S.

NO PAGE
INDEX NO
1 INTRODUCTION 1

2 DEFINITION 1

3 INCIDENCE 1

4 ANATOMY AND PHYSIOLOGY 3-4

5 TYPES 5

6 ETOLOGY 7-8

7 PATHOPHYSIOLOGY 9

8 CLINICAL MANIFISTRATION 10

9 DIAGNOSTIC EVALUATION 11

10 MANAGEMENT 11-15

1-MEDICAL MANAGMENT
2-SURGICAL MANAGEMENT
11 16
3-NURSING MANAGEMENT

NURSING CARE PLAN 17

12 BIBLIOGRAPHY 18

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 GLAUCOMA

INTRODUCTION :-
Glaucoma damages the eye's optic nerve. It is a leading cause
of blindness in the United States. It usually happens when the fluid pressure inside the
eyes slowly rises, damaging the optic nerve.

Definition :-

1) “Glaucoma is a disease in which the optic nerve is damaged, leading to

progressive, irreversible loss of vision. It is often, but not always, associated with
2) increased pressure of the fluid in the eye.”
- En.wikipedia.org

3) “A disease of the eye in which the pressure of fluid inside the eyeball is
abnormally high, caused by obstructed outflow of the fluid. The increased pressure
can damage the optic nerve and lead to partial or complete loss of vision.”

- www.thefreedictionary.com
4) Glaucoma is a group of ocular conditions characterized by optic nerve damage. The
optic nerve damage is related to the intra ocular pressure (IOP) caused by
congestion of aqueous humor in the eye.
- Bruner & Suddarth’s

Incidence :-
Glaucoma is the leading cause of irreversible blindness. In fact, as
many as 6 million individuals are blind in both eyes from this disease.

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Anatomy & physiology of eye :-

The eye is the organ of the sense of sight situated in the orbital cavity & it is
supplied by the optic nerve i.e. 2 nd cranial nerve. It is almost spherical in shape & is about
2.5 cm in diameter. The space between the eye & the orbital cavity is occupied by adipose
tissue. The bony walls of the orbit & the fat help to protect the eye from injury.

STRUCTURE OF EYE :-
There are 3 layers of tissue in the walls of the eye. They are :-
1) The outer fibrous layer : Sclera & Cornea
2) The middle vascular layer or uveal tract : Coroid,Ciliary body & iris
3) The inner nervous tissue layer : Retina
Structures inside the eyeball are the lens, aqueous fluid (humour) & Vitreous body
(humour).

SCLERA:-
The sclera or white of the eye, forms the outer most layer of tissue of the
posterior & lateral aspects of the eyeball & is continuous anteriorly with the transparent
cornea. It consists of a firm fibrous membrane that maintains the shape of the eye & gives
attachment to the extra ocular or extrinsic muscles of the eye.

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Function of Sclera :-
1. The sclera is an outer fibrous layer that encases and protects the eyeball.
2. It completely envelops the globe except at the front of the eye and maintains the
shape of the globe.
3. It also provides a firm anchorage for the extra ocular muscles that control the eye's
movement.

CORNEA:-
Anteriorly the sclera continuous as a clear transparent epithelial
membrane, the cornea. Light rays pass through the cornea to reach the retina. The cornea
is convex anteriorly & is involved in refracting or bending light rays to focus them on the
retina.
Function of Cornea:-
1. It helps to shield the rest of the eye from germs, dust, and other harmful matter. The
cornea shares this protective task with the eyelids, the eye socket, tears, and the sclera, or
white part of the eye

2. The cornea acts as the eye's outermost lens. It functions like a window that controls and
focuses the entry of light into the eye. The cornea contributes between 65-75 percent of
the eye's total focusing power.

CHOROID :-
It is very rich in blood vessels & is deep chocolate brown in color. Light
enters the eye through the pupils, stimulates the nerve endings in the retina & is then
absorbed by the choroid.

Function of Choroid:-
1. It absorbs light and prevents internal reflection.
2. The choroid provides oxigen and nourishment to the outer layers of the retina.

