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Glaucoma comprises a group of ocular disorders characterized by increased intraocular pressure,

optic nerve atrophy, and visual field loss it is estimated that more than 80.000 people in the
united state are blind as a result of glaucoma. The incidence of glaucoma is about 1,5% and is
black between ages 45 and 65 years, the prevalence is at least five times that of whites in the
same age group. In most cases blindness can be prevented if treatment is begin early
Classification
Many terms are used to describe the various types of glaucoma :
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Primary and secondary glaucoma refer to whether the cause is the disease alone or
another condition.
Acute and chronic refer to the onset and duration of the disorder
Open (wide) and closed (narrow) describe the width of the angle between the cornea and
the iris. Anatomically narrow anteriorchamber angles predispose people to an acute onset
of angle-closure glaucoma

Primary open-angle glaucoma


Primary open-angle glaucoma, the most common form, is a multifactorial disorderthat is often
genetically being lost. Aqueous humor flow is slowed or stopped because of obstruction by the
trabecular meshwork
Angle-closure Glaucoma
An acute artack of angle-closure glaucoma can develop only in on eye in which the anterior
chamber angle is anatomically narrow.the artack occus because of suddent blockage of the
anterior angle by the base of the iris.
Ather form of glaucoma
Normal-tension glaucoma resemble primary open-angle glaucoma.in this type of glaucoma ,the
optic nerve is damage even though intraocular pressure (IOP)is not high.secondary glaucoma
may occur as a result of trauma that can disrupt the flow patern of aqeous humor.
Etiology and risk factors
About 90% of primary glaucoma accurs in people with apen angles. Because there are no early
warning clnical manifestations , it is imperative that regular ophthalmic examinations include
tonometry and assessment of the optic nerve head (dick). The most common cause of chronic
open-angle glaucoma is degenerative change in the trabecular meshwork, resulting, in decreased
outflow of aqueous humor. Hypertension, cardioveskuler disease, diabetes, and obesity are
associated with the development of glaucoma. Increased IOP alao results from weitis
(inflammation of filtering structures). Encroachment by a rapidly growing tumor and chronic use
of topical corticosteroids may also produce manifestations of open-angle glaucoma. Neither the

cause of low-tension glaucoma nor the reasons prtis nerves are damaged even though the IOP is
normal (i.e, between 12 and 22 mmhg) are known . people at higher risk for this from lowtension glaucoma are those with a family history of normal-tension glaucoma, people of japanase
ancestry, and people with a history of systemic hert disease,such as irregular heart rhythm.
Secondary glaucoma develops from edema, eye injury(hyphema), inflammation, tumor, or
advanced cases of cataract of diabetes. Edematous tissue may inhibit the outflow of aqueous
humor through the trabecular meshwork. Diayed healing of corneal wound edges may result in
epithelial cell growth int the anterior chamber.
Pathophysiology
Intraocular pressure is determined by the rate of aqueous humor production in the ciliary body
and the resistance to outflow of aqueous humor from the eye. IOP varies with diurnal cycles (the
highest pressure is usually on awakening) and body position (increased when lying down).
Normal variation do not usually exceed 2 to 3 mmHg. IOP and blood pressures are independent
of each other, but variations in systemic blood pressure may be associated with corresponding
variations in IOP. Increased IOP may result from hyperproduction of aqueous humor or
obstruction of outflow. As aqueous fluid accumulates in the eye, the increased pressure inhibits
blood supply to the optic nerve and the retina. These delicate tissues become ischemic and
gladually lose function.
Clinical manifestations
Acute angle-closure glaucoma causes severe pain and blurred vision or vision loss. Some clients
see rainbow halos around lights, and some experience nausea and vomiting. Secondary glaucoma
has the same clinical manifestations as acute angleclosure glaucoma. Visual field dfects are the
result of the loss of blood supply to areas in the retina. The individual response to IOP varies,
some clients sustain damage from high pressure, whereas others sustain damage from relatively
low pressures, whereas others sustain no damage from high pressure.
An ophtinalmoscopic examination shows atrhopy (pale color) and cuppling (indentation) of the
optic nerve head. The visual fiel examination is used to determine the extend of perhiperal vision
loss (see visual fields in chapter 64). In chronic open-angle glaucoma, a small crescent-shaped
scotoma (blind spot) appears early in the disease. In acute angle-closure glaucoma, the fields
demonstrate larger areas of significant loss of vision.
In clients with angle-closure glaucoma, a slit-lamp examination may demonstrate an
erythematous conjunctiva and corneal cloudiness. The aqueous humor in the anterior chamber
may also appear turbid (hazy), and the pupil may be nonreactive. Increased IOP (<23 mmHg)
indicates the need for further evaluation. Gonioscopy is performed to determine the depth of the
anterior chamber angle and to examine the entire circumference of the angle and to examine the
entire circumference of the angle for any abnormal changes in the filtering meshwork.

