age (glaucoma

becomes more
likely as you get medical history
older) in the UK, people with diabetes may
chronic open- be at increased risk of
angle glaucoma developing glaucoma
affects up to two in
every 100 people short
over 40 years old sightedness
and around five in
every 100 people (myopia) people
over 80 years old who are short-sighted
are more likely to family history if
develop chronic open- you have a close
angle glaucoma relative, such as a
ethnic origin parent, brother or sister
who has glaucoma, you
people of African or Afro-
are at increased risk of
Caribbean origin are at
developing the condition
increased risk of developing ocular hypertension (OHT yourself
chronic open-angle raised pressure in the eye) your
glaucoma and people of optometrist will be able to diagnose
Asian origin are at increased OHT (see diagnosing glaucoma),
risk of developing acute which increases your risk of
angle-closure glaucoma developing chronic open-angle
glaucoma

chronic open-angle glaucoma
the most common type which
often has few symptoms
usually no noticeable
symptoms because the
condition develops very slowly
the first part of the eye to be
affected is the outer field of
vision (peripheral vision).
secondary glaucoma caused
by other conditions or eye
treatments
misty vision
rings or halos around lights.
acute angle-closure glaucoma
which often has severe symptoms
intense pain
redness of the eye
headache
tender eye area
seeing halos or 'rainbow-like' rings around
lights
misty vision
loss of vision in one or both eyes that
progresses very quickly
developmental glaucoma a rare
condition affecting young babies
large eyes due to the pressure in the eyes
causing them to expand
being sensitive to light (photophobia)
having a cloudy appearance to their eyes
having watery eyes
jerky movements of the eyes
having a squint, which is an eye condition
that causes one of the eyes to turn inwards,
outwards or upwards, while the other eye
looks forward
References

Kimble, M.A.K. et al. 2008. Applied Therapeutics:

The Clinical Use of Drugs. Philadelphia: Lippincott
Williams & Wilkins.
Burn, M.A.C. et al. 2007. Pharmacotherapy
Principles and Practice. USA: The McGraw Hill
Companies.
Dipiro, J.T. et al. 2002. Pharmacotherapy: A
Pathophysiologic Approach. USA: The McGraw
Hill Companies.
TREATMENT OF
GLAUCOMA
 PRINCIPLE OF GLAUCOMA TREATMENT :
I. to maintain the patients quality of life at a
sustainable cost
II. reduction of intra ocular pressure,
III. improvement of ocular blood flow,
IV. direct neuroprotection

THERAPY

Medical Surgical
Miotics
Beta-blockers Argon laser trabeculoplasty
Carbonic anhydrase Trabeculectomy
inhibitors Filtering procedure
Prostaglandin Cyclocryotherapy
analogues Cyclolaser ablation
Alpha-2 agonists Iridotomy
GLAUCOMA ALGORITHM
 Prostaglandin analogues:
Action: increase aqueous outflow via the uveoscleral route.

Contra-indications: active uveitis, pregnancy and breast-feeding.

Caution: brittle or severe asthma, aphakia (patient with no lens),

pseudophakia (patient with artificial lens); do not take within five
minutes of using thiomersal-containing preparations.

Common ocular side-effects: change in eye colour: brown

pigmentation, thickening and lengthening of eye lashes; more rarely:
uveitis, ocular pruritus, photophobia and keratitis.

Systemic side-effects: rarely - hypotension, bradycardia.

Examples include latanoprost (Xalatan) and bimatoprost (Lumigan)

Beta-blockers:
Action: reduce aqueous secretion by inhibiting beta-
adrenoceptors on the ciliary body.

Contra-indications: bradycardia, heart block, uncontrolled

heart failure, asthma and history of chronic obstructive
pulmonary disease (COPD).

Caution: depression, myasthenia gravis, possible interactions

with other medication such as verapamil.

Common ocular side-effects: irritation, erythema, dry eyes,

blepharo-conjunctivitis and allergy anaphylactic reaction
possible

Common systemic side-effects: bronchospasm, bradycardia,

exacerbation of heart failure, nightmares.

