Glaucoma: Mohd Roslee Bin Abd Ghani

MOHD ROSLEE BIN ABD GHANI
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GLAUCOMA
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LEARNING OBJECTIVE
 Define glaucoma
 Explain the pathophysiology glaucoma
 Explain three types of glaucoma
 State the investigation of glaucoma
 State the signs and symptoms glaucoma
 Describe the treatment of glaucoma
 State the complications of glaucoma

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DEFINITION
 It is a group of disorders characterized by an abnormally high intra
ocular pressure (IOP), optic nerve dystrophy (weakness) and

peripheral visual field loss (tunnel vision.)
 It is a symptomatic condition of the eye where the IOP is more than
normal (above 25mm Hg).
 Untreated of glaucoma leads to permanent damage of the optic
nerve and resultant visual field loss, which can progress to

blindness.
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AQUEOUS HUMOUR
 It is the fluid which fills the anterior and posterior chamber.
 Formation:
 1) Active secretion: By the non-pigmented epithelium of the ciliary
processes in the posterior chamber, depending on several enzyme
systems (e.g. Na/K ATPase pump & Carbonic anhydrase).
 2) Passively: (minor role) the water contents diffuse passively along
osmotic gradient.
 Aqueous flows from the posterior chamber via the pupil

into the anterior chamber, from where it exits the eye
(Drained).
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Drainage
 By two different routes:

1. Trabecular (conventional) route: (90%) The aqueous
flows through the trabeculum into aqueous into
Schlemm canal and is then drained by the episcleral
veins.
2. 2) Uveoscleral (unconventional) route: (10%) The
aqueous passes across the face of the ciliary body into
the suprachoroidal space and is drained by the venous
circulation in the ciliary body, choroid and sclera.
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THE INTRAOCULAR PRESSURE (IOP)
 The Normal IOP: The IOP within the general population

has a range of 11- 21 mmHg.
 However, in some patients glaucoma occurs with IOP

less than 21 mmHg (normal- tension glaucoma), while
others remain unaffected with IOP up to 50 mmHg
(ocular hypertension)
 Fluctuation in IOP:: Normal IOP varies with the time of

day, with a tendency to be higher in the morning and
lower in the afternoon and evening.
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CAUSES AND RISK FACTORS
 Genetics:- Family history of glaucoma
 Ageing
 Ocular hypertension
 is a condition where the pressure in your eyes, or IOP, is too high.
 Continually high pressure within the eye can eventually damage
the optic nerve and lead to glaucoma or permanent vision loss.
 Severe myopia:-
 It is associated with an increased risk of pathological ocular
complications and may lead to blinding disorders like glaucoma
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CAUSES AND RISK FACTORS…
 Eye trauma:-
 It is most commonly caused by blunt trauma, which is an injury that

doesn't penetrate the eye, such as a blow to the head or an injury directly
on the eye.
 This can lead to an increase in eye pressure, which can damage the optic
nerve.
 Ocular surgery:-
 can cause a change in the eye's pressure. Sharp increases in eye

pressure are called “pressure spikes” and sometimes occur in patients
after cataract surgery.
 Often these pressure spikes are short-term and can be treated with
medicines.
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 Migraine:-
 Prolonged increased pressure can lead to visual loss if not

corrected.
 Black ethnicity:-
 African Americans are also more likely to develop glaucoma

at a younger age and suffer blindness from the disease.
 The genetic causes underlying glaucoma remain unclear,
but these ethnic disparities in the risk of developing
glaucoma suggest a genetic basis that is ethnicity-specific
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 Prolonged use of local or systemic corticosteroids:-
 Long-term use of topical and systemic steroids produces
secondary open- angle glaucoma similar to chronic simple

glaucoma.
 The increased intraocular pressure [IOP] caused by
prolonged steroid therapy is reversible but the damage

produced by it is irreversible.
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PATHOPHYSIOLOGY
 IOP is a function of production of liquid aqueous humor by

the ciliary processes of the eye and its drainage through
the trabecular meshwork.
 The raised pressure (IOP) 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.
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SIGNS AND SYMPTOMS
1. Severe headache
2. Eye pain
3. Nausea and vomiting
4. Blurred vision
5. Halos around lights
6. Eye redness
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TYPES OF GLAUCOMA
1. Congenital Glaucoma
2. Primary Glaucoma
1. Open-angle glaucoma
2. Angle-closure glaucoma
3. Secondary Glaucoma
4. Normal-tension glaucoma
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TYPES OF GLAUCOMA….
Congenital Glaucoma
 It is rare disease, occurs when a congenital defect
in the angle of the anterior chamber obstructs the

out flow of aqueous humor.
 If untreated, causes damage to the optic nerve and
blindness. In most cases, surgery is required

