GLAUCOMA

Glaucoma is not just one eye disease, but a group

of eye conditions resulting in optic nerve damage, which
causes loss of vision. Abnormally high pressure inside
your eye (intraocular pressure) usually, but not always,
causes this damage.

Glaucoma is the second leading cause of blindness. Sometimes called the silent
thief of sight, glaucoma can damage your vision so gradually you may not notice any
loss of vision until the disease is at an advanced stage. The most common type of
glaucoma, primary open-angle glaucoma, has no noticeable signs or symptoms except
gradual vision loss.

Early diagnosis and treatment can minimize or prevent optic nerve damage and
limit glaucoma-related vision loss. It's important to get your eyes examined regularly,
and make sure your eye doctor measures your intraocular pressure.

The Causes of Glaucoma

For reasons that doctors don't completely understand, increased pressure within
the eye (intraocular pressure) is usually associated with the optic nerve damage that
characterizes glaucoma. This pressure comes from a buildup of aqueous humor, a fluid
naturally and continuously produced in the front of your eye.

Aqueous humor normally exits your eye through a drainage system at the angle
where the iris and the cornea meet. When the drainage system doesn't work properly,
the aqueous humor can't filter out of the eye at its normal rate, and pressure builds
within your eye.

A. Primary open-angle glaucoma

In primary open-angle glaucoma, the drainage angle formed by the cornea and
the iris remains
open, but the microscopic drainage channels in the angle (called the trabecular
meshwork) are
partially blocked, causing the aqueous humor to drain out of the eye too slowly.
This leads to
fluid backup and a gradual increase of pressure within your eye. Damage to the
optic nerve is
painless and so slow that a large portion of your vision can be lost before you're
even aware of a
problem. The exact cause of primary open-angle glaucoma remains unknown.

B. Angle-closure glaucoma

Angle-closure glaucoma, also called closed-angle glaucoma, occurs when the

iris bulges forward to narrow or block the drainage angle formed by the
cornea and the iris. As a result, aqueous fluid can no longer reach the
trabecular meshwork at the angle, so the eye pressure increases abruptly.
Angle-closure glaucoma usually occurs suddenly (acute angle-closure
glaucoma), but it can also occur gradually (chronic angle-closure glaucoma).

C. Low-tension glaucoma

Another form of the disease, poorly understood but not uncommon, is low-
tension glaucoma. In this form, optic nerve damage occurs even though eye
 pressure stays within the normal range. Why this happens is unknown. Some
experts believe that people with low-tension glaucoma may have an
abnormally sensitive optic nerve or a reduced blood supply to the optic nerve
caused by atherosclerosis — an accumulation of fatty deposits (plaques) in
the arteries — or another condition limiting circulation. Under these
circumstances, optic nerve damage can occur even with normal pressure.

D. Pigmentary glaucoma

Pigmentary glaucoma, a type of glaucoma that can develop in young to

middle-aged adults, is associated with a dispersion of pigment granules within
the eye. The pigment granules appear to arise from the back of the iris. When
the granules accumulate on and in the trabecular meshwork, they can
interfere with the outflow of aqueous and cause a rise in pressure. Physical
activities, such as jogging, sometimes stir up the pigment granules, depositing
them on the trabecular meshwork and causing intermittent pressure
elevations. This type of glaucoma can usually be easily diagnosed by your
ophthalmologist.

The Risk Factors

Elevated internal eye pressure (intraocular pressure).

If your intraocular pressure is higher than normal, you're at increased risk of developing
glaucoma, though not everyone with elevated intraocular pressure develops the
disease.

Age.

Everyone older than 60 is at increased risk of glaucoma. For certain population groups
such as African-Americans, however, the risk is much higher and occurs at a younger
age than that of the average population. If you're African-American, ask your doctor
when you should start having regular comprehensive eye exams.

Ethnic background.

African-Americans are five times more likely to get glaucoma than are Caucasians, and
they're much more likely to experience permanent blindness as a result. Mexican-
Americans and Asian-Americans also face an increased risk.

Family history of glaucoma.

If you have a family history of glaucoma, you have a much greater risk of developing it.
Glaucoma may have a genetic link, meaning there's a defect in one or more genes that
may cause certain individuals to be unusually susceptible to the disease. A form of
juvenile open-angle glaucoma has been clearly linked to genetic abnormalities.

Medical conditions.

Diabetes and hypothyroidism increase your risk of developing glaucoma.

Other eye conditions.

Severe eye injuries can result in increased eye pressure. Injury can also dislocate the
lens, closing the drainage angle. Other risk factors include retinal detachment, eye
tumors and eye inflammations, such as chronic uveitis and iritis. Certain types of eye
surgery also may trigger secondary glaucoma.
Nearsightedness.

Being nearsighted, which generally means that objects in the distance look fuzzy
without glasses or contacts, increases the risk of developing glaucoma.

