1. Paras Guide to Glaucoma
Diagnosis, Treatment and Management of Glaucoma
Desinee Drakulich O.D.

2. Review What is Glaucoma?
A progressive optic neuropathy that damages retinal ganglion cells and other mechanisms in the visual pathway.
Retinal ganglion cells are very pressure sensitive and once damaged they do not regenerate.

4. Review
Eye Pressure- most people associate eye pressure or Intraocular Pressure (IOP) with glaucoma.
Normal eye pressure is between 10 mmHg and 21 mmHg
Average is between 14 mmHg and 16 mmHg
Misconception is that the measured value is the pressure in the eye, it is actually the difference between the pressure in the eye and the atmospheric pressure.
Not all forms of glaucoma have IOPs > 21 mmHg

5. Review
Anatomy of the Eye

8. Review Types of Glaucoma Primary Open Angle Glaucoma
Angle Closure Glaucoma
Low Tension Glaucoma
Pigmentary Glaucoma
Exfoliative Glaucoma
Acute Glaucoma
Congenital Glaucoma
Secondary Glaucoma
Traumatic Glaucoma

9. Low Tension Glaucoma Most difficult to diagnose
Patient have IOPs in the normal range
Thought to be caused by poor blood flow to the optic nerve
New research is answering some questions
In the past, diagnosis was made with the appearance of visual field loss.
With scanning laser technology normal tension patients are often caught before visual field damage appears

10. Primary open Angle
The most common form of glaucoma in African Americans and Caucasians.
Approximately 1% of Americans have this form of glaucoma.
Most common form in people over the age of 50.
Defined as increased intraocular pressure inconsistent with a health optic nerve and consistent with an open angle of aqueous drainage.

11. How to detect POAG Increased IOP > 21 mmHg
Thin central corneal thickness > 555 um
Peripapillary Atrophy
Notching or thinning of the neuroretinal rim
Family History
Large cup to disc ratio

12. Angle closure glaucoma
Affect about half a million people in the US
Tends to be inherited
Affects Asians and hyperopes most frequently
Anterior chamber smaller than average
Angle < 45 degrees
Iris forced up against trabecular meshwork causes complete closure or an acute glaucoma attack
Age can be a factor due to increasing size of the lens of the eye

13. How do we treat POAG
Medication Drops
Laser Treatments
Surgery

14. How to detect acg

15. What can Optometrist Do?
Optometrist can detect and treatment POAG in adults with drops.
If pressure and vision loss can not be controlled with drop referrals must be made to Ophthalmology for laser or surgical consideration.

16. Current Types of Glaucoma Drops
Cholinergics
Beta Blockers
Alpha Agonists
Carbonic Anhydrase Inhibitors
Prostaglandins

17. Cholinergics Older method of treating glaucoma rarely used anymore.
Two major drugs: Pilocarpine and Carbachol
How do they work?
They constrict the pupil increasing drainage out of the trabecular meshwork in the angle of the eye.
Side effects included decrease vision in dim lighting and headaches

18. Beta Blockers
Also an older method of treating Glaucoma however still commonly used today
Most commonly used drops are: Timolol, Betoptic and Betagan.
How do they work? Decrease the production of aqueous
Side effects include decreased heart rate, decreased pulse, fatigue and shortness of breath. Caution with people with Asthma or COPD and people currently taking Beta Blockers for BP control.

19. Alpha Agonists Newer method of glaucoma treatment.
Two different drops available: Iopidine and Alphagan P
How to they work? Both decreasing aqueous production and increasing outflow of aqueous. Also considered a neuroprotective agent.
Side effects include fatigue, headache and dry mouth.

20. Carbonic Anhydrase Inhibitors
Commonly used for patients who can’t take Beta Blockers
Two drops available and one oral medication: Azopt, Trusopt and Diamox. Optometrists in NE can’t Rx Diamox.
How do they work? Decrease the production of aqueous.
Side effects include tingling or loss of strength of the hands and feet, upset stomach, mental fuzziness, memory problems, depression, kidney stones, and frequent urination.

21. Combination Drops
Relatively new, good for patient who drop want to do multiple drops per day.
Two types of drops: Combigan and Cosept
Combigan is Alphagan and Timolol.
Cosept is Trusopt and Timolol
How to they work? Both increase outflow and decrease production
Side effects are the same as the individual drugs.

22. Prostaglandins
Newest method of treating glaucoma considered the DOC of glaucoma medication.
Three major drops: Xalatan, Lumigan and Travatan
How do they work? Increase drainage of the aqueous via and uveal scleral pathway.
Side effects include iris pigment change, redness in eye, stinging and itching.

23. So What is the Best Drop?
Current studies from the Review of Optometry March 2009 show that the DOC is still Xalatan.