08 - glaucoma

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Glaucoma

Dr. Sugiarti Kadarhartono, SpMK

Dr. Sutarya Enus, SpMK Dr. Andika Prahasta, SpM

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Definition of Glaucoma

• Glaucoma is an optic disc neuropathy

which is characteried !y"

# $igh intra ocular pressure %&'P( ) *+ m$g,

# 'ptic nere -i!ers death optic disc damage,

# Progressie isual -ield de-ect,

# ause o- third permanent !lindness.

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Incidence

• Primary glaucoma is"

# hereditary

# -emale ) male

# especially at age ) /0 years

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Incidence

• ongenital glaucoma age 0 1 * years

• &n-antile glaucoma age ) * years

• 2uenile glaucoma age ) +3 year

• Secondary glaucoma" glaucoma as a

complication -rom other eye disease

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Aqueous humor secretion

• 405 is secreted !y non pigmented ciliaryepithelium ia actie meta!olic process that

depends on a num!er o- enymatic systems%car!onic anhydrase enyme(,

• *05 is produced !y passie processes asultra-iltration and di--usion.

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Aqueous outflow

• A$ -ills posterior cham!er pupil

anterior cham!er

leaes the eye !y twodi--erent routes"

# 605 tra!ecular route Schlemm7s canal

leaes the eye episcleral ein.

# +05 ueoscleral route" passes ciliary !ody

suprachoroidal space enous system in the

ciliary !ody.

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Aqueous outflow

A$ -ills posterior cham!er pupil

8ra!ecular route anterior cham!er

Schlemm7s canal ueoscleral route %+05(

suprachoroidal space ciliary !ody

leaes the eye

through episcleral ein enous system in the ciliary !ody

60 5

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Aqueous outflow

9ormal out-low o-

a:ueous humour"

a. onentional

tra!ecular route

!. ;eoscleral route

c. 8hrough the iris

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Trabecular Meshwork

• 8he 8M is located at the anterior cham!er

angle, which consists"

# Descemet mem!rane Schwal!e7s line

# Sclera scleral spur

# &ris iris processus

# iliary !ody angle recess

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Aqueous outflow

a. ;ealmeshwork

!. orneoscleralmeshwork

c. Schwal!e7s line

d. Schlemm7s canal

e. ollector

channels-. iliary !ody

g. Scleral spur

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Aqueous outflows, influenced by:

• $igh intra ocular pressure %&'P(,

• $igh episcleral pressure,

• A:ueous iscosity" e

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Trabecular Meshwork

• 8he 8M is deided into three portions"

# ;eal meshwork, large spaces, resistance >, # orneoscleral meshwork, smaller space,

# Endothelial meshwork, ma?or proportion o-

normal resistance to a:ueous out-low.

• '!struction o- a:ueous -low usually at

tra!ecular meshwork high &'P.

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Anatomy of

Trabecular Meshwork

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Intra Ocular Pressure IOP!

• 9ormal &'P @ *+ mm $g,

• &'P ) *+ mm $g glaucoma suspect,

• Diurnal -luctuation o- &'P in */ hour" # &'P higher in the morning

# &'P lower in the a-ternoon and eening

• 'cular hypertension" &'P ) *+ mm$g without any

nere -i!er damage,• 9ormal tension glaucoma" normal &'P, !ut

presenting glaucomatous signs.

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Patho"enesis of

Glaucomatous Dama"e

• 8here are two current theories"

# 8he indirect ischaemic theory" &'P 11 nere-i!er death B inter-ering o- micro circulation o-

the optic disc,

# Direct mechanical theory" &'P 11 damage

retinal nere -i!er at the optic disc.

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#lassification of the "laucomas

• According to"

# 'ut-low impairment" open angle and angle

closure glaucoma,

# Cactor contri!uting &'P " primary and

secondary glaucoma,

# Age" congenital, in-antile, ?uenile, adult.

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Primary "laucomas

• $igh &'P is not associated with any ocular

disorder # 'pen angle

# Angle closure

# ongenital %deelopmental(

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$econdary "laucomas

• A:ueous out-low alters !y ocular = non

ocular disorders &'P "

