Glaucoma presentation for ophthalmology course, presented as a student seminar. Class location: ophthalmology unit, An-Najah National University Hospital.

1. Hasan Arafat
Glaucoma ‫األسود‬ ‫الماء‬ ‫أو‬ ‫األزرق‬ ‫الماء‬ ،‫رق‬َّ‫الز‬

2. Introduction
• Glaucomas are a group of disease;
• All of these diseases cause damage to the optic nerve
head;
• Axon loss results in visual field defects and decreased
visual acuity.

3. Anatomy & Physiology
• IOP is determined by a balance between
production and removal of aqueous
humor
• Aqueous is actively secreted into the
posterior chamber by the ciliary
processes
• It then passes through the pupil into the
anterior chamber and leaves the eye
• Aqueous drains through two pathways

4. Glaucoma and Blindness
• Glaucoma is the second most common cause of
blindness, two theories exist:
 Raised intraocular pressure causes mechanical damage to the
axons
 Raised intraocular pressure causes ischemia of the nerve axons by
reducing blood flow at the nerve head

5. Classification: Primary Glaucoma
• The mechanism by which aqueous
drainage is reduced provides a
means to classify the glaucoma:
 clear of the trabecular meshwork
(open angle glaucoma);
 covering the meshwork (closed angle
glaucoma).

6. Open-Angle Glaucoma
• The trabecular meshwork is normal structurally
• Functionally, the meshwork shows increased resistance
to aqueous outflow
• Causes:
 Thickening in the trabecular lamellae (reduced pore size);
 reduction in the number of lining trabecular cells;
 increased extracellular material in the trabecular meshwork spaces.
• Normal tension/low tension glaucoma
• Ocular hypertension

7. Open Angle Glaucoma
History
 Symptoms depend on the rate in
which IOP rises
 Usually symptomless
 The patient might present after they
notice a visual deficit
 Usually discovered by chance by an
optometrist
Examination
 White eye, clear cornea
 Measure the IOP using a tonometer
 Measure the corneal thickness using
a pachymeter
 Examine the iridocorneal canal using
a gonioscopy
 Examine the optic disc and identify
pathologic cupping
 Exclude secondary causes

8. • Goldman Tonometer • Pachymeter

9. Gonioscope

10. Open-Angle Glaucoma
Medical Treatment
• Topical Agents
 β-blockers
 Parasympathomimetics
 Sympathomimetic
 α-2 agonists
 Carbonic Anhydrase Inhibitors
 Prostaglandin Analogues
• Systemic Agents
 Carbonic Anhydrase Inhibitors
Surgical Treatment
• Trabeculectomy
• Laser Trabeculoplasty

11. Open-Angle Glaucoma
Trabeculectomy Procedure Trabeculectomy Bleb

12. Closed-Angle Glaucoma
• Occurs in small eyes (hypermetropes/Asians) due to
their shallow anterior chamber
• Increased resistance to aqueous flow increases the pre
ssure in the posterior chamber
• Pressure pushes the iris forward, obstructing aqueous
outflow
• Long standing contact between the iris and the
drainage angle leads to peripheral anterior synechiae

13. Closed-Angle Glaucoma
• Impaired drainage increases IOP
• Increased pressure deprives the entire cornea of
nutrition and the posterior cornea from oxygen
• This leads to clouding of the cornea and pressure on
the optic nerve, leading to decreased vision
• Usually preceded by subacute attacks, in which the
patient experiences increased IOP, headache and
colored halos around light

14. Closed-angle glaucoma affects Asians because of their naturally
small eyes

15. Closed-Angle Glaucoma
History
 Photophobic, very painful eye
 Watering of the eye
 Loss of vision
 N/V, referred abdominal pain
Examination
 Visual acuity is reduced
 Red eye
 Cloudy cornea
 Oval, dilated, fixed pupil

16. Closed-Angle Glaucoma
Treatment
• Combined medical and surgical, must be urgent
 Acetazolmide (IV & oral)
 Topical pilocarpine and β-blockers
 Iridotomy/ iridectomy
 +/- a procedure to relieve PAS

17. Secondary Glaucoma
• Caused by obstruction of the trabecular meshwork
Meshwork abnormalities
Hyphema
Uveitis
Pigment dispersion syndrome
Pseudoexfoliative glaucoma
Steroid-induced glaucoma
Angle abnormalities
 Angle recession (trauma)
 Uveitis
 Large choroidal melanoma
 Cataract
 Rubeosis iridis

18. Secondary Glaucoma
Treatment
• Depends on the primary cause
• In refractory cases, ablation of the ciliary processes
might be required, this is performed using laser or
cryoprobe to the sclera overlying the area of choice

19. Congenital Glaucoma
• The cause of congenital glaucoma remains uncertain
• One view is that the iridocorneal angle is
developmentally abnormal and covered with a
membrane which increases the outflow resistance

20. Congenital Glaucoma
• S/Sx
 excessive tearing, photophobia and blepharospasm;
 an increased corneal diameter and enlargement of the globe (buphthalmos),
 resulting in progressive myopia;
 a cloudy cornea due to epithelial and stromal edema;
 splits in Descemet’s membrane.

21. Congenital Glaucoma
Treatment
• Surgical treatment
 Goniotomy
 Trabeculotomy

22. A child with congenital glaucoma

23. Prognosis of Glaucoma