1. RN Elisa Urruchi
ORBIS International
GLAUCOMA

2. GLAUCOMA What is it? involving:
A disease of progressive optic neuropathy
involving:
Structural changes in the optic nerve head
Visual field loss
Resulting in blindness if left untreated.
And you thought glaucoma was a disease in which there was too much pressure in the eye! So did most ophthalmologists until several years ago. 2

3. GLAUCOMA What causes it?
There is a dose-response relationship between intraocular pressure and the risk of damage to the visual field.
But pressure certainly plays a role. Glaucoma is just too complicated to fit a nice simple definition.
Elevated IOP is sometimes called ocular hypertension. If your doctor diagnoses ocular hypertension, it does not mean you have glaucoma, but it does mean you are at a higher risk for developing the condition, and you should see an ophthalmologist
Normal (or low) tension glaucoma is an unusual and poorly understood form of the disease. In this type of glaucoma, the optic nerve is damaged even though the IOP is consistently within a range usually considered normal.
Secreted by ciliary body
•Flows into posterior chamber
•Flows through pupil into anterior chamber•
Leaves eye through the trabecular meshwork
Into the bloodstream.
Elevated IOP
Glaucoma
Normal IOP
Glaucoma 3

4. GLAUCOMA Intraocular Pressure
Pressure within the eye is maintained by a balance between aqueous production and aqueous drainage
Normal Range mm Hg
•Average mm Hg
•Glaucoma Suspect over 21 mm Hg 4

5. DIAGNOSING GLAUCOMA How do we measure IOP? Goldman applanation
tonometry
Tono - pen
Schiotz tonometer
No contact tonometer
Non-contact
These techniques illustrate the most common means of measuring intra-ocular pressures. Applanation is probably the most accurate method but requires a slit lamp to use it.
Remove your corrective lens, such as contact lens
Topic anesthesia
Goldmann applanation --a small amount of an orange dye called fluorescein will be placed in the eye
The numbing drops wear off in about 20 minutes and the dye washes out in a few minutes. It is important not to rub your eye while it is numb.
Possible complications or side effects of tonometry are corneal abrasion or an allergic reaction to the anesthetic drops, but this would be extremely rare 5

6. DIAGNOSING GLAUCOMA Incorrect IOP reading can be caused by:
Cornea being thicker or thinner than normal
A history of eye surgery, such as LASIK

7. DIAGNOSING GLAUCOMA VISUAL FIELD Goldmann perimeter
Humphrey automated perimetry 7

8. Visual fields in glaucoma
DIAGNOSING GLAUCOMA
Visual fields in glaucoma
Vision loss is slow, progressive,
& irreversible
Early 8

9. DIAGNOSING GLAUCOMA Cup-to-disk ratio Normal Glaucoma
No two disks are alike. Signs suggesting glaucoma as seen in the right photo include a large cup, nasalization of vessels, and pallor of the cup. Note the peripapilary depigmentation on the right which can make the true cup:disk ratio difficult to estimate.
In glaucoma of all types, if not controlled. There is progressive enlargement of the cup, increased pallor of the base of the cup, and nasalization of the disk vessels.
Whie there is lots of variation in glaucomatous disks, three common characteristics stand out: large cups, pale color and nasalization of the vessels. 9

10. GLAUCOMA CLASIFICATION
The classification of glaucoma depends on the following factors:
1.According to the appearance of the drainage angel (open or closed).
2.Presence of any other factors that may contribute to the rise in IOP.
3. Primary glaucoma has no other ocular disorders associated with a rise in IOP.
4.Secondary glaucoma is associated with another condition such as inflammation, neovascular disease, et. And accounts for one-third of all glaucoma cases.
Is caued for some other ocular or systemic disease.
•steroid induced
•inflammation
•ocular disease
•due to trauma/surgery: Hyphema, blunt, no penetrating trauma to globe and orbit
This lecture covers only congenital and adult varieties of glaucoma but it is important to realize there are many other causes

11. GLAUCOMA 2. Open angle 1. Closed angle
Poor access to the drainage system
Problems in the drainage system
aqueous suppressants (timoptic, betagan, trusopt)
•miotic (pilocarpine alone may be sufficient in mild attacks)
•intravenous or oral carbonic anhydrase inhibitors
•intravenous or oral hyperosmotic agents
Secreted by ciliary body•Flows into posterior chamber•Flows through pupil into anterior chamber•Leaves eye through the trabecular meshwork•Flows into Canal of Schlemm & into episcleral veins

12. Primary Open Angle Glaucoma
Most common form
Also know as Chronic Open Angle Glaucoma
Gradually increased resistance to outflow of aqueous through the trabecular meshwork
Pressure slowly increases

13. Primary Open Angle Glaucoma
Risk factors
Elevated IOP
Increases with age
Positive family history
African American background 13

14. Primary Open Angle Glaucoma
Onset: 50+ years of age
Signs
Elevated IOP
Visual field loss
Glaucomatous disk
changes
Symptoms
Usually none
May have loss of central
and peripheral vision
Remember: most patients with open angle glaucoma have no symptoms. This is the best reason to have periodic eye examinations with pressure checks and optic nerve evaluations.
Painless until pressure is very high
•May not notice any vision loss until severe damage has occurred
•Peripheral vision is affected 1st
•Central vision spared initially
•Tunnel vision: only a few surviving fibres from macula
•Disc Changes: nerve fibres atrophy with sustained pressure 14

