GLAUCOMA

• INRODUCTION
• Glaucoma is an eye disease in which the optic
nerve is damaged in a characteristic pattern. This
can permanently damage vision in the affected
eye(s) and lead to visual field loss and blindness
and if left untreated.
• It is normally associated with increased fluid
pressure in the eye (aqueous humour).The term "
ocular hypertension" is used for people with
consistently raised intraocular pressure (IOP)
without any associated optic nerve damage.
 Intro …
• Glaucoma has been called the "silent thief of
sight" because the loss of vision often occurs
gradually over a long period of time, and
symptoms only occur when the disease is quite
advanced.
Once lost, vision cannot normally be recovered,
so treatment is aimed at preventing further loss.
If the condition is detected early enough, it is
possible to arrest the development or slow the
progression with medical and surgical means.
 DEFINITION

• Glaucoma is a group of ocular disorders

characterized by an increase in the intra
ocular pressure (IOP), optic nerve damage and
peripheral visual field loss.
 THE FLOW OF AQUEOUS
• The front part of the eye is filled with a clear
fluid called ‘aqueous humour’.
• This fluid is always being made in the cilliary
body (behind the coloured part of the eye).
• It leaves the eye through channels in the front
of the eye in an area called the ‘anterior
chamber angle’.
 The flow of aqueous …
• Aqueous humor flows from the ciliary processes
into the posterior chamber, bounded posteriorly
by the lens and anteriorly by the iris.
• It then flows through the pupil of the iris into the
anterior chamber, bounded posteriorly by the iris
and anteriorly by the cornea.
• From here, the trabecular meshwork drains
aqueous humor via Schlemm's canal into
scleral plexuses and general blood circulation
 The flow of aqueous …
• This means that there should be a balance
between aqueous fluid production rate and out
flow rate.
• Anything that slows or blocks the flow of this
fluid out of the eye will cause pressure to build
up in the eye. This pressure is called intraocular
pressure (IOP).
• Normal ranges is 10-21mm/Hg. In most cases of
glaucoma, this pressure is high and causes
damage to the optic nerve.
 EPIDERMIOLOGY

• Worldwide, glaucoma is the second-leading

cause of blindness after cataracts. It is also the
first leading cause of blindness among African
countries.
• The incidence of Glaucoma increases with
age..
 CAUSES
• Causes are discussed according to type of
glaucoma.
 RISK FACTORS

• Ethnicity and gender: World wide, women are

three times more likely than men to develop
acute angle closure glaucoma due to their
shallower anterior chambers.
• In African women are three times more likely
to develop primary open angle glaucoma.
 Risk factors …
• Genetics: Especially primary open angle glaucoma is
associated with mutations in several different genes
and not other types. Although congenital causes are
rare.
• Prolonged use of steroids: Steroids can induced
glaucoma e.g. steroid induced glaucoma.
• Conditions: Other conditions that severely restrict
blood flow to the eye,: Such as severe
diabetic retinopathy and central retinal vein occlusion,
ocular trauma, uveitis (uveitic glaucoma).
• Systemic hypertension may eventually increase IOP
 Risk factors …
• Dietary: No clear evidence indicates vitamin
deficiencies cause glaucoma in humans but
Caffeine increases intraocular pressure in
those with glaucoma, but does not appear to
affect normal individuals.
 Classification /Types of Glaucoma

• Glaucoma can be classified as primary,

secondary and associated. The two major
types are primary and secondary glaucoma.
 Classification /Types of Glaucoma ...

• Primary glaucoma: The structures involved in the

circulation of aqueous humour undergo direct
pathological changes.
• There are two types of primary glaucoma;"open-
angle" and "closed-angle" (or "angle closure")
glaucoma.
• The "angle" in both cases refers to the drainage
angle inside the eye (the area between the iris
and cornea) that controls aqueous outflow or
through which fluid must flow to escape.
 Classification /Types of Glaucoma ...

