GLAUCOMA

Introduction
Glaucoma is optic nerve damage (often, but not always, associated
with increased eye pressure) that leads to progressive, irreversible loss of
vision.
Incidence
Almost 3 million people in the United States and 14 million people
worldwide have glaucoma. Glaucoma is the third leading cause of blindness
worldwide and the second leading cause of blindness in the United States,
where it is the leading cause of blindness among blacks and Hispanics.
Types of glaucoma
There are many forms of adult and childhood glaucomas. Most
glaucomas fall into two categories: open-angle or closed-angle glaucomas.

Open-angle glaucoma is more common. In open-angle glaucoma,

the drainage canals in the eyes become clogged gradually over
months or years. Pressure in the eye rises slowly because fluid is
produced at a normal rate but drains sluggishly.

Closed-angle glaucoma is less common than open-angle glaucoma.

In closed-angle glaucoma, the drainage canals in the eyes become
blocked or covered because the angle between the iris and cornea is
too narrow. The blockage can occur suddenly or slowly. If the blockage
occurs suddenly, pressure in the eye rises rapidly. If the blockage
occurs slowly, the pressure in the eye rises slowly like in open-angle
glaucoma.

People at highest risk are those with any of the following:

Age older than 40

African-American race
Pathophysiology
the
drainage
canals
clogged,
blocked, or
Family
members
who become
have (or had)
the disease
cannot leave the eye even though new fluid is being
Farsightedness
or nearsightedness
posterior
chamber.
In other words, the sink backs up
is still running. Because there is nowhere in the eye for
Diabetes in the eye increases. When the pressure
pressure
than
the optic
nerve
can tolerate,
Long-term
use of
corticosteroid
drugsdamage to the optic
This damage is called glaucoma. Sometimes eye
Previous eye
injury
increases
within
the range of normal but is nonetheless
optic nerve to tolerate (called low tension glaucoma).

In glaucoma,
covered. Fluid

produced in the
while the faucet
the fluid to go,
becomes higher

nerve occurs.

pressure
too high for the

Anatomical narrowing of anterior chamber

Blockage of acquios humor
Accumulation of acquios humor
Increased intra ocular pressure
Damage to the optic nerve
Blindness
Signs and Symptoms
Open-Angle Glaucoma:
Open-angle glaucoma is painless and causes no early symptoms.
The most important symptom of open-angle glaucoma is the
development of blind spots, or patches of vision loss, over months
to years.
The blind spots slowly grow larger and coalesce.
Peripheral vision is usually lost first.
Vision loss occurs so gradually that it is often not noticed until much
of it is lost.
Because central vision is generally lost last, many people develop
tunnel vision:
they see straight ahead perfectly but become blind in all other
directions.
If glaucoma is left untreated, eventually even tunnel vision is lost,
and a person
Closed-Angle Glaucoma:
If eye pressure rises rapidly in closed-angle glaucoma (acute closedangle glaucoma),
people typically notice an abrupt onset of severe eye pain and
headache,
redness,
blurred vision,
rainbow-colored halos around lights, and
sudden loss of vision.
They may also have nausea and vomiting as a response to the
increase in eye pressure.

 Acute closed-angle glaucoma is considered a medical emergency,

because people can lose their vision as quickly as 2 to 3 hours after the
appearance of symptoms if the condition is not treated.
People who have had open-angle or closed-angle glaucoma in one eye are
likely to develop it in the other.
Screening and Diagnosis
Because the most common types of glaucoma can cause slow and
silent loss of vision over years, early detection of the disease is
extremely important. All people at high risk of glaucoma should have a
comprehensive eye examination every 1 to 2 years.
There are four parts to a comprehensive eye examination for
glaucoma.
First, pressure in the eye is measured. This measurement is taken
painlessly with an instrument called a tonometer .
In general, eye pressure readings of greater than 20 to 22 millimeters
of mercury (mm Hg) are considered higher than normal.
But measuring eye pressure is not enough, because a third or more of
people with glaucoma have eye pressure in the average range. So
doctors also use an ophthalmoscope and a slit lamp to look for
changes in the optic nerve that indicate damage caused by glaucoma
In addition, visual field (peripheral vision) testing allows a doctor to
detect blind spots. Most often, visual field testing is done with a
machine that determines the person's ability to see small dots of light
in all areas of the visual field.
Finally, doctors may also use a special lens to examine the drainage
channels in the eye, a procedure known as gonioscopy. The gonioscope
allows the doctor to determine whether the glaucoma is of the openangle or closed-angle type.
Treatment
Once a person loses vision because of glaucoma, the loss is
permanent.
But if glaucoma is detected, proper treatment can prevent further
vision loss. So the goal of glaucoma treatment is to prevent the onset
of vision loss or stop its progression.
Treatment of glaucoma is lifelong.
It involves decreasing eye pressure by increasing fluid drainage out of
the eyeball or by reducing the amount of fluid produced inside the
eyeball.