CILIARY BODY:-
It is the anterior continuation of the choroid consisting of ciliary
muscles & secretary epithelial cells. It gives attachment to the suspensory ligament which,
as its other end, is attached to the capsule enclosing the lens. The epithelial cells secrete
aqueous fluid into the anterior segment of the eye, i.e.the space between the lens & the
cornea (anterior & posterior chambers).The ciliary body is supplied by parasympathetic
branches of the oculomotor nerve i.e. 3 rd cranial nerve.
Functions of Ciliary Body:-
The ciliary body has three functions:
1. accommodation,
2. aqueous humor production and

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 3. the production and maintenance of the lens zonules.
 It also anchors the lens in place.
 Accomommodation essentially means that when the ciliary muscle contracts, the
lens becomes more convex, generally improving the focus for closer objects. When
it relaxes, it flattens the lens, generally improving the focus for farther objects.
4. One of the essential roles of the ciliary body is also the production of the aqueous
humor, which is responsible for providing most of the nutrients for the lens and the
5. cornea and involved in waste management of the areas.

IRIS :-
The iris is the visible colored part of the eye & extends anteriorly from the
ciliary body, lying behind the cornea in front of the le The eye into Anterior & Posterior
chambers, which contain aqueous fluid secreted by the ciliary body. It is a circular body
composed of pigment cells & 2 layers of smooth muscles fibers –one circular & the other
radiating. In the centre there is an aperture called the pupil. The iris is supplied by
parasympathetic & sympathetic nerves. Parasympathetic stimulation constricts the pupil
& Sympathetic stimulation dilates it.
Functions of Iris :-
1. It controls how much light enters the eye. At night or in a dark room for example,
we need more light to see, so the pupil dilates to allow more light to enter. Another
factor plays a role here, when the pupil was constricted (before you entered the
dark room) the light was focused on the central retina, where there are almost no
rods (rods are sensitive to light, basically we need the to see where there is
minimum illumination).Now, the cones in the central retina are not sensitive to
light, so when the iris dilates the pupil so the light could get to the rods.

LENS :-
The lens is a highly elastic circular biconvex body, behind the pupil. It
consist of fibers enclosed thin a capsule. Its thickness is controlled by the ciliary muscles
through the suspensory ligament. The lens has three main parts: the lens capsule, the lens
epithelium, and the lens fibers. The lens capsule forms the outer most layer of the lens
and the lens fibers form the bulk of the interior of the lens. The cells of the lens epithelium
located between the lens capsule and the outermost layer of lens fibers, are found only on
the anterior side of the lens.

LENS CAPSULE :- The lens capsule is a smooth, transparent basement membrane that
completely surrounds the lens. The capsule is elastic and is composed of collagen

LENS EPITHILIUM :- The lens epithelium, located in the anterior portion of the lens
between the lens capsule and the lens fibers, is a simple cuboidal epithelium.

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LENS FIBERS :- The lens fibers are long, thin, transparent cells, firmly packed, with
diameters typically between 4-7 micrometers. It divides the anterior segment of

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The eye into Anterior & Posterior chambers, which contain aqueous fluid secreted by the
ciliary body. It is a circular body composed of pigment cells & 2 layers of smooth muscles
fibers –one circular & the other radiating. In the centre there is an aperture called the
pupil. The iris is supplied by parasympathetic & sympathetic nerves. Parasympathetic
stimulation constricts the pupil & Sympathetic stimulation dilates it.
Functions of Iris :-
2. It controls how much light enters the eye. At night or in a dark room for example,
we need more light to see, so the pupil dilates to allow more light to enter. Another
factor plays a role here, when the pupil was constricted (before you entered the
dark room) the light was focused on the central retina, where there are almost no
rods (rods are sensitive to light, basically we need the to see where there is
minimum illumination).Now, the cones in the central retina are not sensitive to
light, so when the iris dilates the pupil so the light could get to the rods.

LENS :-
The lens is a highly elastic circular biconvex body, behind the pupil. It
consist of fibers enclosed thin a capsule. Its thickness is controlled by the ciliary muscles
through the suspensory ligament. The lens has three main parts: the lens capsule, the lens
epithelium, and the lens fibers. The lens capsule forms the outer most layer of the lens
and the lens fibers form the bulk of the interior of the lens. The cells of the lens epithelium
located between the lens capsule and the outermost layer of lens fibers, are found only on
the anterior side of the lens.

