position memory. Abstracts New York: Springer; October , Sinaia, Romania, page Yanoff M, Duker JS. St Louis: Mosby; Campbell DG, Vela A. Modern goniosynechialysis for the treatment of High prevalence of plateau iris con- Angle repermeation, surgery of choice in neglected figuration in family members of patients with plateau iris syndrome.

An introduction to the theory of knots. Published December 11, Clinically, four throws have been found to be optimal 4. Terhune M. Materials for wound closure. J Surg Educ. Satteson ES. Updated: August 14, We have yet to see an SFT loop that opens and Bordeianu.

Single-pass four-throw pupilloplasty knot lowed by a securing loop. The SFT knot comprises only mechanics. Single-pass four-throw technique for pu- Second, the authors reproduced the scenario in a dry- pilloplasty. Eur J Ophthalmol. We would be glad to know the details of this 3. Narang P. Knot mechanics of single-pass four-throw pupillo- dry-lab setting because in cases of loss of tonicity in an plasty.

Published November 5, Updated August 14, Additionally, with excessive tightening presented herein. Tendon end separation with loading in an Achilles tendon repair model: comparison of non-absorbable vs. Cyclic testing of arthroscopic knot security By Philip Noble. The behaviour of knots and sutures during the first 12 hours following a Bankart repair By Cronan Kerin.