Glaucoma Abdulrahman Al-Amri, MD

Glaucoma  Definition & Epidemiology  Anatomy & physiology  POAG  ACG  Secondary glaucoma  Management  Quiz

 leading cause of blindness worldwide

GLAUCOMA IOP Cupping Visual Field Loss IOP Cupping Visual Field Loss

Anatomy and physiology Aqueous Humour  Secreted by the CB  Carbonic anhydrase enzyme is required  Aqueous outflow : TMW Uveoscleral TMW Uveoscleral Schlemm’s canal Schlemm’s canal Venous circulation Venous circulation

A/C angle structures  Schwalbe’s line  TMW: fenistrated sheet sheet  SS  CB

Anatomy of NFL

Tonometry Tonometry  Contact tonometry -Applanation tonometry -Applanation tonometry  Non-contact tonometry (NCT) -Air puff -Air puff

Gonioscopy examining AC angle

Perimetry Visual field testing

Classification of glaucomas  Cong vs acquired  Open vs closed  Primary vs secondary

Congenital glaucoma  Trabeculodysgenesis  Usually Sporadic Symp.  Photophobia  Tearing  Blepharospasm

Signs  High IOP  Buphthalmos  Large cornea  Corneal edema+/-  Cupping (Normal C:D ratio =0.3)

Treatment Surgica l

Acute Angle Closure Glaucoma Acute elevation of IOP Acute elevation of IOP Angle closure by: Angle closure by: -Pupillary block -Iris crowding Predisposing factors

Symptoms  Sudden ocular pain   Rapid loss of vision*   Tearing   Photophobia   Headache   Nausea   Vomiting

Signs  Ciliary congestion  Mid dilated pupil (due to pressure on ciliary nerves and vessles)  High IOP  Corneal edema  Closed angle

Surgical YAG laser iridotomy

Treatment of Acute Angle-Closure Glaucoma Hyperosmotic agents Intravenous mannitol B- Topical therapy Pilocarpine Beta-blockers 1.Medical A-Systemic CAI Acetazolamide 2.Surgical YAG laser iridotomy

Primary Open Angle Glaucoma- POAG  Above 40yr usually  Bilateral  Asymptomatic in early stages

Risk Factors  Age  FH  Steroids  Myopia  DM

Primary Open angle Glaucoma POAG Mechanical Ischemic

IOP > 21 mmHg Cupping Open angle Visual field loss Primary Open Angle Glaucoma-POAG

Progression

Pseudoexfoliation  Firillar material, similar to amyloid  Deposition in the TMW….high IOP

Phacomorphic glaucoma

Glaucoma Drugs  Drugs to decrease the production of aqueous humor.  Drugs to increase the outflow of aqueous humor. –Trabecular channels –Uveoscleral channels

Management  Medical -Topical-Systemic  Surgical -Trabeculectomy -Tube-shunt surgery -Cyclodestructive procedures

Medical Topical Production  Sympathomimetics (adrenergic agonists)  Beta blockers Outflow  Parasympathomimetics (Miotics-cholinergic ag)  Prostaglandin analogues

–Allergic conjunctivitis –Punctate keratitis –Bradycardia –Bronchospasm –Hypotension – libido –Depression Glaucoma Drugs – Side Effects Betablockers

Generics –Brimonidine Tartrate (0.2% solution) Glaucoma Drugs Adrenergic Drugs

–Lid edema –Conjunctivitis –Fatigue –Drowsiness –Apnea –bradycardia –hypotension Glaucoma Drugs – Side Effects Adrenergic Drugs

 Generics –Acetazolamide (250 mg tabs, 500mg caps, (250 mg tabs, 500mg caps, 500 mg IV solution) 500 mg IV solution)  Brands –Diamox Glaucoma Drugs Carbonic Anhydrase Inhibitors (CAI’s)

Ocular: –Allerg conjunctivitis Systemic: *Tingling sensation of hands & feet *Steven-johnson sx *Renl stone *GIT –Headache / fatigue –Dry mouth –Dec. libido, –Depression Glaucoma Drugs – Side Effects Carbonic Anhydrase Inhibitors (CAI’s)

 Action: –Reduce IOP by increasing the outflow through uveoscleral channels –Lowers IOP in 3- 4 hrs after instillation  Generics –Latanaprost (0.005% Sol.) (0.005% Sol.)  Brands –Xalatan Glaucoma Drugs Prostaglandin Analogs

Heterochromia

MIOTICS (2% Sol.) –Produce miosis (small pupil) Generics –Pilocarpine Hydrochloride Glaucoma Drugs Drugs to Increase the Outflow

Medical Systemic   Hyperosmotic agents   Carbonic anhydrase inhibitors

 Generally used in emergency situation when rapid decrease of IOP is needed for AACG.  Action: – increased S. osmolarity : drawing fluid out of the vit across vascular barriers. drawing fluid out of the vit across vascular barriers. Glaucoma Drugs Osmotic Agents

Management  Surgical -Trabeculectomy -Tube-shunt surgery -Cyclodestructive procedures