Glaucoma

- It is a disease in which the optic nerve is damaged, leading to

progressive, irreversible loss of vision. It is often, but not always,
associated with increased pressure of the fluid in the eye. The nerve
damage involves loss of retinal ganglion cells in a characteristic pattern.
There are many different sub-types of glaucoma but they can all be
considered a type of optic neuropathy.
- Glaucoma can be divided roughly into two main categories, "open
angle" and "closed angle" glaucoma. Closed angle glaucoma can
appear suddenly and is often painful; visual loss can progress quickly
but the discomfort often leads patients to seek medical attention before
permanent damage occurs. Open angle, chronic glaucoma tends to
progress at a slower rate and the patient may not notice that they have
lost vision until the disease has progressed significantly.
- Glaucoma has been nicknamed the "silent thief of sight" because the
loss of vision normally occurs gradually over a long period of time and
is often only recognized when the disease is quite advanced. Once lost,
this damaged visual field cannot be recovered. Worldwide, it is the
second leading cause of blindness. It is also the first leading cause of
blindness among African Americans. Glaucoma affects 1 in 200 people
aged fifty and younger, and 1 in 10 over the age of eighty. If the
condition is detected early enough it is possible to arrest the
development or slow the progression with medical and surgical means.

Risk Factors:

Primary glaucoma
-Aging
-Heredity
-Central retinal vein occlusion

Secondary glaucoma
-Uveitis
-Iritis
-Neovascular disorders
-Trauma
-Ocular tumors
-Eye surgery

Associated glaucoma
-Diabetes mellitus
-Hypertension
-Severe myopia
-Retinal detachment
Pathophysiology:

The major risk factor for most glaucomas and focus of treatment is increased
intraocular pressure. Intraocular pressure is a function of production of liquid
aqueous humor by the ciliary processes of the eye and its drainage through the
trabecular meshwork. Aqueous humor flows from the ciliary processes into the
posterior chamber, bounded posteriorly by the lens and the zonules of Zinn and
anteriorly by the iris. It then flows through the pupil of the iris into the anterior
chamber, bounded posteriorly by the iris and anteriorly by the cornea. From here
the trabecular meshwork drains aqueous humor via Schlemm's canal into scleral
plexuses and general blood circulation. In open angle glaucoma there is reduced
flow through the trabecular meshwork; in angle closure glaucoma, the iris is
pushed forward against the trabecular meshwork, blocking fluid from escaping.

The inconsistent relationship of glaucomatous optic neuropathy with ocular

hypertension has provoked hypotheses and studies on anatomic structure, eye
development, nerve compression trauma, optic nerve blood flow, excitatory
neurotransmitter, trophic factor, retinal ganglion cell/axon degeneration, glial
support cell, immune, and aging mechanisms of neuron loss.

Manifestations:

 Pale optic disc

 Diminished visual fields
 Severe pain around the eye
 Headache or brow pain
 Nausea
 Vomiting
 Seeing colored halos around lights
 Sudden blurred vision
 Reddened sclera
 Cornea foggy
 Cloudy aqueous humor
 Moderately dilated, nonreactive pupil

Medical management:

Drug therapy
 Papillary constriction
• Pilocarpine hydrochloride (Isopto Carpine)
• Carbachol (Isopto Cabachol)
• Echothiophate iodide (Phospholine Iodide)
• Prostaglandin agonist (e.g latanoprost, travoprost)
  Inhibition of aqueous humor
• Beta blockers (e.g timolol, levobunolol)
• Carbonic anhydrase inhibitors (e.g acetazolamide,
methazolamide)
• Epinephrine
• Dipiverfrin hydrochloride (Propine)

Surgical management
 Laser trabeculoplasty - a 50 μm argon laser spot is aimed at
the trabecular meshwork to stimulate opening of the mesh to allow more
outflow of aqueous fluid.
 Trabeculectomy - the most common conventional surgery
performed for glaucoma
 Glaucoma drainage implants
 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 in a similar fashion to a
viscocanalostomy.

Nursing diagnosis:

1. Disturbed sensory perception r/t altered sensory reception

a) Ascertain type/ degree of visual loss
b) Encourage expression of feelings about loss/possibility of loss of
vision
c) Recommend measures to assist patient to manage visual
limitations e.g. reducing clutter, arranging furniture out of travel path
2. Risk for injury r/t decreased vision
a) Recommend measures to assist patient to manage visual
limitations e.g. reducing clutter, arranging furniture out of travel path
b) Walk one or two steps ahead of the client, with client’s hand on
your elbow
c) Provide adequate lighting
3. Self-care defecit r/t perceptual impairement
a) Evaluate patient’s ability to function within limits of visual
impairment.
b) Help family or caregiver identify and make arrangements at home
c) Tell the patient to take a bath everyday
4. Social isolation r/t reduced visual acuity, fear of injury, or fear of
embarrassment
a) Encourage patient to participate in the therapy
b) Encourage family to communicate with the patient as often
c) Encourage expression of feelings about loss/possibility of loss of
vision
5. Anxiety r/t disease process
a) Introduce self to patient, and acknowledge visual impairment. This
reduces patient’s anxiety.
b) Orient patient to environment. Orientation reduces fear related to
unfamiliar environment
c) Encourage use of radios, tapes, and talking books. Diversional
activities should be encouraged