15. Goal TREATMENT To preserve vision by reducing IOP to a level thought
to be safe for the optic nerve.
Medical
Laser
Surgical
Colateral effects: Allergy, Hypotension n children, cardiac failure, heart block, bronchospasm, renal insufficiency, stroke,hypertension, hipotension, headaches, macular edema, iris colour change, lash growth so this patients might have a strict follow up. No treatment works all the time!
Reduces aqueous production by destruction of the ciliary body
Used in severe glaucoma when conventional treatment fails to control IOP
Medical
Decrease aqueous fluid production in the ciliary body
Improve aqueous outflow via the trabecular meshwork
Laser
Argon laser trabeculoplasty
Cyclolaser ablation
Iridotomy
Surgical
Trabeculectomy
Filtering procedure
Drainage procedures
Cyclocryotherapy

16. Medical Medications TREATMENT
Decrease aqueous fluid production in the ciliary epithelium.
Improve aqueous outflow via the trabecular meshwork or uveoscleral route or both

17. Colateral effects: Allergy, Hypotension n children, cardiac failure, heart block, bronchospasm, renal insufficiency, stroke,hypertension, hipotension, headaches, macular edema, iris colour change, lash growth so this patients might have a strict follow up. No treatment works all the time!

18. Laser treatment of glaucoma
Argon laser
trabeculoplasty
These are the two most common surgical procedures for open angle glaucoma with success rates of 80+%.
it stimulates the trabecular meshwork to perform its function efficiently by creating evenly spaced minute burns onto the area.
Creates a small hole in the peripheral iris 18

19. Trabeculectomy TREATMENT
Creating a path for the aqueous to escape into the sub-conjunctival space is the aim of filtration surgery.
Creates a new drainage system within the eye to under the conjunctiva 19

20. Valve Implant TREATMENT
The device works by bypassing the trabecular meshwork and redirecting the outflow of aqueous humor through a small tube into an outlet chamber or bleb. The IOP generally decreases from around 33 to 10 mmHg

21. Postoperative Care
Glaucoma medications are usually discontinued to improve aqueous humor flow to the bleb.
Topical medications consist typically of antibiotic drops 4 times per day and anti-inflammatory therapy e.g. with prednisolone drops every 2 hours.
A shield is applied to cover the eye until anesthesia has worn off (that also anesthetizes the optic nerve) and vision resumes.
Patients are instructed to call immediately for pain that cannot be controlled with over the counter pain medication or if vision decreases
do not rub the eye and to wear the shield at night for several days after surgery.

22. Laser Cyclophotocoagulation
TREATMENT
Laser Cyclophotocoagulation
Reduces aqueous production by
destruction of the ciliary body
Used in severe glaucoma when
conventional treatment fails to control
IOP
Cyclophotocoagulation is generally used to treat advanced or aggressive open-angle glaucoma. It is usually used after other treatments have proven unsuccessful.
In open-angle glaucoma, the eye's aqueous humor (the clear liquid that circulates inside the front portion of the eye) does not drain properly. This causes pressure to build up within the eye. The medical term for this pressure is intraocular pressure. Such pressure inside the eye may damage the optic nerve and lead to vision loss. Medications, laser surgery, or other glaucoma surgeries may be used to lower and control the eye pressure.

23. Medical Emergency Acute/Primary Angle Closure Glaucoma
Flow of aqueous is prevented from the posterior chamber to the anterior chamber
Aqueous collects behind the iris & pushes it forward to block the trabecular meshwork
Drainage of aqueous from the eye is prevented

24. Acute/Primary Angle Closure Glaucoma
Risk factors
Hyperopia
Elderly
Woman
Family history
African American background 24

25. Acute/Primary Angle Closure Glaucoma
Onset: 50+ years of age
Symptoms
Severe eye/headache
Pain
Blurred vision
Nausea and vomiting
Halos around lights
Intermittent eye ache
at night
Signs
Red, teary eye
Elevated IOP (usually
over 40 mm Hg)
Corneal edema
Shallow AC
Mid-dilated, fixed pupil
Eye feels hard
Closed angle seen
With gonioscopy
The classical signs and symptoms of narrow angle glaucoma. 25

26. Acute/Primary Angle Closure Glaucoma
Mid-dilated, fixed pupil, cloudy cornea
Mid-dilated, fixed pupils and cloudy corneas during an angle closure attack. 26

27. Treatment Acute/Primary Angle Closure Glaucoma
Aqueous suppressants (timoptic, betagan, trusopt)
Miotic (pilocarpine alone may be sufficient in mild attacks)
Intravenous or oral carbonic anhydrase inhibitors
Intravenous or oral hyperosmotic agents
Acetazolamide is an inhibitor of carbonic anhydrase. It is used for glaucoma
Common agents include glycerin (glycerol), isosorbide, mannitol and urea

28. Narrow Angle Glaucoma Treatment: Peripheral Laser Iridotomy
Goal
To preserve vision by reducing IOP to a level thought to be safe for the optic nerve
Creates a small hole in the peripheral iris

29. Key Points
Once peripheral or central vision is lost from glaucoma, it can never be restored by any form of treatment.
Early detection of glaucoma is critical. Progression of the disease & permanent blindness can be prevented by appropriate treatment.
Glaucoma is an increasingly important public health concern due to our aging population demographics

30. Glaucoma Quiz Glaucoma is more common in Blacks than in Whites
Glaucoma tends to run in families
A person can have glaucoma and not know It
People over age 60 are more likely to get glaucoma
Eye pain is often a symptom of glaucoma
Glaucoma can be controlled
Glaucoma is caused by increased eye pressure
Vision lost from glaucoma can be restored
A complete glaucoma exam consists only of measuring eye pressure

31. THANK YOU ALL FOR LISTENING!31