Glaucoma note for medical student, 2014

Glaucoma Lecture note for undergraduate students

Abeba T. Giorgis, MD

Department of Ophthalmology, School of Medicine, Addis Abeba University. 2014

What is Glaucoma?
Glaucoma refers to group of eye disease with two common characteristics that are
progressive optic nerve head damage and visual field (surrounding vision) loss.
Glaucoma, if not detected or left untreated, it leads to irreversible blindness.

Magnitude of glaucoma
Glaucoma is a major blinding disease worldwide and single largest cause of irreversible
blindness. The disease affects 4% of world population. In 2010, it was estimated about
61 million to live with glaucoma, of whom 8.4 million being bilaterally blind. This figure is
expected to raise to about 80 million people to live with glaucoma and 11 million to be
=symptomless nature of the majority types of glaucoma, 50% people in the developed
and 90% people in the developing countries living with glaucoma do not know that they
have the disease.

Glaucoma is a second blinding disease, next to cataract, in most African countries.

Africans are at 3-4 fold higher risk of having glaucoma, particularly for primary open
angle glaucoma as compared to the white population.

A prevalence of 10,000 people with glaucoma for every one million with annual
incidence of 400 new cases per million was estimated for East, Central and South
Africa. Therefore, it is obvious that for Ethiopia with huge number of population to have

quite large number of people living with glaucoma.

According to National survey conducted in Ethiopia in 2006 on causes of blindness and

low vision, glaucoma was found to be 5th as cause blindness, accounting for 62, 000
blind people by then. The figure could be higher because the survey did not include the
secondary glaucoma and visual field in determination of blindness. Moreover, the other

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 Glaucoma note for medical student, 2014

leading causes of blindness (Cataract, Trachoma) during the survey could be reduced
and even eliminated (Trachoma) as the socioeconomic status and eye care service
improves in the country.

Risk factors for glaucoma

1. Elevated eye pressure ( Intraocular pressure, IOP)
It is the most identified risk as well as causal factor for most types of glaucoma.
The higher the level of IOP, the more chance of developing glaucoma. It may
take 14 to 15 years to be blind from glaucoma when the IOP is in the range of 20
to 25 mm Hg. But, an eye pressure above 40 mm Hg may lead to blindness in
few months.
2. Age
The prevalence of glaucoma is 4% to 5% in age group 40 to 70; and rises to
about 10% to 15% in age about 80 years; though any age group can be affected.
3. Race.
o Blacks are at 4X increased risk of being affected by primary open angle
glaucoma (POAG) as compared to the Caucasians.
o Chinese are at higher risk for angle closure glaucoma (ACG).
o Japanese are at risk for normal tension glaucoma (NTG).
4. Family history.
o If glaucoma occurs in one of parents, the risk for the children to
develop glaucoma is 5 times.
o If there is affected sibling, in addition to presence in the parent,
then the risk increases to 9 times.
5. Sight/ refractive error.
o Hyperopic (far sighted) are at risk for angle closure glaucoma.
o Myopic (short sighted) are at risk for open angle glaucoma.
6. Eye injury or surgery.

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o Any eye injury or intraocular surgery may lead to secondary either open or
closed angle glaucoma.
7. Drugs.
Steroid: There are steroids responders people, particularly those with family
history of open angle glaucoma, who can responde to any form steroid use, even
from dermal application.
The response or level of IOP elevation depends on:
 Route of administration- eye > other routes
 Strength of the steroid- Dexamthason, hydrocortisone > medrysone
 Frequency of application – More drops higher risk

8. Systemic low blood pressure.

Low blood pressure from any cause is associated with glaucomatous damage to
the optic nerve head from disruption of auto-regulation mechanism of blood flow
to the nerve.

9. Vasospastic syndrome (migraine, Reynaud phenomena).

People with such problem are at risk for glaucoma due to disruption to auto-
regulation and high sensitivity even to normal level of IOP.

Intraocular pressure (IOP)

Intraocular pressure /eye pressure/ is related the aqueous humor in the anterior
segment of the eye. The IOP depends on the rate of aqueous production (inflow)
and excretion (outflow).

Aqueous humor
Aqueous is a dynamic fluid filling the anterior and posterior chambers of the eye.
It is produced at average of 2 l/minute (range 1.8 to 4.3 l/m) by the non
pigmented epithelial lining of the ciliary body processes in the posterior chamber
and flows through the pupil into the anterior chamber.