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TYPES OF GLAUCOMA….
Open-angle glaucoma
 Open-angle glaucoma is the most common form of the disease.
 The drainage angle formed by the cornea and iris remains

open, but the trabecular meshwork is partially blocked.
 This causes pressure in the eye to gradually increase.
 This pressure damages the optic nerve.
 It happens so slowly that you may lose vision before you're

even aware of a problem.
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TYPES OF GLAUCOMA…
Angle-closure glaucoma
 Angle-closure glaucoma, also called closed-angle glaucoma,

occurs when the iris bulges forward to narrow or block the
drainage angle formed by the cornea and iris.
 As a result, fluid can't circulate through the eye and pressure

increases.
 Angle-closure glaucoma may occur suddenly (acute angle-

closure glaucoma) or gradually (chronic angle-closure
glaucoma).
 Acute angle-closure glaucoma is a medical emergency.

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Secondary Glaucoma
 Glaucoma can develop as a complication from other

conditions including:
1. Eye injuries
2. Diabetes
3. Steroid use
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Normal-tension glaucoma
 In normal-tension glaucoma, your optic nerve becomes

damaged even though your eye pressure is within the normal
range.
 No one knows the exact reason for this.
 You may have a sensitive optic nerve, or you may have less
blood being supplied to your optic nerve.
 This limited blood flow could be caused by atherosclerosis —

the buildup of fatty deposits (plaque) in the arteries — or other
conditions that impair circulation.
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DIAGNOSIS
 History taking
 Physical examination
 Investigation
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INVESTIGATIONS
1. Tonometry
2. Ophthalmoscopy
3. Perimetry
4. Gonioscopy
5. Pachymetry
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INVESTIGATIONS…
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
 Most glaucoma cases are diagnosed with pressure exceeding 20mm Hg.
 However, some people can have glaucoma at pressures between 12 -22mm

Hg.
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INVESTIGATIONS…
Ophthalmoscopy
 This diagnostic procedure helps the doctor examine the optic nerve
for glaucoma damage.
 Eye drops are used to dilate the pupil so that the doctor can see
through the 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 the optic nerve looks unusual, a doctor may ask the patient to
have one or two more glaucoma exams: perimetry and gonioscopy.
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INVESTIGATIONS…
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 a vision has been
affected by glaucoma.
 During this test, a patient will be asked to look straight ahead as

a light spot is repeatedly presented in different areas of the
peripheral vision.
 This helps draw a "map" of the vision.

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INVESTIGATIONS…
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).
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INVESTIGATIONS…
Pachymetry
 Pachymetry is a simple, painless test to measure the thickness

of the 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 the diagnosis, because corneal thickness

has the potential to influence eye pressure readings.
 With this measurement, a doctor can better understand the IOP

reading and develop a treatment plan that is right for patient.
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MEDICAL MANAGEMENT
1. BETA ADRENERGIC BLOCKERS

 Timolol, betaxolol are used to decreased aqueous humor production.
2. CHOLINERGIC (MIOTICS)
 Pilocarpine, carbacol are used to reduce IOP by facilitating the outflow
of aqueous humor
3. CARBONIC ANHYDRASE INHIBITORS
 Dorzolamide, methazolamide or acetazolamide to decrease the
formation and secretion of aqueous humor.
4. PROSTAGLANDIN ANALOGS
 Latanoprost to reduce IOP by increasing uveoscleral outflow.
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SURGICAL MANAGEMENT
ARGON LASER TRABECULOPLASTY
 It may be used to treat open angle glaucoma.
 In this, thermal argon laser burns are applied to the