Examples include timolol (Betimol, Timoptic) and betaxolol

(Betoptic)
 Carbonic anhydrase inhibitors:
Action: reduce aqueous secretion by ciliary body. Weak systemic
diuresis when given orally.

Contra-indications: renal impairment, metabolite imbalance, severe

hepatic impairment, sulfonamide sensitivity (acetazolamide), breast-
feeding.

Caution: elderly, hepatic impairment, history of renal calculi, history of

intraocular surgery, pregnancy and breast-feeding. Extravasation at
infusion site of intravenous acetazolamide can cause necrosis.

Ocular side-effects: localised discomfort, lacrimation, topical allergy;

more rarely: superficial punctate keratitis, uveitis, transient myopia.

Systemic side-effects: (particularly with systemic administration), taste

disturbance, nausea/vomiting, headache, dizziness, fatigue,
paraesthesia and sulfonamide-related side-effects.

Examples include dorzolamide (Trusopt) and brinzolamide (Azopt).

 Sympathomimetics (alpha adrenergic agonist):

Action: reduce aqueous secretion and increase outflow through

trabecular meshwork.

Contra-indications: angle-closure glaucoma (due to mydriatic effects),

patients currently taking monoamine-oxidase inhibitors (possibility of
hypertensive crisis).

Caution: hypertension, heart disease.

Common ocular side-effects: mydriasis, dry eye, severe smarting and

redness of the eye.

Common systemic side-effects: lethargy, hypotension.

Example is Brimonidine (Alphagan) and Iopidine (Apraclonidine)

 Miotics:
Action: open up the drainage channels in the trabecular meshwork by ciliary muscle
contraction.

Contra-indications: situations where pupillary constriction is undesirable (such as

uveitis), presence of retinal holes.

Caution: darkly pigmented irides require higher concentrations but overdosage

must be avoided, patients with retinal disease (especially previous detachment),
cardiac disease, hypertension, asthma, peptic ulceration, urinary tract obstruction
and Parkinson's disease.

Ocular side-effects: miosis - this can cause blurred vision which can affect driving
and other skilled tasks, especially in the presence of a cataract. Accommodative
spasm with brow ache (often causing intolerance in patients over 40), localised
discomfort, pupillary block.

Systemic side-effects: sweating, bradycardia, gastrointestinal disturbance.

Example is pilocarpine (Isopto Carpine)

GLAUCOMA
Surgical treatment of glaucoma
Argon laser Filtration
Trabeculoplasty Procedures
creates an opening in the white
Laser beam to open clogged
of the eye (sclera) and removes
part of the trabecular meshwork
channels in the trabecular meshwork
 Alternative Medicine For Glaucoma Treatment :
Chinese Herbs to Drain Dampness
Chinese
Common Actions in Relation to
Source (Latin Binomial) Part Used Name
Name Glaucoma
(Pinyin)
promote diuresis, eliminate
dampness, invigorate
hoelen Poria cocos whole fungus fuling
spleen, alleviate phlegm
retention
invigorate the spleen,
Atractylodes
atractylodes rhizome baizhu deprive dampness and
macrocephala
promote diuresis
promote diuresis, for
polyporus Polyporus umbellatus whole fungus zhuling dampness retention
syndrome

promote diuresis, eliminate

alisma Alisma orientale rhizome zexie
dampness, expel heat

clear away heat, promote

plantago
Plantago asiatica seeds chequanzi diuresis, improve visual
seed
acuity
deprive dampness and
pinellia Pinellia ternata rhizome banxia eliminate phlegm, disperse
stagnation
 References
South African Glaucoma Society. 2006. Glaucoma Algorithm
And Guidelines For Glaucoma. Available at
http://www.sags.co.za/docs/glaucoma_document_and_algorit
hm.pdf
access on: 26.04.2016
Subhuti Dharmananda, Ph.D.,1997. Treatment Of Glaucoma
With Chinese Herbs. Institute for Traditional Medicine, Portland,
Oregon. Available at
http://www.itmonline.org/arts/glaucoma.htm access on:
26.04.2016
Primary Open-angle Glaucoma. Available at
http://patient.info/doctor/primary-open-angle-glaucoma
access on:26.04.2016
 Treatment
TREATMENT
evaluation of
glaucoma
EVALUATION
TONOMETRY
Tonometry is a test to measure the pressure
inside your eyes
The test is used to screen for glaucoma

Normal eye pressure range is 10 to 21 mmHg

 Urinary
incontinence
POST-VOID RESIDUAL (PVR)

Measure volume of urine left in bladder

after voiding by catheter or bladder scan

< 50-100 Normal

100 - 400 Monitor until consistently less

than 200cc.

