FARMAKOTERAPI GANGGUAN

KULIT ,TULANG SENDI , MATA

MAKALAH GLAUCOMA

1. JANISS KRISTINE A/P NYANAPRAGASAM

260110142013
2. HEINNA A/P AROKIADASS
260110142015
3. CYNTHIA SANTIAGO
260110142003
4. VITHYA LAKSHMI
260110142018
5. ABDULLAH AZIM
260110142007
6. NOR IZZATI
260110142008
7. MUHAMMAD AFIQ
260110142009
8. SANJIV MENON
260110142010
9. MAISARAH BT MOHD GHAZALI
260110142019
10. Eu Johnny
260110142016
 11.Sharmila karipaya
260110142001
12. Nur syahirah Rosli
260110142012

INTRODUCTION

Glaucoma is a disease of the optic nerve, in which the nerve cells in the front of the
optic nerve (the ganglion cells) die. The process is irreversible. Previously, it was believed
that glaucoma was almost always due to increased intraocular pressure. However, glaucoma
can occur in patients with normal and even low eye pressure, so damage to the optic nerve is
now key for diagnosis. (Simon, 2006)

To understand glaucoma, it is important to first consider aqueous humor, the clear,

watery fluid that circulates continuously through the front (anterior) chamber of the healthy
eye. (This fluid is not related to tears, nor is it the dense jelly-like substance called vitreous
humor that is contained in the rear chamber.)

Aqueous humor serves two important functions in the eye:

Nourishing the area around the colored iris and behind the cornea

Exerting pressure to help maintain the eyes shape

The aqueous fluid is continuously produced within the front of the eye, which builds up
pressure known as intraocular pressure (IOP). To offset the in-flowing fluid and to maintain
normal IOP, the fluid drains out between the iris and cornea (an area known as the drainage
angle). It does so through two channels within this angle:

The trabecular meshwork, a sponge-like, porous network, and its connecting

passageways are referred to as the "conventional" outflow pathway. Most of the eye
fluid outflow occurs in this region and flows from the trabecular meshwork to a group
of vessels encircling the anterior chamber, called Schlemm's canal. From here, the
 fluid enters collection chambers and then flows out into the general blood circulatory
system of the body.

The uveoscleral pathway is located behind the trabecular meshwork and is called the
"unconventional" pathway. Up to 30% of the fluid flows out through this channel.

Increased IOP is present in most cases of glaucoma, but some patients have normal IOP,
which is usually maintained at measurements of 10 - 21 mmHg. Higher IOP measurements
increase the risk of glaucoma, but do not necessarily mean that the patient has glaucoma.
(Simon, 2006)

Glaucoma is a term used to describe several types of eye conditions that affect the
optic nerve. In most cases, damage to the optic nerve is caused by increased pressure in the
eye, also known as intraocular pressure (IOP). Glaucoma can cause partial vision loss, with
blindness as a possible eventual outcome. (Simon, 2006)
TYPES OF GLAUCOMA
Primary Open-Angle Glaucoma

Most people with glaucoma have the form called primary-open-angle glaucoma (also called
chronic open-angle glaucoma). Open-angle glaucoma is essentially a plumbing problem.

The disease process may occur as follows:

o The drainage angle remains open, but tiny drainage channels in the trabecular
meshwork pathway become clogged. This pathway is responsible for most
aqueous humor fluid outflow. An imbalance occurs when fluid continues to be
produced but does not drain out efficiently.

o The fluid in the eyes anterior chamber builds up and increases pressure within
the eye (intraocular pressure).

o The intraocular pressure exerts force on the optic nerve at the back of the eye.

o Over time, the persistent pressure or other factors irreversibly damages the
delicate long fibers of the optic nerve, called axons, which convey images to
the brain.
 o As these axons die, the small cup-like head of the optic nerve may eventually
collapse into an enlarged irregular shape.

Optic nerve damage is the problem in all types of glaucoma. If left untreated, eventually the
nerve deteriorates until a person loses sight, first in the peripheral vision (the vision in the
"corner of the eyes"). If it becomes severe, the person loses central vision (in the middle of
the eyes), and may eventually become blind. (Blindness is nearly always preventable with
early treatment.)

Primary open-angle glaucoma tends to start in one eye but eventually involves both eyes.
About half of patients have generalized (spread out) nerve damage. In the other half the
disease is localized, causing wedge-shaped abnormalities in the nerve fiber layers of the
retina.