Prolonged corticosteroid use.

Using corticosteroids for prolonged periods of time appears to put you at risk of getting
secondary glaucoma. This is especially true if you use corticosteroids eyedrops.

PATHOPHYSIOLOGY

The major risk factor for most glaucomas and focus of treatment is increased intraocular
pressure. Intraocular pressure is a function of production of liquid aqueous humor by the
ciliary processes of the eye and its drainage through the trabecular meshwork. Aqueous
humor flows from the ciliary processes into the posterior chamber, bounded posteriorly
by the lens and the zonules of Zinn and anteriorly by the iris. It then flows through the
pupil of the iris into the anterior chamber, bounded posteriorly by the iris and anteriorly
by the cornea. From here the trabecular meshwork drains aqueous humor via
Schlemm's canal into scleral plexuses and general blood circulation. In open angle
glaucoma there is reduced flow through the trabecular meshwork; in angle closure
glaucoma, the iris is pushed forward against the trabecular meshwork, blocking fluid
from escaping.

The inconsistent relationship of glaucomatous optic neuropathy with ocular

hypertension has provoked hypotheses and studies on anatomic structure, eye
development, nerve compression trauma, optic nerve blood flow, excitatory
neurotransmitter, trophic factor, retinal ganglion cell/axon degeneration, glial support
cell, immune, and aging mechanisms of neuron loss.

Clinical Manifestations

The most common types of glaucoma — primary open-angle glaucoma and acute
angle-closure glaucoma — have completely different symptoms.

Primary open-angle glaucoma signs and symptoms include:

• Gradual loss of peripheral vision, usually in both eyes

• Tunnel vision in the advanced stages
• Acute angle-closure glaucoma signs and symptoms include:
• Severe eye pain
• Nausea and vomiting (accompanying the severe eye pain)
• Sudden onset of visual disturbance, often in low light
• Blurred vision
• Halos around lights
• Reddening of the eye

Medical Management

Glaucoma treatments reduce intraocular pressure by improving aqueous outflow,

reducing the production of aqueous, or both. Glaucoma can't be totally cured, and
damage caused by the disease can't be reversed, but treatment and regular checkups
can prevent visual loss in people with very early glaucoma. If visual loss has already
occurred, treatment can slow or prevent further vision loss.
Eyedrops

Glaucoma treatment often starts with medicated eyedrops. Be sure to use the
drops exactly as prescribed. Otherwise, your optic nerve damage could get even worse.
If your doctor prescribes more than one type of eyedrop, make sure to ask how long to
wait between applications. Because some of the eyedrops are absorbed into your
bloodstream, you may experience side effects unrelated to your eyes. To minimize this
absorption, close your eyes for one to two minutes after putting the drops in. Press
lightly at the corner of your eye near your nose to close the tear duct for one or two
minutes, and wipe off any unused drops from your eyelid.

The types of most commonly prescribed eyedrops include:

• Prostaglandin-like compounds. These eyedrops increase the outflow of aqueous

humor. Examples include latanoprost (Xalatan) and bimatoprost (Lumigan).
Possible side effects include mild reddening and stinging of the eyes and
darkening of the iris, changes in the pigment of the eyelid skin, and blurred vision
from swelling of the retina.
• Beta blockers. These reduce the production of aqueous humor. Examples
include timolol (Betimol, Timoptic), betaxolol (Betoptic) and metipranolol
(Optipranolol). Possible side effects include difficulty breathing, slowed pulse,
hair loss, lower blood pressure, impotence, fatigue, weakness, depression and
memory loss. If you have asthma, bronchitis or emphysema, medications other
than beta blockers may be recommended because beta blockers may worsen
breathing problems. Your doctor also may recommend avoiding beta blockers if
you're taking insulin for diabetes.
• Alpha-agonists. These reduce the production of aqueous humor and increase
drainage. Examples include apraclonidine (Iopidine) and brimonidine (Alphagan).
Possible side effects include fatigue, dizziness, red, itchy or swollen eyes, dry
mouth and allergic reactions.
• Carbonic anhydrase inhibitors. These also reduce the production of aqueous
humor. Examples include dorzolamide (Trusopt) and brinzolamide (Azopt).
Frequent urination and a tingling sensation in the fingers and toes are possible
side effects, occurring more often with oral carbonic anhydrase inhibitors than
with anhydrase inhibitor eyedrops. If you have an allergy or sensitivity to sulfa
drugs, don't use these medications unless there's no alternative.
• Miotic or cholinergic agents. These also increase the outflow of aqueous humor.
Examples include pilocarpine (Isopto Carpine) and carbachol (Isopto Carbachol).
Possible side effects are pain around or inside the eyes, brow ache, blurred or
dim vision, nearsightedness, allergic reactions, a stuffy nose, sweating,
increased salivation, and occasional digestive problems.
• Epinephrine compounds. These compounds, such as dipivefrin (Propine), also
increase the outflow of aqueous humor. Possible side effects include red eyes,
allergic reactions, palpitations, increased blood pressure, headache and anxiety.