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The production is higher in the morning and reduced by half at night. It is also
reduced with age.
Function of aqueous:
 Maintains integrity of the anterior chamber and the whole globe.
 Contains nutrients to the avascular structures of the anterior chamber,
particularly to the corneal and lens.
 Provides colorless and transparent media for the eye optical system.
 Removes metabolite products from the cornea, lens and trabecular
meshwork.
The aqueous drains from the anterior chamber largely (80% to 95%) through
trabecular meshwork. Trabecular meshwork is a structure located at the anterior
chamber angle, a peripheral junction of the cornea, sclera and the iris. The
remaining 5% to 20% drains through uveoscleral pathway. After passing through the
different drainage structures, the aqueous mixes with the eye episcleral venous
system.
The level of IOP is maintained by continuous aqueous formation and drainage.

A B
Ciliary processes Aqueous humor secretion and excretion

Risk factors for elevated IOP

1. Increased rate of production-
Rare condition occurring in cases with uveitis, inflammation of the eye.
2. Resistance or obstruction of the aqueous outflow, the commonest cause
3. Increased episcleral pressure

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Any orbital, ocular, intracranial or idiopathic condition resulting elevated

episcleral venous pressure (above 8 mm Hg) can cause high IOP.

Normal level of intraocular pressure

The normal level in the general population is ranging 10 mm Hg to 20 mm Hg. But this range
may not be normal for glaucoma population. The ideal level of IOP can be defined as an IOP
level that does not cause any glaucomatous damage to the eye. It could be 10 mm Hg or up to
30 mm Hg depending on individual eye sensitivity.

Measurements of intraocular pressure

The IOP can be measured using different means or tonometers.
1. Digital tonometer
It is possible to estimate the level of the IOP by balloting the eye ball over the
eyelids, while looking down, using the two index fingers. It is advisable to
compare the two eyes or with that of eyes of other person without glaucoma to
get good estimate and differentiate the abnormal from normal.

2. Schiotz tonometer. Available in general hospital / health centers.

3. Glodmann applanation tonometer. It is a Gold standard. Requires slit lump
microscope and experience.
4. Tonopen. Handheld instrument used for children and adults.
5. I-Care. Newer instrument which can be used anywhere, without requiring topical
anesthesia to the cornea and for any age.

Schiotz tonometer
Digital tonometer

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Applanation tonometer
Tonopen

What is mechanism for glaucomatous damage of the optic nerve and

vision loss?
Even if elevated IOP exerts pressure to all parts of the eye globe, it the optic nerve head, a site
for exit of the 1.2 million nerve fibers in 1000 bundles, which is very sensitive to be damage. The
theories for glaucomatous optic nerve damage are
1. Direct compression of the nerve fibers by the elevated IOP
2. Ischemic damage from compromised blood flow
3. Disruption of blood flow autoregulation
4. Combined mechanism

Eye pressure damage on the optic nerve head

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Classification of Glaucoma
Glaucoma is commonly classified based on the etiology, mechanism and age of
onset.
1. Open Angle Glaucoma (OAG)
2. Angle Closure Glaucoma (ACG)
3. Juvenile Glaucoma
4. Childhood Glaucoma

1. Open angle glaucoma (OAG)

The type of glaucoma that presents when the drainage angle structure is open on
gonioscope examination is referred to as open angle glaucoma. This type of
glaucoma can be further sub-classified.
1.1. Primary Open angle glaucoma (POAG)
1.2. Normal tension Glaucoma (NTG)
1.3. Ocular Hypertension Glaucoma (OHT)
1.4. Secondary Open angle glaucoma

Open angel drainage structure

1.1. Primary Open Angle Glaucoma (POAG)

Definition: Types of OAG without identifiable cause.
Magnitude: Commonest type of glaucoma worldwide and in Ethiopia as well. It is
common after age 40 and among blacks.
Inheritance pattern: The disease has autosomal dominant and multifactorial
inheritance patter. Therefore, people with family history of glaucoma (POAG) are at risk
to develop the disease.

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Clinical Features: Both eyes are usually affected. Clinical features include elevated
IOP, normal looking angle structure, Glaucomatous optic nerve head and visual field
loss, depending on the severity of the nerve damage. The visual acuity may remain
normal (6/6) until the end stage of the disease.
Management: Controlling the IOP with medical, surgical or laser. Keeping IOP at low
level halts progression of glaucoma and prevents further nerve damage and visual field
loss. Requires lifelong follow-up.

