GLAUCOMAGLAUCOMAGLAUCOMA

Harold E. Cross M.D., Ph.D.Harold E. Cross M.D., Ph.D. 66--2121--04 v. 4.004 v. 4.0

GLAUCOMAGLAUCOMAGLAUCOMA

What is it?What is it?

A disease of progressive optic A disease of progressive optic neuropathy with loss of retinal neuropathy with loss of retinal neurons and the nerve fiber layer, neurons and the nerve fiber layer, resulting in blindness if left resulting in blindness if left untreated.untreated.

GLAUCOMAGLAUCOMAGLAUCOMA

There is a doseThere is a dose--response response relationship between intraocular relationship between intraocular pressure and the risk of damage to pressure and the risk of damage to the visual field.the visual field.

What causes it?What causes it?

ADVANCED GLAUCOMAADVANCED GLAUCOMAINTERVENTION STUDYINTERVENTION STUDY

GLAUCOMAGLAUCOMAGLAUCOMA

GLAUCOMAGLAUCOMAGLAUCOMAHow do we diagnose it?How do we diagnose it?

IOP is not helpful diagnostically until it reaches IOP is not helpful diagnostically until it reaches approximately 40 mm Hg at which level the approximately 40 mm Hg at which level the likelihood of damage is significant.likelihood of damage is significant.Visual fields are also not helpful in the early stagesVisual fields are also not helpful in the early stagesof diagnosis because a considerable number of neurons of diagnosis because a considerable number of neurons must be lost before VF changes can be must be lost before VF changes can be detected.detected.Optic nerve damage in the early stages is difficultOptic nerve damage in the early stages is difficultor impossible to recognize.or impossible to recognize.50% of people with glaucoma do not know it!50% of people with glaucoma do not know it!

GLAUCOMAGLAUCOMAGLAUCOMAIntraocular pressure is not the only factor Intraocular pressure is not the only factor

responsible for glaucoma!responsible for glaucoma!

95% of people with elevated IOP will never have 95% of people with elevated IOP will never have the damage associated with glaucoma.the damage associated with glaucoma.OneOne--third of patients with glaucoma do not havethird of patients with glaucoma do not haveelevated IOP.elevated IOP.Most of the ocular findings that occur in people Most of the ocular findings that occur in people with glaucoma also occur in people without with glaucoma also occur in people without glaucoma.glaucoma.

GLAUCOMAGLAUCOMAGLAUCOMA

Population distribution of IOPPopulation distribution of IOP

GLAUCOMAGLAUCOMAGLAUCOMA

IOP VariablesIOP Variables

Gender influences:Gender influences: Normal Normal vsvs glaucoma:glaucoma:

GLAUCOMAGLAUCOMAGLAUCOMAAngle AnatomyAngle Anatomy

GLAUCOMAGLAUCOMA

Anatomy ofanterior chamberangle

GLAUCOMAGLAUCOMAGLAUCOMAHow do we measure How do we measure

IOP?IOP?

ApplanationApplanation

SchiotzSchiotz

AirAir

NonNon--contactcontact

GLAUCOMAGLAUCOMAGLAUCOMATonometryTonometry

ApplanationApplanationSchiotzSchiotz

GLAUCOMAGLAUCOMAGLAUCOMAThe normal visual field: an island of The normal visual field: an island of vision in a sea of darkness:vision in a sea of darkness:

GLAUCOMAGLAUCOMAGLAUCOMAGoldmannGoldmann perimeterperimeter Glaucoma visual fieldsGlaucoma visual fields

GLAUCOMAGLAUCOMAGLAUCOMACupCup--toto--disk ratiodisk ratio

GLAUCOMAGLAUCOMAGLAUCOMA

NormalNormal

DISK CUPPINGDISK CUPPINGGlaucomaGlaucoma

GLAUCOMAGLAUCOMAGLAUCOMAGlaucomatous cuppingGlaucomatous cupping

GLAUCOMAGLAUCOMAGLAUCOMAThe histology of glaucomatous optic nerve The histology of glaucomatous optic nerve

cupping:cupping:

Normal:Normal:

GlaucomatousGlaucomatous::

GLAUCOMAGLAUCOMAGLAUCOMA

Optic nerve signs of glaucoma progressionOptic nerve signs of glaucoma progression

Increasing C:D ratioIncreasing C:D ratioDevelopment of disk pallorDevelopment of disk pallorDisc hemorrhage (60% will show progression ofDisc hemorrhage (60% will show progression ofvisual field damage)visual field damage)Vessel displacementVessel displacementIncreased visibility of lamina Increased visibility of lamina cribosacribosa

GLAUCOMAGLAUCOMAGLAUCOMAOcular hypertension treatment studyOcular hypertension treatment study

(OHTS study)(OHTS study)

GOALS: To evaluate the effectiveness of topical ocular GOALS: To evaluate the effectiveness of topical ocular hypotensivehypotensivemedications in preventing or delaying visual fmedications in preventing or delaying visual field loss ield loss and/or optic nerve damage in subjects with ocuand/or optic nerve damage in subjects with ocular hyperlar hyper--tension at moderate risk for developing opentension at moderate risk for developing open--angle angle glaucoma (POAG).glaucoma (POAG).

POPULATION:POPULATION: 1636 participants aged 401636 participants aged 40--80 years with IOP 2480 years with IOP 24--32 32 mm HG in one eye, and 21mm HG in one eye, and 21--32 in the other, randomly 32 in the other, randomly assigned to observation and treatment groups.assigned to observation and treatment groups.

GLAUCOMAGLAUCOMAGLAUCOMA

TREATMENT GOALS: Reduce pressure to less than TREATMENT GOALS: Reduce pressure to less than or equal to 24 mm Hg with a minimum pressure or equal to 24 mm Hg with a minimum pressure reduction of 20% from the baseline.reduction of 20% from the baseline.OUTCOME MEASURES: Development of reproducible OUTCOME MEASURES: Development of reproducible visual field abnormality or development of optic disc visual field abnormality or development of optic disc deterioration.deterioration.MEDICATIONS USED: betaMEDICATIONS USED: beta--adrenergic antagonists, adrenergic antagonists, prostaglandin analogues, topical carbonic prostaglandin analogues, topical carbonic anhydraseanhydraseinhibitors, alphainhibitors, alpha--2 agonists, 2 agonists, parasympathomimeticparasympathomimeticagents, and epinephrine.agents, and epinephrine.

OHTS parametersOHTS parameters

GLAUCOMAGLAUCOMAGLAUCOMAOHTS ConclusionsOHTS Conclusions

At 60 months, the At 60 months, the probability of developing probability of developing glaucoma was:glaucoma was:

9.5% in observation group9.5% in observation group

4.4% in treatment group4.4% in treatment group

GLAUCOMAGLAUCOMAGLAUCOMAOHTS parameters that OHTS parameters that

influence the risk of influence the risk of developing POAGdeveloping POAG

AgeAge

CupCup--disk ratiodisk ratio

Central corneal thicknessCentral corneal thickness

IOPIOP

GLAUCOMAGLAUCOMAGLAUCOMAPercentage of OHTS participants in Percentage of OHTS participants in

observation group who developed POAG observation group who developed POAG (mean follow(mean follow--up = 72 mo)up = 72 mo)

IOP IOP vsvs central central corneal thicknesscorneal thickness

GLAUCOMAGLAUCOMAGLAUCOMA

Percentage of OHTS participants in observation groupPercentage of OHTS participants in observation groupwho developed POAG (mean followwho developed POAG (mean follow--up = 72 mo)up = 72 mo)

Vertical CD ratio Vertical CD ratio vsvs central corneal central corneal thicknessthickness

GLAUCOMAGLAUCOMAGLAUCOMATypes of glaucomaTypes of glaucoma

I. Primary:A. CongenitalB. Juvenile (hereditary)C. Adult

1. Narrow angle2. Open angle

II. SecondaryA. InflammatoryB. TraumaticC. RubeoticD. Phacolytic

etc.