inner surface of the trabecular meshwork to open the
intra trabecular spaces and widen the canal of
Schlemm, thereby increasing the outflow of aqueous
humor and decreasing IOP.
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SURGICAL MANAGEMENT…
LASER IRIDOTOMY:-
 An opening is made by the laser bean in the
iris to eliminate the pupillary block.
 It relieves pressure and preserves vision by
promoting outflow of the aqueous humor.
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CYCLOCRYOTHERAPY:-
 Application of a freezing probe to the sclera
over the cilliary body that destroy some of the

cilliary processes, results in the reduction of
the amount of aqueous humor produced.
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TRABECULOTOMY:-
 A partial thickness incision is made in the sclera
and further section of sclera is removed to

produce an opening for aqueous humor outflow
under the conjunctiva, creating a filtering bleb.
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SCLERECTOMY
 A partial thickness incision is made in the sclera and

one or more openings are made with a punch.
 The top flap of sclera is closed over the punched

holes.
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COMPLICATIONS
1. Chronic corneal edema (loss of

transparency)
2. Loss of central or side (peripheral) vision
3. Loss of vision or changes in vision

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THANK YOU

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MOHD ROSLEE BIN ABD GHANI

 Explain the pathophysiology glaucoma

 Explain three types of glaucoma

 State the investigation of glaucoma

 State the signs and symptoms glaucoma

 Describe the treatment of glaucoma

 State the complications of glaucoma

 It is a group of disorders characterized by an abnormally high intra

ocular pressure (IOP), optic nerve dystrophy (weakness) and

 It is a symptomatic condition of the eye where the IOP is more than

normal (above 25mm Hg).

 Untreated of glaucoma leads to permanent damage of the optic

nerve and resultant visual field loss, which can progress to

 Aqueous flows from the posterior chamber via the pupil

 By two different routes:

 The Normal IOP: The IOP within the general population

 However, in some patients glaucoma occurs with IOP

 Fluctuation in IOP:: Normal IOP varies with the time of

 Genetics:- Family history of glaucoma

 It is most commonly caused by blunt trauma, which is an injury that

 can cause a change in the eye's pressure. Sharp increases in eye

 Prolonged increased pressure can lead to visual loss if not

 African Americans are also more likely to develop glaucoma

 Prolonged use of local or systemic corticosteroids:-

 Long-term use of topical and systemic steroids produces

secondary open- angle glaucoma similar to chronic simple

 The increased intraocular pressure [IOP] caused by

prolonged steroid therapy is reversible but the damage

 IOP is a function of production of liquid aqueous humor by

 The raised pressure (IOP) on the retina causes the cells

 This results in a clinically progressive loss of peripheral

3. Nausea and vomiting

5. Halos around lights

 It is rare disease, occurs when a congenital defect

in the angle of the anterior chamber obstructs the

 If untreated, causes damage to the optic nerve and

blindness. In most cases, surgery is required

 Open-angle glaucoma is the most common form of the disease.

 The drainage angle formed by the cornea and iris remains

 This causes pressure in the eye to gradually increase.

 This pressure damages the optic nerve.

 It happens so slowly that you may lose vision before you're

 Angle-closure glaucoma, also called closed-angle glaucoma,

 As a result, fluid can't circulate through the eye and pressure

 Angle-closure glaucoma may occur suddenly (acute angle-

 Acute angle-closure glaucoma is a medical emergency.

 Glaucoma can develop as a complication from other

 In normal-tension glaucoma, your optic nerve becomes

 No one knows the exact reason for this.

 This limited blood flow could be caused by atherosclerosis —

 During tonometry, eye drops are used to numb the eye.

 Then a doctor or technician uses a device called a tonometer to measure the

 A small amount of pressure is applied to the eye by a tiny device or by a warm

 However, some people can have glaucoma at pressures between 12 -22mm

 Perimetry is a visual field test that produces a map of your

 During this test, a patient will be asked to look straight ahead as

 This helps draw a "map" of the vision.

 This diagnostic exam helps determine whether the angle where

 A hand-held contact lens is gently placed on the eye.