Academic year 2024-2025 (5th stage)

Special sense block – Ophthalmology lectures

Lecture: GLAUCOMA

Lecturer: Dr. Wisam Jasim Al Shereefy

Block staff:

Dr. Ahmed M. Al Samak

Dr. Mohammed Abdulelah Al ashoor
Dr. Wisam Jasim Al Shereefy

references:
• AAOO 2020-2021 - GLAUCOMA
• KANSKI CLINICAL OPHTHALMOLOGY 2020
Learning objectives:
• Definition
• Physiology of Aqueous humour secretion and drainage
• Epidemiology
• diagnosis
• Classification
• management
 Glaucoma
is Leading cause of irreversible visual loss
Definition
• group of progressive optic neuropathies characterized by an
excavated appearance of the optic disc, often described as cupped ,
together with loss of retinal ganglion cells and their axons and
corresponding vision loss. Intraocular pressure is a key modifiable
factor
Aqueous production
Aqueous humour is produced from plasma by the ciliary
epithelium of the ciliary body pars plicata(ciliary processes),
using a combination of active and passive secretion
 Aqueous outflow
The trabecular meshwork is a sieve-like structure at the angle of the
anterior chamber (AC) through which 90% of aqueous humour leaves
the eye.
It has three components
○ The uveal meshwork
○ The corneoscleral meshwork
○ The juxtacanalicular (cribriform) meshwork
• The Schlemm canal is a circumferential channel within the
perilimbal sclera.. It contains the openings of collector channels, and
connect directly or indirectly with episcleral veins.
Aqueous humor secretion and drainage
• Trabecular outflow (90%): trabeculum … Schlemm canal
… episcleral veins. It is a pressure-sensitive route so that
increasing IOP will increase outflow.
• Uveoscleral drainage (10%):..
Anterior chamber of eyeball
• between the iris and the cornea's innermost surface and filled
with aqueous humor.

• the depth of AC varies between 1.5 and 4.0 mm, averaging

3.0 mm. It tends to become shallower at older age and in
eyes with hypermetropia (far sightedness)
epidemiology
• Glaucoma affects more than 70 million people
worldwide with approximately 10% being bilaterally
blind, making it the leading cause of irreversible
blindness in the world.
• Glaucoma affects 2–3% of people over the age of 40
years, but up to 50% may be undiagnosed.
Diagnosis

➢Symptoms..??
➢Exam:
❑IOP ?
❑Glaucomatous optic nerve damage.
❑Characteristic visual field loss as damage progresses.
❑ Absence of signs of non-glaucomatous cause for the optic neuropathy.
❑Retinal nerve fibre layer thinning.
 classification
I. Open Angle
A. Primary open-angle glaucoma
Normal-tension/juvenile glaucoma

B. Secondary open-angle glaucoma

1. Pseudoexfoliation glaucoma
2. Pigmentary glaucoma
3. Traumatic glaucoma
4. Steroid-induced glaucoma
5. Lens associated EX. Phacolytic glaucoma (leaked lens proteins
obstruct TM)
2.Angle Closure

A.Primary angle closure ( suspect/closure/glaucoma)

B. Secondary angle-closure glaucoma Ex : phacomorphic glaucoma

• Classification of Pediatric Glaucoma
• Primary pediatric glaucoma

• Secondary pediatric glaucoma

PRIMARY OPEN-ANGLE GLAUCOMA

➢Most common
➢In those older than 70 years of age the prevalence of
POAG has been reported to be 6% in white
populations, 16% in black populations and around
3% in Asian populations.
➢ It affects both genders equally
C/F:

• Asymptomatic.
• Triad of .. Inctreased iop..optic disc damage..vf changes
• open anterior chamber angle.
Examination
Visual acuity (VA) is likely to be normal except in advanced glaucoma.

Pupils. Exclude (RAPD)

Colour vision assessment such as Ishihara chart testing if there is any suggestion of an optic neuropathy other
than glaucoma.

Slit lamp examination. Exclude features of secondary glaucoma such as pigmentary and pseudoexfoliation.

