What a general practitioner

should know about

Glaucoma

Dr. Anthony
20 Dec, 2013

Glaucoma

What is it?

Glaucoma is a disease of
optic nerve. It may have a
classical sign elevated
intraocular pressure.

Glaucoma

Why is it important for

you?

Glaucoma eventually leads

to irreversible blindness if
uncontrolled

Glaucoma

Who has glaucoma?

Glaucoma

Why is it important for

you?

Glaucoma is a silent chronic

bilateral sight-killer. Patient
usually has NO complaints!
And then he goes blind.

Glaucoma

So can we do at least
something with it?

Patient has a good chance to

live a long happy life with a
satisfactory vision, if the
disease is caught in time.
Yes, you can make a difference.

Glaucoma

What are the types of

glaucoma? (1)

There are two major types:

-open angle glaucoma
-angle-closure glaucoma

Anatomical basics of
glaucoma

Reminder of normal anatomy

Glaucoma

What is the nature of

this disease?

Of many types of glaucoma

primary open angle
glaucoma is the most
common

Glaucoma

What is the nature of

this disease?

The pathogenesis of the

primary open angle
glaucoma can be described
like this:

Glaucoma

The nature of the disease

Glaucoma

Actually, the
same goes for
open-angle
glaucoma...

The nature of the disease

Glaucoma

The simple classic explanation of the nature of the disease

Glaucoma

So what is the difference

between two major types?
The level of aquous humor
blockage... In angle-closure type
trabecular meshwork is not
available for humor. In open angle
it is available, though working
badly and sadly.

Glaucoma

So what is the difference

between two major types?
Open angle glaucoma is the most
common form in the European
and African regions.
Angle-closure glaucoma is
characteristic for people of Asian
descent.

Glaucoma

Angle-closure glaucoma scheme

Glaucoma

Classification of
glaucoma

1) open angle / angle-closure

Glaucoma

What are the types of

glaucoma? (2)
Glaucoma can be chronic (and
it usually is), but also it can turn
into acute (one of the biggest
emergencies in
Ophthalmology!)

Glaucoma

What are the types of

glaucoma? (2)

Chronic glaucoma is totally

unremarkable for a physician
and inconspicuous for a
patient

Glaucoma

What are the types of

glaucoma? (2)
Acute glaucoma is the one that
should be very clearly
understood by any doctor.
Therere fulminant forms, that
lead to the blindness during
several hours.

Glaucoma

Types of glaucoma acute glaucoma attack

Glaucoma

Classification of
glaucoma

1) open angle / angle-closure

2) chronic / acute

Glaucoma

What are the types of

glaucoma? (3)

Glaucoma can be either

congenital, or acquired

Glaucoma

Congenital glaucoma - buphtalmos

Glaucoma

Congenital glaucoma - buphtalmos

Glaucoma

Classification of
glaucoma

1) open angle / angle-closure

2) chronic / acute
3) congenital / acquired

Glaucoma

What are the types of

glaucoma? (4)

Glaucoma is always either

primary or secondary

Glaucoma

What are the types of

glaucoma? (4)

For the primary type (either

open angle or angle-closure
glaucoma) - there is no
pre-existing condition.

Glaucoma

What are the types of

glaucoma? (4)
For the secondary type (either
open angle or angle-closure
glaucoma) - there is always
definite pre-existing eye or orbit
disease or systemic condition

Glaucoma

What are the types of

glaucoma? (4)
Secondary open angle glaucoma reasons:
phacolysis, red blood cells, hypertensive
uveitis, pigmentary dispersion,
pseudoexfoliation, neovascularization of
angle, congenital conditions (iridocorneal
endothelial syndrome, sturge-weber
syndrome), carotid-cavernous fistula, trauma
(recession of angle), medications (steroids!)