Normal Tension Glaucoma

Intraocular eye pressure is normal (10 - 21 mmHg) in about 25 - 30% of U.S. glaucoma
cases, a condition known as normal-tension glaucoma or low-pressure glaucoma. Factors are
present that cause optic nerve damage without raising IOP.

Closed-Angle Glaucoma

Closed-angle glaucoma (also called angle-closure glaucoma) is responsible for about 15% of
all glaucoma cases. It is less common than open-angle glaucoma in the U.S., but it constitutes
about half of the world's glaucoma cases because of its higher prevalence among Asians. The
iris is pushed against the lens, sometimes sticking to it, closing off the drainage angle. This
can occur very suddenly, resulting in an immediate rise in pressure. It often occurs in
genetically susceptible people when the pupil shrinks suddenly. Closed-angle glaucoma can
also be chronic and gradual, a less common condition.

Congenital Glaucoma

Congenital glaucoma, in which the eye's drainage canals fail to develop correctly, is present
from birth. It is very rare, occurring in about 1 in 10,000 newborns. This is often an inherited
condition and can usually be corrected with microsurgery.

The Eye
To understand sight, one begins with light and its passage through the eye's sensitive camera-
like structures:

o Light first passes through the cornea, a clear tissue at the front of the eye.

o Behind the cornea, the iris (the colored tissues of the eye) widens and narrows
to regulate the passage of light.

o The lens, located behind the iris, focuses the light, which then hits theretina.

o The retina is an electric fragile membrane of nerve cells

calledphotoreceptors that receive light and translate it into signals.

o A layer of cells, called the retinal ganglia, receive signals from the retina.
These nerve cells are the front ends of the optic nerve, which, in turn, receive
the signals.

o The optic nerve is actually a cable of about 1.2 million nerve fibers
calledaxons. It carries the signals to the brain, which interprets them as
images.

o They exit the eye through the optic disc, located in the back of the eye.

To help support and protect these sensitive structures, the eye contains two fluid-filled
chambers:

o The posterior (rear) chamber is the large area behind the iris.

o Fluid passes from the posterior into the anterior (forward) chamber located in
the bulging area between the iris and the front of the eye.

(Simon, 2006)

The main problem or pathology in glaucoma is caused by raised intraocular pressure. It is this
raised pressure that compresses and damages the optic nerve. Once the optic nerve is
damaged, it fails to carry visual information to the brain and this results in loss of vision.
The exact pathophysiology contributing to this is not fully understood. It is believed that the
raised pressure on the retina causes the cells and nerve ganglions in the sensitive retina to die
off (retinal ganglion apoptosis) and in addition the small blood vessels of the retina are also
compressed depriving it of nutrients. This results in a clinically progressive loss of peripheral
visual field and ultimately vision.

However, debunking this theory of high intraocular pressure alone that causes damage is the
normal tension glaucoma. Here there is no rise of intraocular pressure. These patients are said
to suffer from a problem in the blood vessels and perfusion and derangements of the immune
system (autoimmune causes) that may lead to damage to the optic nerve.

Some studies show that optic nerve heads of these patients are particularly sensitive with
damage occurring at much lower intraocualar pressures than in normal individuals. Thus they
may also benefit from medications that can reduce intraocular pressure.

Causes of raised intraocular pressure

Normally the aqueous humor plays an important role in nutrient delivery and waste disposal
for the cells. It is produced by the ciliary body epithelium and drains out through
the trabecular meshwork at the anterior chamber angle. When this flow is disrupted the
pressure within the eye builds up. This disruption can occur in two ways:-

Blockage at the drainage at the trabecular meshwork (in open angle glaucoma)

Narrowing of the angle of drainage (in angle closure glaucoma)

Glaucoma and age

Age is the most common reason for disruption to aqueous flow. With age the trabecular
meshwork cells work less efficiently and this results in build up of aqueous humor within the
anterior chamber of the eye.

