Glaucoma

Banu Aji Dibyasakti, MD

Ophthalmologist

2018
Dr. Sardjito General Hospital, Yogyakarta
Bethesda Hospital, Yogyakarta
Glaucoma

• Damage to the optic nerve by the effect of raised

intraocular pressure (IOP) on the optic nerve head
• The intraocular pressure depends on the balance btw
production and outflow of aqueous humour
Pathophysiology

• Aqueous is produced from ciliary processes in the

posterior chamber (by active transport and
ultrafiltration)
• Aqueous outflow :
• Conventional pathway : Trabercular meshwork
(iridocorneal angle) - Schlemm’s canal - Episceral
veins
• Uveoscleral pathway
Pathophysiology

• Why can intraocular pressure damage nerve fibers ?

1. Raised IO pressure causes “mechanical” damage
to the optic nerve axon
2. Raised IO pressure causes “ischemia” of the nerve
axon by reducing blood flow to it
Classification

• Primary —> anatomical prefference

• Open angle (POAG)
• Angle closure (PACG) : Acute & Chronic
• Secondary —> caused by other underlying condition
• Open angle (SOAG)
• Angle closure (SACG)
Primary Open Angle Glaucoma (POAG)

• Epidemiology:

• Affects 1-200 of population over the age of 50

• Males = females

• May be a family history, although the exact mode of

inheritance is not clear

• Genetic factors —> mutation in the myocillin gene

(GLC1A) on chromosome 1, optineurin (GLC1E)
POAG

• Pathogenesis:
• The structure of trabecular
meshwork appears
normal but there is an
increased resistance to
the outflow
• Reduction in the
number of lining
trabecular cells
• Increased extracellular
material in the
meshwork spaces
POAG
• History
• Relatively symptomless until patient becomes aware of visual deficit
• Associated with slow rise in pressure
• Ophthalmology examination:
• The eyes are mainly white and the corneas are clear
• Perimetry —> Visual field defect (Arcuate defect, General depresion, nasal
step defect, etc)
• Tonometry :
• POAG : 22-40 mmHg
• Acute PACG : >60 mmHg
POAG

• Glaucomatous Optic Nerve

• Increased Cup/Disc Ratio
• Nasalization
• Lamina cribrosa (+), Bayonet sign (+)
• Notching
• Splinter optic disc hemorrhage
POAG

• Treatment :
• Medication
• Laser —> Laser trabeculoplasty
• Surgery —> Trabeculectomy
POAG
Normo Tension Glaucoma (NTG)

• Optic nerve damage occur in a normal/low IOP

condition (< 21 mmHg)
• Causes —> vascular theory (not related with
mechanical pressure of IOP against optic nerve)
• Treatment :
• IOP lowering 30 % from baseline
• Prostaglandin analogue (Latanoprost) —> 1st drug of
choice
Acute Primary Angle Closure Glaucoma
(PACG)

• Occurs in small eyes (hypermetropic) shallow anterior

chamber
• In response to pupil dilation —> bowing of the iris
forward and closing the drainage angle —> IOP
suddenly raised to very high level
• Corneal edema —> decrease visual acuity
• Severe headache, neausea, vomiting, eye pain
• Peripheral iris contact ultimately leads to adheision
(peripheral anterior synechiae)
Acute PACG
Acute PACG
Acute PACG
Acute PACG

• Treatment
1. Inhibit aqueous humor production
a) Asetazolamid tablet 250 – 500 mg
b) β-blocker : Timolol/Betaxolol 0,5 %
c) α2-adrenergik : Apraclonidin 0,5 % - 1%
Brimonidin 0,2 %
Acute PACG

2. Reduce vitreous volume

• Hyperosmotic : Inf. Mannitol 20 %, IV 1 – 2
g/kgBB (5-10 ml/kgBB)
• Monitor BUN / Creat
3. Steroid Topical
4. Analgetic oral
5. Consider laser iridotomy if cornea is clear
6. Surgery : trabeculectomy
Thank You

@bdibyasakti
Cataract
 Definition of cataract
• Opacity of the lens

• As a cataract develops, the lens becomes clouded, which

scatters the light and prevents a sharply defined image from
reaching retina. As a result, vision becomes blurred.
 Epidemiology
1. Cataracts remain the
leading cause of
blindness.
2. Age-related cataract is
responsible for 48% of
world blindness, which
represents about 18 million
people
3. Cataracts are also an
important cause of low
vision in both developed
and developing countries.
 Causes of cataract
• Old age (commonest) • Congenital
• Ocular & systemic diseases – Dominant
– DM – Sporadic
– Uveitis – Part of a syndrome
– Previous ocular surgery – Abnormal galactose
• Systemic medication metabolism
– Steroids – Hypoglycemia
– Phenothiazines • Inherited abnormality
• Trauma & intraocular – Myotonic dystrophy
foreign bodies – Marfan’s syndrom
– Rubella
• Ionizing radiation – High myopia
– X-ray
– UV
30
 Cataract
Divided to :
• Acquired cataract
Age - related cataract
Presenile cataract
Traumatic cataract
Drug induced cataract
Secondary cataract
• Congenital Cataract
Systemic association
Non-systemic association
 Age -related cataract
It is the Most commonly occurred.
Classified according to:
❖Morphological Classification
• Nuclear
• Cortical
• Subcapsular
• Christmas tree – uncommon
❖Maturity classification
• Immature Cataract
• Mature Cataract
• Hypermature Cataract
 Nuclear cataract
• Most common type
• Age-related
• Occur in the center of the lens.