1.2. Normal Tension Glaucoma (NTG)

Definition: Glaucoma with optic nerve head damage and visual field loss while the IOP
is below 20 mm Hg.
Magnitude: Common among Japanese population. But less common type of glaucoma
in the other race.
Clinical feature: Eye pressure in the normal range when measured at different times,
open angle structure, glaucomatous optic nerve head damage and visual field loss.
Management: Lowering IOP to low 10 with the management options has been proven
to prevent further damage. Controlling low systemic blood pressure, sleep apnea and
managing vaso-spastic systemic condition is also advisable.

1.3. Ocular Hypertension

Definition: Elevated IOP, but no optic nerve damage and no visual field loss.
Magnitude: Not common
Management: May required treatment when the IOP is above 30 mmHg and patient
has additional risk factors, like family history of glaucoma. Check central corneal
thickness.

1.4 Secondary Open Angle Glaucoma

There are a number of causes for secondary open angel glaucoma. Some examples
are Pseudoexfoliative glaucoma, lens related, raised episcleral venous pressure and
steroid induced glaucoma.

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Pseudoexfoliative Glaucoma (PXG)

Definition: Type of glaucoma related to the presence of exfoliative material in the eye.
Magnitude: Common among Scandinavian countries, accounting for 50% of
glaucoma. It is also common in East Africa, while rare in West Africa. A study in 2013
from Jimma University has identified PXG to be the commonest type followed by
POAG. Similar study conducted at Menelik Hospital, where cases are referred from
different parts of the country, identified POAG followed by PXG to be the two common
types accounting for 64% of all types. It is rare below the age of 40.
Mechanism: Formation exfolaitive material is a generalized basement membrane
disorder affecting the eye, lung, heart, liver, kidney and cerebral meninges. Among all
the organs, it is the eye affected with clinical features and damage. The material
hampers drainage of the aqueous humor by blocking and damaging the trabecular
meshwork.

Exfoliative material on the lens surface

Clinical feature: Glaucoma may affect either one eye or both eyes at presentation. It is
characterized by high and fluctuating diurnal IOP, which is more damaging than
elevated and constant IOP. As a result there is more and rapidly progressive optic
nerve damage as compared to POAG.
Management: Treatment for the disease includes medical, surgical and laser. However,
PXG is resistant to medical treatment and is associated with complications intra and
postoperative period as well.

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Lens related Glaucoma: Secondary glaucoma can occur from neglected cataract,
traumatic rapture lens or left cortical lens material in the anterior chamber of the eye.

Raise episcleral venous pressure: The normal episcleral venous pressure is

around 8mm Hg, which lets flow of aqueous. When any vascular, orbital or intracranial
condition causing elevation of the episcleral pressure, that in turn results in resist the
flow of aqueous.

Steroid induced glaucoma: People who are steroid responder may develop
elevated IOP and glaucoma when treated with steroid drugs being administered as eye
or systemic medication. The response and elevation of IOP depends on route of
administration, frequency and potency of the drug. For example: long acting steroid
injected subconjuctivaly or intavitreously is more likely to cause elevated IOP. Health
professionals should be aware of the possibility of secondary glaucoma whenever we
prescribe any form of steroid. Formation of cataract is also a complication of the drug.
Patients should be informed and their eye pressure should be checked while they are
on drug.

2. Angle Closure Glaucoma (ACG)

Definition: A type of glaucoma due to closure of the aqueous drainage system (angle).
Classification: Primary and secondary ACG

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2.1. Primary Angle Closure Glaucoma (PACG)

Magnitude: Primary ACG is the common form of the angle closure glaucoma. It is a
Common type of glaucoma among East Asians; responsible for 90% of bilateral
blindness in Chian, affecting more than 1.5 million Chinese people. Angle closure
glaucoma is third form in Ethiopia following POAG and pseudoexfoliative glaucoma.
Rare below the age of 40.
Risk factors:
1. Race – Asians are more affected than other races.
2. Family history- the incidence is increased in the first-degree relatives of affected
individuals.
3. Sex – females are more affected, 2 to 4 times, than males due to shallower
anterior chamber as compared to males.
4. Refractive error- hyperopic are at risk due to small eye ball size and shallow
anterior chamber.