Congenital GlaucomaCongenital GlaucomaCongenital Glaucoma

Onset: Onset: antenatallyantenatally to 2 years oldto 2 years old

SymptomsSymptomsIrritabilityIrritabilityPhotophobiaPhotophobiaEpiphoraEpiphoraPoor visionPoor vision

SignsElevated IOPBuphthalmosHaab’s striaeCorneal cloudingGlaucomatous cuppingField loss

Congenital GlaucomaCongenital GlaucomaCongenital Glaucoma

BuphthalmosBuphthalmos and cloudy corneasand cloudy corneas

Congenital GlaucomaCongenital GlaucomaCongenital Glaucoma

BuphthalmosBuphthalmos,,glaucomatousglaucomatouscupping, andcupping, andcloudy corneacloudy corneaODOD

Normal OSNormal OS

Congenital GlaucomaCongenital GlaucomaCongenital Glaucoma

Haab’s striae

JUVENILE GLAUCOMAJUVENILE GLAUCOMAJUVENILE GLAUCOMA

GLAUCOMAGLAUCOMAGLAUCOMAAngle anatomyAngle anatomy

Grade I Grade 0 Grade III Grade I Grade 0 Grade III Grade IIGrade II

GLAUCOMAGLAUCOMAGLAUCOMAAnatomy of Angle Closure GlaucomaAnatomy of Angle Closure Glaucoma

Narrow Angle GlaucomaNarrow Angle GlaucomaOnset: 50+ years of ageOnset: 50+ years of age

SymptomsSymptomsSevere eye/headacheSevere eye/headache

painpainBlurred visionBlurred visionRed eyeRed eyeNausea and vomitingNausea and vomitingHalos around lightsHalos around lightsIntermittent eye acheIntermittent eye ache

at nightat night

SignsSignsRed, teary eyeRed, teary eyeCorneal edemaCorneal edemaClosed angleClosed angleShallow ACShallow ACMidMid--dilated, fixeddilated, fixed

pupilpupil““GlaucomfleckenGlaucomflecken””Iris atrophyIris atrophyAC inflammationAC inflammation

Narrow Angle GlaucomaNarrow Angle Glaucoma

Narrow Angle GlaucomaNarrow Angle GlaucomaTreatment: Peripheral Treatment: Peripheral IridotomyIridotomy

Open Angle GlaucomaOpen Angle GlaucomaAkaAka: chronic simple glaucoma (CSG): chronic simple glaucoma (CSG)

and primary open angle glaucoma (POAG)and primary open angle glaucoma (POAG)

Onset: 50+ years of ageOnset: 50+ years of age

SymptomsSymptomsUsually noneUsually noneMay have loss of central May have loss of central and peripheral visionand peripheral visionlatelate

SignsSignsElevated IOPElevated IOPVisual field lossVisual field lossGlaucomatous disk changesGlaucomatous disk changes

GLAUCOMAGLAUCOMAGLAUCOMATreatmentTreatment

MedicalMedical SurgicalSurgical

MioticsMioticsBetaBeta--blockersblockersCarbonic Carbonic anhydraseanhydrase

inhibitorsinhibitorsProstaglandinProstaglandin

analoguesanaloguesAlphaAlpha--2 agonists2 agonists

Argon laser Argon laser trabeculoplastytrabeculoplastyTrabeculectomyTrabeculectomyFiltering procedureFiltering procedureCyclocryotherapyCyclocryotherapyCyclolaserCyclolaser ablationablationIridotomyIridotomy

GLAUCOMAGLAUCOMAGLAUCOMATreatmentTreatment

GLAUCOMAGLAUCOMAGLAUCOMASurgical treatment of glaucomaSurgical treatment of glaucoma

Argon laserArgon lasertrabeculoplastytrabeculoplasty

FiltrationFiltrationproceduresprocedures

GLAUCOMAGLAUCOMAGLAUCOMAFiltration blebsFiltration blebs

THANK YOU ALL FOR LISTENING!THANK YOU ALL FOR LISTENING!