Review of glaucoma
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Glaucoma
Abdulrahman Al-Amri, MD
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GlaucomaGlaucoma
Definition Definition Anatomy & physiologyAnatomy & physiology Types Types
– PrimaryPrimaryPOAGPOAGACGACG
- - Secondary glaucomaSecondary glaucoma ManagementManagement
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Anatomy and physiology Anatomy and physiology Aqueous Humour Aqueous Humour
SecretedSecreted by the CB by the CB Carbonic anhydrase Carbonic anhydrase
enzyme is requiredenzyme is required Aqueous outflowAqueous outflow:: TMWTMW UveoscleralUveoscleral
Schlemm’s canal Schlemm’s canal
Venous circulationVenous circulation
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Classification of glaucomas
Cong vs acquiredCong vs acquired
Open vs closedOpen vs closed
Primary vs secondaryPrimary vs secondary
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TonometryTonometry
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GonioscopyGonioscopy
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Perimetry Perimetry
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Congenital glaucomaCongenital glaucoma
TrabeculodysgenesisTrabeculodysgenesis Usually SporadicUsually Sporadic
Symp.Symp. PhotophobiaPhotophobia TearingTearing BlepharospasmBlepharospasm
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SignsSigns
High IOPHigh IOPBuphthalmosBuphthalmosLarge corneaLarge corneaCorneal edema+/-Corneal edema+/-
Cupping Cupping (Normal C:D ratio =0.3)(Normal C:D ratio =0.3)
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TreatmentTreatment
SurgicalSurgical
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Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma
Acute elevation of IOPAcute elevation of IOP
Angle closure by:Angle closure by:
-Pupillary block-Pupillary block
Age ACRefractive error
Predisposing factors
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SymptomsSymptoms
SuddenSudden ocular pain ocular pain Rapid loss of vision* Tearing Photophobia Headache Nausea Vomiting
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SignsSigns VAVA High High IOPIOP Corneal edemaCorneal edema Ciliary Ciliary congestioncongestion Mid dilated pupil Mid dilated pupil
– Pressure on ciliary nerves and vesslesPressure on ciliary nerves and vessles
Closed angleClosed angle
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Management
• Hyperosmotic agents
Intravenous mannitol
A- Topical therapy
• Pilocarpine • Beta-blockers
B- Systemic• CAI
Acetazolamide
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Surgical YAG laser iridotomy- macromedia
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Primary Open Angle Glaucoma-POAG
Above 40yr usuallyAbove 40yr usually Bilateral Bilateral Asymptomatic in early stagesAsymptomatic in early stages Blurred vision & field loss are lateBlurred vision & field loss are late
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Risk FactorsRisk Factors
Age Age FHFHSteroidsSteroidsMyopia Myopia DMDM
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Primary Open angle GlaucomaPrimary Open angle GlaucomaPOAGPOAG
Mechanical Ischemic
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IOP > 21 mmHg
Cupping
Open angle
Visual field loss
Primary Open Angle Glaucoma-POAG
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ProgressionProgression
APDAPD
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SECONDARY SECONDARY GLAUCOMAGLAUCOMA
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NVG:NVG:– PDR :Proliferative diabetic retinopathyPDR :Proliferative diabetic retinopathy– CRVO:Central retinal vein occlusionCRVO:Central retinal vein occlusion– BRVO:Branch retinal vein occlusionBRVO:Branch retinal vein occlusion– OISOIS :Ocular ischemic syndrome:Ocular ischemic syndrome
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Pseudoexfoliation
Firillar material, Firillar material, (similar to amyloid)(similar to amyloid)
Deposition in the Deposition in the TMW…….high TMW…….high IOPIOP
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Phacomorphic glaucomaPhacomorphic glaucoma
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Glaucoma Glaucoma Phacolytic VS PhacomorphicPhacolytic VS Phacomorphic
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Glaucoma DrugsGlaucoma Drugs
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Glaucoma DrugsGlaucoma Drugs
Drugs to decrease Drugs to decrease the the productionproduction of of aqueous humor.aqueous humor.
Drugs to increase Drugs to increase the the outflowoutflow of of aqueous humor.aqueous humor.– Trabecular channelsTrabecular channels– Uveoscleral Uveoscleral
channelschannels
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ManagementManagement
MedicalMedical
-Topical -Topical
-Systemic-Systemic Surgical Surgical ((Failure of medical Rx )Failure of medical Rx )
-Trabeculectomy-Trabeculectomy
-Tube-shunt surgery-Tube-shunt surgery
-Cyclodestructive procedures-Cyclodestructive procedures
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Medical-topicalMedical-topical
ProductionProduction SympathomimeticsSympathomimetics
(adrenergic agonists)(adrenergic agonists) Beta blockersBeta blockers
OutflowOutflow Parasympathomimetics Parasympathomimetics
(Miotics-cholinergic ag)(Miotics-cholinergic ag) Prostaglandin analoguesProstaglandin analogues
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– Allergic conjunctivitis– Punctate keratitis
– Bradycardia– Bronchospasm– Hypotension – libido– Depression
Glaucoma Drugs – Side Effects
Betablockers
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• MIOTICS (2% Sol.)
–
• Generics– Pilocarpine
Hydrochloride
Drugs to Increase the Outflow
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All miotics are packed in green cap bottles
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ManagementManagement
MedicalMedical
-Topical -Topical
-Systemic-Systemic
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MedicalMedicalSystemicSystemic
Carbonic anhydrase inhibitors
Hyperosmotic agents
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GenericsGenerics– AcetazolamideAcetazolamide
(250 mg tabs, 500mg caps, (250 mg tabs, 500mg caps,
500 mg IV solution)500 mg IV solution)
Usage:Usage:– 1-2 times daily1-2 times daily
BrandsBrands– DiamoxDiamox
Glaucoma DrugsGlaucoma Drugs
Carbonic Anhydrase Inhibitors Carbonic Anhydrase Inhibitors (CAI’s)(CAI’s)
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• Ocular:– Allerg conjunctivitis
Systemic:*Tingling sensation of
hands & feet*Steven-johnson sx*Renl stone *GIT– Headache / fatigue– Dry mouth– Dec. libido,– Depression
Glaucoma Drugs – Side Effects
Carbonic Anhydrase Inhibitors (CAI’s)
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Glaucoma DrugsGlaucoma Drugs
Osmotic AgentsOsmotic Agents
Increased serum osmolarity..drawing fluid out of Increased serum osmolarity..drawing fluid out of the vit across vascular barriers.the vit across vascular barriers.
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GenericsGenerics– Glycerol Glycerol (oral liquid)(oral liquid)
– Mannitol Mannitol (20% IV Sol.)(20% IV Sol.)
Glaucoma DrugsGlaucoma Drugs
Osmotic AgentsOsmotic Agents
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SurgicalSurgical
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--TrabeculectomyTrabeculectomy
-Tube-shunt surgery-Tube-shunt surgery
-Cyclodestructive procedures-Cyclodestructive procedures
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DefinitionEpidemiology Anatomy & physioPOAGACGSecondary glaucoma