Glaucoma
Pawan Kumar
M.Optom
Epidemiology
• Global prevalence of glaucoma 3.84% (Aged40-80)
• African population 4.20 % POAG
• PACG 1.09% Asia
• Worldwide 64.3 million
• Cause of irreversible blindness worldwide
Definition
• Group of disorders
• Progressive optic neuropathy
• Irreversible visual field defects
• Frequently associated with normal/high IOP
Pathogenesis of glaucoma
• Mechanical
• Vascular
• Elevated Iop
• axoplasmic flow
• Death of axon /RGC
• Excavation in ON
Classification
• Congenital and developmental glaucoma
• Primary adult glaucoma
• Secondary glaucoma
Congenital glaucoma
• 1:10000
• Bilateral / asymmetrical
• Group of diverse disorder
• High IOP
• Impairment of aqueous outflow
Continues..
• True congenital glaucoma(40%)
• IOP is elevated during intrauterine life
• Infantile glaucoma(55%)
• Manifest prior to 3 years of age
• Juvenile glaucoma (least common)
• Iop rises between 3-16 years of age
Presentation
• Corneal haze
• Buphthalmos
• Haab striae
• Corneal /scarring vasculrization
• Optic disc cupping
• Asymmetrical eyes
• Blepharospasm
.
.
EUA
• Refraction
• IOP
• Anterior chamber examination
• Optic disc examination
• Corneal diameter
• Gonioscopy
Management
• Goniotomy
• Trabeculotomy
Differential diagnosis
• Cloudy cornea
• Birth trauma
• Rubella Keratits
• Metabolic disorder
• Congenital hereditary endothelial dystrophy.
• Sclerocornea.
Continues..
• Large cornea
• Megalocornea.
• High myopia.
• Epiphora
Primary open angle glaucoma
• 3% Asian
• Race (African Caribbean)
• POAG Hispanics
• Bilateral
• Iop> 21
• Optic nerve damage
Continues..
• Open anterior chamber angle
• VF-loss
Etiopathogenesis
• Not known exactly
• Age
• Gender
• Family history
• Race
• Myopes
Continues..
• Diabetics
• Cigarette smoking
• Hypertension
Screening
• Optometric eye examination
• Diagnosis
• History
• Visual symptoms – Absent / unless advanced
• Previous ophthalmic history-
• Refractive status- Myopia- Hyperopia- PACG
• Family history
Past medical h/o
• Asthma, heart failure, perivascular diseases
• Head injury, intracranial pathology ,stroke
• Vasospasm, migraine
• DM, Hypertension
• Oral contraceptive
Current medications
• Steroid including skin ,cream/inhalants
• Oral beta- blockers
• Social h/o
• Allergies
Examination
• VA- Normal early
• Pupils- advanced cases RAPD
• CV- ON
• Slit lamp examination
• Tonometry
• Gonioscopy
• Optic disc examination
Investigations
• Pachymetry for CCT
• Perimetry-24-2
• Imaging
• Optic disc
• RNFL
• OCT
.
Fundus examination
• Vertically oval cup
• Asymmetrical cups- 0.2
• Large cups 0.6
• Splinter haemorrhage
• Pallor area on disc
• Atrophy nerve fibre layer (red free light)
Continues..
• Thinning of NRR rim
• Nasal shifting of blood vessels
• Lamellar dot sign
.
.
.
OCT RNFL
VFD
• Early changes
• Baring of blind spot
• Small paracentral depression (NTG)
• Nasal step
• Temporal wedge
• Arcuate defect
Continues.
• Ring scotoma
• End stage-10-2
• Summary measure -1db
Visual field defects
•
.
Report HFA
.
Management
• Prevent functional impairment of vision
• Lowering of IOP
• Aggressive Rx
Patient Instructions
• Nature of diseases
• Timing of medications
• Technique to use eye drops
Rx goals
• Target pressure
• Vertical c/d
• VF defects
• Level of IOP
• CCT
• Age
Continues..
