Glaucoma

Zarieh Dawn Novela Medicine 2

Glaucoma
The term glaucoma covers several diseases with differing etiologies that share the common finding of optic neuropathy with characteristic pathologic findings in the optic nerve head and a specific pattern of visual field defects. The disease is often, but not always, associated with increased intraocular pressure. The final stage of glaucoma is blindness. Primary glaucoma
refers to glaucoma that is not caused by other ocular disorders.

Secondary glaucoma
may occur as the result of another ocular disorder or as an undesired side effect of medication or other treatment.

Epidemiology
Throughout the world, there are about 70M people suffering from glaucoma and 7 M who have been blinded by the disease. Glaucoma is the second most frequent cause of blindness in developing countries after diabetes mellitus. Some 1520% of blind persons have lost their eyesight as a result of glaucoma.

Intraocular pressure
Normal IOP: 15mmHg 21mmHg is regarded as suspect for glaucoma Regulation of IOP is by the anterior segment of the eye Incd IOP in granuloma is dt:
Abnormal aqueous outflow Rarely, to over production Most rarely, to incd venous back pressure

1-2% of total anterior and posterior chamber (0.2-0.4mL) is replaced at rate of 2-6 uL. Physiologic resistance from pupil and trabecular meshwork

Effect of IOP
Ultimately manifested in optic disk Causes ischemia by impairing blood supply to optic nerve impairs nutrition of glial cells Causes acute optic neuropathy
Edema Small hemorrhage in optic disc Loss of nerve fiber bundle configuration

Symptomatology
2 sources
Increased IOP Disturbance of optic nerve function (show little defects)

Acute glaucoma (as in acute angle glaucoma)

Severe ocular pain Sudden diminution of vision Seeing haloes aroung light Ciliary injection Lacrimation Sphincter ms of iris is paralyzed causing pupillary dilatation

Chronic glaucoma (as in chronic angle closure)

Gradual closure of angle Gradual inc in IOP Symptoms may be absent

Diagnostic methods
Suspicion for glaucoma
Normal IOP but disc is cupped or pale Normal disc but IOP is 21mmHg

Tonometry
Measurement of IOP 2 types:
Indentation tonometer of Schiotz most affordable Applanation tonometer most accurate, but expensive

measures the degree to which the cornea can be indented in the supine patient The lower the IOP, the deeper the tonometer pin sinks and the greater distance the needle moves.

most common method of measuring IOP. It permits the examiner to obtain a measurement on a sitting patient within a few seconds

Diagnostic methods
Optic disc ophthalmoscopy The optic disc has a physiologic indentation known as the optic cup. In the presence of persistently elevated IOP, the optic cup becomes enlarged and can be evaluated by ophthalmoscopy. vertical elongation of the optic cup seen in eyes with glaucoma.

Diagnostic methods
Optic disc ophthalmoscopic findings w/ glaucoma Optic disc w/ vertically oval and notched cup Nasalization of central vessels Circumpapillary halo Spontaneous pulse in central retinal artery Extension of cup border to any part Hemorrhage in disc in absence of hemorrhage in any parts of fundus

Primary angle closure glaucoma

IOP incd because aqueous could not flow to trabecular meshwork due to apposition of iris to anterior chamber angle
Angle: blocked Outflow impediment: iris tissue occluded the trabecular meshwork

Mc form of glaucoma (90%) Incidence increases over age 60 3x more in female

Primary angle closure glaucoma

Etiology Anatomically predisposed eyes with shallow anterior chambers pose a relative impediment to the flow of aqueous humor through the pupil. This pupillary block increases the pressure in the posterior chamber The pressure displaces the iris anteriorly toward the trabecular meshwork, suddenly blocking the outflow of aqueous humor (angle closure).