LENS CAPSULE :- The lens capsule is a smooth, transparent basement membrane that
completely surrounds the lens. The capsule is elastic and is composed of collagen

LENS EPITHILIUM :- The lens epithelium, located in the anterior portion of the lens
between the lens capsule and the lens fibers, is a simple cuboidal epithelium.

LENS FIBERS :- The lens fibers are long, thin, transparent cells, firmly packed, with
diameters typically between 4-7 micrometers and lengths of up to 12 mm long.

Functions of lens :-
1. It focuses the image by bending the light to strike the retina correctly. This is also
called refraction.
2. The cells of the lens epithelium regulate most of the homeostatic functions of the
lens.
3. The iris controls the size of the pupil.
4. It controls the amount of light entering the eye.

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RETINA :-
The retina is the inner most layer of the wall of the eye. it is an extremely
structure & is specially adapted for stimulation by light rays. It is composed of several
layers of nerve cells bodies& their axons, lying on a pigmented layer of epithelial cells,
which attach it to the choroid. The layer highly sensitive to light is the layer of sensory
receptor cells: rods & cones. The rods & cones contain photosensitive pigments that
convert light rays into nerve impulses. The small area of retina where the optic nerve
leaves the eye is the optic disc or blind spot. It has no light sensitive cells.

Functions of retina :-
1. The retina is the photosensitive part of the eye. The light sensitive nerve cells are
the Rods & Cones. Light rays cause chemical changes in photosensitive pigments in
these cells & they generate nerve impulses which are conducted to the occipital
lobes of the cerebrum via the optic nerves.
2. The Rods are more sensitive than the Cones. They are stimulated by low intensity or
dim light.eg. by the dim light in the interior of a darkened room.
3. The Cones are sensitive to bright light & color. The different wave length of visible
light stimulates photosensitive pigments in the cones, resulting in the perception of
different colors. The rods are more numerous towards the periphery of the retina.
Visual purple (Rhodesian) is a photosensitive pigment present only in the rods. It is
bleached (degraded) by bright light & is quickly regenerated when an adequate
supply of vitamin A is available.

Types :-
Glaucoma

Congenital infantile Acquired

Buphthalmos
Hydrophthalmos

Primary Secondary

Open angle/ Angle Closure/

Wide angle/ Narrow angle/
Chronic Closed angle

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Congenital infantile buphthalmos hydrophthalmos :-

It is characterized by elevation of intra ocular pressure (IOP)

associated with developmental abnormalities of the angle of anterior chamber
depending upon the age of onset.
This developmental glaucoma’s are termed as :
1. True or primary congenital glaucoma (IOP is raised during intrauterine life)
2. Infantile glaucoma’s (Diseases manifests prior to the child)
3. Juvenile glaucoma (Children develop pressure rise between 3-16 yrs of life)

OPEN ANGLE GLAUCOMA :-

It is the most common form of the disease and generally does
not affect people until they are in their 40s .

1) Primary chronic open angle glaucoma (COAG) :-

It is the most common type of the glaucoma. Its
frequency increases greatly with age. The aqueous fluid does not drain from the eye
properly. The pressure within the eye, therefore, builds up painlessly and without
symptoms.

2) Normal tension (pressure) glaucoma or low tension glaucoma :-

This type of glaucoma is thought to be due to
decreased blood flow to the optic nerve. This condition is characterized by progressive
optic-nerve damage and loss of peripheral vision (visual field) despite intraocular
pressures in the normal range or even below normal.

3) Childhood glaucoma :-
Childhood glaucoma is an uncommon pediatric condition often
associated with significant visual loss. It may most commonly be caused by trauma,
surgery or other acquired or secondary causes or abnormal increase intra ocular
pressure.

4) Secondary open angle glaucoma :-

It can result from an eye (ocular) injury, inflammation in
the iris (iritis), retinal vein blockage etc.

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5) Pigmentary glaucoma :-
In this granules of pigment detach from the iris, which is the colored
part of the eye. These granules then may block the trabecular meshwork, is a key
element in the drainage system of the eye. Finally the blocked drainage system leads to
elevated intraocular pressure which results in damage to the optic nerve.

6) Exfoliative glaucoma :-
This type of glaucoma is characterized by deposits of flaky material on
the front surface of the lens (anterior capsule) & in the angle of the eye. The
accumulation of this material in the angle is believed to block the drainage system of
the eye and raise the eye pressure.

