Glaucoma for the students and general practitioners

What a general practitioner should know about

Glaucoma

Dr. Anthony20 Dec, 2013

What is it?

Glaucoma – is a disease of optic nerve. It may have a

classical sign – elevated intraocular pressure.

Glaucoma

Why is it important for

you?

Glaucoma eventually leads to irreversible blindness if

uncontrolled

Glaucoma

Who has glaucoma?

Glaucoma

Why is it important for

you?

Glaucoma is a silent chronic bilateral sight-killer. Patient usually has NO complaints!

And then he goes blind.

Glaucoma

So can we do at least

something with it?

Patient has a good chance to live a long happy life with a

satisfactory vision, if the disease is caught in time.

Yes, you can make a difference.

Glaucoma

What are the types of

glaucoma? (1)

There are two major types:

-open angle glaucoma

-angle-closure glaucoma

Glaucoma

Anatomical basics of

glaucoma

Reminder of normal anatomy

What is the nature of

this disease?

Of many types of glaucoma –primary open angle

glaucoma is the most common

Glaucoma

What is the nature of

this disease?

The pathogenesis of the primary open angle

glaucoma can be described like this:

Glaucoma

Glaucoma

The nature of the disease

Glaucoma

Actually, the same goes for

open-angle glaucoma...

The nature of the disease

Glaucoma

The simple classic explanation of the nature of the disease

So what is the difference

between two major types?

The level of aquous humorblockage... In angle-closure type

trabecular meshwork is not available for humor. In open angle

it is available, though working badly and sadly.

Glaucoma

So what is the difference

between two major types?

Open angle glaucoma is the most common form in the European

and African regions.Angle-closure glaucoma is

characteristic for people of Asian descent.

Glaucoma

Glaucoma

Angle-closure glaucoma scheme

Classification of

glaucoma

1) open angle / angle-closure

Glaucoma

What are the types of

glaucoma? (2)

Glaucoma can be chronic (and it usually is), but also it can turn

into acute (one of the biggest emergencies in

Ophthalmology!)

Glaucoma

What are the types of

glaucoma? (2)

Chronic glaucoma is totally unremarkable for a physician

and inconspicuous for a patient

Glaucoma

What are the types of

glaucoma? (2)

Acute glaucoma is the one that should be very clearly

understood by any doctor. There’re fulminant forms, that

lead to the blindness during several hours.

Glaucoma

Types of glaucoma – acute glaucoma attack

Glaucoma

Classification of

glaucoma

1) open angle / angle-closure

2) chronic / acute

Glaucoma

What are the types of

glaucoma? (3)

Glaucoma can be either congenital, or acquired

Glaucoma

Congenital glaucoma - buphtalmos

Glaucoma

Congenital glaucoma - buphtalmos

Glaucoma

Classification of

glaucoma

1) open angle / angle-closure

2) chronic / acute

3) congenital / acquired

Glaucoma

What are the types of

glaucoma? (4)

Glaucoma is always either primary or secondary

Glaucoma

What are the types of

glaucoma? (4)

For the primary type (either open angle or angle-closure

glaucoma) - there is no

pre-existing condition.

Glaucoma

What are the types of

glaucoma? (4)

For the secondary type (either open angle or angle-closure glaucoma) - there is always

definite pre-existing eye or orbit disease or systemic condition

Glaucoma

What are the types of

glaucoma? (4)

Secondary open angle glaucoma reasons: phacolysis, red blood cells, hypertensive

uveitis, pigmentary dispersion, pseudoexfoliation, neovascularization of angle, congenital conditions (iridocorneal

endothelial syndrome, sturge-webersyndrome), carotid-cavernous fistula, trauma (recession of angle), medications (steroids!)