Primary angle closure glaucoma

Signs and symptoms
Sudden diminution of vision w/ prodromes of seeing haloes around lights Pain on or around eye Parasympa stimultion in form of nausea, vomiting and abdominal pain Ciliary congestion Corneal edema Shallow anterior chamber w/ aqueous flare and cells Dilated pupil Sector iris atrophy Firm eyebal

Primary angle closure glaucoma

Treatment An acute glaucoma attack is an emergency, and the patient requires immediate treatment by an ophthalmologist. Medical therapy. The goals of conservative therapy are:
Decrease intraocular pressure. Allow the cornea to clear (important for subsequent surgery). Relieve pain.

Primary angle closure glaucoma

Treatment Principles of medical therapy in primary angle closure glaucoma
Osmotic reduction in the volume of the vitreous body is achieved via systemic hyperosmotic solutions (oral glycerin, 1.01.5 g/kg of bodyweight, or IV mannitol, 1.02.0 g/kg of body weight). Production of aqueous humor is decreased by inhibiting carbonic anhydrase (IV acetazolamide, 250500 mg). Both steps are taken initially to reduce intraocular pressure to below 50 60mmHg.

Secondary angle closure glaucoma

Same as in primary angle closure glaucoma,the increase in IOP is due to blockage of the trabecular meshwork.
Angle: blocked Outflow impediment: displacement of trabecular meshwork produces anterior synechiae, scarring and neurovasularization

Most important cause: rubeosis iridis

Secondary angle closure glaucoma

Treatment Secondary glaucomas can be caused by many different factors, and the angle may be open or closed. Therefore, treatment will depend on the etiology of the glaucoma. The underlying disorder is best treated first. Glaucomas with uveitis (such as iritis or iridocyclitis) initially are treated conservatively with anti-inflammatory and antiglaucoma agents. Surgery is indicated where conservative treatment is not sufficient. The prognosis for secondary glaucomas is generally poorer than that for primary glaucomas.

Primary open angle glaucoma

Aqueous has access to anterior chamber all the time.
Angle: completely open Outflow impediment: in trabecular meshwork

MC form of glaucoma (90%) Incidence incs over age 0f 40 There appears to be a genetic predisposition Signs and symptoms
The majority of patients do not experience any subjective symptoms for years. However, may experience occasional unspecific symptoms such as headache, a burning sensation in the eyes, or blurred or decreased vision may also perceive rings of color around light sources at night

Secondary open angle glaucoma

The anatomic relationships bw the root of the iris, the trabecular meshwork, and peripheral cornea are not disturbed. However, the trabecular meshwork is congested and the resistance to drainage is increased.
Angle: completely open Outflow impediment: Erythrocytes, pigment, and inflammatory cells occlude the trabecular meshwork

Primary infantile glaucoma

Angle: undifferentiated Outflow impediment: In the trabecular meshwork (which is not fully differentiated and/or is occluded by embryonic tissue)

Recessive type of inheritance S&S:

Lacrimation Blepharospasm Photophobia Corneal enlargement Glaucomatous cupping Tx: surgical - goniotomy

Glaucoma asso w/ Hereditary or Familial Dse

Marfans syndrome
Arachnodectyly Cardiac anomalies lens subluxation

Axenfeld syndrome
Corneal arcus (posterior embryotoxon) Ectopia of pupil Polycoria Hypoplasia of anterior iris

Sturge-Weber syndrome/ Encephalofacial hemangioma Neurofibromatosis Marchesani syndrome (Spherophakia)

Highly myopic Brachycephalic Short and stocky w/ short fingers

Aniridia

Quiz Time!

Now, Eyem gonna ask questions coz Eye saw you listening

No. 1
What is the normal IOP? What IOP is regarded as suspicious for glaucoma?

No. 2
Discuss briefly the aqueous humor circulation.

No. 3
What do you call this diagnostic method? What does it do?

No. 4
What type of glaucoma is this?

No. 5
Most important cause of secondary angle closure glaucoma?

No. 6
Where is the outflow impediment in primary open angle glaucoma?

No. 7
Give 1 glaucoma associated with hereditary or familial disease?

No. 8
What type of glaucoma is this?

No. 9
Most common type of glaucoma?

No. 10
Did you learn?

Thank you!