ANGLE CLOSURE GLAUCOMA :-

Angle-closure glaucoma may be acute or chronic. The common
element in both is that the entire drainage angle becomes anatomically closed, so that
the aqueous fluid within the eye cannot even reach all or part of the trabecular
meshwork.

1) Acute angle closure glaucoma :-

When the drainage angle of the eye suddenly becomes completely
blocked, pressure builds up rapidly, and this is called acute angle-closure glaucoma.
The symptoms include severe eye pain, blurred vision, headache, nausea & vomiting.

2) Chronic angle closure glaucoma:-

When the drainage angle of the eye gradually becomes
completely blocked, pressure builds up gradually, and this is called chronic angle-closure
glaucoma. The drainage tissues gradually start to scar. This condition is generally silent,
and severe glaucoma damage can occur without the person's knowledge.

Etiology :-
-Aqueous humor is a clear fluid in the front
Part of the eye.
-Vitreous humor is a clear, jelly-like substance
That fills the eye behind the lens and helps
The eyeball keeps its shape.
-In a normal eye, aqueous humor is produced,
Circulates through the eye and then drains
Out through the trabecular meshwork, which

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is the eye's filtration system. This is a series
Of tiny channels near the angle formed by
The cornea (the clear portion of the eye), the
Iris (the colored portion of the eye) and the
Sclera (the white of the eye).
-If there is any sort of blockage in these channels, pressure builds up inside the eyeball .

- The main causes are :-

1) Eye injury
2) Eye surgery
3) Eye tumors
4) Diabetes
5) Cataract
6) Trauma
7) Steroid use
8) Emotional stress
9) Anti-histamine use
10) Hypothyroidism
11) Sleep apnea
12) Leukemia
13) Sickle cell anemia

Risk factors :
1) Age over 45 years
2) Family history of glaucoma
3) Diabetes
4) History of elevated intra-ocular pressure
5) Near-sightedness (Myopia)
6) Use of steroids
7) Thin cornea
8) A history of severe anemia or shock
9) Cardiovascular disease
10) Eye trauma
11) Race
12) Abnormally high intra-ocular pressure
13) Peripheral vision is decreased.
14) Provision eye injury
15) Not seeing a rainbow.

Clinical manifestation :-

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 1) Severe eye pain
2) Eye redness
3) Blurred vision
4) Severe headache
5) Nausea
6) Vomiting
7) Dry eyes with itching or burning
8) Dark spot at the center of viewing
9) Excess tearing or watery eyes
10) Difficulty focusing on near or distant object

Path physiology :-

 There are 2 accepted theories regarding how increased IOP damages the optic
nerve in glaucoma.
 The direct mechanical theory suggests that high IOP damages the retinal layer as it
passes through the optic nerve head.
 The indirect ischemic theory suggests that high IOP compresses the microcirculation
in the optic nerve head, resulting in cell injury & death.
 Some glaucoma’s appear as exclusively mechanical & some are exclusively ischemic
types. Typically most cases are a combination of both.

 Regardless of the cause of damage, glaucomatous changes typically evolve through

clearly stages :-

1. Initiating Events: - Precipitating factors include illness, emotional stress,

congenital narrow angles, long term use of corticosteroids & mydriatics
(medications causing papillary dilation).These events lead to second stage.

2. Structural alterations in the aqueous outflow system: - Tissue & cellular

changes caused by factors that affect aqueous humor dynamics lead to structural
alterations & to the third stage.
3. Functional alterations: - Conditions such as increased IOP or impaired blood
flow create functional changes that lead to fourth stage.

4. Optic nerve damage: - Atrophy of the optic nerve is characterized by loss of

nerve fibers & blood supply & this fourth stage inevitably progresses to the fifth
stage.

5. Vision loss: - Progressive loss of vision is characterized by visual field defects.

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Assessment & diagnostic evaluation :-

1) Ocular & medical history to investigate the the history of predisposing factors.

2) Tonometry: - It determines the pressure in the eye by measuring the tone or

firmness of its surface.

3) Ophthalmoscope: - This procedure is done to examine the optic nerve (seen as

the optic disc) at the back of the eye.

4) Gonioscopy: - To examine the filtration angle of the anterior chamber. The

purpose of this test is to examine the drainage angle and drainage area of the eye.