In addition with age the lens also hardens and increases in size. This further narrows the
anterior chamber of the eye and physically narrows the anterior chamber angle
CAUSES OF GLAUCOMA

Causes of Primary Open-Angle Glaucoma

The exact cause of primary open-angle glaucoma is unknown. A number of conditions, alone
or in combination, are needed to trigger the processes leading to increased pressure and then
to the nerve damage that destroys sight. The damage done to the optic nerve in glaucoma is
triggered in most cases by the excessive pressure on the optic nerve that, over time, causes
damage. Because optic nerve damage occurs in patients with normal as well as high
intraocular pressure, however, there are other factors that occur and can damage the optic
nerve. (Simon, 2006)

Causes of Closed-Angle Glaucoma

People with acute closed-angle glaucoma often have a structural defect that produces a
narrow angle between the iris and cornea where the aqueous humor circulates. Conditions
that suddenly dilate (widen) the pupils may cause this shallow angle to close and precipitate
attacks of acute glaucoma in susceptible people. Such conditions may include:

o Certain drugs such as antihistamines, tricyclic antidepressants, some asthma

medications (nebulized ipratropium), some anti-seizure drugs (topiramate)

o Darkness

o Emotional stress

Causes of Secondary Glaucoma

When glaucoma is caused by other diseases or conditions, it is known as secondary

glaucoma. Both open-angle glaucoma and closed-angle glaucoma can be secondary
conditions.

Medical Conditions. A number of diseases can contribute to the development of glaucoma:

 o Diseases that affect blood flow to the optic nerve (such as diabetes, high blood
pressure, and migraine; people with type 2 diabetes should be regularly
screened for glaucoma.)

o Hypothyroidism (underactive thyroid gland)

o Sleep apnea

o Physical injury to the eye

o Extreme nearsightedness (myopia)

o Previous eye surgery

o Other disorders, including leukemia, sickle cell anemia, and some forms of
arthritis

Corticosteroids, commonly called steroids, have multiple effects on the trabecular meshwork.
Steroids pose a higher or lower risk depending on the form:

o Taking topical steroid treatments in the eye poses the highest risk. Use of
topical steroids must be monitored carefully since, in some cases, damage may
be permanent.

o Taking oral corticosteroids, particularly in high doses or for long periods,

increases the chance of glaucoma. In such cases, the eye disorder typically
develops almost immediately and reverses within 2 weeks after the drug has
been withdrawn.

o Inhaled steroids do not appear to cause glaucoma, but there may be some risk
in people with a family history of glaucoma and other risk factors.

Syndromes Associated with Increased Optic Pressure and Glaucoma

Specific syndromes have been identified with glaucoma. Many have an inherited component,
although in most cases other factors must be present to activate the disease process.

Pseudoexfoliation Syndrome. Pseudoexfoliation (PEX) syndrome (also known as exfoliation

syndrome) is the most common condition associated with glaucoma. PEX syndrome is
marked by dandruff-like flakes that accumulate on the surface of the eyes lens. The material
can clog the drainage angle of the eye and lead to build-up of intraocular pressure. People can
have this condition and not develop glaucoma, but they are at high risk. PEX has a strong
genetic component but other factors (possibly sunlight, an autoimmune response, or slow
virus) may be needed to trigger the disease.

Pigment glaucoma starts with a condition called pigment dispersion syndrome, an inherited
condition in which granules of pigment (the substance that colors the iris) flakes off into the
intraocular fluid. These fragments clog the trabecular meshwork and can increase intraocular
pressure.

In irido corneal endothelial syndrome (ICE), cells on the back surface of the cornea spread to
the drainage angle, sometimes forming scars that connect the iris to the cornea.

Neovascular glaucoma is always associated with other disorders, usually diabetes, that result
in abnormal formation of new blood vessels on the iris and in the drainage system. (Simon,
2006)

Examining... Name of Test

The inner eye pressure Tonometry

The shape and color of the optic nerve Ophtalmoscopy (dilated eye
exam)

The complete field of vision Perimetri (visual field test)

The angle in the eye where the iris meets the Gonioscopy
cornea

Thickness of the cornea Pachymetry

Regular glaucoma check-ups include two routine eye tests: tonometry and ophthalmoscopy.

Tonometry

Tonometry measures the pressure within your eye. During tonometry, eye drops are used to
numb the eye. Then a doctor or technician uses a device called a tonometer to measure the
inner pressure of the eye. A small amount of pressure is applied to the eye by a tiny device or
by a warm puff of air.
The range for normal pressure is 12-22 mm Hg (mm Hg refers to millimeters of mercury, a
scale used to record eye pressure). Most glaucoma cases are diagnosed with pressure
exceeding 20mm Hg. However, some people can have glaucoma at pressures between 12
-22mm Hg. Eye pressure is unique to each person.

Ophthalmoscopy

This diagnostic procedure helps the doctor examine your optic nerve for glaucoma damage.
Eye drops are used to dilate the pupil so that the doctor can see through your eye to examine
the shape and color of the optic nerve.

