Glaucoma for the students and general practitioners
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What a general practitioner should know about
Glaucoma
Dr. Anthony20 Dec, 2013
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What is it?
Glaucoma – is a disease of optic nerve. It may have a
classical sign – elevated intraocular pressure.
Glaucoma
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Why is it important for
you?
Glaucoma eventually leads to irreversible blindness if
uncontrolled
Glaucoma
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Who has glaucoma?
Glaucoma
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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
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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
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What are the types of
glaucoma? (1)
There are two major types:
-open angle glaucoma
-angle-closure glaucoma
Glaucoma
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Anatomical basics of
glaucoma
Reminder of normal anatomy
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What is the nature of
this disease?
Of many types of glaucoma –primary open angle
glaucoma is the most common
Glaucoma
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What is the nature of
this disease?
The pathogenesis of the primary open angle
glaucoma can be described like this:
Glaucoma
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Glaucoma
The nature of the disease
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Glaucoma
Actually, the same goes for
open-angle glaucoma...
The nature of the disease
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Glaucoma
The simple classic explanation of the nature of the disease
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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
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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
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Glaucoma
Angle-closure glaucoma scheme
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Classification of
glaucoma
1) open angle / angle-closure
Glaucoma
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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
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What are the types of
glaucoma? (2)
Chronic glaucoma is totally unremarkable for a physician
and inconspicuous for a patient
Glaucoma
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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
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Types of glaucoma – acute glaucoma attack
Glaucoma
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Classification of
glaucoma
1) open angle / angle-closure
2) chronic / acute
Glaucoma
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What are the types of
glaucoma? (3)
Glaucoma can be either congenital, or acquired
Glaucoma
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Congenital glaucoma - buphtalmos
Glaucoma
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Congenital glaucoma - buphtalmos
Glaucoma
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Classification of
glaucoma
1) open angle / angle-closure
2) chronic / acute
3) congenital / acquired
Glaucoma
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What are the types of
glaucoma? (4)
Glaucoma is always either primary or secondary
Glaucoma
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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
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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
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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
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Secondary open angle glaucoma – phacolytic
Glaucoma
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Secondary open angle glaucoma – hyphema
Glaucoma
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Secondary open angle glaucoma – bilateral sturge-weber syndrome
Glaucoma
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Secondary open angle glaucoma – pseudoexfoliation syndrome
Glaucoma
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What are the types of
glaucoma? (4)
Secondary angle-closure glaucoma reasons: iridocorneal
synechiae (iridocyclitis), subluxation of a lens, tumors
Glaucoma
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Secondary angle-closure glaucoma – posterior synechiae of iris
Glaucoma
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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
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Classification of
glaucoma
1) open angle / angle-closure
2) chronic / acute
3) congenital / acquired
4) primary / secondary
Glaucoma
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What are the signs of
this disease?
Chronic glaucoma at the beginning is clinically
irrelevant
Glaucoma
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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
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What are the signs of
this disease?
Any damage to optic nerve (including glaucoma)
inevitably leads to visual field defect
Glaucoma
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Visual field deterioration during the glaucoma progression
Glaucoma
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What are the signs of
this disease?
False! Typically patients do not notice these kinds of
defects, if notice any at all!
Glaucoma
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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
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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
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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
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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.
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Visual field simple confrontational test. It allows to detect very rough field
defects
Glaucoma
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Ophthalmoscopy. There’s only one disc of optic nerve that is normal here.
Glaucoma
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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
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Ophthalmoscopy. There’s only one disc of optic nerve that is normal here.
Glaucoma
Tonometry with schiotz
tonometer
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Tonometry with slit lamp Goldmann tonometer
Glaucoma
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Gonioscopy with slit lamp and four-mirror contact lens
Glaucoma
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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
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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
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How can we stop this
blinding condition?
In case medications failed to stabilize the process – we move forward to laser or
surgical treatment.
Glaucoma
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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
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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?