5) Perimeter:-To assess the visual fields. The visual fields to detect any early (or late)
signs of glaucomatous damage to the optic nerve. Visual fields are measured by a
computerized assessment.

6) pachymetry:-It is a relatively new test being used for the diagnosis and treatment
of glaucoma.Pachymetry determines the thickness of the cornea.
After the eye has been numbed with anesthetic eyedrops,the pachymeter tip is
touched lightly to the front surface of the eye (cornea).Recent studies have shown
that corneal thickness can affect the measurement of intraocular pressure.

7) Dilated pupil examination

Medical management :-

 The aim of glaucoma treatment is prevention of optic nerve damage through

medical therapy.
 Lifelong therapy is almost always necessary b’coz glaucoma cannot be cured.
 The treatment goal is to maintain an IOP within a range unlikely to cause further
damage.
 The pt is monitored for the stability of the optic nerve.
 Medical management relies on systemic & topical ocular medications that lower
IOP.
 The pt is usually started on the lowest dose of topical medication & then advanced
to increased conc. until the desired IOP level is reached& maintained.
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  Several types of ocular medications are used to treat glaucoma.

S. NAME OF DOSE ACTION SIDE EFFECT NSG.

N. DRUG RESPONSIBILIT
Y
1. Cholinergic 1%, 2% - It increases aqueous - Per orbital - Caution pts
(Miotics): or 4% / fluid outflow by pain, blurry about
Pilocarpine, 3-4 contracting the ciliary vision, difficulty diminished
Carbachol times/ muscles & causing seeing in the vision in dimly
day meiosis (constriction of dark. lit areas.
the pupil) & opening of
the trabecular
meshwork.
2. Adrenergic 0.5%, - Eye redness & - Teach pt
agonists : 1% or - Reduces production of burning, anxiety punctual
Dipivefrin, 2% / 1- aqueous humor & palpitation, occlusion to
Epinephrine 2 times increases outflow. elevated B.P., limit systemic
/day headache & effects.

3. Beta 0.25 or - Bradycardia, Contraindicated

blockers : 0.5% - Decreases aqueous hypotension in pts with
Betaxolol, /2 humor production. asthma, COPD
Timolol times or cardiac
/day failure.

4. Alpha 0.5% / - Eye redness, - Teach pt

adrenergic 2-3 - Decreases aqueous dry mouth & punctual
agonists : times/ humor production. nasal passage occlusion to
Apraclonidin day limit systemic
Brimonidine effects

5. Carbonic 250 mg - Electrolyte loss, - Monitor

anhydrase / tds or - Decreases aqueous depression, electrolyte
inhibitors : qid humor production. lethargy, GI levels & Do not
Acetazolami upset, weight administer to
de, loss & topical pts with sulfa
methazolam allergy allergies
ide

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Surgical management :-

1) Laser trabeculoplasty :- ( for glaucoma)

In this laser burns are applied to the inner surface of the
trabecular meshwork to open the intra trabecular spaces.Thereby promoting
outflow of aqueous humor & decreasing IOP.The procedure is indicated when IOP is
inadequately controlled by medication’s serious complication is a transient rise in
IOP (usually 2 hrs.after surgery).

2) Laser iridotomy :- ( for papillary block glaucoma)

In this an opening is made in the iris to eliminate the
papillary block. This procedure is contraindicated in pts with corneal edema.
Potential complication is burns to the cornea, lens or retina, transient elevated IOP.

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 3) Filtering procedures :- ( for chronic glaucoma)
These are used to create an opening or fistula in the
trabecular meshwork to drain aqueous humor from the anterior chamber to the
subconjunctival space, thereby bypassing the usual drainage structures. This allows
the aqueous humor to flow & exit by different routes.

4) Trabeculectomy :-
It is the standard filtering technique used to remove part of the
trabecular meshwork. Complication include hemorrhage,loe or elevated
IOP,cataract etc.

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 5) Drainage implants or shunts :-
These are an open tubes implanted in the anterior
chamber to shunt aqueous humor to an attached place in the conjunctiva space. A
fibrous capsule develops around the episcleral plate & filters the aqueous humor,
thereby regulating the outflow & controlling IOP.