• 1).Primary open-angle glaucoma/ Chronic

glaucoma (POAG): This is the most common
type of glaucoma representing about 90% of
cases. It usually bilateral .
• In primary open angle glaucoma, the outflow of
aqueous humour at the trabercular meshwork is
decreased resulting in increased intra ocular
pressure.
• The drainage channels become clogged like a
‘clogged kitchen sink’.
 Primary open-angle glaucoma ...
• Causes
• The common causes are; aging, hereditary
and central retinal vein occlusion.
 Signs & symptoms

• It is asymptomatic in early stages.

• This type progresses at a slower rate and patients
may not notice they have lost vision until
permanent damage has occurred or the disease
has progressed significantly
• If the increased intra ocular pressure (IOP)
remains high, the destruction caused by Primary
open angle glaucoma can progress until tunnel
vision develops, and patient will be able to see
only objects that are straight ahead.
 Signs & symptoms ...

• It is asymptomatic in early stages.

• This type progresses at a slower rate and
patients may not notice they have lost vision
until permanent damage has occurred or the
disease has progressed significantly
 Signs & symptoms ...
• If the increased intra ocular pressure (IOP)
remains high, the destruction caused by
Primary open angle glaucoma can progress
until ‘tunnel vision’ develops, and patient will
be able to see only objects that are straight
ahead.
• Sometimes, there may be gradual reduction of
peripheral vision without other symptoms.
 2. Primary angle-closure glaucoma/ Closed angle
glaucoma/Narrow angle/ Acute glaucoma:
• It accounts for about 10% of cases. As the
name implies, the mechanism that reduces
the flow of aqueous is angle closure.
• This condition occurs suddenly and its an
ocular emergency.
 Causes
• Forward displacement of the iris against the
cornea narrows or closes the angles chamber and
obstructing the aqueous outflow.
• Lens bulging forward as a result of age-related
processes.
• Pupil dilatation in patients with anatomically
narrow angles as dilatation of pupils causes
peripheral iris to bulgy and cover the trabecular
meshwork there by blocking the outflow
channels.
 Causes ...
• Conditions in which the pupil remains in a
partially dilated state long enough to cause an
acute and significant rise of intra ocular
pressure precipitating an acute attack.
• Drug induced Mydriatics from either
prescribed systemic medications or over the
counter drugs (OTC).
 Signs & symptoms

• It produces sudden symptoms such as eye

pain, headaches (in acute angle closure
glaucoma).
• Dilated pupils
• Vision loss which can progress quickly
• Red eyes
• Nausea and vomiting.
 Signs & symptoms ...

• Very high intraocular pressure (>30 mmHg).

• Rainbow-like halos around lights
• Eye feels swollen
• Mid-dilated pupil or oval pupil
• Decreased or cloudy vision, often called
"steamy" vision.
 Signs & symptoms ...

• Reduced visual acuity not corrected by

glasses.
• These signs may last for a few hours, then
return again for another round.
• Sudden decrease in vision
• The discomfort often leads patients to seek
medical attention before permanent damage
occurs.
 2. Secondary glaucoma
• Secondary glaucoma: This type may occur
following other ocular conditions such as eye
injury, eye infection, inflammation, a tumour
or enlargement of the lens due to a cataract,
increased aqueous volume, iritis, trauma,
degenerative eye changes and eye surgery.
 3. Associated glaucoma
• Associated glaucoma: These are caused by
disease other than the ocular conditions e.g.
Diabetes mellitus, hypertension
 Other types

• Normal tension' or 'low tension' glaucoma: Is

used for those with optic nerve damage and
associated visual field loss, but normal or low
IOP.
 Other types ...
• Pigmentary glaucoma: This rare form of
glaucoma is caused by clogging of the
drainage angle of the eye by pigment that has
broken loose from the iris, reducing the rate
of aqueous outflow from the eye.
• Over time, an inflammatory response to the
blocked angle damages the drainage system.
Signs and symptoms are rare e.g. pain and
blurry vision (may occur after exercise).
 Other types ...
• Congenital glaucoma: This is the inherited
form of glaucoma ( present at birth).
• About 80 percent of cases diagnosed by age of
one year.
• These children are born with narrow angles or
some other defect in the drainage system of
the eye.
 Other types ...
• It's difficult to spot signs of congenital
glaucoma, because children are too young to
understand what is happening to them. If you
notice a cloudy, white, hazy, enlarged or
protruding eye in the child, you should seek
medical advice.
• Congenital glaucoma typically occurs more in
boys than in girls.
 Pathophysiology

