1. Glaucoma
By: Saja Aloran

2. Definition:
It is a group of eye diseases in which damage to the optic nerve (optic neuropathy) is usually “ not always” caused by raised ocular pressure (normal IOP is 15.5 mmHg) acting
on the nerve head.
Its optic neuropathy and visual field defect
with or without increase intraocular pressure .

4. : Aqueous humour 1.Conventional pathway 2.Uveo-scleral pathway
IOP: Depends on the balance between production and removal of aqueous humour .

5. Cont…. Conventional pathway :
Aqueous humour is secreted by the ciliary processes in the posterior chamber, then it passes through the pupil into the anterior chamber and leaves the eye via Trabecular meshwork, Schlemm’s canal, and episcleral veins.
:Uveo-scleral pathway
Drains a small proportion of aqueous (4%).
It drains it across the ciliary body into the supra- coroidal space, and into the venous circulation across the sclera.

7. pressure How elevated intraocular ! damages the optic nerve fibres
Two theories : 1 Raised intraocular pressure causes mechanical damage to the axons. 2 Raised intraocular pressure causes ischaemia of the nerve axons by reducing blood flow at the nerve head

8. :Risk factors of glaucoma
-Family history of glaucoma -Age 60 and older. -Eye injury , certain eye surgeries or chronic eye inflammation. -Diabetes, high blood pressure, heart disease or hypothyroidism . -steroids for long periods of time .

9. :Classification

10. :Primary glaucoma

12. Primary OPEN angle glaucoma:
In open angle glaucoma the trabecular meshwork appears normal on gonioscopy but functionally, it offers an increased resistance the outfl ow of aqueous : The causes of outflow obstruction include • Thickening of the trabecular lamellae, which reduces pore size. • Reduction in the number of lining trabecular cells. • Increased extracellular material in the trabecular meshwork spaces

13. Open irido-corneal angle (Trabecular meshwork is not covered)

14. Cont…. It is the most common type of glaucoma
It is the 3rd cause of blindness in the UK.
It is also called chronic open angle glaucoma.
It causes SLOW damage to the optic nerve, causing gradual loss of vision.

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

16. Cont….
.Symptoms :
1.Because the vision loss is gradual, usu. Bilateral and asymmetrical the patient usually present when severe damage has occurred & Its painless .
2.Most patients are detected by optometrist routine examination. Other sign is disck cupping .
3. Visual field defect : Gradual loss of peripheral vision, usually in both eyes, Tunnel vision in the advanced stages

17. Cont….
Risk group :
1.Affects 1 in 200 of population over the age of 40.
2.Males and females are equally affected.
3.There maybe family history but the exact mode of inheritance is not clear.
4.Myopic patient .

18. POAG criteria: (you need 2 out of 3)
1.IOP
2.Visual field changes
3.Optic nerve damage (cupping)
Cupping takes place first then the visual field changes.
Visual field changes:
1) nasal step 2) arcuate scotoma
3)tuunle vision 4)blurring in central vision

19. Cont…
C:D(cup:disk) ratio 0.4; visual acuity changes take place after cupping reaches 0.8 { normal is ) Note: *visual acuity is the least affected in glaucoma. Don’t mix between v. field and v. acuity.

20. Optic disc cupping
The optic disc marks the exit point of the retinal nerve fibers from the eye. With a sustained rise in IOP the nerve fibers atrophy, leaving the characteristic sign of chronic glaucoma—the cupped, pale optic disc.

22. Management:
Aim of treatment is to decrease the IOP Amount of decrease depends on the level at which no more damage to the optic nerve happens .
This level differs from patient to other
Modalities :
1- Medical Treatment
2- Laser Treatment
3- Surgical Treatment

23. Medical treatment Topical eye drops  five families:
1.Prostaglandins analogues  Latanoprost (1st line of Rx)
2.B-blocker  Timilol (2nd line of Rx) contraindicated in asthma .we can use bate 1 selective but with caution in asthmatic patient.
3.Carbonic anhydrase inhibitors  Dorsolamide
4.Alpha 2 agonist 
5.Cholinergic agonist 
MOA :
1+4+5 > increase aqueous humor outflow .
2+3+4 > decrease aqueous secretion

24. Cont… Systemic (IV / oral)
1.CAI (Acetazolamide )  S/E: hypokalemia, metabolic acidosis, renal stones, nephritis,
parasthesia (m. common S/E)
2.Manitol {hyperosmotic} S/E: rebound increased IOP.

25. If IOP remains elevated the choice lies between
Adding additional medical treatment
Laser treatment
Surgical drainage procedures

26. Ddx of tunnel vision 1) Open angle glaucoma
2) Retintis pigmentosa : ( "classic triad" seen on fundoscopic exam of bony spicule pigmentation, vascular narrowing, and abnormal pallor of the optic disc)

27. Acute angle closure glaucoma:
-The condition occurs in small eyes (as in hyperopoia) with shallow anterior chambers.
-In the normal eye the point of contact between the pupil margin and the lens offers a resistance to aqueous fl ow from the posterior into the anterior chamber (relative .(pupil block

28. Cont…
Sometimes when the pupil is dilated, the lens sticks to the back of the iris causing obstruction of fluid flow from posterior to anterior chambers. Fluid will accumulate behind the iris and pushes it on to the Trabecular meshwork preventing drainage of aqueous from the eye. This causes rapid increase in IOP.

30. Risk factors : Hypermetropia : closed angle glaucoma
Myopia : open angle

31. Cont… Symptoms: 1) The eyes becomes red and
painful due to rapid increase
in IOP & ischemic
tissue damage.
2) Blurred vision; because
the cornea becomes edematous.

32. Cont..
3.Patient may notice haloes (circles of light(rainbow)) around light due to dispersed light in waterlogged cornea.
4.Headache
5.Nausea and vomiting due to vagal
stimulation
6.Photophobia.

33. :Sings Red eye Increase IOP .
mid dilated fixed ( reacted poorly to the light) pupil
shallow anterior chamber
Cloudy cornea

34. Diagnostic tests
#Gonioscopy : Gonioscopy is the gold-standard method of diagnosing angle closure ,This technique involves using a special lens for the slit lamp, which allows the ophthalmologist to visualizethe angle and diagnose angle closure
#Slit lamp grading of anterior chamber depth
#Ultrasound biomicroscopy

35. Management Urgent Treatment is necessary All efforts to decrease IOP
For the acute attack
-IV/oral acetazolamide. If nausea and vomiting are not tolerated switch to manitol.
-Topical antiglaucoma  Pilocarpine, B-blockers
For prevention of subsequent attacks:
Laser ( iridotomy )
Surgery (iridectomy )IS THE MAIN STEP IN TREATMENT .
Prophylactic to the fellow eye.