Medical Management
Reduces intraocular pressure (Promote Aqueous Flow) intraocular pressure can be reduced by
increasing the outflow of aqueous fluids. In narrow-angle glaucoma the pupil is constricted using
topical miotics or epinephrine, which opens the canal of schiemm and promotes drainage of
aqueous humor. Further the production of aqueous humor can be reduced by using topical beta
blocker or alpha-adrenergic agents or oral-carbonic anhydrase inhibitors.
Nursing Management of the medical client
Assessment. Nursing assessment includes estabilishing demographic data of age and race
because open-angle glaucoma occurs most often in clients more than 40 years of age and
in black.determine whether there is a family history of glaucoma or ather eye problems
and whether the client has had oculary surgery,infections,or trauma.an accurate list of
current medications is imperative because over-the-counter medications (such as
antihistamines)may dilate the pupil increasing the risk for angle-closur galukoma.always
note a history of allergic reactions,particularly to medications of dyes.
ask the client to describe any changes in vision.although the manifestation of
primary open-angle glaucoma are insidious,the client may describe blind spots in the
periphery or an overall decrease visual acuity with loss of contrast sensitivity.decrease
uncorrect-irreversible damage to the optic nerve.
If it has been previously established that the client has visual loss from
glaucoma,asseas how the client is coping with this loss.although people adapt to the loss
of vision in different ways,they manifest grief and loss at any stage of the desease
process.client may be under-stanably anxious during examinations because they may fear
discovery that further vision loss has accurred.assessthe clients perception of glaucoma
and the effect it has on quality of life.help the client identify effective coping skills that
may have been used in the past
Diagnostics, outcomes, interventions
Diagnosis : Disturbed Sensory Perception (Visual). The increased IOP alters thr function of
the optic nerve, decreasing vision. The nursing diagnosis Disturbed Sensory Perception
(Visual) related to recent loss of vision may be appropriate if the loss of vision is a new
problem for the client.
Outcomes. The client will maintain as much functional vision as possible, report no
further loss of vision, adapt to any visual loss, be able to perform activities of daily living
(ADL) , and recognize clinical manifestations of complications.
Interventions. Reassure the client that although some vision has been lost and cannot be
restored, further loss may be prevented by adhering to the treatment plan.

Diagnosis: Grieving. Vision lost to glaucoma is irreparable. With the most aggressive medical
and surgical management, vision loss may progress. A typical nursing diagnosis would
therefore be Greving Related to loss of vision. Significant loss of vision represents the
need for compromise and adaptation for both the client and the clients family.
Outcomes. The client will express grief, describe the meaning of the loss, and share the
grief with significant others.
Interventions. Assess the causative and contributing factors that may delay the work of
greaving and promote family cohesiveness. The social stigma of blindness underlines the
anxiety that clients experience with actual or potential loss of vision. Total loss of vision
isolates a person within a different reality. Although most clients are successfully
rehabilitated, some losses are permanent. Also, some people, for a variety of reasons,
remain socially isolated. The image of a blind person who is pitied and must accept the
charity of others is disturbing.
Use therapeutic communication to express empathy as the client relates expected
and actual losses that are due to loss of vision. People with actual or potential loss of
vision may be faced with barriers in their vocations that forces an unwanted change. Not
all jobs and work environments are adaptable for a person who is visually impaired. Age
may be a major factor in the persons ability to meet this challenge.
Self-esteem is closely related to the roles of people in their particular lifestyle.
Loss of control in personal, family, and work situations can be devastating. The issue of
dependence versus independence may also be a factor in the personss ability to cope with
the stressors of vision loss.
Diagnosis: Risk for Ineffective Therapeutic Regimen Management (Individuals). The
regimen for eyedrops and oral medications to control glaucoma ranges from simple to complex.
The nursing diagnosis should be stated as Risk for ineffective therapeutic regimen management
(Individuals) related to complex medication schedule.
Outcomes. The client will describe the diseases process and the regimen for diseases
control and will relate how the medication routine will be incorporated into ADL.
Interventions. The client may need to instill as many as three of four different eyedrops
from one to six times a day. Constricting eyedrops are are usually prescribed four times a
day, and beta-blockers are usually