GLAUCOMA

DEFINITION:

Glaucoma is an eye disease in which the optic nerve is damaged leading to permanent damage of
vision in the affected eye(s) and lead to blindness if left untreated which is normally associated with
increased fluid pressure in the eye.
Glaucoma is "A disease of the eye characterized by increased intraocular pressure, excavation, and
atrophy of the optic nerve; produces defects in the field of vision and eventual loss of vision."
Raised intraocular pressure (above 21 mmHg) is the most important and only modifiable risk factor
for glaucoma.

Classification:
Basic Types:
1. Open Angle
2. Closed angle
3. Congenital

Based on causes:
1. Primary (Not caused by another eye disorder)
2. Secondary (Diseases, Drugs etc)

Based on severity:
1. Ocular Hypertension
2. Mild (Mild loss of peripheral vision)
3. Moderate (Loss of peripheral vision)
4. Severe (Loss of central vision)

OPEN ANGLE GLAUCOMA:

Open-angle glaucoma has been called simple glaucoma, chronic glaucoma, and wide-angle
glaucoma.
The increased pressure is caused by trabecular blockage. Because the microscopic passageways are
blocked, the pressure builds up in the eye and causes imperceptible very gradual vision loss.
Peripheral vision is affected first, but eventually the entire vision will be lost if not treated.

CLOSED ANGLE GLAUCOMA

Primary angle closure glaucoma is caused by contact between the iris and trabecular meshwork,
which in turn obstructs outflow of the aqueous humor from the eye. This contact between iris and
trabecular meshwork (TM) may gradually damage the function of the meshwork until it fails to
keep pace with aqueous production, and the pressure rises.
 RISK FACTORS AND CAUSES

• Old age - people over the age of 60 years have a higher risk of developing the disease. For
African-Americans, the risk rises at a younger age.
• Ethnic background - East Asians, because of their shallower anterior chamber depth
• Sex: Females are three times as likely to develop glaucoma as males.
• Some illnesses and conditions - people with diabetes or hypothyroidism have a much higher
chance of developing glaucoma.
• Eye injuries or conditions - some eye injuries, especially severe ones, are linked to a higher
glaucoma risk. Retinal detachment, eye inflammations and eye tumors can also cause
glaucoma to occur.
• Eye surgery - some patients who underwent eye surgery have a higher risk of glaucoma.
• Myopia - people with myopia (nearsightedness) have a higher risk of glaucoma.
• Corticosteroids - patients on long-term corticosteroids have a raised risk of developing several
different conditions, including glaucoma. The risk is even greater with eyedrops containing
corticosteroids.

In open/wide-angle glaucoma, flow is reduced through the trabecular meshwork, due to the
degeneration and obstruction of the trabecular meshwork, whose original function is to absorb the
aqueous humor. Loss of aqueous humor absorption leads to increased resistance and thus a chronic,
painless buildup of pressure in the eye.
In close/narrow-angle, the iridocorneal angle is completely closed because of forward
displacement of the final roll and root of the iris against the cornea, resulting in the inability of the
aqueous fluid to flow from the posterior to the anterior chamber and then out of the trabecular
network. This accumulation of aqueous humor causes an acute increase of pressure and pain.
The pressure gradient across the trabecular meshwork is increased, causing stress to the retinal
ganglion cells and their eventual destruction.
Additionally, the compression of axons may lead to impaired axonal transport, which causes cell
death due to an insufficiency of trophic factors. Another possibility is that ischaemia, due to faulty
blood flow to the retina, may cause cell death and eventual blindness.
 CLINICAL MANIFESTATIONS
Primary open-angle glaucoma signs and symptoms include:
Gradual loss of peripheral vision, usually in both eyes
Tunnel vision in the advanced stages

Acute angle-closure glaucoma signs and symptoms include:

Eye pain
Nausea and vomiting (accompanying the severe eye pain)
Sudden onset of visual disturbance, often in low light
Blurred vision
Halos around lights
Reddening of the eye

COMPLICATIONS:

Optic nerve damage - Optic nerve damage results from too high internal pressure
Blindness
Motor accidents - from loss of peripheral vision
Loss of peripheral vision
Progressive trabecular dysfunction
Ocular hypertension
Glaucomatous optic neuropathy
Permanent damage of the optic nerve and resultant visual field loss

DIAGNOSTIC EVALUATIONS



Tonometry: Inner eye pressure.
Ophthalmoscopy (dilated eye exam)Shape and color of the optic spots.
Perimetry (visual field test)Complete field of vision. The patient looks straight ahead and is asked to
indicate when light passes the patients peripheral field of vision. This allows the examiner to map
the patient’s field of vision.
Gonioscopy: Angle in the eye where the iris meets the cornea. Eye drops are used to numb the eye.
Pachymetry measures Thickness of the cornea.The examiner places a pachymeter gently on the
front of the eye to measure its thickness.
Nerve fiber analysis: measure Thickness of the nerve fiber layer. Using one of several techniques,
the nerve fibers are examined.
 MANAGEMENT

MEDICAL MANAGEMENT

Intraocular pressure can be lowered with medication, usually eye drops.

Prostaglandin analogs, such as latanoprost (Xalatan), bimatoprost (Lumigan) and travoprost

(Travatan), increase uveoscleral outflow of aqueous humor. Bimatoprost also increases trabecular
outflow.

Topical beta-adrenergic receptor antagonists, such as timolol, levobunolol (Betagan), and

betaxolol, decrease aqueous humor production by the ciliary body.

Alpha2-adrenergic agonists, such as brimonidine (Alphagan) and apraclonidine, work by a dual

mechanism, decreasing aqueous humor production and increasing uveoscleral outflow.

Less-selective alpha agonists, such as epinephrine, decrease aqueous humor production through
vasoconstriction of ciliary body blood vessels, useful only in open-angle glaucoma.

Miotic agents (parasympathomimetics), such as pilocarpine, work by contraction of the ciliary

muscle, tightening the trabecular meshwork and allowing increased outflow of the aqueous humour.

Carbonic anhydrase inhibitors, such as dorzolamide (Trusopt), brinzolamide (Azopt), and

acetazolamide (Diamox), lower secretion of aqueous humor by inhibiting carbonic anhydrase in the
ciliary body.

SURGICAL MANAGEMENT
Laser trabeculoplasty
A trabeculoplasty is a modification of the trabecular meshwork. Laser trabeculoplasty (LTP) is the
application of a laser beam to burn areas of the trabecular meshwork, located near the base of the
iris, to increase fluid outflow.

Iridotomy
An iridotomy involves making puncture-like openings through the iris without the removal of iris
tissue. Performed either with standard surgical instruments or a laser, it is typically used to decrease
intraocular pressure in patients with angle-closure glaucoma.

Iridectomy
An iridectomy, also known as a corectomy or surgical iridectomy, involves the removal of a portion
of iris tissue.

A surgical goniotomy involves cutting the fibers of the trabecular meshwork to allow aqueous fluid
to flow more freely from the eye.

Endoscopic goniotomy, which employs an endoscope to view the anterior chamber angle, may be
performed, a trabeculotomy which accesses the angle from the exterior surface of the eye.
Tube-shunt surgery or drainage implant surgery involves the placement of a tube or glaucoma
valves to facilitate aqueous outflow from the anterior chamber.

Canaloplasty
Canaloplasty is a nonpenetrating procedure utilizing microcatheter technology. To perform a
canaloplasty, an incision is made into the eye to gain access to Schlemm's canal. The catheter is
then removed and a suture is placed within the canal and tightened.

Cyclocryotherapy, or cyclocryopexy, uses a freezing probe. Cyclophotocoagulation, also known as

transscleral cyclophotocoagulation, ciliary body ablation, cyclophotoablation,and
cyclophototherapy uses a laser.

Cyclodiathermy uses heat generated from a high frequency alternating electric current passed
through the tissue, while cycloelectrolysis uses the chemical action caused by a direct current.