6) Canaloplasty :-
Canaloplasty utilizes a micro catheter or tube placed in the Canal of Schlemm
(the natural site of drainage for healthy eyes) to enlarge the drainage canal,
relieving pressure inside the eye. Studies have been published demonstrating long-
term efficacy and safety

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 7) Diode laser cycloablation :-

When trabeculectomy or glaucoma drainage tube (seton)

has failed to control glaucoma, then the treating physician may consider cycloablation
(ablation or destruction of the ciliary body which produces the aqueous fluid).Because
cycloablation involves permanent destruction of the ciliary body, it is usually the last
line of treatment for uncontrolled glaucoma. Before the advent of laser, this was done
using a cry probe (freezing probe) to freeze the ciliary body (cyclocryotherapy).

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Nursing management :-

1) Assessment :- Evaluate patient for severe pain.

Nursing diagnosis :- Acute pain related to increased intra-ocular pressure.
Nursing goal :- Provide medication, thereafter Client will have Reducing pain.
Nursing Interventon :-

S. NURSING INTERVENTION RATIONALE

N.
1. Administered Opioids & other  Opioids reduce the pain.
medications as directed.
2. Explain the pt that the goal of  To reduce anxiety.
treatment is to reduce IOP as quickly as
possible.
3. Reassure patient that, with reduction in  Reassurance is essential to reduce
IOP, pain & other sign & symptoms fear & anxiety of the patient. Fear &
should subside. anxiety increases the perception of
pain.

Evaluation :- Patient will relieve from pain, after giving opioids.

2) Assessment: - Assess patient’s level of anxiety & knowledge.

Nursing diagnosis: - Fear related to pain & potential loss of vision.
Nursing goal: - Provide emotional support, thereafter Client will have Reducing fear

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Nursing intervention:-

S. NURSING INTERVENTION RATIONALE

N.
1. Provide reassurance & calm
presence to reduce anxiety & fear.
2. Provide emotional support.
 Reassurance is essential to reduce fear &
anxiety of the pt.
 Emotional support is essential to reduce
fear & anxiety of the patient. Fear &
anxiety increases the perception of pain.

Evaluation: - Patient’s fear & anxiety will reduce.

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 3) Assessment: - Evaluate patient for nausea & vomiting.
Nursing diagnosis: - Nausea & vomiting related to opioids & other medications.
Nursing goal: - Provide antiemetic drugs, thereafter Client will have Relieving from
Nausea & vomiting .
Nursing intervention:-

S. NURSING INTERVENTION RATIONALE

N.
1. Patient may be medicated with  Antiemetic reduced nausea & vomiting.
antiemetic.
2. Explain the patient & provide  Explanation & support are reduced the
support. fear & anxiety.

Evaluation: - Patient will relieve from Nausea & vomiting, after taking antiemetic
Drugs.

4) Assessment: - Assess the level of knowledge of the patient regarding disease.

Nursing diagnosis: - Knowledge deficit related to disease.
Nursing goal: - Provide knowledge regarding glaucoma.
Nursing intervention:-

S. NURSING INTERVENTION RATIONALE

N.
1. Provide knowledge regarding
glaucoma, their sign & symptoms &
Management.
2. Provide knowledge regarding
medication & their side effects.
 Patient is able to understand regarding
disease.
 Patient is able to understand regarding
medication.

Evaluation: - Patient is able to understand regarding glaucoma.

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Bibliography :-

1) BLACK JOYCE M.,HOWKS JANE HOKANSON (2009),MEDICAL SURGICAL NURSING,8TH

EDITION,VOLUME-2, NEW DELHI : ELSEVIER

2) SMELTZER SUZANNE C., BARE BRENDA (2004), BRUNNER & SUDDARTH’S TEXTBOOK
OF MEDICAL SURGICAL NURSING, 10TH EDITION, LONDON: LIPPINCOTT WILLIAMS
& WILKINS.

3) WAUGH ANNE,ALLISON GRANT (2007),ROSS AND WILSON ANATOMY AND

PHYSIOLOGY IN HEALTH & ILLNESS,10TH EDITION,LONDON : ELSEVIER

4) www.wrongdiagnosis.com
5) www.ehealthmd.com
6) www.glaucomafoundation.org
7) www.webmd.com
8) en.wikipedia.org
9) www.answer.com
10) www.enotes.com
11) Medicaldictionary.thefreedictionary.com
12)www.patient.co.uk
13)www.emedicinehealth.com
14)www.healthline.com

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