1. PRIMARY OPEN ANGLE GLAUCOMA
PROF.DR.ÖZCAN OCAKOĞLU

2. HISTORICAL ASPECTS
THE GLAUCOMA TERM IS DERIVED FROM THE OLD GREEK WORD “GLAUKOS” WHICH MEANS “GREYISH-BLUE”
HIPPOCRATES DEFINED GLAUCOMA AS “A DISEASE OF THE ELDERLY PATIENTS IN WHICH THE PUPILLA BECOMES BLUE”.
A PERSON WITH A SWOLLEN CORNEA AND A RAPIDLY DEVELOPING CATARACT AND CHRONIC (LONG-TERM) ELEVATED PRESSURE INSIDE THE EYE
c. 460 BC–c. 380 BC

3. WHAT IS THE INTRAOCULAR PRESSURE?
PRESSURE INSIDE THE EYE IS TERMED ”INTRAOCULAR PRESSURE (IOP)”
EYE PRESSURE IS MEASURED IN MILLIMETERS OF MERCURY (mmHg)
“NORMAL EYE PRESSURE” IS NOT A STABLE NUMBER(S), IT RANGES FROM 10 to 21 mmHg
ELEVATED IOP IS AN EYE PRESSURE OF “GREATER THAN 21 mmHg”

4. WHAT IS GLAUCOMA?
CURRENTLY, GLAUCOMA IS DEFINED AS “A PROGRESSIVE OPTIC NEUROPATHY WHICH CAUSES PERMANENT BLINDNESS BY DAMAGING THE OPTIC NERVE AND THE PERIFERIC VISUAL FIELD”
GLAUCOMA AFFECTS 3% OF THE SOCIETY AND THE SECOND FREQUENT REASON OF PERMANENT BLINDNESS (ESPECIALLY IN DEVELOPED COUNTRIES).
THE PREVALANCE IS HIGHER IN ELDERLY POPULATION.

5. CLASSIFICATION OF GLAUCOMA
VARIOUS CLASSIFICATIONS ARE AVAILABLE.
MANY CLASSIFICATIONS ARE BASED ON ETIOLOGY, ANATOMY AND CLINICAL PRESENTATION.
CLASSIFICATION BY THE TIME OF ONSET IS AS;
CONGENITAL GLAUCOMAS
ACQUIRED GLAUCOMAS
PRIMARY GLAUCOMAS
SECONDARY GLAUCOMAS

6. CLASSIFICATION OF THE ACQUIRED GLAUCOMAS
PRIMARY OPEN ANGLE GLAUCOMA
NORMAL PRESSURE GLAUCOMA
OCULAR HYPERTENSION
PRIMARY ANGLE CLOSURE GLAUCOMAS
ACUTE ANGLE CLOSURE GLAUCOMA
SUBACUTE ANGLE CLOSURE GLAUCOMA
SECONDARY OPEN ANGLE GLAUCOMAS
PSEUDOEXFOLIATION GLAUCOMA
PIGMENTARY GLAUCOMA
PHACOLYTIC GLAUCOMA
SECONDARY TO OCULAR INFLAMMATION
SECONDARY TO HIGH EPISCLERAL VENOUS PRESSURE
SECONDARY TO STEROID THERAPY
SECONDARY ANGLE CLOSURE GLAUCOMAS
DUE TO PERIPHERAL ANTERIOR SYNECHIAE
SWOLLEN LENS OR PUPILLARY SECLUSION ANTERIOR MOVEMENT OF THE IRIS-LENS DIAPHRAGM
NEOVASCULAR GLAUCOMA
PLATEAU IRIS SYNDROME

7. PRIMARY OPEN ANGLE GLAUCOMA
POAG IS DESCRIBED AS OPTIC NERVE DAMAGE FROM MULTILP POSSIBLE CAUSES THAT IS CHRONIC AND PROGRESSES OVER TIME
A LOSS OF OPTIC NERVE FIBERS IS CHARACTERISTIC OF THE DISEASE
POAG CHARACTERISTICS ARE OPEN ANTERIOR CHAMBER ANGLE, HIGH INTRAOCULAR PRESSURE IN THE EYE ,VISUAL FIELD ABNORMALITIES AND CUPPING AND ATROPHY OF THE OPTIC DISC

8. POAG CAUSES ? RAISING THE IOP!! THE EXACT CAUSE OF POAG IS UNKNOWN
THE MOST IMPORTANT (AND WELL KNOWN) CAUSE OF POAG IS INCREASED IOP
THE CAUSE OF THE HIGH IOP IS GENERALLY ACCEPTED TO BE BECAUSE OF AN IMBALANCE IN THE PRODUCTION AND DRAINAGE OF FLUID IN THE EYE (AQUEOUS HUMOR)
THE FLUID IS CONTINUALLY BEING PRODUCED BUT CANNOT BE DRAINED BECAUSE OF THE IMPROPERLY FUNCTIONING DRAINAGE CHANNELS (CALLED TRABECULAR MESHWORK)
RAISING THE IOP!!

