Glaucoma Clinical UpdateGlaucoma Clinical Update

Barry Emara MD FRCS(C)Barry Emara MD FRCS(C)

Giovanni Caboto ClubGiovanni Caboto Club

October 3, 2012October 3, 2012

ObjectivesObjectives

• Understand the different categories of Understand the different categories of glaucomaglaucoma

• Recognize the symptoms and signs of open Recognize the symptoms and signs of open angle and angle-closure glaucomaangle and angle-closure glaucoma

• Identify and refer patients at risk for damage Identify and refer patients at risk for damage caused by glaucomacaused by glaucoma

• Understand the basic management of open Understand the basic management of open angle and angle-closure glaucoma angle and angle-closure glaucoma

• Recognize current testing modalities which Recognize current testing modalities which assist in early detectionassist in early detection

OutlineOutline

• Anatomy of anterior chamber and optic nerveAnatomy of anterior chamber and optic nerve

• Categories of glaucomaCategories of glaucoma

• DefinitionDefinition

• EpidemiologyEpidemiology

• Risk Factors Risk Factors

• SymptomsSymptoms

• SignsSigns

• ManagementManagement

AnatomyAnatomy

Anterior Chamber Anterior Chamber Anatomy Anatomy

Anatomy of the Optic Anatomy of the Optic NerveNerve

• Vitreous cavityVitreous cavity Large space filled with Large space filled with

transparent gel called transparent gel called vitreous humourvitreous humour

• RetinaRetina Neural tissue lining the Neural tissue lining the

vitreous cavity vitreous cavity posteriorlyposteriorly

Transparent except for Transparent except for blood vessels on its inner blood vessels on its inner surfacesurface

• MaculaMacula Area of retina Area of retina

responsible for fine, responsible for fine, central visioncentral vision

Depression in centre of Depression in centre of macula is called the macula is called the foveafovea

• Optic DiscOptic Disc Portion of ON visible Portion of ON visible

within the eyewithin the eye Axons whose cell bodies Axons whose cell bodies

are located in ganglion are located in ganglion cell layer of retinacell layer of retina

GlaucomaGlaucoma

CategoriesCategories

Glaucoma: CategoriesGlaucoma: Categories

1.1.Open angle Open angle i) Primary ii) Secondaryi) Primary ii) Secondary

2.2.Closed angle i) Primary ii) SecondaryClosed angle i) Primary ii) Secondary

Anterior Chamber AngleAnterior Chamber Angle

DefinitionsDefinitions

Primary Open Angle Primary Open Angle Glaucoma: DefinitionGlaucoma: Definition

• Primary open-angle glaucoma is a progressive, chronic Primary open-angle glaucoma is a progressive, chronic optic neuropathy in adults in which intraocular pressure optic neuropathy in adults in which intraocular pressure (IOP) and other currently unknown factors contribute to (IOP) and other currently unknown factors contribute to damage and in which, in the absence of other identifiable damage and in which, in the absence of other identifiable causes, there is a characteristic acquired atrophy of the causes, there is a characteristic acquired atrophy of the optic nerve and loss of retinal ganglion cells and their optic nerve and loss of retinal ganglion cells and their axons. This condition is associated with an anterior axons. This condition is associated with an anterior chamber angle that is open by gonioscopic appearance.chamber angle that is open by gonioscopic appearance.

IN OTHER WORDS....IN OTHER WORDS....

POAG ISPOAG IS

OPTIC NEUROPATHY RELATED TO ELEVATED IOP CAUSING OPTIC NEUROPATHY RELATED TO ELEVATED IOP CAUSING CHARACTERISTIC OPTIC NERVE APPEARANCE WITH CHARACTERISTIC OPTIC NERVE APPEARANCE WITH

ASSOCIATED VF LOSS WITH OPEN AC ANGLEASSOCIATED VF LOSS WITH OPEN AC ANGLE

Primary Angle Closure Primary Angle Closure Glaucoma: DefinitionGlaucoma: Definition

• Primary angle closure is appositional or synechial Primary angle closure is appositional or synechial closure of the anterior chamber angle caused by closure of the anterior chamber angle caused by multiple mechanisms, leading to elevated IOP multiple mechanisms, leading to elevated IOP causing a characteristic acquired atrophy of the causing a characteristic acquired atrophy of the optic nerve and loss of retinal ganglion cells and optic nerve and loss of retinal ganglion cells and their axonstheir axons

EpidemiologyEpidemiology

Open Angle Glaucoma: Open Angle Glaucoma: EpidemiologyEpidemiology

• Primary open-angle glaucoma is a significant public health Primary open-angle glaucoma is a significant public health problemproblem

• Affects 1 in 100 Canadians over age 40Affects 1 in 100 Canadians over age 40

• Prevalence of POAG for adults 40 and older in the United States Prevalence of POAG for adults 40 and older in the United States was estimated to be about 2%was estimated to be about 2%

• 45 million people in the world have open-angle glaucoma (OAG)45 million people in the world have open-angle glaucoma (OAG)

