The information I think medical students and general practitioners should know about glaucoma

1. What a general practitioner
should know about
Glaucoma
Dr. Anthony
20 Dec, 2013

2. Glaucoma
What is it?
Glaucoma – is a disease of
optic nerve. It may have a
classical sign – elevated
intraocular pressure.

3. Glaucoma
Why is it important for
you?
Glaucoma eventually leads
to irreversible blindness if
uncontrolled

4. Glaucoma
Who has glaucoma?

5. 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.

6. 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.

7. Glaucoma
What are the types of
glaucoma? (1)
There are two major types:
-open angle glaucoma
-angle-closure glaucoma

8. Anatomical basics of
glaucoma
Reminder of normal anatomy

9. Glaucoma
What is the nature of
this disease?
Of many types of glaucoma –
primary open angle
glaucoma is the most
common

10. Glaucoma
What is the nature of
this disease?
The pathogenesis of the
primary open angle
glaucoma can be described
like this:

11. Glaucoma
The nature of the disease

12. Glaucoma
Actually, the
same goes for
open-angle
glaucoma...
The nature of the disease

13. Glaucoma
The simple classic explanation of the nature of the disease

14. Glaucoma
So what is the difference
between two major types?
The level of aquous humor
blockage... In angle-closure type
trabecular meshwork is not
available for humor. In open angle
it is available, though working
badly and sadly.

15. 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.

16. Glaucoma
Angle-closure glaucoma scheme

17. Glaucoma
Classification of
glaucoma
1) open angle / angle-closure

18. 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!)

19. Glaucoma
What are the types of
glaucoma? (2)
Chronic glaucoma is totally
unremarkable for a physician
and inconspicuous for a
patient

20. 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.

21. Glaucoma
Types of glaucoma – acute glaucoma attack

22. Glaucoma
Classification of
glaucoma
1) open angle / angle-closure
2) chronic / acute

23. Glaucoma
What are the types of
glaucoma? (3)
Glaucoma can be either
congenital, or acquired

24. Glaucoma
Congenital glaucoma - buphtalmos

25. Glaucoma
Congenital glaucoma - buphtalmos

26. Glaucoma
Classification of
glaucoma
1) open angle / angle-closure
2) chronic / acute
3) congenital / acquired

27. Glaucoma
What are the types of
glaucoma? (4)
Glaucoma is always either
primary or secondary

28. 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.

29. 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

30. 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-weber
syndrome), carotid-cavernous fistula, trauma
(recession of angle), medications (steroids!)

31. Glaucoma
Secondary open angle glaucoma – phacolytic

32. Glaucoma
Secondary open angle glaucoma – hyphema

33. Glaucoma
Secondary open angle glaucoma – bilateral sturge-weber syndrome

34. Glaucoma
Secondary open angle glaucoma – pseudoexfoliation syndrome

35. Glaucoma
What are the types of
glaucoma? (4)
Secondary angle-closure
glaucoma reasons: iridocorneal
synechiae (iridocyclitis),
subluxation of a lens, tumors

36. Glaucoma
Secondary angle-closure glaucoma – posterior synechiae of iris

37. 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

38. Glaucoma
Classification of
glaucoma
1)
2)
3)
4)
open angle / angle-closure
chronic / acute
congenital / acquired
primary / secondary

39. Glaucoma
What are the signs of
this disease?
Chronic glaucoma at the
beginning is clinically
irrelevant

40. 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

41. Glaucoma
What are the signs of
this disease?
Any damage to optic nerve
(including glaucoma)
inevitably leads to visual
field defect

42. Glaucoma
Visual field deterioration during the glaucoma progression

43. Glaucoma
What are the signs of
this disease?
False! Typically patients do
not notice these kinds of
defects, if notice any at all!

44. 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

45. 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

46. Glaucoma
What is the diagnostics?
1)
2)
3)
4)
5)
6)
assess family history! Any blinds? Glaucoma is
inheritable!
check visual acuity
check intraocular pressure (at least by palpation!)
check pupillary reactions (are pupils reactive? are
the reactions symmetric?)
perform ophthalmoscopy (if available)
perform confrontational visual field test

47. Intraocular pressure sometimes
makes the eye “hard as a stone”.
Just touch each eyes with two fingers, palpate it.
Glaucoma
Visual field deterioration during the glaucoma progression

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

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

50. Glaucoma
What we do in eye
clinics
1)
2)
3)
4)
5)
Basic ophthalmological exam (visual acuity, intraocular
pressure, external exam)
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)
In certain cases we must perform automated visual field
test with computer
We can perform tomography of optic nerve disc, if optic
tomograph is available
We make an appointment! We see if our treatment
works.

51. Glaucoma
Tonometry with schiotz
tonometer
Ophthalmoscopy. There’s only one disc of optic nerve that is normal here.

52. Glaucoma
Tonometry with slit lamp Goldmann tonometer

53. Glaucoma
Gonioscopy with slit lamp and four-mirror contact lens

54. 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.

55. Glaucoma
How can we stop this
blinding condition?
We use medications (in acute
glaucomas – acetazolamide
p/o; mannitol i/v; in chronic
glaucomas – timolol and
latanoprost eyedrops)

56. Glaucoma
How can we stop this
blinding condition?
In case medications failed to
stabilize the process – we
move forward to laser or
surgical treatment.

57. 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.

58. 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.
Any questions?