The doctor will then use a small device with a light on the end to light and magnify the optic
nerve. If your intraocular pressure is not within the normal range or if the optic nerve looks
unusual, your doctor may ask you to have one or two more glaucoma exams: perimetry and
gonioscopy.

Perimetry

Perimetry is a visual field test that produces a map of your complete field of vision. This test
will help a doctor determine whether your vision has been affected by glaucoma. During this
test, you will be asked to look straight ahead and then indicate when a moving light passes
your peripheral (or side) vision. This helps draw a "map" of your vision.

Do not be concerned if there is a delay in seeing the light as it moves in or around your blind
spot. This is perfectly normal and does not necessarily mean that your field of vision is
damaged. Try to relax and respond as accurately as possible during the test.

Your doctor may want you to repeat the test to see if the results are the same the next time
you take it. After glaucoma has been diagnosed, visual field tests are usually done one to two
times a year to check for any changes in your vision.

Gonioscopy

This diagnostic exam helps determine whether the angle where the iris meets the cornea is
open and wide or narrow and closed. During the exam, eye drops are used to numb the eye. A
hand-held contact lens is gently placed on the eye. This contact lens has a mirror that shows
the doctor if the angle between the iris and cornea is closed and blocked (a possible sign of
angle-closure or acute glaucoma) or wide and open (a possible sign of open-angle, chronic
glaucoma).

Pachymetry

Pachymetry is a simple, painless test to measure the thickness of your cornea -- the clear
window at the front of the eye. A probe called a pachymeter is gently placed on the front of
the eye (the cornea) to measure its thickness. Pachymetry can help your diagnosis, because
corneal thickness has the potential to influence eye pressure readings. With this measurement,
your doctor can better understand your IOP reading and develop a treatment plan that is right
for you. The procedure takes only about a minute to measure both eyes

DIAGNOSIS

Glaucoma Diagnosis acute

a.Tonometry tonometry is a measurement of intraocular pressure . comprehensive instrument

digunakanadalah aplanasi Goldmann tonometer , which diletakkkan to slitlamp and measure
the power needed for the area flatten the cornea . The intra ocular pressure normal 10 mmHg
- 21 mmHg and parents meningkatsamapai 24 mmHg . In angle-closure glaucoma acute intra-
ocular pressure reaches 60 mmHg- 80 mmHg .

b . Gonioskopi Gonioskopi examination be postponed until the corneal edema is reduced . on

examination gonioskopi will indicate the presence of peripheral irido -corneal contact
( Shaffer grade 0 )

c.Penilaian optic disc Normal optic disc has a hollow in the center ( central depression ) cup
physiological whose size depends on the relative amount of constituent fibers of the optic
nerve the size of the hole straight sclera passed by the fibers . In glaucoma maybe there is an
enlargement aka konsektrik optic cup or pencekungan ( Cupping ) superior and inferior , and
accompanied by the formation of tactics ( notching ) focal by discus optic and looked edema
and hyperemia .

d . Field inspections visual field of 30 degrees of visual field especially regarding the central
section . Early changes are in fact increasingly blind spot

Medication for Glaucoma

A number of medications are currently in use to treat glaucoma. Your doctor may prescribe a
combination of medications or change your prescription over time to reduce side effects or
provide a more effective treatment. Typically medications are intended to reduce elevated
intraocular pressure and prevent damage to the optic nerve.

Eye drops used in managing glaucoma decrease eye pressure by helping the eyes fluid to
drain better and/or decreasing the amount of fluid made by the eye. Drugs to treat glaucoma
are classified by their active ingredient. These include: prostaglandin analogs, beta blockers,
alpha agonists, and carbonic anhydrase inhibitors. Combination drugs are available for
patients who require more than one type of medication. But the major three that we will
choose from are the ones below. As beta blockers causes contraindications with ashtma.

Furthermore, the group of medication suggested by the doctor is Prostaglandin Analogs, if

seen below the medication doesnt cause any contraindications with asthma. Therefore, it is
safe to be given to the patient and patient should continue with the medication.

