Acute Glaucoma

Aqueous humor circulation

The aqueous humor is formed by the
ciliary processes and secreted into
the posterior chamber of the eye
Produce 26 l per minute and a
total anterior and posterior chamber
volume of about 0.20.4ml, about 1
2% of the aqueous humor is replaced
each minute.

Aqueous humor circulation

Definition
Glaucoma is a disorder in which
increased intraocular pressure
damages the optic nerve.
Primary glaucoma refers to
glaucoma that is not caused by other
ocular disorders.
Secondary glaucoma may occur as
the result of another ocular disorder
or an undesired side effect of
medication or other therapy.

Classification

According to the spesific pathofisiology

Primary open angle

glaucoma
structure of the trabecular look
normal but an increase in flow out of
aqueous resistance which causes
increased ocular pressure
Etiology : drainage of aqueous humor
is impeded.

Epidemiology
The most common form of glaucoma
90% of adult glaucomas.
The incidence of the disorder
significantly increases beyond the
age of 40, reaching a peak between
the ages of 60 and 70.

Symtomps

Unspesific symptoms
Headache
Burning sensation in the eyes
Blurred or decreased vision
Halo

Secondary open
angle
Classification
glaucoma
The anatomic relationships between
the root of the iris, the trabecular
meshwork, and peripheral cornea are
not disturbed.
The trabecular meshwork is
congested and the resistance to
drainage is increased.

Secondary open angle

glaucoma
Inflammatory glaucoma.
Two mechanisms contribute to the increase in intraocular
pressure:
1. The viscosity of the aqueous humor increases as a result of
the influx of protein from inflamed iris vessels.
2. The trabecular meshwork becomes congested with
inflammatory cells and cellular debris.
Phacolytic glaucoma.
This is acute glaucoma in eyes with hypermature
cataracts. Denatured lens protein passes through the intact
lens capsule into the anterior chamber and is phagocytized.
The trabecular meshwork becomes congested with proteinbinding macrophages and the protein itself.

Classification
Primary angle closure
glaucoma

Acute episodic increase in intraocular

pressure to several times the normal
value (1020mm Hg) due to sudden
blockage of drainage.
Production of aqueous humor and
trabecular resistance are normal.
Etiology : the iris anteriorly toward
the trabecular meshwork, suddenly
blocking the outflow of aqueous
humor

Symtomps
Acute onset of intense pain. The
elevated intraocular pressure acts on
the corneal nerves to cause dull pain.
Nausea and vomiting
visual acuity
Prodromal symptoms--blurred
vision or the appearance of colored
halos around lights

Acute glaucoma attack: pupillary

block

Conjunctival and ciliary injection (red eye).

Corneal edema.
Opacification of the corneal
Anterior chamber is shallow.
The pupil is oval instead of round and
dilated.
Intraocular pressure is elevated; the eye is
rock hard to palpation.
Severe headache and gastrointestinal
symptoms are present.

Classification
Secondary angle closure
glaucoma

In secondary angle closure glaucoma

as in primary angle closure
glaucoma,the increase in intraocular
pressure is due to blockage of the
trabecular meshwork.
However, the primary configuration
of the anterior chamber is not the
decisive factor.

Secondary angle closure

glaucoma
Trauma.
Post-traumatic presence of blood or
exudate in the angle of the anterior
chamber and prolonged contact
between the iris and trabecular
meshwork in a collapsed anterior
chamber can lead to anterior
synechiae and angle closure

Classification
Juvenile glaucoma

Any abnormal increase in intraocular

pressure during the first years of life
will cause dilatation of the wall of the
globe, and especially of the cornea.
The result is a characteristic,
abnormally large eye (buphthalmos)
with a progressive increase in
corneal diameter.

Symptoms

Photophobia
Epiphora
corneal opacification,
Unilateral or bilateral enlargement of the
cornea.
These changes may be present from birth (in
congenital glaucoma) or may develop shortly
after birth or during the first few years of life.
Children with this disorder are irritable, poor
eaters, and rub their eyes often.

Pathogenesis
The major mechanism of visual loss
in glaucoma is retinal ganglion cell
apoptosis, leading to thinning of the
inner nuclear and nerve fiber layers
of the retina and axonal loss in the
optic nerve. The optic disk becomes
atrophic, with enlargement of the
optic cup

Pathogenesis
Increase of TIO induced mechanic
damage in akson optic nerve
Increase of TIO also induced ischemic
of nerve akson due to decreased
blood flow in papil optic nerve.

Examination
Oblique illumination of the anterior chamber--The anterior chamber is illuminated by a beam of light
tangential. a shallow anterior chamber an angle that
is partially or completely closed
Slit lamp examination-- To evaluate the depth of the
anterior chamber
Gonioscopy --- evaluae the angle of the anterior
chamber
Measuring intraocular pressure--- Palpation, Schitz,
Optic disk ophtalmoscopy --- increase in the size of
the optic cup and to pale discoloration of the optic disk
Visual field testing

Treatment
Inhibit aqueous humor prodduction
Increase trabecular outflow
Increase uveoscleral outflow

Treatment
Pilokarpin 2% a drop/min in 5 min,
after that every 1 hour
Asetazolamid 500mg IV (TIO >
50mmHg) or oral (TIO < 50mmHg)
alternative : mannitol 20% 12g/KgBB, gliserol 50% 1-1,5g/kgBB
(KI: DM).

Surgical Indications
Medical therapy is insufficient.
The patient does not tolerate medical
therapy.
The patient is not a suitable candidate
for medical therapy due to lack of
compliance in applying eyedrops.
In the angle closure glaucoma is
emergency and the underlying causes of
the disorder require surgical treatment.

Trabeculoplasty
Laser burns in the trabecular
meshwork cause tissue contraction
that widens the intervening spaces
and improves outflowthrough the
trabecular meshwork.
Laser surgery in the angle of anterior
chamber is possible only if the angle
is open.

Peripheral iridectomy
A limbal incision is made at 12
oclock under topical anesthesia or
general anesthesia,

THANKS..

Factors that increase resistance to pupillary outflowand

predispose to angle
closure glaucoma