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GLAUCOMA
PRESENTATION BY SHALAKYA-TANTRA DEPARTMENT

A SILENT KILLER

The healthy eye

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Light rays enter the eye through the cornea, pupil and lens. These light rays are focused directly onto the retina, the light-sensitive tissue lining the back of the eye. The retina converts light rays into impulses; sent through the optic nerve to your brain, where they are recognized as images.
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D R A F T
From www.ahaf.org

D R Major types are open angle and closed angle Differences among various types of glaucoma A complicate the nomenclature F Glaucoma is commonly associated with elevated intraocular pressure (IOP), but the disease can occur in Tthe context of normal IOP

What is glaucoma?

Optic neuropathy that is the leading cause of irreversible blindness in the world

Our understanding and treatment of the disease is very focused on IOP

What is glaucoma?

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Disease of the optic nerve.

When damage to the optic nerve fibers occurs, blind spots develop; blind spots usually go undetected until optic nerve is significantly damaged.

Normal vision

Leading cause of blindness in the asian continent, especially for older people.

Early detection and treatment are keys to preventing vision loss from glaucoma.
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Vision as it might be affected by glaucoma

Anatomy of glaucoma

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Clear liquid called aqueous humor circulates inside the front portion of the eye.

To maintain a healthy level of pressure within the eye, a small amount of aqueous humor is produced constantly, while an equal amount flows out of the eye through a microscopic drainage systemthe trabecular meshwork.
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Anatomy of glaucoma

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With glaucoma, aqueous humor does not flow through the trabecular meshwork properly.

Over time, intraocular pressure IOP increases, damaging the optic nerve fibers.

Classification of Glaucoma:

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1.
1. 2.

Primary glaucoma: Chronic open angle Acute and chronic closed angle Congenital glaucoma:
1. 2. 3.

2.

Primary Rubella Seconday to other inherited ocular disorders (e.g. an-iridia; absense of iris) Secondary glaucoma (causes):

3.
1. 2. 3. 4. 5.

trauma Ocular surgery Associated with other ocular diseases (uveitis) Raised episcleral venous pressure Steroid induced

Primary Glaucoma:

D Is the iris: R NOT covering the Covering the A Trabecular meshwork Trabecular meshwork F OPEN angle glaucoma CLOSED angle glaucoma T

Types of glaucoma Open-angle

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Open-angle glaucoma
Trabecular meshwork becomes less efficient at draining aqueous humor. Intraocular pressure (IOP) builds up, which leads to damage of the optic nerve. Damage to the optic nerve occurs at different eye pressures among different patients. Typically, glaucoma has no symptoms in its early stages.

Open-angle glaucoma

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Open Angle Glaucoma

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Obstruction at the level of the trabecular meshwork Progressive loss of visual field over time from periphery to center Presence of hollowed out optic disc (cupping) due to retinal ganglion cell death Open anterior chamber angle Majority of patients have IOP > 21 mmHg, asymptomatic

From http://www.merckfrosst.ca/e/health/glaucoma/glaucoma/classify/h

rabecular meshwork is not covered)

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Open irido-corneal angle

Case 1

D Mr. S presents to you with diminished peripheral vision. R complains that he feels like the world is closing in on He him. He also that he has trouble looking at A all appearnotesbe surrounded by halos. You lights as they to perform fundoscopic and gonioscopic exam with tonometry and F diagnose glaucoma. T

The patient first loses the peripheral visual field then it progress to total blindness if left untreated.

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As fluids accumulates in the anterior chamber due to decreased drainage, intra-ocular pressure increases and cases damage to the optic nerve.

Types of glaucoma Open-angle

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Open-angle glaucoma is the most common form of the disease, is progressive and characterized by optic nerve damage. The most significant risk factor for the development and advancement of this form is high eye pressure. Initially, there are usually no symptoms, but as eye pressure gradually builds, at some point the optic nerve is impaired, and peripheral vision is lost. Without treatment, an individual can become totally blind.

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Glaucoma risk factors Open-angle

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Strong risk factors for open-angle glaucoma include:

High eye pressure (IOP) Family history of glaucoma Age 40 and older for African Americans Age 60 and older for the general population, especially Mexican Americans Thin cornea

Suspicious optic nerve appearance with increased cupping (size of cup, the space at the center of optic nerve, is larger than normal)

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Continued

Glaucoma risk factors Open-angle (cont)

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Additional risk factors for open-angle glaucoma include:

High myopia (severe nearsightedness) Diabetes Eye surgery or injury High blood pressure Use of corticosteroids (for example, eye drops, pills*, inhalers and creams)

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Types of glaucoma Closed-angle