Tonometry .
Pachymetry.
Gonioscopy.
Optic disc examination
Risk factors

• IOP. The higher the IOP, the greater the likelihood of Glaucoma
• Age..
• Race.
• Family history of POAG. First-degree relatives
• Diabetes mellitus
• Myopia
• Contraceptive pill
• Vascular disease. HT, cardiovascular disease, DM and vasospastic
conditions such as migraine
Benefit of IOP Reduction
• Its estimated that each 1-mm-Hg decrease in IOP was
associated with a roughly 10% reduction in the risk of visual
field or optic disc progression
• Once the decision begins; medical treatment is made,
• the goal is : to reduce progression risk by preventing, or at least
slowing, glaucomatous damage to the optic nerve.
• To this day, lowering intraocular pressure (IOP) has been the
only means to accomplish this goal, regardless of the stage of
the disease(medically,surgically, or both)
Glaucoma management
 Classification
Anti glaucoma drops
Pilocarpine Eye drop

timolol Eye drop

Brimonidine eye drop

dorzolamide Eye drop

latanoprost
Non pharmaceutical treatment of glaucoma include
❑ laser therapies

❑ surgery involving
❑ Migs
❑ trabeculectomy
❑ valves devices,
typically performed when initial medical therapy fails. Untreated glaucoma can cause
progressive visual loss potentially leading to blindness
 PRIMARY ANGLE-CLOSURE GLAUCOMA

❑occlusion of the trabecular meshwork by the

peripheral iris, obstructing aqueous outflow.

❑PACG may be responsible for up to half of all cases

of glaucoma globally and is common in Asia.
❑It progresses rapidly and is more likely to result in
visual loss than POAG
Clinical features:
❑ intermittent symptoms .. blurring (‘smoke-filled room’) and haloes
(‘rainbow around lights’) due to corneal epithelial oedema

❑ acute symptoms :
➢ decreased vision
➢ redness and ocular/periocular pain/headache.
➢ Abdominal pain and other gastrointestinal symptoms may occur

❑ Asymptomatic: including most of those with intermittently or

chronically elevated IOP.
 Signs:
❑ VA is usually 6/60 to HM.
❑ IOP …very high (50–80 mmHg).
❑ Conjunctival hyperaemia
❑ Corneal epithelial oedema
❑ AC is shallow
❑ non-reactive mid-dilated vertically oval pupil is
classic
❑ fellow eye typically shows an occludable angle.
Precipitating/risk factors

❖Age/race/family history /Hypermetropes

❖Shallow ac ,precipitated by :
❑watching television in a darkened room
❑pharmacological mydriasis
❑adoption of a semi-prone position (e.g. reading)
❑acute emotional stress
 Treatment:
❑supine position to encourage the lens to shift posteriorly.
❑Mannitol 20% 1–2 g/kg intravenously over 1-hour
❑Acetazolamide
❖ 500 mg is given intravenously if IOP >50 mmHg and orally if
IOP is <50 mmHg.
❖Contraindications :
1. sulfonamide allergy
2. angle closure secondary to topiramate or other sulfonamide
derivatives.
❑ A single dose of apraclonidine 0.5% or 1%, timolol 0.5% and
dexamethasone 0.1%, leaving 3–5 minutes between each.
❑Pilocarpine 2% one drop to the affected eye, repeated after half an hour

❑ Analgesia and an antiemetic.

❑Early laser iridotomy or iridoplasty after clearing corneal oedema

❑Surgical options: peripheral iridectomy, lens extraction, goniosynechialysis,

trabeculectomy and cyclodiode laser treatment.
 PRIMARY CONGENITAL GLAUCOMA
➢incidence of 1: 10000
➢Boys are more commonly affected than girls
➢caused by impaired aqueous outflow due to
maldevelopment of the anterior chamber angle
(trabeculodysgenesis)
➢usually sporadic, 10% are inherited in an AR

• True congenital glaucoma (40%) in which IOP is elevated

during intrauterine life.
• Infantile glaucoma (55%) which manifests prior to age 3.
• Juvenile glaucoma, the least common, in which IOP rises
between 3 and 16 years of age.
Diagnosis

Evaluation under general anaesthesia is generally required.

❖High iop
❖corneal haze, large or asymmetrical eyes , watering, photophobia or
blepharospasm
❖Haab striae
❖buphthalmos
❖Optic disc cupping
 Treatment
❖ Goniotomy
❖ Trabeculotomy
❖ Other procedures when angle surgery fails include trabeculectomy, tube shunt implantation
❖ Amblyopia and refractive error