Treatment of Glaucoma

Glaucoma
Glaucoma is characterized by high IOP associated with optic disk cupping and visual field loss

Normal outflow through trabecular meshwork (large arrow) and uveoscleral routes (small arrow) and related anatomy.

In primary open-angle glaucoma, aqueous outflow by these pathways is diminished.

In angle-closure glaucoma, the iris is abnormally positioned so as to block aqueous outflow through the anterior chamber (iridocorneal) angle.

Normal optic disc. Note the distinct optic disc margins, the well-demarcated cup, and the healthy pink color of the neuroretinal rim.
The cup-to-disc ratio of this optic nerve is 0.6. Clinical correlation with the patient's history and examination is required to decide if this optic nerve is abnormal. Glaucomatous optic nerve cupping. The cup in this optic nerve is enlarged to 0.8, and there is typical thinning of the inferior neuroretinal rim, forming a "notch."

Visual Field Impairment
(A)normal (B)loss of visual field in the superior and nasal portion (C)visual field loss extends to superior and inferior portions (D)Finally,extensive damage to the entire visual field occurs, sparing the very central portion of vision.

Glaucoma classified according to etiology
• Primary glaucoma
– Open-angle glaucoma – Angle-closure glaucoma
Chronic angle-closure

• Congenital glaucoma • Secondary glaucoma

Siderosis

Trauma

Neovascular glaucoma
Open-angle, trabecular abnormality

Treatment Goal
The goal of glaucoma treatment is to preserve the visual field of patients and prevent the loss of visual function that is associated with the disease.”
Ref: Survey of Ophthalmology; 2003 Vol. 48(1): S1-S3

THE FIRST TARGET
ACHIEVING A LOW TARGET IOP WHICH IS UNIFORM DAY AND NIGHT

Target IOP: Definition
Target IOP may be defined as a pressure, rather a range of intraocular pressure levels within which the progression of glaucoma and visual field loss will be delayed or stoped
          Ref: Surveys of Ophthalmology 2003; 48 (suppl 1): 53-57

The treatment options of glaucoma includes: • Drugs • Laser • Operation The treatment is decided by many factors:
– Type of glaucoma – Stage of glaucoma – Damage done – Status of the other eye – Response to other treatment already taken – Patient compliance or reliability about taking drugs and follow up examination

Operation -Trabeculectomy

THE SECOND TARGET:
VASOPROTECTION/ NEUROPROTECTION

GLAUCOMA: OPTIC NERVE DAMAGE
Rise in IOP Mechanical back pressure On the junction of optic nerve/retina Reduce the blood supply to the optic nerve Loss of blood supply RGC loss

THE THIRD TARGET
PERSISTENCY/ COMPLIANCE WITH DRUG THERAPY IN GLAUCOMA MANAGEMENT

Glaucoma Therapy: Persistency
Pharmacologic therapy for glaucoma can be effective only if patients fill their prescriptions (persistency) and take their medications as directed (compliance)
Ref: Am. J. Ophthalmol 2004; 137: S3-S12

So
• Let your patients have good compliance
– Tell him what is glaucoma – How to cooperate with doctor – Check your treatment

Differential diagnosis
• Acute conjunctivitis • Acute angle-closure glaucoma (acute ACG)

Symptoms

iridocyclitis Slow decrease comparatively usually located in ocular area No

Acute ACG

Acute conjunctivitis normal

Vision

Toboggan

Pain position

Ophthalmalgia slight or not and migraine Be often accompanied with No

Nausea and vomit Secretion

No

No

A great deal

signs Congestio n Cornea KP Anterior chamber Aqueous humor Iris Pupil Intraocular pressure

iridocyclitis Ciliary or mixed clarity offwhite Not shallow Flare and cells Unclear furrow nodule Shrink, irregular Normal or low IOP

Acute ACG Ciliary or mixed opaque pigmentary shallow Flare and exudation Segmental atrophy of iris Dilate, vertical oval shape High IOP

Acute conjunctivitis Conjunctival clarity No Not shallow Normal Normal Normal Normal

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