Glaucoma

Glaucoma is one of the most common causes of permanent blindness in the world. One of the most fundamental aspects of glaucoma is that it is not an isolated case of illness but a widespread group of illnesses. Can manifested by a broad spectrum of clinical and histopathological findings. Majority of glaucoma px dont have any symtoms in the early stage of the disease.

The elevation of IOP may be a sign of glaucoma but not all cases will have it.

Statistically 2% of the population worldwide are suffering from glaucoma but 3% of the people being 60 years and older.

Group at risk are: Age Hx of eye trauma or surgery HPN/DM Use of steroids

Vascular diseases Hyperopia/Myopia Other eye diseases Family Hx of Glaucoma

Definition

Glaucoma is described as any illness in which can cause a typical glaucomatous damage with the optic nerve head with typical changes in the visual field. There are four factors which we need to diagnose and monitor glaucoma. These are: Damage of the optic nerve Loss of visual field Intraocular pressure Gonioscopy

Damage of the Optic nerve

Typical Glaucomatous Optic Nerve Head Damage Enlarging of the cup-disc ratio of the optic nerve. This can be seen as a some what brighter area at the optic nerve head. Darkening of the nerve fiber layer around the head. Presence of disc hemorrhges. Presence of notching. Reason: Decrease of nerve cells and blood vessels in the papilla. Elevated IOP or disturbances of the blood circulation may cause cupping at the papilla. The extent of the cupping is refered to as cup-Disc Ratio (CD) which is the ratio of the cup to the diameter of the nerve head.

Normal and Glaucomatous Optic Nerve Head

Anatomy of the Optic Nerve

A: Layer of nerve fibers: Is the top layer of the retina facing the vitreous, in this layer the nerve fiber coat the whole retina. B: prelaminar region of the papilla: It is composed of nerve fibers and astrocytes C: Lamina cribrosa (Cribriform area): In this segment are layers of scleral conective tissue. Astrocytes isolate these layers and coat the openings which are used by the neurons to leave the eye. D:Retrolaminar region.

Anatomy of the papilla

Theori of Glaucomatous Damage :

Mechanical Theory : compresion of optic nerve Ischemic Theory : intraneural ischemia

Classification of glaucoma : 1.Open angle glaucoma :

Primary Open Angle Glaucoma Normal Tension Glaucoma Juvenile Glaucoma Suspect Glaucoma Secondary Glaucoma

2.Angle Closure Glaucoma

Acute Angle Closure Subacute Angle Closure Chronic Angle Closure Secondary Angle Closure With Pupillary Block Secondary Angle Closure Without Pupillary Block

3.Childhood Glaucoma
Primary Congenital / infantile Glaucoma Glaucoma Associated With Congenital Anomalies Secondary Glaucoma In Infant And Children

Risk factor of glaucoma :

Race Age Gender Refraction Genetic

Visual Field
There is a distinction between the central (30) and the peripheral visual field. The peripheral visual field is needed for the orientation and spans ,if you look straight on, more than 90 to the temporal side, 70 downwards, and up to 60 at the nasal side and upwards. To roughly determine the visual field one can make the thumbs-test

Visual Field

Visual Field Loss

Untreated glaucomas will always lead to permanent loss of optic nerve cells which would also result to permanent loss of vision. Clinical correlation is important in diagnosing and monitoring. Initially losses of the visual field can be scotomas and normally have an island-like shape. Usually involving the peripheral fields.

Visual Field Loss

Typically bowshaped Bjerrum-scotomas are formed. In the advanced stage only the central and temporal island of vision is left. The central visual field (10) remains relatively long intact until in the end even this area looses its function.

Visual Field

Visual Field Loss

Visual Field Loss

Intraocular Pressure (IOP)

The IOP is dependent to the inflow and outflow of aquous humor in the anterior segment. Aqueous humor is generated by filtration of blood and is secreted from the ciliary body into the posterior chamber. It washes around the iris, lens and the interior side of the cornea and the major part leaves via the iridocorneal angle through the structures of the trabecular meshwork and Schlemms canal.

Intraocular Pressure (IOP)

Three factors determine IOP : 1.rate of aqueous production 2.resistance of aqueous outflow across trabecular meshwork-canalis sclemmi 3.level of episcleral venous pressure

Intraocular Pressure (IOP)

Majority would have 15 mm Hg. Acceptable pressures would range from 18 to 20 mm Hg depending on the optic disc. Women usually have higher IOP compared to men. IOP would increase as one gets older.

Intraocular Pressure (IOP)

Glaucoma px can have high IOP compare to normal individuals.

> 4 mm Hg flactuations
They can have spikes of IOP

Measurements of IOP

Impression tonometry according to Schitz is nowadays only used in special cases .

Measurements of IOP

Normally the Goldmann applanation tonometry or the non-contact tonometry are used.

Reasons for elevated IOP

Excess production of aqueous humor Outflow through the trabecular meshwork is suboptimal or blocked. Excess production is only in rare cases the reason for elevated IOP, whereas variation of the outflow facilities is quite common.

Iridocorneal Angle

The angle of the anterior chamber is formed by the front side is the cornea and the rear side is the iris.
The angle is hidden from frontal side by the limbus and can be made visible only by means of gonioscopic mirrors Viewing the angles will give us the type of glaucoma. Open Angle Glaucoma or Close Angle Glaucoma

Iridocorneal Angle

The iridocorneal angle can be open, narrow, or even closed

Investigation of the Iridocorneal Angle

Gonioscope : This is a special contact lens which is connected optically and mechanically by a viscous water-based liquid with the cornea. A light beam can be diverted such that the chamber angle can be seen.

Investigation of the Iridocorneal Angle

3-Mirror-contact lens: With the help of this binocular contact lens all areas of the retina can be investigated.

Treatment

Topical Eye Medications Laser Surgery

TOPICAL EYE MEDICATION

LASER

Peripheral laser Iridotomy: Angle Closure types of glaucoma. Laser Trabeculoplasty: Open Angle types of glaucoma.

SURGERY

Trabeculectomy: Creation of a bleb were aqueous can flow out of the eye. Implants: Devices which when incerted in the anterior chamber drains aqueous out of the eye.

Thank You Good Day!