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Closed-angle (or narrow-angle) glaucoma:

The drainage angle of trabecular meshwork becomes blocked by the iris. IOP builds up very fast. Symptoms include severe eye or brow pain, redness of the eye, decreased or blurred vision. Must be treated as a medical emergencymust visit ophthalmologist immediately. Closed-angle glaucoma

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Closed Angle Glaucoma

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Apposition of iris and trabecular meshwork Parasympatholytics (pupillary dilation) can precipitate attack Increase risk with age, increase in volume of lens Acute onset, patient complains of nausea, headache (rather than eye ache), malaise, general distress Requires immediate treatment

Types of glaucoma Closed-angle

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Closed-angle glaucoma may be acute or chronic. In acute closedangle glaucoma the normal flow of eye fluid (aqueous humor) between the iris and the lens is suddenly blocked. Symptoms may include severe pain, nausea, vomiting, blurred vision and seeing a rainbow halo around lights. Acute closed-angle glaucoma is a medical emergency and must be treated immediately or blindness could result in one or two days. Chronic closed-angle glaucoma progresses more slowly and can damage the eye without symptoms, similar to open-angle glaucoma.

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Glaucoma risk factors Closed-angle

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Closed-Angle Glaucoma

Age Family history Poor short-distance vision (farsightedness) Eye injury or eye surgery East Asian
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Acute angle closure glaucoma (cont.):

Symptoms: 1. The eyes becomes red and painful due to rapid increase in IOP.

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Acute angle closure glaucoma (cont.):

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2. Blurred vision; because the cornea becomes edematous.

Acute angle closure glaucoma (cont.):

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3. Patient may notice haloes (circles of light) around light due to dispersed light in waterlogged cornea.

Types of glaucoma

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Normal-Tension Glaucoma
Cardiovascular disease Family history of glaucoma Japanese ethnicity Low eye pressure IOP

Normal-tension glaucoma occurs when eye pressure is normal, yet the optic nerve is damaged and peripheral vision is lost. Lowering eye pressure through medication sometimes slows the progress of the disease, but this type of glaucoma may worsen despite low pressure. Treatment is generally the same as for open-angle glaucoma with high eye pressure.
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Types of Glaucoma

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Congenital glaucoma affects infants born with defects that prevent the normal drainage of fluid from the eye. Juvenile glaucoma is open-angle glaucoma that affects children, adolescents and young adults. Secondary glaucoma can be open-angle or closed-angle, and is the result of some other medical condition in the eye or the body.

Examples of secondary glaucoma include: Pigmentary glaucoma, a rare form, in which pigment granules from the iris flake off into the eye fluid (aqueous humor) and clog the eyes drainage system (trabecular meshwork). Pseudoexfoliation Syndrome occurs when white material appears to flake off the lens of the eye and block normal flow of the aqueous humor. Neovascular glaucoma occurs when abnormal blood vessel growth blocks the eyes fluid drainage channels and leads to increased eye pressure. This abnormal growth can be caused by low blood supply to the eye due to diabetes, insufficient blood flow to the head because of blocked neck arteries, or blood vessel blockage in the back of the eye. Iridocorneal Endothelial Syndrome (ICE) has a number of features, including the breaking off of cells from the cornea, which blocks the drainage channels in the eye and leads to increased eye pressure. Scars may also connect the iris to the cornea.

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BOTTOM LINE: IOP from Aqueous Outflow, 3 Sites

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1. Obstructed Trabecular Mesh Open Angle: Age-related, genetic Closed Angle: Anatomic, exacerbated by: 2. Pupillary Block

1 2 3
Modified from: Wood et al. NEJM 339:1298 (1998)

Dilation of pupil iris flattens, flow via pupil, iris forward iris-cornea angle 3. Swelling of Ciliary Body

SIDENOTE:
WHY WOULD YOU WANT TO DILATE MRS. Ps PUPILS WITH PHENYLEPHRINE VS. AN ANTICHOLINERGIC?

Detecting Glaucoma

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Regular glaucoma check-ups include two routine eye tests: 1. Tonometry eye pressure test for measuring IOP 2. Ophthalmoscopy/Fundoscopy is a test that allows a health professional to
see inside the back of the eye (called the fundus) and other structures using a magnifying instrument (ophthalmoscope) and a light source.

Additional tests: Perimetry (the perimetry test is also called a visual field test) Gonioscopy is a painless eye test that checks if the angle where the iris
meets the cornea is open or closed, showing if either open angle or closed angle glaucoma is present.

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Detecting Glaucoma

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Tonometry:
The tonometry eye test measures the inner pressure of the eye also known as Intraocular Pressure or IOP.

Tonometry is carried out by an instrument called a TONOMETER.