# Secondary open angle glaucoma" pretra!ecular,

tra!ecular and post1tra!ecular,

# Secondary angle closure glaucoma caused !y

apposition !etween the peripheral iris andtra!eculum,

# Pathogenesis" anterior -orces = posterior -orces

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$econdary Glaucoma

Mechanism o- o!struction in

secondary glaucoma"

a. Pre1tra!ecular

o!struction %mem!rane(

!. 8ra!ecular o!struction

%pigment granules(

c. Secondary angle closure !y pupil !lock

d. Secondary angle closure

without pupil !lock

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Tonometry

• 8wo main methods o- measuring &'P"

# applanation -orce to -latten the cornea

# indentation -orce to indent the cornea

• 8he main types o- tonometer"

# 8he Schiot tonometer uses a plunger with a

preset weight to indent the cornea. 8he amount

o- indentation is conerted into mm$g !y use

o- Criedenwald ta!les.

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Tonometry

• 8he main types o- tonometer "

# Goldmann tonometer consists o- dou!le prism with

.0 mm in diameter, applanation, more accurate, # Perkins tonometer, hand held, applanation,

# 8he air pu-- tonometer, non contact, applanation, ?et o-

air to -latten the cornea.

# 8ono1pen # Gas 8onometer

# Electrical 8onometer

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$chiot% Tonometer

Porta!le, simple, low cost,

Measure the depth o- indentation o-

cornea !y a plunger withspeci-ic weight,

3 mm indentation represent as each

scale o- Schiot which conerted into

mm$g !y Creidenwald ta!le, Fow accuracy !ecause it is

in-luenced !y ocular rigidity %high

myop, DM, corneal leucoma(.

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Goldmann&s A''lanation

Tonometer

• More accurate, not in-luenced !y ocular rigidity,

• 8he -oot plate o- the plunger is smaller %.0 mm(,

• Disadantages" cannot !e applied to

# orneal edema

# Keratitis, corneal ulcer

# Keratokonus # $igh astigmatic

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Tono"ra'hy

• 8o estimate out-low -acility o- $A,

• Principal" to e

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Pro(ocation Test

• ater drinking test, dark room test,midriatic test, steroid test,

• Positie i- &'P at the end o- the tests aremore than 4 mm$g,

• &ndications"

# 9arrow = closed angle glaucoma # 9ormal tension glaucoma

# Hias &'P

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Goniosco'y

• 8hree main purposes o- gonioscopy"

# &denti-ication o- a!normal angle structure,

# Estimating the width o- the cham!er angle,

# Iisualiation o- the angle during this -ollowing

procedures" goniotomy, laser tra!eculoplasty.

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Indentation Goniosco'y

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Identification of an"le structures

• Schwal!e7s line as an opa:ue line is a

peripheral termination o- Descemet

mem!rane,

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• 8ra!ecular meshwork has a ground glass

appearance, stretches -rom Schwal!e7s line

to scleral spur.

onsists o- two part"

# 8he anterior, non-unctional, non pigmented

part, whitish color, # 8he posterior, -unctional, pigmented part,

greyish1!lue translucent.

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• Schlemm7s canal, slightly darker line, deep

to the posterior tra!eculum,• Scleral spurs, most anterior o- sclera,

narrow, dense, o-ten shiny, whitish !and. As

a landmark -or laser tra!eculoplasty.

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• iliary !ody stands !ehind the scleral spur as dull !rown !and. 8he width depends on iris insertion.

# ure o- the corner at the margin o- the ciliary !ody # &ris processes

• 8he angle recess dipping o- the iris, it inserts intothe ciliary !ody.

• &ris processes, small e

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An"le classification by $haffer

• Grade &I " /3 degrees angle

&&& " *0 1 *3 degrees angle

&& " *0 degrees angle closed

& " +0 degrees angle closed

• Slit angle " less than +0 degrees,• Grade 0 " closed angle, iridocorneal

contact.

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$haffer Gradin"

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O'hthalmosco'y of the o'tic disc

• +.* million a

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9ere -i!er layer anatomy

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9ormal nere -i!er layer

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Di--use nere -i!er atrophy 9ormal nere -i!er layer

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• Scleral canal, the opening o- +.* million nere

-i!er leaes the eye, oal, ertical, +.J3 mm in

diameter,• 8he lamina cri!rosa, plate o- collagenous

connectie tissue, *001/00 pore, containing retinal

nere -i!er !undles,

• 8he large pores hae thin connectie tissue

supports, and large nere -i!ers, ulnera!le to

glaucomatous damage.