• 8.4 million people blind from glaucoma8.4 million people blind from glaucoma

Open Angle Glaucoma: Open Angle Glaucoma: EpidemiologyEpidemiology

• Open-angle glaucoma affects an estimated 2.2 million Open-angle glaucoma affects an estimated 2.2 million people in the United States, and that number is likely to people in the United States, and that number is likely to increase to 3.3 million in 2020 as the population agesincrease to 3.3 million in 2020 as the population ages

• Threefold higher prevalence of OAG in African Americans Threefold higher prevalence of OAG in African Americans relative to non-Hispanic Whites in the United Statesrelative to non-Hispanic Whites in the United States

• Leading cause of blindness in African AmericansLeading cause of blindness in African Americans

• Prevalence of OAG is even higher in Afro-Caribbeans Prevalence of OAG is even higher in Afro-Caribbeans relative to African Americansrelative to African Americans

Angle Closure Glaucoma: Angle Closure Glaucoma: EpidemiologyEpidemiology

• Highest rates are reported in Inuit, Chinese, and other Asian populationsHighest rates are reported in Inuit, Chinese, and other Asian populations

• Lower rates are reported in populations of African and African-derived origin and Lower rates are reported in populations of African and African-derived origin and European and European-derived originEuropean and European-derived origin

• Primary angle-closure glaucoma may account for nearly as many cases of Primary angle-closure glaucoma may account for nearly as many cases of glaucoma as open-angle glaucoma in some Asian populationsglaucoma as open-angle glaucoma in some Asian populations

• Worldwide, 0.7% of people over 40 are estimated to have angle-closure glaucomaWorldwide, 0.7% of people over 40 are estimated to have angle-closure glaucoma

• It is estimated that 21 million people worldwide will have angle-closure glaucoma It is estimated that 21 million people worldwide will have angle-closure glaucoma in 2020in 2020

• In China, PACG is estimated to cause unilateral blindness (visual acuity <3/60 or In China, PACG is estimated to cause unilateral blindness (visual acuity <3/60 or visual field ≤10°) in 1.5 million individuals and bilateral blindness in another 1.5 visual field ≤10°) in 1.5 million individuals and bilateral blindness in another 1.5 millionmillion

Open Angle Glaucoma: Natural Open Angle Glaucoma: Natural CourseCourse

• Optic disc becomes progressively cupped as axons die Optic disc becomes progressively cupped as axons die offoff

• Only optic nerve disorder in which severe cupping Only optic nerve disorder in which severe cupping takes place; in all others, the disc simply becomes paletakes place; in all others, the disc simply becomes pale

• Intraocular pressure is often elevated (higher than 21 Intraocular pressure is often elevated (higher than 21 mm Hg)mm Hg)

• Visual fields characteristic defectsVisual fields characteristic defects

Angle Closure Glaucoma: Natural Angle Closure Glaucoma: Natural CourseCourse

• If patients with unilateral AACG and high IOP do If patients with unilateral AACG and high IOP do not receive treatment, glaucomatous optic not receive treatment, glaucomatous optic neuropathy can occur rapidlyneuropathy can occur rapidly

• Untreated fellow phakic eyes are at increased risk Untreated fellow phakic eyes are at increased risk for developing acute angle closurefor developing acute angle closure

• Untreated patients with AACG and PACG develop Untreated patients with AACG and PACG develop progressive vision loss that may result in bilateral progressive vision loss that may result in bilateral blindnessblindness

The Risk FactorsThe Risk Factors

Primary Open Angle Primary Open Angle GlaucomaGlaucoma

RISK FACTORSRISK FACTORS• Higher IOPHigher IOP

• Older ageOlder age

• Family history of glaucomaFamily history of glaucoma

• Lower ocular perfusion pressureLower ocular perfusion pressure

• Lower systolic and diastolic blood pressureLower systolic and diastolic blood pressure

• Thinner central corneaThinner central cornea

• Disc hemorrhageDisc hemorrhage

• Larger cup-to-disc ratioLarger cup-to-disc ratio

• Larger mean pattern standard deviation on threshold visual field Larger mean pattern standard deviation on threshold visual field testingtesting

Primary Angle Closure Primary Angle Closure GlaucomaGlaucoma

DEMOGRAPHIC RISK FACTORSDEMOGRAPHIC RISK FACTORS

• Family history of angle closure Family history of angle closure

• Older age Older age

• Female sexFemale sex

• Asian or Inuit descent Asian or Inuit descent

Primary Angle Closure Primary Angle Closure GlaucomaGlaucoma

OCULAR RISK FACTORSOCULAR RISK FACTORS• HyperopiaHyperopia

• Shallow peripheral anterior chamber depthShallow peripheral anterior chamber depth