Clinical features: PACG has three different clinical features

1. Acute angle closure glaucoma: characterized by sudden abrupt onset of
sever pain of the affected eye, redness, reduced vision, headache, very high
IOP above 40 mmHg, the cornea could be edematous or cloudy, shallow anterior
chamber and mid dilated and non-reactive pupil.
Management: AACG requires urgent management. The eye pressure should be
reduced using aqueous humor production suppressant and hyperosmotic agents
and the acute inflammation with anti-inflammatory agents. After controlling the
IOP and inflammation, the definitive treatment is required either using laser or
surgery to create peripheral iridotomy (a fistula on the iris) that would allow
passage of aqueous from the posterior to the anterior chamber. A prophylactic
similar procedure should be done to the second eye to prevent similar attach in
the in few years.
2. Subacute angle closure glaucoma: Characterized by self resolving episodes of
blurred vision, halos (color around light) and mild pain caused by elevated IOP.
The episodes could occur periodically over days, weeks or months. The IOP is

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normal between episodes. The attacks could be confused with headaches or

migraines. Iridotomy is the choice of treatment. The condition can progress to
chronic angle closure glaucoma or to acute attack that does not resolve
spontaneously.
3. Chronic angle closure glaucoma: This form of angle closure glaucoma
develops following acute angle closure, if left untreated, or the subacute form
with progressive closure of the drainage angle structures. Management include
both medical and surgical like the open angle glaucoma.
2.2. Secondary angle closure Glaucoma: This form of glaucoma occurs from any
ocular or systemic underlying cause leading closure of the drainage angle.

3. Juvenile Glaucoma
Definition: Open angle glaucoma that occurs between the age of 4 to 35 years.
Magnitude: Rare condition. People with family history glaucoma are at higher
risk. However affected individuals are identified at advanced stage of the disease
or after they have lost their vision, mainly due the asymptomatic nature of the
diseases and even if they come to ophthalmic attention for other complaints, the
glaucoma could be over looked.
Clinical feature: Characterized by high IOP level and deeply excavated optic
nerve head. It may require surgical intervention to control the high IOP in addition
to medical treatment.

4. Childhood glaucoma (CHG)

Definition: Glaucoma occurring during the childhood period starting from the
intrauterine to the first 3 years of life.
Magnitude: Rare condition occurring in 1: 10,000 children. It is common among
communities with consanguineous marriage with autosomal inheritance pattern.
Classification: CHG is classified as primary and secondary. There are number
of ocular and systemic conditions leading to secondary CHG.
Primary CHG is the commonest form. Males are more affected than females.

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Clinical feature: CHG has classic features that are clearly observable in 60% of
the affected children before the age of 6 months and in 80% in the first one year
of life. Enlarged eye balls, large and cloudy corneas, tearing, and photophobia
(fear of light) are the features that can be easily identified by parents and health
professionals. The clinical signs include high IOP, edematous cornea and
excavated optic nerve head.

Childhood glaucoma

Management: The definitive treatment for CHG is surgery. The success rate of
the surgery is about 80%. The outcome is good if they come below the age of
one year. If they present in the first few months of life before permanent damage
to the eyes, the condition can be reversed to normal. Delayed presentation leads
to permanent damage to the eye and poor surgical outcome. A child could be
blind the rest of his/her life by manageable condition if left undiagnosed or
present late.

Evaluation of glaucoma patients

Detailed eye examination is required to glaucoma patients like the other
ophthalmic patients. The major evaluations are focused on:
1. Intraocular pressure (IOP) measurement. It should be done at different
times, like systemic blood pressure, to confirm persistent elevated pressure,
and to document fluctuation.
2. Gonioscopy: It is the assessment of the anterior chamber angle (aqueous
drainage system) using slit lump microscope and goniolens. The examination
enables to identify whether the glaucoma type is open or closed angle or
presence of any changes or abnormalities.

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3. Optic nerve head evolution: Done to identify glaucomatous damage or

progress of the disease during follow-up. Direct ophthalmoscope and
stereoscopic view using slit lump microscope with contact or non contact
lenses are the instruments commonly used for the evaluation.
4. Visual field: The test is useful to detect any field defect, severity of defect or
progression. Progress field loss during follow-up is a key indicator of
glaucoma progress.

