ST.

PAUL UNIVERSITY PHILIPPINES

SCHOOL OF MEDICINE

MANAGEMENT OF GLAUCOMA
By: John Henry Binarao

Management of Glaucoma
Treatment Reduction of IOP
and when possible, Correcting
the underlying cause
Medical and Surgical Treatments

Medical Treatment
Raised IOP

A. Suppression of Aqueous Production

Topical beta-adrenergic blocking agents:
used alone or in combination with other drugs
o Timolol maleate
o Betaxolol
o Levobunolol
A2-adrenergic agonist
o Apraclonidine
o aqueous humor formation without effect
on outflow
o Useful for preventing rise of IOP after
anterior segment laser treatment and used
on a short-term basis in refractory cases

A. Suppression of Aqueous Production

A-adrenergic agonist
o Brimonidine
o 1 inhibits aqueous production and 2 aqueous outflow

Systemic Carbonic Anhydrase Inhibitors

o Acetazolamide is the most widely used (dichlorphenamide
and methazolamide)
o Chronic glaucoma when topical therapy is insufficient
o Acute glaucoma when very high IOP needs to be controlled
quickly
o Suppressing aqueous production by 4060%.

Topical Carbonic Anhydrase Inhibitors

o Dorzolamide hydrochloride and brinzolamide that are
especially effective when employed adjunctively

B. Facilitation of Aqueous Outflow

Prostaglandin analogues
o
o
o
o
o
o

Bimatoprost
Latanoprost
Travoprost
uveoscleral outflow of aqueous.
Highly effective first-line or adjunctive agents
All the prostaglandin analogues conjunctival
hyperemia, hyperpigmentation of periorbital skin,
eyelash growth, and permanent darkening of the
iris

B. Facilitation of Aqueous Outflow

Parasympathomimetic agents
(Cholinergics)
o Pilocarpine eg. Carbachol
o aqueous outflow by action on the trabecular
meshwork through contraction of the ciliary
muscle

Epinephrine
o aqueous outflow with some decrease in aqueous
production.
o Dipivefrin is a prodrug of epinephrine that is
metabolized intraocularly to its active state

C. Reduction of Vitreous Volume

Hyperosmotic agents
o Blood hypertonic, thus drawing water out of
the vitreous and causing it to shrink
o In addition to aqueous production
o Oral glycerin (glycerol)\
o MC- 1 mL/kg of body weight in a cold 50%
solution mixed with lemon juice but it should be
used with care in diabetics.

o Alternatives are oral Isosorbide and

Intravenous Urea or Mannitol

D. Miotics, Mydriatics, and Cycloplegics

Constriction of the pupil Primary angleclosure glaucoma and Angle crowding of plateau iris

Pupillary dilation Angle closure secondary to

iris bomb due to posterior synechiae

Cycloplegics (cyclopentolate and

atropine)When angle closure is secondary to
anterior lens displacement
o used to relax the ciliary muscle and thus tighten the
zonular apparatus in an attempt to draw the lens
backward

Surgical & Laser Treatment

Peripheral Iridotomy, Iridectomy, and
Iridoplasty

Pupillary block in angle-closure

glaucoma Forming a direct
communication between the anterior and
posterior chambers that removes the
pressure difference between them

Laser Peripheral Iridotomy

neodymium:YAG
o Laser creates a hole on the outer edge,
or rim, of the iris, the colored part of
the eye.
o This opening allows fluid to flow

Peripheral Iridotomy, Iridectomy, and

Iridoplasty
Surgical Peripheral Iridectomy - if YAG laser
iridotomy is ineffective
Argon Laser Peripheral Iridoplasty (ALPI)
o when it is not possible to control the IOP
medically or YAG laser iridotomy cannot be
performed
o A ring of laser burns on the peripheral iris
contracts the iris stroma, mechanically
pulling open the anterior chamber angle