Prostaglandin Analogs

Company Brand Name Generic Name

Alcon, Inc. Travatan Z Travaprost 0.004%
Allergan Inc. Lumigan Bimatoprost 0.01%, 0.03%
Merck & Co. ZIOPTAN Tafluprost ophthalmic solution 0.0015%
Pfizer Inc. Xalatan Latanoprost 0.005%

Prostaglandin analogs work by increasing the outflow of intraocular fluid from the eye. They
have few systemic side effects but are associated with changes to the eye itself, including
change in iris color and growth of eyelashes. Depending on the individual, one brand of this
type of medication may be more effective and produce fewer side effects. Prostaglandin
analogs are taken as eye drops. They are effective at reducing intraocular pressure in people
who have open-angle glaucoma.

Side Effects

Side effects can include stinging, blurred vision, eye redness, itching, and burning. These
medications are relatively new to the market, and long term follow up of people who use
them is not yet available.

Alpha Agonist

Company Brand Name Generic Name

Alcon, Inc. Iopidine Apraclonidine HCI 0.5%, 1%
Allergan Inc. Alphagan P Brimonidine tartrate 0.1%, 0.15%

Alpha agonists work to both decrease production of fluid and increase drainage. Alphagan P
has a purite preservative that breaks down into natural tear components and may be more
effective for people who have allergic reactions to preservatives in other eye drops. Alphagan
is available in a generic form.

Side Effects

Side effects can include burning or stinging upon instillation of the eye drop, fatigue,
headache, drowsiness, dry mouth and dry nose.

Carbonic Anhydrase Inhibitors

Company Brand Name Generic Name

Alcon, Inc. Azopt Brinzolamide ophthalmic suspension 1%
Fera Pharmaceuticals Neptazane Methazolamide
Merck & Co. Inc. Trusopt Dorzolamide HCI 2%
Teva Pharmaceuticals Diamox Sequels Acetazolamide

Carbonic anhydrase inhibitors (CAIs) reduce eye pressure by decreasing the production of
intraocular fluid. These are available as eye drops and as pills. If you need to use more than
one type of eyedrop, you may need to take each medicine in a certain order as prescribed by
your doctor. If you are using more than one type of eyedrop, wait 5 minutes between eyedrop
medicines. The pill form is an alternative for people whose glaucoma is not controlled by
medication eye drops.

Side Effects

Side effects of the pill form of these medications can include tingling or loss of strength of
the hands and feet, upset stomach, mental fuzziness, memory problems, depression, kidney
stones, and frequent urination. Since the eye drop form of this medication is relatively new,
long-term studies are yet to be completed. Side effects of the eye drop include stinging,
burning and other eye discomfort.

Cholinergic (Miotic)

Company Brand Name Generic Name

Alcon, Inc. Isopto Carpine Pilocarpine HCl 1%, 2%,
4%
Alcon, Inc. Isopto Carbachol Carbachol 0.75%, 1.5%,
3%
Alcon, Inc. Pilopine HS Gel Pilocarpine HCl gel 4%
Bausch & Lomb Pilocarpine HCl Ophthalmic Pilocarpine HCI 1%, 2%,
Inc. SolutionUSP 4%

These medications reduce eye pressure by increasing the drainage of intraocular fluid through
the trabecular meshwork.Cholinergics can be used alone or combined with other glaucoma
medications. A combination of medications can help control how much fluid is produced in
the eye and increase the amount of fluid that drains out of the eye.

Side Effects

Many people who use these medications complain of dim vision, especially at night or in
darkened areas such as movie theaters. This is due to constriction of the pupil. Miotics
increase drainage of intraocular fluid by making the pupil size smaller, thereby increasing the
flow of intraocular fluid from the eye.

Furthermore, the group of medication suggested by the doctor is Prostaglandin Analogs, if

seen below the medication doesnt cause any contraindications with asthma. Therefore, it is
safe to be given to the patient and patient should continue with the medication.

HERBAL MEDICINE FOR GLAUCOMA

Herbs are a way to strengthen and tone the body's systems. As with any therapy, you
should speak with your health care provider before starting treatment. may use herbs such as
dried extracts (capsules, powders, and teas), glycerites (glycerine extracts), or tinctures
(alcohol extracts). Unless otherwise indicated, make teas with 1 tsp. herb per cup of hot
water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots.
Drink 2 to 4 cups per day. You may use tinctures alone or in combination as noted.
 Bilberry (Vaccinium myrtillus) standardized extract, 80 mg, 2 to 3 times daily, for
antioxidant and vision support. Bilberry may interact with diabetes medication and may
increase the effect of blood-thinning medications, such as aspirin and warfarin (Coumadin).
An extract of the European blueberry, bilberry is available through the mail and in some
health food stores. It is most often advertised as an antioxidant eye health supplement that
advocates claim can protect and strengthen the capillary walls of the eyes, and thus is
especially effective in protecting against glaucoma, cataracts, and macular degeneration.
There is some data indicating that bilberry may improve night vision and recovery time from
glare, but there is no evidence that it is effective in the treatment or prevention of glaucoma.