• Due to any cause, the end result is raised

intraocular pressure (above 21 mmHg or 2.8 kPa)
is the most important and only modifiable risk
factor for glaucoma. In open/wide-angle
glaucoma, flow is reduced through the trabecular
meshwork, due to the degeneration and
obstruction of the trabecular meshwork, whose
original function is to absorb the aqueous humor.
• Loss of aqueous humor absorption leads to
increased resistance and thus a chronic, painless
buildup of pressure in the eye.
 Pathophysiology ...

• In close/narrow-angle, the iridocorneal angle is

completely closed because of forward
displacement of the root of the iris against the
cornea, resulting in the inability of the aqueous
fluid to flow from the posterior to the anterior
chamber and then out of the trabecular network.
• This creates an imbalance between aqueous fluid
rate of production (in-flow) and rate of
absorption (out-flow).
 Pathophysiology ...

• This accumulation of aqueous humor causes

an acute increase of intra ocular pressure
which decreases the blood flow to the optic
nerve and retina causing pain.
• This results in optic nerve and the retina
becoming insensitive, get damaged and dies
(optic neuropathy) leading to permanent loss
of vision.
 Signs& symptoms of congenital
glaucoma
• Symptoms are usually noticed when the child
is a few months old
• Cloudiness of the front of the eye
• Enlargement of one eye or both eyes
• Red eye
• Sensitivity to light
• Tearing
 General signs & symptoms

• Glaucoma often is called the "silent thief of

sight," because most types typically cause no
pain and produce no symptoms until
noticeable vision loss occurs.
• Increased intra ocular pressure
• Diminished visual field or peripheral vision
loss.
• Diminished accommodation
 INVESTIGATIONS/ DIAGNOSIS
• Fundoscopic examination: Reviews increased cup-
to-disc ratio due to optic nerve changes especially
in open angle glaucoma.
• Optic nerve imaging: Photographs or laser
scanning images are taken and shows images of
the inside of the eye.
Picture showing: Conjunctival vessels dilated at the
corneal edge and hazy cornea characteristic of acute
angle closure glaucoma
 Investigations/diagnosis …
• Tonometry: Is done to check eye pressure. It is
not confirmatory because eye pressure can be
normal in some people with glaucoma i.e. normal-
tension glaucoma.
• Gonioscopy: Is an examination done using a
special lens to look into the eye and examine the
size of drainage angle, also to evaluate if it is
blocked or not.
 Investigations/diagnosis …

• Examination of the retina in the back of the eye

• Slit lamp examination:
• Visual acuity test: There’s reduced visual field.
• Visual field measurement: It is reduced.
 Treatment
• The goal of treatment is to reduce intra ocular
pressure and prevent further loss of vision.
Treatment depends on the type of glaucoma
• In open-angle glaucoma: Most people can be
treated successfully with eye drops.
• Drugs to reduce intra ocular pressure is
prescribed e.g. Diamox and pilorcapine.
• Laser therapy called an iridotomy: This
procedure uses a laser to open a new pathway in
the colored part of the eye. This relieves pressure
and prevents another attack.
 Treatment ...
• In acute angle-closure attack is a medical
emergency. Blindness will occur in a few days
if it is not treated:
• Eye drops such as Diamox or pilocarpine to
lower eye pressure, given by mouth or intra
venously.
• Emergency operation, called an iridotomy.
• Traberculectomy may be done.
 Treatment ...

• In congenital glaucoma is almost always

treated with surgery. This is done using
general anesthesia.
• In secondary glaucoma: Treatment of the
underlying disease may be done
 Prognosis

• Open-angle glaucoma cannot be cured. However,

symptoms can be managed closely by taking
medication. Regular check-ups are needed to
prevent blindness.
• Angle-closure glaucoma is a medical emergency.
Patient need treatment right away to save the
vision.
• Babies with congenital glaucoma usually do well
when surgery is done early.
• Prognosis also depends on the causes of
glaucoma
 NURSING CARE
• Assignment: pre-operative & post operative