Oral medications

If eyedrops alone don't bring your eye pressure down to the desired level, your
doctor may also prescribe an oral medication, usually in the form of a carbonic
anhydrase inhibitor. Take these pills with meals to reduce side effects.

Initially, carbonic anhydrase inhibitors may cause frequent urination and a

tingling sensation in your fingers and toes. After several days, these symptoms usually
disappear. Other possible side effects of carbonic anhydrase inhibitors include rashes,
depression, fatigue, kidney stones, lethargy, stomach upset, a metallic taste in
carbonated beverages, impotence and weight loss.
Drugs that protect the optic nerve

Lowering the intraocular pressure provides only a partial solution when it

comes to preserving vision in people with glaucoma. Ongoing clinical trials are
evaluating certain drugs that may help protect the optic nerve from damage associated
with glaucoma.

Surgery

You may need surgery to treat glaucoma if you can't tolerate medications or if
they're ineffective. Sometimes a single surgical procedure may not lower eye pressure
enough, in which case you'll need to continue using eyedrops or have another
operation. Possible complications from glaucoma surgery may include infection,
bleeding, abnormally high or low eye pressure, and, potentially, loss of vision. Having
eye surgery may also speed up the development of cataracts. Most of these
complications can be effectively treated.

Surgeries used to treat glaucoma include:

• Laser surgery. In the last couple of decades, a procedure called trabeculoplasty

(truh-BEK-u-lo-plas-tee) has had an increased role in treating open-angle
glaucoma. After giving you an anesthetic eyedrop, the doctor uses a high-energy
laser beam to open clogged drainage canals and help aqueous humor drain
more easily from the eye.

• Filtering surgery. If eyedrops and laser surgery aren't effective in controlling your
eye pressure, you may need an operation called a filtering procedure, usually in
the form of a trabeculectomy (truh-bek-u-LEK-tuh-me).

• Drainage implants. Another type of operation, called drainage implant surgery,

may be an option for people with secondary glaucoma or for children with
glaucoma. Drainage implant surgery takes place in a hospital or an outpatient
clinic. The eye surgeon inserts a small silicone tube in your eye to help drain
aqueous humor. After the surgery, you'll wear an eye patch for 24 hours and use
eyedrops for several weeks to prevent infection and scarring.

• Treating acute angle-closure glaucoma

Acute angle-closure glaucoma is a medical emergency. When you come in with
this condition, doctors may administer several medications to reduce eye
pressure as quickly as possible. You'll also likely have an iridotomy, a laser
procedure that creates a small hole in your iris so that aqueous humor can pass
into the trabecular meshwork. Many doctors recommend an iridotomy on the
other eye at a later date because of the high risk that its drainage angle will close
as well.

Nursing Care Plans

1. Risk for injury r/t the loss of peripheral visions secondary to the damage of the optic
nerve

Interventions

• Maintain a safe environment

• Assist with ambulation and self care activities as needed
• Keep side rails raised and bed in low position
• Ascertain type/ degree of visual loss
 • Encourage expression of feelings about loss/possibility of loss of vision

2. Disturbed body image r/t the loss of vision secondary to the damage of the optic
nerve

Interventions

• Provide hope within parameters of individual situations; do not give false

reassurance
• Assist patient to identify extent of actual change in appearance/body functions
• Support and encourage patient; provide care with a positive, friendly attitude
• Recommend measures to assist patient to manage visual limitations e.g.
reducing clutter, arranging furniture out of travel path
• Walk one or two steps ahead of the client, with client’s hand on your elbow

3. Anxiety r/t to the fear of blindness secondary to glaucoma

Interventions

• Promote self- concept without moral judgement

• Provide accurate, consistent information regarding prognosis of the disease.
Avoid arguing about patient’s perception of the situation
• Encourage expressions of fears, negative feelings and grief over body changes
• Introduce self to patient, and acknowledge visual impairment. This reduces
patient’s anxiety.
• Orient patient to environment. Orientation reduces fear related to unfamiliar
environment

4. Chronic low self- esteem r/t the changes in visual acuity secondary to glaucoma

Interventions

• Promote self- concept without moral judgement

• Provide accurate, consistent information regarding prognosis of the disease.
Avoid arguing about patient’s perception of the situation.
• Encourage expressions of fears, negative feelings and grief over body changes
• Encourage patient to participate in the therapy
• Encourage family to communicate with the patient as often

5. Knowledge deficit r/t the occurrence of the disease process and its management

Interventions

• Review disease process/surgical procedures and future expectations

• Identify specific limitations of activity as individually as appropriate
• Provide clear, accurate information in a factual but sensitive manner
• Evaluate patient’s ability to function within limits of visual impairment.
• Help family or caregiver identify and make arrangements at home