Ginkgo (Ginkgo biloba) standardized extract, 40 to 80 mg, 3 times daily, for antioxidant
and immune support. Ginkgo has been proven to act at the mitochondrial level, by stabilizing
the inner membrane and increasing the membrane potential, restoring the respiratory chain
and increasing ATP-production.Mean mitochondrial respiratory activity was decreased
significantly by 21% in patients with glaucoma compared with control subjects. These results
reveal a spectrum of mitochondrial abnormalities in patients with glaucoma and may open up
new experimental and therapeutic opportunities for glaucoma.Ginkgo may increase bleeding
in sensitive individuals, such as those taking blood-thinning medications, including aspirin.
Ginkgo may not be appropriate for people who have diabetes, infertility, seizure history, or
bleeding disorders.

Green tea (Camellia sinensis) standardized extract, 250 to 500 mg daily, for antioxidant
and immune effects. Use caffeine-free products. You may also prepare teas from the leaf of
this herb

HEALTHY LIFESTYLE

Nutrition and Supplements

 Eliminate all suspected food allergens, including dairy (milk, cheese, and eggs), wheat
(gluten), soy, corn, preservatives, and food additives. Your health care provider may want to
test you for food allergies. Eat more antioxidant-rich foods (such as green, leafy vegetables
and peppers) and fruits (such as blueberries, tomatoes, and cherries). Some studies show that
a higher intake of fruits and vegetables is associated with a lower risk of glaucoma. Avoid
refined foods, such as white breads, pastas, and sugar. Eat fewer red meats and more lean
meats, cold-water fish, tofu (soy, if no allergy), or beans for protein. Use healthy oils in
foods, such as olive oil or coconut oil.

Reduce or eliminate trans fatty acids, found in such commercially-baked goods as

cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
Avoid coffee and other stimulants, alcohol, and tobacco. Drink 6 to 8 glasses of filtered water
daily.

You may address nutritional deficiencies with the following supplements: A multivitamin
daily, containing the antioxidant vitamins A, C, E, the B-complex vitamins and trace
minerals, such as magnesium, calcium, zinc, and selenium. Omega-3 fatty acids, such as fish
oil, 1 to 2 capsules or 1 tablespoon oil daily, to help reduce inflammation. Fish oil may
increase bleeding in sensitive individuals, such as those taking blood-thinning medications
(including aspirin). Vitamin C, 500 to 1,000 mg daily, as an antioxidant. Coenzyme Q10,
100 to 200 mg at bedtime, for antioxidant support. Coenzyme Q10 may interfere with the
action of blood-thinning medications, such as warfarin (Coumadin) among others. Alpha-
lipoic acid, 25 to 50 mg twice daily, for antioxidant support. Lutein, 2 to 6 mg daily, for
antioxidant support in eye health.

Lower your insulin levels:

As your insulin levels rise, it causes your blood pressure, and possibly also your eye
pressure, to increase. In time this can cause your body to become insulin resistant, and studies
show insulin resistance -- which is common in people with diabetes, obesity and high blood
pressure -- is linked to elevated eye pressure. The solution is to avoid sugar and grains, the
two food groups that will inevitably cause surges in your insulin levels. Even whole,
organic grains will rapidly break down to sugars, so they too should be avoided. So in
addition to avoiding sugar, if you have glaucoma or are concerned about it, youll want to
avoid foods like Breads, Pasta, Rice, Cereal, and Potatoes

Taking an animal-based omega-3 fat supplement.

A type of omega-3 fat called docosahexaenoic acid (DHA) may help protect and
promote healthy retinal function. DHA is concentrated in your eye's retina and has been
found to be particularly useful in preventing macular degeneration, the leading cause of
blindness.

Omega-3 fat, including DHA, is found in fish, but I don't recommend eating fish due to the
concerns of mercury and other toxins that have been found in fish from oceans, lakes and
streams and farm-raised fish. Instead, my most highly recommended source for omega-3 fat
is krill oil.

Getting loads of lutein and zeaxanthin.