• Shallow central anterior chamber depth Shallow central anterior chamber depth

• Steep corneal curvatureSteep corneal curvature

• Thick crystalline lens Thick crystalline lens

• Short axial lengthShort axial length

Mechanism: Open Angle Mechanism: Open Angle GlaucomaGlaucoma

Open angle glaucomaOpen angle glaucoma

Mechanism: Angle Closure Mechanism: Angle Closure GlaucomaGlaucoma

Angle closure glaucoma

SymptomsSymptoms

Open Angle Glaucoma Open Angle Glaucoma SymptomsSymptoms

•Asymptomatic Asymptomatic •until late in diseaseuntil late in disease

Open Angle GlaucomaOpen Angle Glaucoma

Angle Closure Glaucoma Angle Closure Glaucoma SymptomsSymptoms

• Patients may be asymptomaticPatients may be asymptomatic

• Sudden onset of: Sudden onset of: 1.1. painpain

2.2. redness redness

3.3. nausea/vomitting nausea/vomitting

4.4. decreased visiondecreased vision

5.5. haloes around lights haloes around lights

Angle Closure GlaucomaAngle Closure Glaucoma

SignsSigns

Open Angle Glaucoma SignsOpen Angle Glaucoma Signs

SUBTLESUBTLE

• Normal cup-disc ratioNormal cup-disc ratio • Increased cup-disc ratioIncreased cup-disc ratio

Angle Closure Glaucoma SignsAngle Closure Glaucoma Signs

DRAMATICDRAMATIC

• Cloudy/steamy corneaCloudy/steamy cornea

• Fixed mid-dilated pupilFixed mid-dilated pupil

• Conjunctival injectionConjunctival injection

• Elevated IOPElevated IOP

ManagementManagement

ManagementManagement

• Primary(Acute) Angle Closure Primary(Acute) Angle Closure Glaucoma=URGENT REFERRALGlaucoma=URGENT REFERRAL

• Primary Open Angle Glaucoma=Non-Primary Open Angle Glaucoma=Non-urgent referralurgent referral

Goals of Management: Open Angle Goals of Management: Open Angle GlaucomaGlaucoma

PRESERVE VISIONPRESERVE VISION

• Intraocular pressure controlled in the target Intraocular pressure controlled in the target range range

• Stable optic nerve/retinal nerve fiber layer Stable optic nerve/retinal nerve fiber layer statusstatus

• Stable visual fieldsStable visual fields

Visual FieldsVisual Fields

Optical Coherence Optical Coherence TomographyTomography

Management: Open Angle Management: Open Angle GlaucomaGlaucoma

1.1. MedicationsMedications

2.2. LaserLaser

3.3. Incisional filtering surgeryIncisional filtering surgery

Pressure Lowering AgentsPressure Lowering Agents

• Aqueous suppressantsAqueous suppressants1.1. Beta blockers (Timolol,Betagan)Beta blockers (Timolol,Betagan)

2.2. Alpha agonists (Alphagan)Alpha agonists (Alphagan)

3.3. Carbonic anhydrase inhibitorsCarbonic anhydrase inhibitors

(Trusopt, Azopt)(Trusopt, Azopt)

Pressure Lowering AgentsPressure Lowering Agents

• Increased uveoscleral outflowIncreased uveoscleral outflow

1.1. Prostaglandin analoguesProstaglandin analogues

(Xalatan, Lumigan, Travatan)(Xalatan, Lumigan, Travatan)

2.2. Cholinergics (pilocarpine)Cholinergics (pilocarpine)

Laser TrabeculoplastyLaser Trabeculoplasty

TrabeculectomyTrabeculectomy

Goals of Management: Acute Angle Closure Goals of Management: Acute Angle Closure GlaucomaGlaucoma

• Reverse or prevent angle-closure process Reverse or prevent angle-closure process

• Control IOPControl IOP

• Prevent damage to the optic nerve Prevent damage to the optic nerve

Management: Acute Angle Closure Management: Acute Angle Closure GlaucomaGlaucoma

1.1. Medications to lower pressureMedications to lower pressure

2.2. Laser peripheral iridotomyLaser peripheral iridotomy

ReferencesReferences

Eye care America, The Foundation of the American Academy of Eye care America, The Foundation of the American Academy of Ophthalmology (www.eyecareamerica.org)Ophthalmology (www.eyecareamerica.org)

Canadian Ophthalmological Society website (www.eyesite.ca)Canadian Ophthalmological Society website (www.eyesite.ca)

Ophthalmology Study Guide for students and practitioners of medicine. Ophthalmology Study Guide for students and practitioners of medicine. American Academy of Ophthalmology, 1987.American Academy of Ophthalmology, 1987.

Albert DM, Jakobiec FA. Albert DM, Jakobiec FA. Priniciples and Practice of OphthalmologyPriniciples and Practice of Ophthalmology. . Philadelphia, WB Saunders Co, 2000.Philadelphia, WB Saunders Co, 2000.

Preferred Practice Patterns, Primary Open Angle Glaucoma. www.aao.orgPreferred Practice Patterns, Primary Open Angle Glaucoma. www.aao.org

Preferred Practice Patterns, Primary Angle Closure Glaucoma. www.aao.orgPreferred Practice Patterns, Primary Angle Closure Glaucoma. www.aao.org

Thank youThank you

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