Some people with high eye pressure who do not have signs of optic
nerve damage (known as glaucoma suspects) can be monitored
closely without treatment.
Eye drops and surgery are the main treatments for open-angle and
closed-angle glaucomas.
Eye drops containing beta-blockers, prostaglandin-like compounds,
alpha-adrenergic agonists, carbonic anhydrase inhibitors, or cholinergic
drugs are commonly used to treat glaucoma.
Most people with open-angle glaucoma respond well to these drugs.
These drugs are also used for people with closed-angle glaucoma,
although surgery, not eye drops, is the main treatment.
Glaucoma eye drops are generally safe, but they may cause a variety
of side effects.
People need to use them for the rest of their lives, and regular checkups are necessary to monitor eye pressure, optic nerves, and visual
fields.
Sometimes a kind of diuretic (osmotic diuretic) given by mouth or by
vein is also used briefly to help decrease eye pressure rapidly in acute
closed-angle glaucoma.
Surgery may be needed if eye drops cannot effectively control eye
pressure, if a person cannot take eye drops, or if people develop
intolerable side effects from the eye drops.
Laser surgery can be used to increase drainage in people with openangle glaucoma (laser trabeculoplasty) or to make an opening in the
iris (laser peripheral iridectomy or iridotomy) in people with acute
closed-angle glaucoma.
Laser surgery is done in the doctor's office or in a hospital or clinic.
Anesthetic eye drops are used to prevent pain.
People are usually able to go home the same day of any of these
surgical procedures.
Glaucoma filtration surgery is the other form of surgery doctors use to
treat glaucoma. With traditional glaucoma filtration surgery, doctors
manually create a new drainage system (trabeculectomy or tube
shunt) to allow fluid to bypass the clogged or blocked canals and filter
out of the eye.
Glaucoma filtration surgery is generally performed in a hospital.
Newer filtration procedures (viscocanalostomy and Trabectome)
remove only part of the drain to enhance the outflow of fluid. People
are usually able to return home the day of the procedure.

The most common complication of glaucoma laser surgery is

a temporary increase in eye pressure, which is treated with glaucoma
eye drops.

Rarely, the laser used in laser surgery may burn the cornea, but
these burns usually heal quickly.
With laser and glaucoma filtration surgery, inflammation and
bleeding within the eye may occur but are usually short-lived.
Glaucoma filtration surgery may occasionally lead to double vision,
cataracts, or infection.
Because severe closed-angle glaucoma is a medical emergency,
doctors may use very strong and fast-acting drugs that affect the eye
pressure more rapidly than the standard eye drops or surgery. Doctors
may use glycerin or acetazolamide or DIAMOX pills or drugs given by vein
(such as mannitol) if they think the eye is vulnerable to high pressure.
Eye drops are also given as soon as possible.
Emergency surgery is performed if necessary.
The treatment of glaucoma caused by other disorders depends on the
cause. For infection or inflammation, antibiotic, antiviral, or
corticosteroid eye drops may provide a cure.
A tumor obstructing fluid drainage should be treated, as should a
cataract that is so large it causes eye pressure to rise.
High eye pressure that results from cataract surgery is treated with
glaucoma eye drops that reduce eye pressure.
If eye drops do not work, glaucoma filtration surgery can be performed.
Drugs Used to Treat
Glaucoma

Drug

Selected Side Effects

Comments

Beta-blockers
Betaxol
ol

KERLO
NE

Shortness of breath in
people with asthma or
other lung disorders
that cause wheezing
Slow heart beat

Prostaglandin-like compounds

How they work:

Decrease aqueous
humor production
Given as: Eye drop

Bimato
prost
Lumiga
n

Increased eye and skin

pigmentation
Elongated and
thickened eyelashes
Muscle, joint, and back
pain

How they work:

Increase aqueous
humor outflow
Given as: Eye
drops

Alpha-adrenergic agonists
Apraclo
nidine
Iopidine

Increase in blood
pressure or heart rate
Abnormal heart rhythm

How they work:

Decrease aqueous
humor production
and increase
aqueous humor
outflow

Carbonic anhydrase inhibitors

Acetazo
lamide
Diamox

Acetazolamide Diamox
and methazolamide:
Fatigue

How they work:

Decrease aqueous
humor production

Altered taste

Given as:
Acetazolamide
Diamox

Loss of appetite
Cholinergic drugs
Carbac
hol
Miostat

Hinder the eyes' ability

to adapt to darkness
Pupil constriction

How they work:

Increase aqueous
humor outflow
Given as: Eye
drops

Osmotic diuretics
Glycerin
Mannito
l

Increase urine
production
Can cause serious
effects in some people
(for example,
dysfunction of the brain
or nerves) by changing
body salt (electrolyte)
levels or may cause

How they work:

Increase
concentration of
salts in the blood,
which draws fluid
from the eye by
osmosis
Given: By mouth or

dehydration

by vein