GlaucomaGlaucomaAbdulrahman Al-Amri, MDAbdulrahman Al-Amri, MD

GlaucomaGlaucoma

Definition & Epidemiology Definition & Epidemiology Anatomy & physiologyAnatomy & physiology POAGPOAG ACGACG Secondary glaucomaSecondary glaucoma ManagementManagement Quiz Quiz

leading cause of blindness leading cause of blindness worldwideworldwide

GLAUCOMAGLAUCOMA

IOP Cupping Visual Field LossIOP Cupping Visual Field Loss

Anatomy and physiology Anatomy and physiology Aqueous Humour Aqueous Humour

SecretedSecreted by the CB by the CB Carbonic anhydrase Carbonic anhydrase

enzyme is requiredenzyme is required Aqueous outflowAqueous outflow:: TMWTMW UveoscleralUveoscleral

Schlemm’s canal Schlemm’s canal

Venous circulationVenous circulation

A/C angle structuresA/C angle structures Schwalbe’s lineSchwalbe’s line TMW: fenistrated TMW: fenistrated

sheetsheet SSSS CBCB

Anatomy of NFLAnatomy of NFL

TonometryTonometry

Contact tonometryContact tonometry

-Applanation tonometry-Applanation tonometry

Non-contact tonometry (NCT)Non-contact tonometry (NCT)

-Air puff -Air puff

GonioscopyGonioscopyexamining AC angleexamining AC angle

PerimetryPerimetry

Visual field testingVisual field testing

Classification of glaucomas Cong vs acquiredCong vs acquired

Open vs closedOpen vs closed

Primary vs secondaryPrimary vs secondary

Congenital glaucomaCongenital glaucoma

TrabeculodysgenesisTrabeculodysgenesis Usually SporadicUsually Sporadic

Symp.Symp. PhotophobiaPhotophobia TearingTearing BlepharospasmBlepharospasm

SignsSigns

High IOPHigh IOPBuphthalmosBuphthalmosLarge corneaLarge corneaCorneal edema+/-Corneal edema+/-Cupping Cupping (Normal C:D ratio =0.3)(Normal C:D ratio =0.3)

TreatmentTreatment

SurgicaSurgicall

Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma

•Acute elevation of IOPAcute elevation of IOP•Angle closure by:Angle closure by:

-Pupillary block-Pupillary block

-Iris crowding-Iris crowding

Predisposing factors

SymptomsSymptoms

SuddenSudden ocular pain ocular pain Rapid loss of vision* Tearing Photophobia Headache Nausea Vomiting

SignsSigns Ciliary Ciliary congestioncongestion Mid dilated pupil Mid dilated pupil (due to pressure on (due to pressure on

ciliary nerves and vessles)ciliary nerves and vessles) High High IOPIOP Corneal edemaCorneal edema Closed angleClosed angle

Surgical YAG laser iridotomy

Treatment of Acute Angle-Closure Glaucoma

• Hyperosmotic agentsIntravenous mannitol

B- Topical therapy• Pilocarpine • Beta-blockers

1. MedicalA-Systemic• CAI

Acetazolamide

2. Surgical YAG laser iridotomy

Primary Open Angle Glaucoma-POAG

Above 40yr usuallyAbove 40yr usually Bilateral Bilateral Asymptomatic in early stagesAsymptomatic in early stages

Risk FactorsRisk Factors

Age Age FHFHSteroidsSteroidsMyopia Myopia DMDM

Primary Open angle GlaucomaPrimary Open angle GlaucomaPOAGPOAG

Mechanical Ischemic

IOP > 21 mmHg

Cupping

Open angle

Visual field loss

Primary Open Angle Glaucoma-POAG

ProgressionProgression

Pseudoexfoliation

Firillar material, Firillar material, similar to amyloidsimilar to amyloid

Deposition in the Deposition in the TMW….high TMW….high IOPIOP

Phacomorphic glaucomaPhacomorphic glaucoma

Glaucoma DrugsGlaucoma Drugs

Drugs to decrease Drugs to decrease the the productionproduction of of aqueous humor.aqueous humor.