Surgical & Laser Treatment

Laser Trabeculoplasty
Application of laser (usually argon)
burns via a goniolens to the
trabecular meshwork facilitates
aqueous outflow by virtue of its
effects on the trabecular meshwork
and Schlemm's canal or cellular
events that enhance the function of
the meshwork.
Laser trabeculoplasty may be used in
the initial treatment of primary openangle glaucoma

Surgical & Laser Treatment

Glaucoma Drainage Surgery
Trabeculectomy
o MC used to bypass the normal
drainage channels, allowing direct
access from the anterior chamber
to the subconjunctival and orbital
tissues
The major complication is fibrosis in
the episcleral tissues, leading to
closure of the new drainage pathway

Aqueous Shunt Surgey

Implantation of a silicone
tube to form a permanent
conduit for aqueous flow out of
the eye (alternative procedure for
eyes that are unlikely to respond to
trabeculectomy)

Indications: secondary
glaucomaparticularly
neovascular glaucomaand
glaucoma following corneal
graft surgery

Surgical & Laser Treatment

Cyclodestructive Procedures
Failure of medical and surgical
treatment in advanced glaucoma may
lead to consideration of laser or
surgical destruction of the ciliary body
to control IOP
Cryotherapy, diathermy, thermal
mode neodymium:YAG laser, or
diode laser
Treatment is usually applied externally
through the sclera

Acute Angle Closure- Ophthalmic Emergency!

Treatment is initially directed at reducing
IOP
Intravenous and oral acetazolamidealong
with topical agents, such as beta-blockers
and apraclonidine, and, if necessary,
hyperosmotic agentswill usually reduce
the intraocular pressure.
Topical steroids may also be used to
reduce secondary intraocular inflammation
Once the intraocular pressure is under
control, laser peripheral iridotomy should
be undertaken to form a permanent
connection between the anterior and
posterior chambers, thus preventing
recurrence of iris bomb.

Subacute Angle Closure

Treatment consists of laser peripheral iridotomy
Chronic Angle-Closure Glaucoma
Laser peripheral iridotomy should always be undertaken as the
first step in the management of these patients.
Intraocular pressure is then controlled medically if possible
Plateau Iris
Long-term miotic therapy or laser iridoplasty is required
Congenital Glaucoma
Treatment is always surgical, and either a goniotomy or
trabeculectomy can be undertaken

Secondary Glaucoma
Treatment involves controlling IOP by medical and surgical
means but also dealing with the underlying disease if possible
Pigmentary Glaucoma
o Both miotic therapy and laser peripheral iridotomy
o Laser trabeculoplasty is frequently used in this condition but is
unlikely to obviate the need for drainage surgery.

Glaucoma Secondary to Changes in the Lens

Lens Dislocation
o In anterior dislocation, the definitive treatment is lens
extraction once the intraocular pressure has been controlled
medically
o In posterior dislocation, the lens is usually left alone and
the glaucoma treated as primary open-angle glaucoma

Intumescence of the Lens

o Treatment consists of lens extraction once the intraocular
pressure has been controlled medically.

Glaucoma Secondary to Changes in the Uveal Tract

Uveitis
Treatment is directed chiefly at controlling the uveitis with
concomitant medical glaucoma therapy as necessary
Long-term therapy, including surgery, is often required
because of irreversible damage to the trabecular meshwork
Glaucoma Secondary to Trauma
Treatment is initially medical, but surgery may be required
if the pressure remains elevated

Ciliary Block Glaucoma (Malignant Glaucoma)

Treatment consists of cycloplegics, mydriatics, aqueous
suppressants, and hyperosmotic agents.
Neovascular Glaucoma
Treatment of established neovascular glaucoma is difficult and often
unsatisfactory
Topical atropine 1% and intensive topical steroids should be given to
reduce inflammation and improve comfort.
In many cases, vision is lost and cyclodestructive procedures are
necessary to control the intraocular pressure