9. OUTFLOW PATHWAYS AND RESISTANCE POINTS

10. GLAUCOMATOUS DAMAGE
THE BASIS OF THE GLAUCOMATOUS DAMAGE IS THE LOSS OF RETINAL GANGLION CELLS.
THE GANGLION CELLS CONSTITUTING THE RETINAL NERVE FIBER LAYER AND THEIR AXONS DIE DURING THE GLAUCOMATOUS DAMAGE PROCESS.

11. SYMPTOMS
MOST CASES ARE ASYMPTOMATIC UNTIL THE VISUAL FIELD ABNORMALITIES BECOME PROMINENT AND AFFECT CENTRAL VISION.
THUS, ANNUAL ROUTINE EXAMINATION IS ESSENTIAL FOR EARLY DIAGNOSIS.

12. THE EVALUATION OF GLAUCOMA PATIENTS
VISUAL ACUITY (BEST CORRECTED)
BIOMICROSCOPY (CLUES TO SPESIFIC DIAGNOSIS...)
MEASUREMENT OF INTRAOCULAR PRESSURE
APPLANATION TONOMETRY (GOLDMANN)
NONCONTACT TONOMETRY
PACHYMETRY (CENTRAL CORNEAL THICKNESS)
EVALUATION OF THE ANTERIOR CHAMBER ANGLE (GONIOSCOPY)
VISUAL FIELD TESTING
FUNDUSCOPY

13. TONOMETRY
TONOMETRY IS A METHOD USED TO MEASURE THE PRESSURE INSIDE THE EYE
BECAUSE IOP VARIES FROM HOUR TO HOUR IN ANY INDIVIDUAL (DIURNAL VARIATION), MEASUREMENTS MAY BE TAKEN AT DIFFERENT TIMES OF DAY (MORNING AND NIGHT)
A DIFFERENCE IN PRESSURE BETWEEN MORNING AND NIGTH OF 5 mmHg OR MORE MAY SUGGEST GLAUCOMA
A DIFFERENCE IN PRESSURE BETWEEN THE TWO EYES OF 3 mmHg OR MORE MAY SUGGEST GLAUCOMA

14. THE TECHNIQUES OF IOP MEASUREMENTS
TonoPen XL Applanation Tonometer
                                                                                 
TonoPen XL Applanation Tonometer
                                                                                 
TonoPen XL Applanation Tonometer
                                                                                 
APPLANATION TONOMETRY
PERRKINS HAND
HELD TONOMETER
THE TECHNIQUES OF IOP MEASUREMENTS
SCHIOTZ TONOMETER
TONOPEN XL
NON CONTACT TONOMETER

15. PACHYMETRY
NORMAL CENTRAL CORNEAL THICKNESS IS VARIABLE MICRONS
THINNER CORNEA (CCT < 500 m) CAN GIVE FALSELY LOW PRESSURE READINGS
SEVERE GLAUCOMA PATIENTS MAY BE FAILED DIAGNOSE
A THICK CORNEA (>600 m) CAN GIVE FALSELY HIGH PRESSURE READINGS
UNNECESSARY TREATMENTS !!

16. GONIOSCOPY GONIOSCOPY IS PERFORMED TO CHECK
THE DRAINAGE ANGLE OF AN EYE
A SPECIAL CONTACT LENS(GONIOLENS)
IS PLACED ON THE EYE
THIS TEST IS IMPORTANT TO
DETERMINE IF THE ANGLES ARE OPEN,
NARROWED, OR CLOSED
OPEN ANGLE: LONG TERM,SLOWLY, INSIDIOUS DISEASE
CLOSE(OR NARROWED): RISK OF ACUT GLAUCOMA CRISIS
SL:SCHWALBE’S LINE
TM:TRABECULAR MESHWORK
SS:SCLERAL SPUR
CBB:CILIARY BODY BAND

17. VISUAL FIELD TESTING
VF TESTING TO CHECK THE PATIENTS PERIPHERAL VISION
TYPCALLY BY USING AN AUTOMATED VISUAL FIELD MACHINE
THIS TEST IS DONE TO RULE OUT ANY VISUAL DEFECTS DUE TO GLAUCOMA
VF DEFECTS MAY NOT BE APPERENT UNTIL OVER 40% OF THE OPTIC NERVE FIBER LAYER HAS BEEN LOST
VF TESTING MAY NEED TO BE REPEATED
A LOW RISK OF GLAUCOMATOUS DAMAGE, THE TEST MAY BE PERFORMED ONCE A YEAR
A HIGH RISK OF GLAUCOMATOUS DAMAGE, TEST MAY BE PERFORMED AS FREQUENTLY AS EVERY 2 MONTHS