Drugs to increase Drugs to increase the the outflowoutflow of of aqueous humor.aqueous humor.– Trabecular channelsTrabecular channels– Uveoscleral Uveoscleral

channelschannels

ManagementManagement

MedicalMedical

-Topical -Topical

-Systemic-Systemic Surgical Surgical

-Trabeculectomy-Trabeculectomy

-Tube-shunt surgery-Tube-shunt surgery

-Cyclodestructive procedures-Cyclodestructive procedures

MedicalMedicalTopicalTopical

ProductionProduction SympathomimeticsSympathomimetics

(adrenergic agonists)(adrenergic agonists) Beta blockersBeta blockers

OutflowOutflow Parasympathomimetics Parasympathomimetics

(Miotics-cholinergic ag)(Miotics-cholinergic ag) Prostaglandin analoguesProstaglandin analogues

– Allergic conjunctivitis– Punctate keratitis

– Bradycardia– Bronchospasm– Hypotension – libido– Depression

Glaucoma Drugs – Side Effects

Betablockers

Generics– Brimonidine Tartrate

(0.2% solution)

Glaucoma Drugs

Adrenergic Drugs

– Lid edemaLid edema– ConjunctivitisConjunctivitis

– FatigueFatigue– Drowsiness Drowsiness – Apnea Apnea

– bradycardiabradycardia– hypotensionhypotension

Glaucoma Drugs – Side EffectsGlaucoma Drugs – Side Effects

Adrenergic DrugsAdrenergic Drugs

GenericsGenerics– AcetazolamideAcetazolamide

(250 mg tabs, 500mg caps, (250 mg tabs, 500mg caps,

500 mg IV solution)500 mg IV solution)

BrandsBrands– DiamoxDiamox

Glaucoma DrugsGlaucoma Drugs

Carbonic Anhydrase Inhibitors Carbonic Anhydrase Inhibitors (CAI’s)(CAI’s)

• Ocular:– Allerg conjunctivitis

Systemic:*Tingling sensation of

hands & feet*Steven-johnson sx*Renl stone *GIT– Headache / fatigue– Dry mouth– Dec. libido,– Depression

Glaucoma Drugs – Side Effects

Carbonic Anhydrase Inhibitors (CAI’s)

Action:Action:– Reduce IOP by increasing the outflow Reduce IOP by increasing the outflow

through uveoscleral channelsthrough uveoscleral channels– Lowers IOP in 3- 4 hrs after instillationLowers IOP in 3- 4 hrs after instillation

GenericsGenerics– Latanaprost Latanaprost (0.005% Sol.)(0.005% Sol.)

BrandsBrands– XalatanXalatan

Glaucoma DrugsGlaucoma Drugs

Prostaglandin AnalogsProstaglandin Analogs

•Heterochromia

• MIOTICS (2% Sol.)

– Produce miosis (small pupil)

• Generics– Pilocarpine

Hydrochloride

Glaucoma Drugs

Drugs to Increase the Outflow

MedicalMedicalSystemicSystemic

Hyperosmotic agents Carbonic anhydrase inhibitors

Generally used in emergency Generally used in emergency situation when rapid decrease of situation when rapid decrease of IOP is needed for AACG.IOP is needed for AACG.

Action:Action:– increased S. osmolarity :increased S. osmolarity :

drawing fluid out of the vit across drawing fluid out of the vit across vascular barriers.vascular barriers.

Glaucoma DrugsGlaucoma Drugs

Osmotic AgentsOsmotic Agents

ManagementManagement SurgicalSurgical

--TrabeculectomyTrabeculectomy

-Tube-shunt surgery-Tube-shunt surgery

-Cyclodestructive procedures-Cyclodestructive procedures