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GLAUCOMA

Dewa Benny Raharja


GLAUCOMA DEFINITION
• Optic neuropathy characterized by : 1

• Optic disc cupping

• Visual Field Loss

Usually associated with elevated intraocular pressure


1. Riordan-Eva, P & Whitcher, J.P. 2010. Glaucoma. Vaughan & Asbury’s : General Ophthalmology.
GLAUCOMA INTRAOCULAR PRESSURE (IOP)
• High IOP  ≥ 22 mmHg
• IOP Examination Method2 :

1. Digital 3.
2. Schiotz
Palpation Aplannation

4. Non contact
tonometer

2. Wilson, F.M. 2005. Tonometry. Practical Ophthalmology.


GLAUCOMA ANATOMY
AQUEOUS HUMOR FLOW
3

Ciliary body  Posterior chamber  Pupil  Anterior


chamber  Trabecular meshwork  Canal Schlemm 
vena system

3. Olver, J., Cassidy, L. 2005. Glaucoma. Ophthalmology at a Glance


GLAUCOMA CLASSIFICATION1
A. Primary Glaucoma
1. Primary Open Angle Glaucoma
 Normal Tension Glaucoma
2. Primary Angle Closure Glaucoma

1. Riordan-Eva, P & Whitcher, J.P. 2010. Glaucoma. Vaughan & Asbury’s : General Ophthalmology.
GLAUCOMA CLASSIFICATION1
B. Secondary Glaucoma *
1. Secondary Open Angle Glaucoma
• Mature / hypermature cataract  Phacolytic glaucoma
• Infection  uveitis
• Drug-induced glaucoma (>>> corticosteroid)
• Neovascularization
2. Secondary Angle Closure Glaucoma
• Lens Dislocation
• Immature Cataract  Phacomorphic glaucoma
• Neovascularization
C. Childhood Glaucoma

1. Riordan-Eva, P & Whitcher, J.P. 2010. Glaucoma. Vaughan & Asbury’s : General Ophthalmology.
CHILDHOOD GLAUCOMA
CHILDHOOD GLAUCOMA
Classification by Childhood Glaucoma Research Network4

4. Shaarawy, T.M et al. 2015. Childhood Glaucoma. Glaucoma: Medical Diagnosis and Therapy.
Childhood
Glaucoma
PRIMARY CONGENITAL GLAUCOMA4

 Prevalence  1 : 10.000 births


 65-80% cases are bilateral
 Male > female
 Risk factors:
 Most cases  sporadic, no family history
 10% familial (autosomal recessive)
Mutation: GLC3A-D

4. Shaarawy, T.M et al. 2015. Childhood Glaucoma. Glaucoma: Medical Diagnosis and Therapy..
Congenital
Glaucoma
PATHOGENESIS

 Unproven
 Cellular or membranous abnormality in the
trabecular meshwork:
a. Impermeable trabecular meshwork, or
b. Barkan membrane covering the trabecular
meshwork

4. Shaarawy, T.M et al. 2015. Childhood Glaucoma. Glaucoma: Medical Diagnosis and Therapy..
Congenital
Glaucoma
CLINICAL FEATURES
 Triad: epiphora, photophobia,
blepharospasm
 High IOP
 Reduced in visual acuity
 Buphthalmos
 Corneal enlargement (diameter >
12 mm)
 Corneal edema
 “Haab striae” : tears in descemet
membrane
 Glaucomatous cupping

4. Shaarawy, T.M et al. 2015. Childhood Glaucoma. Glaucoma: Medical Diagnosis and Therapy..
Congenital
Glaucoma
MANAGEMENT

 Need examination under anesthesia (EUA) :


 IOP
 Gonioscopy
 Optic disc examination
 USG  axial length
 Medical th/ :
 Oral carbonic anhydrase inhibitor (CAI)
 Topical CAI
 Topical Beta Blocker 2x (0,25% if < 1 year old; 0,5% if
older)

4. Shaarawy, T.M et al. 2015. Childhood Glaucoma. Glaucoma: Medical Diagnosis and Therapy..
Congenital
Glaucoma
MANAGEMENT
1. Goniotomy
 Surgical
1. Goniotomy
2. Trabeculotomy
3. Trabeculectomy

2. Trabeculotomy 3. Trabeculectomy

4. Shaarawy, T.M et al. 2015. Childhood Glaucoma. Glaucoma: Medical Diagnosis and Therapy..
CHRONIC GLAUCOMA
CHRONIC GLAUCOMA

Primary Open Secondary Open Angle


Glaucoma (SOAG)
Angle Glaucoma • Lens-induced Glaucoma
(POAG) • Exfoliation Syndrome
• Uveitic Glaucoma
Normal-tension • Drug-induced Glaucoma
Glaucoma

1. Riordan-Eva, P & Whitcher, J.P. 2010. Glaucoma. Vaughan & Asbury’s : General Ophthalmology.
CHRONIC GLAUCOMA

Primary Open Angle


Glaucoma (POAG)
Normal Tension Glaucoma
POAG PRIMARY OPEN ANGLE GLAUCOMA

 The commonest form of glaucoma (in Caucassian & Afro-


Caribbean populations)
 Risk factors:
a. Elevated IOP
b. Age >40  increased incidence with age
c. Family History
 No sex predilection

5. BCSC Glaucoma. American Academy of Ophthalmology 2015-2016


POAG CLINICAL MANIFESTATION

Symptoms :
1. Asymptomatic
2. Central vision lost  “tunnel vision”