Glaucoma

Secondary open angle glaucoma – phacolytic

Glaucoma

Secondary open angle glaucoma – hyphema

Glaucoma

Secondary open angle glaucoma – bilateral sturge-weber syndrome

Glaucoma

Secondary open angle glaucoma – pseudoexfoliation syndrome

Glaucoma

What are the types of

glaucoma? (4)

Secondary angle-closure glaucoma reasons: iridocorneal

synechiae (iridocyclitis), subluxation of a lens, tumors

Glaucoma

Secondary angle-closure glaucoma – posterior synechiae of iris

Glaucoma

What are the types of

glaucoma? (4)

In any case of secondary glaucoma the IOP is highly elevated, and it eventually

leads to irriversible optic nerve damage

Glaucoma

Classification of

glaucoma

1) open angle / angle-closure

2) chronic / acute

3) congenital / acquired

4) primary / secondary

Glaucoma

What are the signs of

this disease?

Chronic glaucoma at the beginning is clinically

irrelevant

Glaucoma

What are the signs of

this disease?

During the development of the chronic disease patiend may start noticing blurred vision, and the gradual decrease of

visual field

Glaucoma

What are the signs of

this disease?

Any damage to optic nerve (including glaucoma)

inevitably leads to visual field defect

Glaucoma

Visual field deterioration during the glaucoma progression

Glaucoma

What are the signs of

this disease?

False! Typically patients do not notice these kinds of

defects, if notice any at all!

Glaucoma

What are the signs of

this disease?

The only patient with glaucoma, who is complaining – is either the patient with advanced glaucoma

(significant visual acuity decrease!) or the patient with an

acute glaucoma attack

Glaucoma

What are the signs of

this disease?

In acute glaucoma attack:-painful eye (+irradiation of pain)

-no discharge, no pus-blurred vision

-red eye-fixed dilated pupil

-highly elevated IOP

Glaucoma

What is the diagnostics?

1) assess family history! Any blinds? Glaucoma is inheritable!

2) check visual acuity3) check intraocular pressure (at least by palpation!)4) check pupillary reactions (are pupils reactive? are

the reactions symmetric?)5) perform ophthalmoscopy (if available)6) perform confrontational visual field test

Glaucoma

Visual field deterioration during the glaucoma progression

GlaucomaIntraocular pressure sometimes

makes the eye “hard as a stone”.

Just touch each eyes with two fingers, palpate it.

Visual field simple confrontational test. It allows to detect very rough field

defects

Glaucoma

Ophthalmoscopy. There’s only one disc of optic nerve that is normal here.

Glaucoma

What we do in eye

clinics

1) Basic ophthalmological exam (visual acuity, intraocular pressure, external exam)

2) Slit lamp examination of anterior and posterior segment of the eyeball (gonioscopy and ophthalmoscopy! We’re looking for angle-closure and “cupping” of the disc)

3) In certain cases we must perform automated visual field test with computer

4) We can perform tomography of optic nerve disc, if optic tomograph is available

5) We make an appointment! We see if our treatment works.

Glaucoma

Ophthalmoscopy. There’s only one disc of optic nerve that is normal here.

Glaucoma

Tonometry with schiotz

tonometer

Tonometry with slit lamp Goldmann tonometer

Glaucoma

Gonioscopy with slit lamp and four-mirror contact lens

Glaucoma

How can we stop this

blinding condition?

We should lower intraocular pressure at least by 30% of initial

point.

This is the only measure now, that is proven to help such patients.

Glaucoma

How can we stop this

blinding condition?

We use medications (in acute glaucomas – acetazolamidep/o; mannitol i/v; in chronic

glaucomas – timolol and latanoprost eyedrops)

Glaucoma

How can we stop this

blinding condition?

In case medications failed to stabilize the process – we move forward to laser or

surgical treatment.

Glaucoma

Can we stop this

blinding condition?

Unfortunately glaucoma continues progressing even with the best control of IOP. But the rate of

progression is much slower with treatment. The prognosis for vision is satisfactory with treatment and poor

without treatment.

Glaucoma

Can we stop this

blinding condition?

Unfortunately glaucoma continues progressing even with the best control of IOP. But the rate of

progression is much slower with treatment. The prognosis for vision is satisfactory with treatment and poor

without treatment.

Glaucoma

Any questions?