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• 8he optic cup, pale depression in the center o- theoptic cup, a!sent o- nere -i!er,

• 8he neuroretinal rim, tissue !etween outer edge o-the cup and the outer margin o- the disc, the coloris pink orange, uni-orm width, contains nere-i!ers,

• 9ere -i!ers death thinning o- retinal rim,• $igh &'P posterior !owing o- lamina cri!rosa,

nasalisation o- central retinal essels.

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• 8he cup1disc ratio" -raction o- ertical and

horiontal diameter cup and diameter o- the

disc, normal c=d ratio is 0. or less.

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O'tic disc chan"es in "laucoma

9ormal disc with small cup

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Farge physiological

cups

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• Progressie loss o- the retinal nere -i!ers

notching = thinning o- neuroretinal rim %9(

• 8he cup is enlarged " # concentrically di--use thinning o- 9

# localied e

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• up and disc ratio ) 0.,

• Peripapillary atrophy at temporal region,

• Splinter1shaped hemorrhage on the discmargin.

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)ormal *isual +ield -amination

• 9asally 0 degrees

• 8emporally 63 degrees

• Superiorly 30 degrees

• &n-eriorly J0 degrees

• 8he !lind spot is located temporally +01*0 degrees

• Iisual -ield is an island o- ision surrounded !ysea o- darkness, the sharpest is at the top o- island.

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*isual +ields in Glaucoma

• Haring o- the !lind spot

• Focalied paracentral scotoma at +0 1 *0

degrees o- -i

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*isual +ields in Glaucoma

• Peripheral scotoma that spreads and

coalesce to the paracentral scotoma

• Feaing central island and accompanying

temporal island, een i- the central ision is

still normal

• 8emporal island total !lindness

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*isual +ieldsin Glaucoma

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#lassification

• Primary open1angle glaucoma

• Secondary open1angle glaucoma

• Primary closed1angle glaucoma

• Secondary closed1angle glaucoma

• Primary congenital glaucoma• Secondary congenital glaucoma

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Primary O'en.An"le Glaucoma

$im'le Glaucoma!

• Hilaterally, not necessarily symmetrical, a!sence

o- secondary causes o- high &'P,

• Glaucomatous optic nere damage,• 'pen and normal angle, &'P ) *+ mm$g,

• Adult onset, hereditary, steroid responsieness,

• Glaucomatous isual -ield de-ects, central tunnelision,

• Minimal clinical signs.

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Mana"ement of Primary O'en

An"le Glaucoma

• &nitial therapy is usually medical, e

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$ur"ical Indications for

$im'le Glaucoma

• ;ncontrolled &'P !y ma

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Primary #losed.An"le Glaucoma

• '!struction o- a:ueous out-low as a resulto- closure o- the angle !y the peripheral iris

• Anatomically predisposed, !ilateral,• Predisposition"

# rowded anterior segment

# elatiely anterior location iris lens diaphragm, # Shallow anterior cham!er,

# 9arrow entrance to the cham!er angle.

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PA#G sta"e

• Cie oerlapping stage"

# Fatent

# &ntermittent %su! acute(

# Acute %congestie and post congestie(

# hronic

# A!solute

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/atent an"le.closure "laucoma

• Shallow anterior cham!er, cone

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Intermittent

an"le.closure "laucoma

• apid partial closure anterior cham!er angleand reopening o- the angle a-ter some rest,

• Precipitating -actors" physiological mydriasis,watching 8I in dark room, prone position,reading, sewing, emotion, stress,

• 8ransient !lurring o- ision, halo, headache,

• ecoery a-ter some rest.