• Early stage —> small “myopia” —>

temporary reduce presbyopia —> 2nd
sight

• As the cataract progresses, the lens may

even turn brown
 Cortical cataract
• Occur on the outer edge of the lens (cortex).
• Begins as whitish, wedge-shaped opacities or streaks.
• It’s slowly progresses, the streaks extend to the center and
interfere with light passing through the center of the lens.
• Problems with glare are common with this type of cataract.
 Posterior Subcapsular Cataracts
• Begins at the back of the lens (posterior pole) & spreads to the
periphery or edges of the lens.
• It can be developed when:
– Part of the eye are chronically inflamed.
– Heavy use of some medications (steroids).

• Affects vision more than other types of cataracts because the light
converges at the back of the lens.

• Dilating drops useful in this type by keeping the pupils large and
thus allow more light into the eye.
37
 Mature Cataract
• Lens is completely opaque.
• Vision reduced to just perception of light
• Iris shadow is not seen
• Lens appears pearly white

Right eye mature cataract, with obvious

white opacity at the centre of pupil
 Hypermature Cataract
• Shrunken and wrinkled anterior capsule due to leakage of water
out of the lense.

• This may take any of two forms:

1.Liquefactive/Morgagnian Type
2.Sclerotic Cataract
 Liquefactive/Morgagnian Type
• Cortex undergoes auto-lytic liquefaction and turns uniformly
milky white.
• The nucleus loses support and settles to the bottom.
 Sclerotic Cataract

• The fluid from the cortex gets absorbed

and the lens becomes shrunken.
• There may be deposition of calcific
material on the lens capsule.
• Iridodonesis: Anterior chamber deepens
and iris becomes tremulous.
• The zonules become weak, increasing
the risk of subluxation / dislocation of
lens.
 Symptoms
• Reduced visual acuity (near and distant object)
• Glare in sunshine or with street/car lights.
• Distortion of lines.
• Monocular diplopia.
• Altered colours ( white objects appear yellowish)
• Not associated with pain, discharge or redness of the eye
 Signs
• Reduced acuity.
• An abnormally dim red reflex is seen when the eye is viewed
with an ophthalmoscope.
• Reduced contrast sensitivity can be measured by the
ophthalmologist.
• Only sever dense cataracts causing severely impaired vision
cause a white pupil.
• After pupils have been dilated, slit lamp examination shows
the type of cataract.
 Treatment
• Glasses: Cataract alters the refractive power of the natural lens
so glasses may allow good vision to be maintained.
• Surgical removal: when visual acuity can't be improved with
glasses.

• Surgical techniques
– Phacoemulsification method
– Extracapsular method
– Intracapsular method
 Congenital Cataract
• Occur in about 3:10000 live birth.
• 2/3 of case are bilateral (half of the cause can be identified)
• The most common cause is genetic mutation usually AD
• It can cause ambylopia in infants.
• It is divided to:
1. Systemic association
2. Non-systemic association
 Systemic association
1. Metabolic:
• Galactosaemia, galactokinase deficiency, Lowe
syndrome, others (hypoparathyroidism,
pseudohypoparathyroidism, mannosidosis)
2. Prenatal infection:
• Congenital rubella (~15% of cases), other intrauterine
infection (toxoplasmosis, cytoegalovirus, herpes
simplex varicella)
3. Chromosomal Abnormalities:
• Down syndrome~5%
• Patau (trisomy 13)
• Edward (trisomy 18 ) syndrome.
Bilateral cataracts in an infant due to
Congenital rubella syndrome
 Non-systemic association
1. Isolated hereditary cataract
➢ About 25% of cases.
➢ Most frequently AD, but maybe AR or X-linked
➢ Better visual prognosis than coexisting ocular and systemic
abnormalities
➢ Classified to:
➢Zonular cataract: opacity occupies a discrete zone in the
lens
➢Polar cataract: opacities occupy subcapsular cortex at
anterior or posterior pole of lens
 Zonular cataract

The lens opacities (“riders”) are located in only one layer of lens
fibers, often only in the equatorial region as shown here.
Congenital anterior polar cataract and
persistent pupillary membrane
 Nuclear cataract

This variant of the lamellar cataract affects only the outer layer of
the embryonic nucleus, seen here as a sutural cataract.
 Management in congenital cataract
• Bilateral congenital cataract require urgent cataract surgery and
the fitting of the contact lens to correct the aphakia

• After the age of 2 years there is a general agreement to use

intraocular lenses (IOLs), but before is still controversial

• Uniocular congenital cataract treatment remains controversial

• Follow-up for children with congenital cataract should continue

because of the risk for developing
– Glaucoma
– Amblyopia
– Strabismus
Thank You

@bdibyasakti