1. Riordan-Eva, P & Whitcher, J.P. 2010. Glaucoma. Vaughan & Asbury’s : General Ophthalmology.
POAG CLINICAL MANIFESTATION
Sign:
1. IOP > 22 mmHg
2. Gonioscopy  open angle

1. Riordan-Eva, P & Whitcher, J.P. 2010. Glaucoma. Vaughan & Asbury’s : General Ophthalmology.
POAG CLINICAL MANIFESTATION
Sign:

1. Riordan-Eva, P & Whitcher, J.P. 2010. Glaucoma. Vaughan & Asbury’s : General Ophthalmology.
POAG CLINICAL MANIFESTATION

3. Perimetry  visual field defect

1. Riordan-Eva, P & Whitcher, J.P. 2010. Glaucoma. Vaughan & Asbury’s : General Ophthalmology.
POAG CLINICAL MANIFESTATION
4. Funduscopy / Indirect Ophthalmoscopy  Optic Disc Cupping
POAG MANAGEMENT
1. MEDICAL
Purpose :
• Decrease the production of aqueous humor (Beta-
blocker  Timol ed, carbonic anhydrase inhibitor 
Glaucon, alpha-1 agonist  Alphagan ed)
• or Increase the outflow (Prostaglandin analog 
Xalatan / travatan ed, miotic  Carpin)

5. BCSC Glaucoma. American Academy of Ophthalmology 2015-2016


POAG MANAGEMENT

2. SURGERY
- Trabeculectomy
Indications:
1. Inadequate IOP control
2. Progression of visual
fields inspite of good
IOP control
3. Intolerance of
medication
4. Advanced glaucoma
5. Lack of availability &
inability to afford cost of
glaucoma medication
6. Patient preference

5. BCSC Glaucoma. American Academy of Ophthalmology 2015-2016


NTG NORMAL TENSION GLAUCOMA
 Low-tension Glaucoma
 Progressive optic neuropathy similar to POAG
 No documented high IOP (> 22 mmHg)
 Risk Factors :
 Migraine, Raynaud, ischemic vascular disease & autoimmune disease
 Clinical manifestation  = POAG
 The goal of therapy:
 To achieve IOP as low as possible , without development complications

5. BCSC Glaucoma. American Academy of Ophthalmology 2015-2016


OH OCULAR HYPERTENSION
 High IOP, but with NORMAL Optic Nerve, NORMAL Visual
Field, and Gonioscopy.
 Work Up :
a. Visual Field
b. Central Corneal Thickness
c. Optic Coherence Tomography

5. BCSC Glaucoma. American Academy of Ophthalmology 2015-2016


CHRONIC GLAUCOMA

Secondary Open Angle Glaucoma


(SOAG)
• Lens-induced Glaucoma
• Exfoliation Syndrome
• Uveitic Glaucoma
• Drug-induced Glaucoma
SOAG LENS-INDUCED GLAUCOMA

PHACOLYTIC GLAUCOMA
• Patogenesis :
Mature / hypermature cataract
 Leakage of lens material
through lens capsule 
obstruct trabecular meshwork
• Symptom :
• Unilateral pain, ↓ visual acuity
• Signs :
- ↑ IOP, inflammation reaction
in Anterior Chamber
• Th/ : Lens Extraction

1. Riordan-Eva, P & Whitcher, J.P. 2010. Glaucoma. Vaughan & Asbury’s : General Ophthalmology.
PSEUDOEXFOLIATION SYNDROME /
SOAG
EXFOLIATIVE GLAUCOMA
PSEUDOEXFOLIATION (PXF)
• Patogenesis :
Unknown
• Clinical Findings :
• PXF material on lens
capsule & iris
• Phacodonesis
• Lens subluxation • Th/ :
• Exfoliative glaucoma   Argon Laser
High IOP Trabeculoplasty
 Trabeculectomy +/- Lens
extraction

5. BCSC Glaucoma. American Academy of Ophthalmology 2015-2016


SOAG UVEITIC GLAUCOMA

UVEITIC GLAUCOMA
• Patogenesis :
1) Trabecular meshwork
blocked by inflammatory
cells
2) Trabeculitis
• Clinical Findings:
 High IOP Management:
 Hyperemic conjunctiva 1. Th/ underlying disease :
 Keratic Precipitate (KP) in Corticosteroid (oral,
corneal endothel
topical),
 Mild-moderate inflammation in Immunosuppresive Agent
Anterior Chamber (AC)
2. Mydriatic/cycloplegic
3. Anti glaucoma medication
5. BCSC Glaucoma. American Academy of Ophthalmology 2015-2016
SOAG DRUG-INDUCED GLAUCOMA

STEROID INDUCED GLAUCOMA


• Prolong use of topical, periocular, inhaled or
systemic corticosteroid
• Management:
 Stop steroid (if possible)
 Anti glaucoma medication
 Surgery : Trabeculectomy  if IOP
uncontrolled

1. Riordan-Eva, P & Whitcher, J.P. 2010. Glaucoma. Vaughan & Asbury’s : General Ophthalmology.
Tugas
• 1. Gambar penampang Sagital Bola Mata lengkap
dengan keterangan
• 2. Jelaskan Fisiologi Aquous Humor
• 3. Jelaskan komplikasi Katarak
• 4. Penatalaksaan Glaukoma Akut