A

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Acute con"esti(e


• Presentation" # apidly progressie impairment o-

ision, sometimes the ision +=00 # 0, # Eye ache and -rontal headache,

# ongestion, nausea, omiting.

A i

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Acute con"esti(e


• E

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Acute con"esti(e


• ide pupil, slow = negatie lightre-le

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Acute con"esti(e


A i

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Acute con"esti(e


• Di--erential diagnosis"

# ed eyes"

•acute glaucoma, con?unctiitis, iridocyclitis

# Silent eyes"

• simple glaucoma, ocular hypertension

# Glaucomatous isual -ield de-ect"

•anomaly o- the optic nere and retina

# Papillary atrophy"

• anomaly at optic nere

# ongenital megalocornea without high &'P

A i

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Acute con"esti(e


• 8reatment"

# &mmediately decrease &'P with ma

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Postcon"esti(e


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#hronic closed.an"le "laucoma

• linical -eatures o- chronic AG are similar as

P'AG e

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#hronic closed.an"le "laucoma

• Signs and therapy are similar as simple

glaucoma"

# 8ra!eculectomy,

# Faser gonioplasty to make an angle,

# Argon Faser 8ra!eculopasty %AF8(

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Primary #on"enital Glaucoma

• 35 o- patients are male, +" +0.000,

• &nheritance is autosomal recessie, !ilateral,

• Maldeelopment o- the tra!eculum and

iridotra!ecular ?unction, a!scent o- angle

recess, tra!eculodysgenesis,

• 8he iris insertion can !e -lat or concae,

• Poorly prognosis.

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• linical signs"

# Depends on the age o- onset and the leel o-

&'P, # According to age o- onset there are types"

• 8rue congenital glaucoma %/05(. &'P eleated

intrauterine !uphthalmos,

• &n-antile glaucoma %335( mani-est a-ter !irth,

• 2uenile glaucoma" &'P at *1+ years o- age, with

clinical mani-estation the same as P'AG.

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• E

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• 8reatment"

# &nitial drug treatment,

# Goniotomy i- cornea is still clear,

# 8ra!eculotomy at corneal clouding,

# 8ra!eculectomy and tra!eculotomy,

# 8ra!eculectomy with antimeta!olic agent, # 'utcome o- the operation is poor.

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$econdary Glaucoma

• &n-lammation and residual in-lammation o-the ueal tissue" iridocyclitis, posterior

synechia,• &mmature cataract, hipermature cataract,

• Fens lu

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$econdary Glaucoma

• Pigmentary gl. 1 9eoascular gl.

• &n-lammatory gl. 1 Phacolytic glaucoma

• ed cell gl. 1 Ghost cell glaucoma

• Angle recession glaucoma

•&ridocorneal endothelial syndrome

• Pseudoe

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Thera'y

• 9ere -i!er damage caused !y glaucoma is

irreersi!le,

• Principal o- therapy is to decrease &'P medicallyor surgically to maintain the current condition,

• 8he purposes o- decreasing the &'P is to reduce

progressiity o- the nere -i!er damage and isual

-ield de-ect,

• Early -inding.

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Indications of Medical Treatment

• Simple glaucoma

• Acute = chronic closed angle glaucoma• Maintain the diurnal &'P

• Fowering &'P !e-ore operation

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0educin" aqueous 'roduction

• ar!onic anhydrase inhi!itor # acetaolamide *30 mg :id orally,

# dorolamide eye drop tid,• Heta1adrenergic antagonist"

# !eta1!locker %timolol maleat 0.*310.35( !id,

# !eta

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Other anti"laucoma dru"s

• Parasympathomimetic agents"

# pilocarpin eye drop *1/5, *1 < = day

# car!achol 0.J35 used a-ter cataract operation• &ncrease the latanoprost ueoscleral -low

• $yperosmotic -luid

# glycerol 305 +1* ml=kg !ody weight, drink all at once,

# manitol *05 swi-t in-usion preoperatie, +.31 ml=kg

!ody weight.

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$ur"ical treatment

• Peripheral iridectomy" # Acute attack glaucoma, with good tra!ecular meshwork,

# Preentie treatment -rom acute attack -or the -elloweye.

• 8ra!eculectomy -or all types o- glaucoma,

• Goniotomy -or congenital glaucoma i- the cornea isstill clear,

• 8ra!eculotomy -or congenital glaucoma i- thecornea is edema.

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$ur"ical treatment

• 8reatment -or a!solute glaucoma" # cyclocryo coagulation destroys the ciliary !ody

to decrease $A production, # enucleation i- all treatment is not success-ull.

• Faser treatment" # iridotomy

# gonioplasty

# tra!eculoplasty

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Good Pro"nosis

• Early and right diagnosis,

• Ade:uate control o- &'P !y medical =

surgical treatment,

• ompliance o- the patients -or checking

their &'P and use medical treatment,

• ase -inding among glaucoma -amily.

08 - glaucoma

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