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Types of Tonometry:
Applanation tonometry measures intraocular pressure either by the force required to flatten a constant area of the cornea (e.g. Goldmann tonometry) or by the area flattened by a constant force.

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Goldmann tonometer: Stationary device requires anesthesia drops, requires contact with cornea and is attached to a slit lamp usually is used by an Ophthalmologist.
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Types of tonometry

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non-contact tonometry or air-puff tonometry:

This type of tonometer uses a rapid air pulse to applanate the cornea. Intraocular pressure is estimated by detecting the force of the air jet at the instance of applanation.

In most cases a stationary unit, Does not require anesthetic drops

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Schiotz Tonometer

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Indentation (Schiotz) tonometry

D The pressure in your eye is measured by how much weight is R needed to flatten your cornea. This test is not as accurate as applanation tonometry and is A not used very much by ophthalmologists and optometrists. F T

This type of tonometry uses a plunger to gently push on your cornea.

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Types of tonometry

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Tono-pen - is a portable electronic, digital pen-like instrument that determines IOP by making contact with the cornea, after use of topical anesthetic eye drops tip covers are used between the patients.

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Types of tonometry

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The newest Advancement in tonometry is DIATON TONOMETER It measures intraocular pressure (IOP) through the Eyelid.
Diaton Tonometer is intended for use by Inpatient & Outpatient Clinics such as Hospitals, Emergency Rooms, Nursing & Elderly Homes, General & Specialty Practitioners as well as Ophthalmologists and Optometrists.

DIATON Requires No Contact with Cornea No Anesthetic Drops, No Risk of Infecting

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Diaton Tonometry

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Safe Quick Efficient Painless Noninvasive

Can be used on Children and Adults

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Four Key Facts About Glaucoma

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Glaucoma is a leading cause of blindness

Glaucoma can cause blindness if it is left untreated. And unfortunately approximately 10% of people with glaucoma who receive proper treatment still experience loss of vision.

There is no cure (yet) for glaucoma

Glaucoma is not curable, and vision lost cannot be regained. With medication and/or surgery, it is possible to halt further loss of vision. Since glaucoma is a chronic condition, it must be monitored for life. Screening, detection and prevention is the first step to preserving your vision.

Everyone is at risk for glaucoma

Everyone is at risk for glaucoma from babies to senior citizens. Yes, older people are at a higher risk for glaucoma but babies can be born with glaucoma (approximately 1 out of every 10,000 babies born in the india). Young adults can get glaucoma, too. African-Americans in particular are susceptible at a younger age.

There may be no symptoms to warn you

With open angle glaucoma, the most common form, there are virtually no symptoms. Usually, no pain is associated with increased eye pressure. Vision loss begins with peripheral or side vision. You may compensate for this unconsciously by turning your head to the side, and may not notice anything until significant vision is lost. The best way to protect your sight from glaucoma is to get tested. If you have glaucoma, treatment can begin immediately.

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Diagnosis and Management of Primary Open Angle Glaucoma

D hypertension can be defined as IOP greater than Ocular 21mmHg where the optic disc and visual field are normal. R The Baltimore Eye Survey, found 6.6% of people had an intraocular pressure greater than 22mmHg in one or both eyes. A F T
Ocular Hypertension

REVIEW: Autonomic NS Effect on the Eye

RECEPTOR ACTIVATION WILL: TO LOWER IOP, AIM FOR:

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IRIS, Circular Fibers IRIS, Radial Fibers CILIARY MUSCLES

mAchR : Constrict Pupil 1 R 2 R : Dilate Pupil : Relax for Far Vision

Activity Activity Activity

mAchR : Contract for Accomodation Activity

TREATMENT RATIONALE

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LOWER IOP BY: (1) Decreasing Production of Aqueous Humor (2) Increasing Outflow of Aqueous Humor

Focus on Pharmacologic Rx: First-line

DRUGS THAT DECREASE AQUEOUS PRODUCTION I. Beta-Blockers [levobunolol, timolol, carteolol, betaxolol] -Mechanism: Act on ciliary body to production of aqueous humor -Administration: Topical drops to avoid systemic effects -Side Effects: Cardiovascular (bradycardia, asystole, syncope), bronchoconstriction (avoid with 1-selective betaxolol), depression I. Alpha-2 Adrenergic Agonists [apraclonidine, brimonidine] -Mechanism: production of aqueous humor -Administration: Topical drops -Side Effects: Lethargy, fatigue, dry mouth [apraclonidine is a derivative of clonidine (antihypertensive) which cannot cross BBB to cause systemic hypotension] I. Carbonic Anhydrase Inhibitors [acetazolamide, dorzolamide] -Mechanism: Blocks CAII enzyme production of bicarbonate ions (transported to posterior chamber, carrying osmotic water flow), thus production of aqueous humor -Administration: Oral, topical -Side Effects: malaise, kidney stones, possible (rare) aplastic anemia

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DRUGS THAT INCREASE AQUEOUS OUTFLOW

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I.