• General health
• Decision regarding Sx
Proportional reduction
• 30 % reduction
• Monitor further
• Advanced damage
Response to progression
• Progression
• GC- greater impact on VN
• 1mm reduction- 10% reduction rate of NFL loss
Medical therapy
• Commencing medical therapy
• Lowest concentration- desired therapeutic effect
• Fewest side effects
• One type of medication
Review
• Individual patients
• Usually 4-8 weeks
• Target iop
Perimetry
• 6-12 months is sufficient
• Gonioscopy – annually
• Optic disc examination
• Serial imaging
Cause of Rx failure
• Inappropriate target IOP
• Poor compliance
• Wide fluctuation of IOP
• May deteriorate good control of IOP
Surgery
• Trabeculotomy
• Cyclocryopexy
• Valve implant
Primary angle closure glaucoma
• Refer to the occlusion of trabecular meshwork by
peripheral iris(ITC)
• Obstruction of aqueous outflow
• Half of cases associated with Pacg
Classification
• Primary angle closure suspect
• Gonioscopy shows post. Meshwork ITC
• Three quadrants / more No PAS
• two quadrant ITC – pigment smudging
• Normal iop , disc , VF,
• No PAS
Primary angle closure
• Gonioscopy shows three more quadrants ITC
• IOP raised
• PAS
• Excessive pigment smudging
• Disc, VF normal
PACG
• ITC in three or more quadrants
• GL neuropathy
• Episodes of Iop elevation
• Acute angle closure may not appear as GL cupping
Pupillary block
.
Reduced aqueous outflow
• Appositional obstruction by iris
• Degeneration of the TM
• Elevated IOP
• Permanent occlusion
Risk
• Age
• Gender
• Race
• Family h/o
• Refraction
• Axial length
Diagnosis
• Clinical presentation
• Asymptomatic
• Haze
• Haloes
• Acutely decreased vision
• Redness
• Pain
Precipitating factors
• Dark room
• Pharmacological
• Acute emotional distress
• Systemic medication
Signs
• VA normal initially
• Ac shallow
• Iop elevation intermittent
• ITC – contact - PAS
• Optic nerve signs
Acute primary angle closure
• VA 20/200 to HM
• IOP -50-100 mm Hg
• Conjunctival hyperaemia –CCG
• Corneal epithelial oedema
• IOP control – medication
Investigation
• AS- OCT
• AC- depth measurement
• Biometry
• Posterior segment USG
Provocative test
• Dark room / prone position
• Mydriasis test
Differential diagnosis
• Lens induced angle closure
• NVG GL
• Hypertensive GL
• Scleritis
Rx
• Laser iridotomy
• Laser iridoplasty
Normal tension glaucoma
• Iop <21mmHg
• Sign of ON damages in characteristic GL pattern
• GC death
• Open anterior chamber angle
• VF- loss
• No feature of secondary GL
Pathophysiology
• Abnormal ocular blood flow
• CCT assessment
• Nocturnal Iop spikes
Risk factors
• Age
• Race-Japanese
• Gender- females
• Family h/o
• CCT
• Abnormal vasoregulation
• Systemic hypotension
Continues..
• Sleep apnea
• Ocular perfusion
• Myopia
Differential diagnosis
• Angle closure Gl
• Low CCT
• POAG
• Previous episodes of raised IOP
• Congenital disc anomalies
• neurological
Clinical features
• h/o
• Migraine /Raynaud’s phenomenon
• Episodes of shock
• Head / eye injury
• Iop
Optic nerve head
• Larger on NTG than POAG
• Pattern of cupping similar
• PPA
• Disc splinter hmg
• Pallor
Other investigation
• Assessment of systemic vascular risk
• BP
• Carotid doppler
• MRI
• Laser flowmetry
Rx
• Medical Rx
Alpha -2 agonist
Carbonic anhydrase inhibitors
• Surgery
• Control of systemic vascular diseases
• Antihypotensive measures
Secondary glaucoma
• Open angle GL site of aqueous outflow
• Pre-trabecular
• Fibro vascular tissue
• Endothelial cellular membranous proliferation
.