Many have never heard of these two vision powerhouses, but they are incredibly
important for your eyesight. Lutein, which is a carotenoid found in particularly large
quantities in green, leafy vegetables, acts as an antioxidant, protecting cells from free radical
damage.

Some excellent sources include kale, collard greens, spinach, broccoli, brussels sprouts and
egg yolks, particularly raw egg yolks. Egg yolks also have zeaxanthin, another carotenoid, in
an equal amount to lutein. Zeaxanthin is likely to be equally as effective as lutein in
protecting eyesight.

It is important to note that lutein is an oil-soluble nutrient, and if you merely consume the
above vegetables without some oil or butter you can't absorb the lutein. So make sure youre
eating some healthy fat along with your veggies,
Eggs yolks are also loaded with these nutrients but once the egg is cooked they tend to be
damaged and non useful. So you can consume them raw by whipping them up in a shake or
cooking them minimally as in sunny side or poach them with runny yolks.

Avoiding trans fats

Trans fat may interfere with omega-3 fats in your body, which are extremely important
for your eye health. A diet high in trans fat also appears to contribute to macular
degeneration. Trans fat is found in many processed foods and baked goods, including
margarine, shortening, fried foods like French fries, fried chicken and doughnuts, cookies,
pastries and crackers.

Eating dark-colored berries.

The European blueberry, bilberry, is known to prevent and even reverse macular
degeneration, and bioflavonoids from other dark-colored berries including blueberries,
cranberries and others will also be beneficial. They work by strengthening the capillaries that
carry nutrients to eye muscles and nerves.

However, because berries contain natural sugar they should be eaten in moderation to avoid
upsetting your insulin levels

Exercise

Some evidence suggests that regular exercise may modestly reduce eye pressure in
patients with open-angle glaucoma. Exercise has no effect on closed-angle glaucoma.
Exercise can be dangerous for patients who have pigmentary glaucoma. Vigorous high-
impact exercise causes pigment to be released from the iris, which increases eye pressure.
Glaucoma patients should avoid yoga and other exercises that involve head-down or inverted
positions. Talk with your doctor about an appropriate exercise program.
Sleep with your head elevated.

Using a wedge pillow that keeps your head slightly raised, about 20 degrees, has been
shown to reduce intraocular eye pressure while you sleep.

ALTERNATIVE THERAPHY

Yoga and Recreational Body Inversion

The long-term effects of repeatedly assuming a head-down or inverted position on the

optic nerve head (the nerve that carries visual images to the brain) have not been adequately
demonstrated, but due to the potential for increased IOP, people with glaucoma should be
careful about these kinds of exercises. Glaucoma patients should let their doctors know if
yoga shoulder and headstands or any other recreational body inversion exercises that result in
head-down or inverted postures over extended periods of time are part of their exercise
routines.

Self-Regulation Techniques

The results of studies regarding changes in IOP following relaxation and biofeedback
sessions have generated some optimism in controlling selected cases of open-angle glaucoma,
but further research is needed.

However, findings that reduced blood pressure and heart rate can be achieved with relaxation
and biofeedback techniques show promise that non-medicinal and non-surgical techniques
may be effective methods of treating and controlling open-angle glaucoma

Laser Surgery (Trabeculoplasty)

Laser trabeculoplasty is used to treat open-angle glaucoma. It involves the following

steps: The procedure uses a laser to burn 80 - 100 tiny holes in the drainage area. The two
main types of surgery are argon laser trabeculoplasty (ALT) and selective laser
trabeculloplasty (SLT). A tiny scar forms, which increases fluid outflow. The procedure is
performed on an outpatient basis, takes 15 minutes, causes almost no discomfort, and has
very few complications. Laser surgery is not a cure. Although it reduces intraocular pressure,
patients still need to take medications every day. Within 2 - 5 years eye pressure increases
and most patients require either additional surgery or new medications.

Filtration Surgery (Trabeculectomy)

Filtration surgery has been used for more than 100 years with only minor
modifications. It uses conventional surgical techniques known as full-thickness filtering
surgery or guarded filtering surgery (trabeculectomy). The surgeon creates a sclerostomy, a
passage in the sclera (the white part of the eye) for draining excess eye fluid. A flap is created
that allows fluid to escape without deflating the eyeball. The surgeon may also remove a tiny
piece of the iris (called an iridectomy) so that fluid can flow backward into the eye. A small
bubble called a bleb nearly always forms over the opening, which is a sign that fluid is
draining out. Although surgeons aim for a thick bleb, which poses less risk than a thin one for
later leakage, the ideal operation would have no bleb at all.