Nonspecific Adrenergic Agonists [epinephrine, dipivefrin] -Mechanism: uveoscleral outflow of aqueous humor -Administration: Topical drops -Side Effects: Can precipitate acute attack in patients with narrow iriscorneal angle, headaches, cardiovascular arrhythmia, tachycardia

I.

Parasympathomimetics [pilocarpine, carbachol, echothiophate] -Mechanism: contractile force of ciliary body muscle, outflow via TM -Administration: Topical drops or gel, (slow-release plastic insert) -Side Effects: Headache, induced miopia. Few systemic SE for direct-acting agonists vs. AchE inhibitors (diarrhea, cramps, prolonged paralysis in setting of succinylcholine). Why isnt Ach used? I. Prostaglandins [latanoprost] -Mechanism: May uveoscleral outflow by relaxing ciliary body muscle -Administration: Topical drops -Side Effects: Iris color change

Commonly prescribed Anti-glaucoma Eye Drops

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Beta-blockers Timoptol (Timolol maleate), Levobunolol (Betagan) Betaxalol ( Betoptic ) Carteolol ( Teoptic)

Other Common Medications Brimonidine (Alphagan) Dorzolamide (Trusopt) Latanaprost (Xalatan) Pilocarpine Dipivefrin (Propine)

Initial IOP Life expectancy Ethnicity Extent of optic nerve damage Compliance A target IOP should be determined. This represents the IOP aimed for following therapy. For example, a patient with advanced glaucomatous optic neuropathy may require a target IOP of 12 mmHg.

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Factors to consider in glaucoma management include-

Diagnosis and Management of Primary Open Angle Glaucoma

D . R A useful clinical concept is that each eye treated for glaucoma has a target pressure, this is based upon a A general assessment of each individual patients disease burden. F T 30% to 50% reduction of the pressure at which
Target Pressure damage occurs ?

Rx GLAUCOMA: ADDITIONAL CONSIDERATIONS

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1. No single medication can be used in all patients 2. Compliance - Critical: Rx often requires several agents, multiple times a day, everyday - Role of slow-release drug delivery devices (Langer) 1. Non-pharmacologic ways to lower IOP: - Laser (argon laser trabeculoplasty) - aqueous outflow, loses effectiveness over time - Surgical (trabeculectomy) - Creates alternative path for aqueous outflow - Only definitive therapy for closed angle 1. Effectiveness of Rx measured by ability to lower IOP, but other factors may be (more) important: - Neuroprotection/increased blood flow to optic nerve

Statistics About Glaucoma

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It is estimated that over 4 million indians have glaucoma but only half of those know they have it. (1) Approximately 120,000 are blind from glaucoma, accounting for 9% to 12% of all cases of blindness in india. About 2% of the population ages 40-50 and 8% over 70 have elevated IOP. Glaucoma is the second leading cause of blindness in the world, according to the World Health Organization. Glaucoma is the leading cause of blindness among indians. Other high-risk groups include: people over 60, family members of those already diagnosed, diabetics, and people who are severely nearsighted. Estimates put the total number of suspected cases of glaucoma at around 65 million worldwide. (5)

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Statistics About Glaucoma cont Prevent Blindness America Survey found that:
Blindness ranked third (after cancer and heart disease) as peoples major fear. 20% of people knew that glaucoma was related to elevated pressure within the eye. Most of them mistakenly thought people could tell if they had glaucoma due to symptoms, or that it was easily cured, or that it did not lead to blindness. 50% had heard of glaucoma, but werent sure what it was. 30% had never heard of glaucoma.

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Statistics About Glaucoma

Economic Impact: Glaucoma accounts for over 7 million visits to physicians each year. (1) In terms of Social Security benefits, lost income tax revenues, and health care expenditures, the cost to the indian government is estimated to be over $2.5 billion annually.

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Statistics About Glaucoma

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60 million INDIANS are at RISK for developing Glaucoma,

as per AIIMS,DELHI UNIVERSITY, Department of Ophthalmology.

In INDIA - there are ONLY: 17,000 Ophthalmologists & 30,000 Optometrists

There is a great NEED for ADDITIONAL screening locations

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Glaucoma Prevention Initiative

D R Thank you for your attention and your openness to challenge the silent thief of sight! A LETS US KILL THIS SILENT KILLER!!! F T
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