Management of glaucoma
To date reduction of the IOP is the proven management of glaucoma. Low IOP
level halts nerve fibers loss and optic nerve head damage. The blood perfusion
pressure to the optic nerve head is also improved with low IOP level.
Management options are:

1. Medical
2. Surgical
3. Laser

Medical agents
There are five groups of drugs used clinically. These are:
A. Sympathomimetics – lower IOP by reducing aqueous production
Beta adrenergic antagonists :
o Timolol (eye drop) 0.5% or 0.25% - Dose BID
o Betaxolol (eye drop) 0.5% - Dose BID

Adrenergic agonist :
o Apraclonidine (eye drop) – Dose BID or TID
o Brimonidine ( Eye drop) 2% - Dose BID or TID
Timolol and betaxolol are available in the market in the country. Timolol is the
most prescribed drugs. It is contraindicated for patients with obstructive

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pulmonary and cardiovascular diseases. Betaxolol, selective beta-blocker is

prescribed for patient with obstructive respiratory diseases.

B. Parasympatomimetics – Lower IOP by facilitating outflow of the aqueous

humor. Pilocarpine available in 2% to 4% in the country is prescribed 2-3
times daily. The drug is used to treat open angle glaucoma
.
C. Prostaglandine analogues: Lower IOP by enhancing aqueous humor out
flow
Latanoprost, Travoprost, Bimatoprost and Tafluprost are in the group.

D. Carbonic anhydrase inhibitors – Lower IOP by reducing aqueous

production.
o Actazolamide (Tablet) – Dose125 - 500mg 2-4 times daily.
o Metazolamide (Tablet) – Dose 50 - 100mg 2-3 times daily.
o Dorzolamide (eye drop) - Dose 2-3 times daily
o Brinzolamide (eye drop) – Dose 2-3 times daily
Acetazolamide (Diamox) is the one available in the country and usually
prescribed for patients with high IOP level for short pried of time because of
its systemic side effects.

E. Hyperosmotic agents – Lower IOP by dehydrating the Vitreous

o Manitol (Parentaral) 20%- Dose 1.5g/kg IV
o Glycerol(Oral); dose 1.5g/kg, contraindicated for diabetic patients
The agents are used to lower high IOP prior to glaucoma surgery and for
acute angle closure glaucoma

There are fixed combination of timolol with the other drugs:

Timolol/Brinzolamide, Timolol/Dorzolamide, Timolol/latanoprost,
Timolol/Travatan and Timolol/ brimonidine

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5. Surgical Management
Filtration Surgery: Creation of artificial or alternative path for the flow of the
aqueous humor. Trabeculectomy is the commonest type of filtration surgery
performed worldwide.

Tube-shunt surgery: With this procedure a silicon tube is inserted into the anterior
chamber and its plate is fixed to the sclera. The aqueous flows through the tube
and then over the plate in the sub-conjunctival space.

Laser: It has a different role in the management of glaucoma

o Laser trabeculoplasty: Laser applied to the angle drainage structure to
facilitate the aqueous humor outflow.
o Laser cyclophotocoagulation: The some part of the ciliary body and its
process is destroyed to reduce aqueous production.

The management option or decision is based on different factors

Medical treatment is preferred for
 IOP in 20s
 Early to moderate stage of glaucoma
 Good compliant patients
 Patients who can afford and have access for the glaucoma drugs
Filtration surgery is preferred for
 Uncontrolled IOP with medications
 Advanced stage glaucoma to achieve and maintained low level IOP
 Patients from far areas
 Poor compliant patents
 Patients who cannot afford or access the drugs
Tube-shunt surgery is usually recommended for refractory or failed previous
surgery.
Childhood glaucoma is primarily managed by surgery.

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Glaucoma situation in Ethiopia

Glaucoma is a commonly encountered cause of visual loss. Above 60% of
glaucoma patients presents with advanced stage of the disease. The same
proportion are either unilateral or bilaterally blind from preventable blindness. The
main reasons for the late presentation are believed to be the symptomless nature
of the most types of glaucoma, lack of awareness and inaccessibility of eye care
service. Limited drug options, availability and cost have also impact on
progression of glaucoma.
To address this major problem a number of activities have been done as of 2007,
particularly on raising awareness.

Key points
 Glaucoma is preventable cause of blindness if identified at early stage and
properly managed.
 Once vision is lost from glaucoma; it is irreversible with any form of
treatment modality.
 Health professionals should be able to identify glaucoma cases and refer
for management.
 Do not miss childhood glaucoma. Children may remain blind their whole
life from treatable glaucoma if identified and managed at early age.
 Do not misdiagnosed acute angels closure glaucoma as conjunctivitis

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