Trabecular
• Pigmentary GL
• Red blood cell
• Degenerative red cell
• Macrophages & lens protein
• Pseudoexfoliative GL
Without pupillary glaucoma
• PAS/NVG
• Capsular block syndrome
• Malignant glaucoma
Angle closure with pupillary block
• Seclusio pupillae
• Subluxated lens
• Phacomorphic glaucoma
• Capsular block syndrome
• Aphakic pupillary Gl
Pseudoexfoliation
• PXF material
• Rare before the age of 50
• More common in F-M
• 5% prevalence
• Scandinavia
Pathogensis
• Grey white fibrillary material
• Ocular tissue
• Deposition of material
• PxF associated with increased prevalence
• Open angle glaucoma associated with PxS
• Liberation of iris pigments/ secondary degenerative outflow
dysfunction
Clinical features
• Diagnosis incidental
• Cornea , PxF deposits on endothelium
• AC- aqueous flare
• Iris- PXF deposits – iris transillumination defects
• Lens – central disc – cataract
PXF
Continues..
• IOP
• Associated with high IOP
• Prognosis
• Poor
Rx
• Medical – failure is more common
• Surgical
• Phacoemulsification
Neovascular glaucoma
• Pathogenesis
• Aggressive iris (rubeosis of iris)
• chronic retinal ischaemia
• Impairing aqueous outflow
• Secondary synechial angle-closure
Causes
• ICRVO
• DM
• ARVD
Clinical features
• Symptoms- none to severe pain
• Decreased Vn / photophobia
• Cornea -oedema
• Iop- early normal
• AC
Continues..
• Pupillary margin
• Iris surface
• Gonioscopy
• Cataract
• Posterior segment
• Investigation
.
Rx
• Address the cause
• Reviews- frequents
• Medical Rx of IOP
• PRP
• IV-VEGF
Continues..
• Retinal detachment repair
• Filtration surgery
• Pars plana Vitrectomy
• Enucleation
Lens induced Glaucoma
• Phacolytic glaucoma-
• Secondary open angle Gl
• Hypermature Cataract
• High molecular protein leakage
Diagnosis
• Presentation – Pain , poor vision
• SLT- corneal oedema , hypermature cataract
• AC –deep
• White material floating in AC
• Pseudohypopyon
• Gonioscopy
.
Rx
• IOP control medically
• Cataract extraction
Phacomorphic GL
• Pathogenesis
• Acute secondary angle closure Gl
• suspensory ligament
• Anteroposterior growth leads to increased iridolenticular
contact
.
Presentation
• PACG similar
• Fellow eye- more likely with shorter eye
• OCT- AS
Rx
• Similar to PACG
• Cataract extraction
Pupillary block /Disruption of lens
glaucoma
• Blunt ocular trauma if relatively trivial
• Lens dislocation
• Weak Zonules
• Example
• Pseudo exfoliation / homocystinuria
• Dislocation my be in AC
Diagnosis
• A lens fully or partially dislocated in AC
• Acute pupillary block cause
• Sudden elevation of IOP
• Visual impairment
.
Rx
• Osmotic agent
• Urgent Rx
• Endothelial damage
Initial Rx
• Adopt supine posture with dilated pupil
• Definitive Rx- surgical lens extraction
• AC-iol
• Scleral fixing IOL will be necessary
Hyphaema
• Traumatic hyphaema
• Transient elevation in IOP
• Trabecular obstruction rbs
• Blood clot
• Prolonged IOP
Continues..
• Size of hyphaema is useful indicator
• Visual prognosis
• Entire AC filled with blood
• 1/3 good recovery
• Secondary Hmg
• Poor indicator- VN
Rx
• A coagulation abnormality, particularly a
haemoglobinopathy
• Current anticoagulant medication should be discontinued
• Hospitalisation
• Strict bed rest unnecessary
• Protective eye shield
Rx
• Medical Rx
• Beta blockers
• CAI
• Hyper osmotic agent
• Topical steroid
• Atropine
Continues..
• Sx evacuation – 5%
• Intolerable Iop
• 5 days
• Reduced risk of
• Corneal staining
• OA
• PAS
.