The procedure is usually performed on an outpatient basis but some patients may need to
stay overnight in the hospital. For many patients, trabulectomy eliminates the need for
medications. In some patients, eye pressure eventually increases again and patients may need
to go back on medication or undergo a second trabeculectomy. A newer instrument called a
trabectome allows for a less invasive type of trabulectomy surgery. The trabectome procedure
uses an electrosurgical pulse to remove a small section of the trabecular meshwork. Side
Effects. Many of the serious side effects or complications that occur with filtration surgery
involve blebs (blister-like bumps). Bleb Leaks and Infections. Blebs, particularly thin ones,
commonly leak. Leakage can occur early on or sometimes as late as months or years after
surgery. Untreated, leaks can be serious and even cause blindness. Surgical repair is the most
effective way of managing leaking blebs, although drug therapies, pressure patching, and
other nonsurgical techniques may be tried first. Due to the dangers of leaking blebs, doctors
recommend lifelong monitoring after surgery.

In some cases, scars form around the incision, closing up the drainage channels and
causing pressure to rebuild. Scarring is a particular problem in young patients, African-
Americans, and patients who have taken multiple drugs, have had an inflammatory disease,
or have had cataract surgery. Releasing the surgical stitches used in the procedure may help
prevent scarring and pressure build-up. A second procedure called bleb needling can
sometimes open up the scarred area and restore drainage. With this technique, the tip of a
very fine hypodermic needle is used to carefully cut loose the particles closing off the
drainage area. Drugs may also be used to prevent scarring. The procedure is highly associated
with the development of cataracts over time. Because cataracts are associated with glaucoma
anyway, it is not entirely clear whether the cataracts are caused by the surgery or would
develop in any case.

Drainage Implants (Tube Shunts)

Drainage implants, also known as tube shunts or aqueous shunts, may be used to drain
fluid if patients have not been helped by laser or filtration surgery. They are also used to treat
children with glaucoma. The procedure is performed in an operating room using a local
anesthetic. The procedure involves: An implant, most commonly a 1/2 inch silicone tube, is
inserted into the eye's front (anterior) chamber. The tube drains the fluid onto a tiny plate that
is sewn to the side of the eye. Fluid collects on the plate and then is absorbed by the tissues in
the eye. The patient wears an eye patch and shield until the first post-operative visit. Healing
time takes about 6 - 8 weeks. Complications are uncommon but may include very low eye
pressure (hypotony), drooping eyelid, double vision, and retinal detachment. Occasionally the
tube falls out and needs to be replaced

Acupuncture

Many studies have been done, and in most cases there were no changes in IOP or v.

Eye Massage
 Use your fingers to massage crucial points around your eyes to relax eye muscles
not unlike acupuncture philosophy. Simply place thumb below eyebrow and above the inside
corners of your eyes and allow your four fingers to rest on your forehead. Using light
pressure, press thumb into the point and hold for 4 breaths. Use thumb and index finger to
massage the bridge of your nose. Glide your thumb and finger along your nose, upward
motion with some light pressure. Press and squeeze for 4 breaths. Next, place middle finger
on your cheek bone, directly below the middle of your eye. Massage the center part of your
cheek for 4 breaths. You can do these exercises at separate times or you can simply graft them
into your daily activities.

Palming

Used to reduce stress around the eyes, the exercise involves using your palm to
diffuse stress, relax the muscles around the eyes and induce circulation to the eyes. Place the
palm of your left hand over your left eye, with the hollow of the palm directly over the eye
but not touching it. The heel of your palm should be resting on your cheekbone. Do the
same for the right palm. Breathe and relax. This gives your eyes the opportunity to relax. Do
this for 3 minutes and it can be repeated anytime you feel a stress coming.

Figure of Eights

By tracing an imaginary figure of eight (the horizontal version, like the infinity sign),
approximately 10 feet from you, this exercise increases the flexibility of your eyes while
relaxing the eye muscles. Trace the figure with your eyes without moving your head, first in
one direction, then in another. Remember to breathe, relax, and blink from time to time to
help your eyes relax.
COUNSELING FOR PATIENTS WITH GLAUCOMA

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Simon H. 2006. Retrieved at http://www.healthcentral.com/encyclopedia/adam/glaucoma-

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Vaughan, 2000. Tersedia dari URL : http://repository.usu.ac.id (diunduh

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