18. DIFFERENT STAGES OF GLAUCOMATOUS VISUAL FIELD DEFECTS
AUTOMATED VISUAL FIELD ANALYZER
NORMAL VF
EARLY STAGE
MODERATE STAGE
END STAGE

19. OPTIC NERVE HEAD EXAMINATION
EACH OPTIC NERVE HEAD IS EXAMINED FOR ANY DAMAGE OR ABNORMALITIES
THIS MAY REQUIRE DILATION OF THE PUPILS TO ENSURE AN ADEQUATE EXAMINATION OF THE OPTIC NERVES
FUNDUS PHOTOGRAPHS,WHICH ARE PICTURES OF YOUR OPTIC DISC ARE TAKEN FOR FUTURE REFERENCE AND COMPARISON
DIFFERENT IMAGING STUDIES MAY BE CONDUCTED TO DOCUMENT THE STATUS OF OPTIC NERVE AND TO DETECT CHANGES OVER TIME

20. FUNDOSCOPIC CHANGES
NORMAL OPTIC DISC
GLAUCOMATOUS OPTIC DISCS

21. CONFOCAL SCANNING LASER OPHTHALMOSCOPY
NORMAL OD
GLAUCOMATOUS OD
HEIDELBERG RETINA TOMOGRAPHY

22. NORMAL TENSION (OR LOW TENSION) GLAUCOMA
TWO DIFFERENT SITUATION
OCULAR HYPERTENSION
NORMAL TENSION (OR LOW TENSION) GLAUCOMA
PEOPLE CAN HAVE ELEVATED PRESSURES WITHOUT SIGNS OF OPTIC NERVE DAMAGE OR VISUAL FIELD LOSS
THEY ARE CONSIDERED AS A RISK FOR GLAUCOMA
THESE PEOPLE ARE KNOWN AS GLAUCOMA SUSPECT
PEOPLE CAN HAVE OPTIC NERVE DAMAGE WITHOUT HAVING ELEVATED IOP
THE MAIN REASON OF THIS CONDITION IS VASCULAR INSUFFICIENCY (OCULAR ISCHEMIA?)

23. GENERAL TREATMENT OPTIONS FOR GLAUCOMA
THE GOAL OF GLAUCOMA TREATMENT IS
REDUCE THE PRESSURE BEFORE IT CAUSES
GLAUCOMATOUS LOSS OF VISION
MEDICAL THERAPY
LASER THERAPY
SURGICAL THERAPY

24. OUTFLOW FACILITATIVE DROGS
MEDICAL THERAPY
ADRENERGIC ANTAGONISTS
(BETA BLOCKERS)
NONSELECTIVE
TIMOLOL, LEVOBUNOLOL,
CARTEOLOL (ISA+), METIPRANOLOL
SELECTIVE
BETAXOLOL
ADRENERGIC AGONISTS
(SELECTIVE ALPHA-2 AGONISTS)
APRACLONIDINE
BRIMONIDINE
CARBONIC ANHYDRASE INHIBITORS
SYSTEMIC
ACETOZOLAMIDE
TOPICAL
DORZOLAMIDE
BRINZOLAMIDE
CHOLINERGICS
PILOCARPINE
PROSTAGLANDINS
LATANOPROST
TRAVOPROST
BIMATOPROST
AQUEUS SUPPRESANTS
OUTFLOW FACILITATIVE DROGS
FIXED COMBINATIONS
TIMOLOL MALEAT + + +
Dorzolamide
Latanoprost
Travoprost  
COSOPT
XALACOM
DOUTRAV

25. LASER THERAPY LASER TRABECULOPLASTY CYCLOPHOTOCOAGULATION
ARGON LASER TRABECULOPLASTY (ARGON LASER)
SELECTIVE LASER TRABECULOPLASTY (ND:YAG)
CYCLOPHOTOCOAGULATION
TRANSSCLERAL (ND:YAG, DIODE)
TRANSPUPILLARY (ARGON)
TRANSVITREAL (DURING VITRECTOMY)
ENDOSCOPIC (ARGON)
ARGON LASER TRABECULOPLASTY
DIODE LASER TRANSSCLERAL
CYCLOPHOTOCOAGULATION

26. DIODE LASER CYCLOPHOTOCOAGULATION

27. SURGICAL THERAPY FILTRATION SURGERY NON PENETRATING SURGERY
(TRABECULECTOMY)
NON PENETRATING SURGERY
SHUNT (IMPLANT) SURGERY
(AHMED GLAUCOMA VALV)

28. TRABECULECTOMY

29. NON PENETRATING SURGERY

30. AHMED GLAUCOMA VALVE