Glaucoma

Secondary open angle glaucoma phacolytic

Glaucoma

Secondary open angle glaucoma hyphema

Glaucoma

Secondary open angle glaucoma bilateral sturge-weber syndrome

Glaucoma

Secondary open angle glaucoma pseudoexfoliation syndrome

Glaucoma

What are the types of

glaucoma? (4)
Secondary angle-closure
glaucoma reasons: iridocorneal
synechiae (iridocyclitis),
subluxation of a lens, tumors

Glaucoma

Secondary angle-closure glaucoma posterior synechiae of iris

Glaucoma

What are the types of

glaucoma? (4)
In any case of secondary
glaucoma the IOP is highly
elevated, and it eventually
leads to irriversible optic nerve
damage

Glaucoma

Classification of
glaucoma

1)
2)
3)
4)

open angle / angle-closure

chronic / acute
congenital / acquired
primary / secondary

Glaucoma

What are the signs of

this disease?

Chronic glaucoma at the

beginning is clinically
irrelevant

Glaucoma

What are the signs of

this disease?
During the development of the
chronic disease patiend may
start noticing blurred vision,
and the gradual decrease of
visual field

Glaucoma

What are the signs of

this disease?

Any damage to optic nerve

(including glaucoma)
inevitably leads to visual
field defect

Glaucoma

Visual field deterioration during the glaucoma progression

Glaucoma

What are the signs of

this disease?

False! Typically patients do

not notice these kinds of
defects, if notice any at all!

Glaucoma

What are the signs of

this disease?
The only patient with glaucoma,
who is complaining is either the
patient with advanced glaucoma
(significant visual acuity
decrease!) or the patient with an
acute glaucoma attack

Glaucoma

What are the signs of

this disease?
In acute glaucoma attack:
-painful eye (+irradiation of pain)
-no discharge, no pus
-blurred vision
-red eye
-fixed dilated pupil
-highly elevated IOP

Glaucoma

What is the diagnostics?

1)
2)
3)
4)

5)
6)

assess family history! Any blinds? Glaucoma is

inheritable!
check visual acuity
check intraocular pressure (at least by palpation!)
check pupillary reactions (are pupils reactive? are
the reactions symmetric?)
perform ophthalmoscopy (if available)
perform confrontational visual field test

Intraocular pressure sometimes

makes the eye hard as a stone.
Just touch each eyes with two fingers, palpate it.

Glaucoma

Visual field deterioration during the glaucoma progression

Glaucoma

Visual field simple confrontational test. It allows to detect very rough field
defects

Glaucoma

Ophthalmoscopy. Theres only one disc of optic nerve that is normal here.

Glaucoma

What we do in eye
clinics
1)
2)
3)
4)
5)

Basic ophthalmological exam (visual acuity, intraocular

pressure, external exam)
Slit lamp examination of anterior and posterior segment
of the eyeball (gonioscopy and ophthalmoscopy! Were
looking for angle-closure and cupping of the disc)
In certain cases we must perform automated visual field
test with computer
We can perform tomography of optic nerve disc, if optic
tomograph is available
We make an appointment! We see if our treatment
works.

Glaucoma
Tonometry with schiotz
tonometer

Ophthalmoscopy. Theres only one disc of optic nerve that is normal here.

Glaucoma

Tonometry with slit lamp Goldmann tonometer

Glaucoma

Gonioscopy with slit lamp and four-mirror contact lens

Glaucoma

How can we stop this

blinding condition?
We should lower intraocular
pressure at least by 30% of initial
point.
This is the only measure now, that
is proven to help such patients.

Glaucoma

How can we stop this

blinding condition?
We use medications (in acute
glaucomas acetazolamide
p/o; mannitol i/v; in chronic
glaucomas timolol and
latanoprost eyedrops)

Glaucoma

How can we stop this

blinding condition?

In case medications failed to

stabilize the process we
move forward to laser or
surgical treatment.

Glaucoma

Can we stop this

blinding condition?
Unfortunately glaucoma continues
progressing even with the best
control of IOP. But the rate of
progression is much slower with
treatment. The prognosis for vision is
satisfactory with treatment and poor
without treatment.

Glaucoma

Can we stop this

blinding condition?
Unfortunately glaucoma continues
progressing even with the best
control of IOP. But the rate of
progression is much slower with
treatment. The prognosis for vision is
satisfactory with treatment and poor
without treatment.

Any questions?