> 400cc - Insert Foley catheter

- Cystometry
Monitoring
AndPrevention
and
Prevention
monitoring
MONITORING (CONDITION)
If your healthcare professional thinks you're at risk of developing
glaucoma (whether you are having treatment or not), you should be
offered regular monitoring, using tests similar to those used to
diagnose glaucoma.
If consider high risk of glaucoma,You might have to take eye drops
for your treatment this is covered below. If you have just started
taking eye drops, or if you have recently changed your eye drops,
your eye pressure should also be tested 1 to 4 months after starting
the new treatment
If you don't need to use eye drops, your healthcare professional
should still test your eyes regularly
If monitoring tests show that there is no deterioration in your eyes
after 3 to 5 years (or earlier if tests confirm your eyes are normal),
you may be discharged because you do not have glaucoma. But you
should still visit your optician every year to be checked by the
optometrist so that any future changes can be detected.
(Nice.org,2009)
MONITORING

Regular glaucoma check-ups include two routine eye tests: tonometry and
ophthalmoscopy.
(Glaucoma.org,2013)
 Tonometry
Tonometry measures the pressure within your eye.
During tonometry, eye drops are used to numb the eye
Then a doctor or technician uses a device called a tonometer
to measure the inner pressure of the eye. A small amount of
pressure is applied to the eye by a tiny device or by a warm
puff of air.
The range for normal pressure is 12-22 mm Hg (mm Hg
refers to millimeters of mercury, a scale used to record eye
pressure). Most glaucoma cases are diagnosed with pressure
exceeding 20mm Hg. However, some people can have
glaucoma at pressures between 12 -22mm Hg. Eye pressure
is unique to each person.
 Ophthalmoscopy
This diagnostic procedure helps the doctor examine your optic nerve for
glaucoma damage.
Eye drops are used to dilate the pupil so that the doctor can see through
your eye to examine the shape and color of the optic nerve.
The doctor will then use a small device with a light on the end to light
and magnify the optic nerve.

Perimetry
Perimetry is a visual field test that produces a map of your complete
field of vision. This test will help a doctor determine whether your vision
has been affected by glaucoma
During this test, you will be asked to look straight ahead and then
indicate when a moving light passes your peripheral (or side) vision.
This helps draw a "map" of your vision.
After glaucoma has been diagnosed, visual field tests are usually done
one to two times a year to check for any changes in your vision.
 Gonioscopy
This diagnostic exam helps determine whether the angle where
the iris meets the cornea is open and wide or narrow and closed
During the exam, eye drops are used to numb the eye. A hand-
held contact lens is gently placed on the eye. This contact lens has
a mirror that shows the doctor if the angle between the iris and
cornea is closed and blocked (a possible sign of angle-closure or
acute glaucoma) or wide and open (a possible sign of open-angle,
chronic glaucoma).

Pachymetry
Pachymetry is a simple, painless test to measure the thickness of
your cornea -- the clear window at the front of the eye. A probe
called a pachymeter is gently placed on the front of the eye (the
cornea) to measure its thickness
Pachymetry can help your diagnosis, because corneal thickness
has the potential to influence eye pressure readings.
(Glaucoma.org,2013)
 Prevention

You may not be able to prevent glaucoma.

But self-care can help you detect it early, limit vision loss or slow its progress.
PREVENTION

Know your family's

regular eye exams
eye health history

Prevention

Exercise Protect Your Eyes

PREVENTION
1. Regular eye exams
are the best form of prevention against significant glaucoma
damage.
Early detection and careful, lifelong treatment can maintain
vision in most people. In general, a check for glaucoma
should be done:
before age 40, every two to four years
from age 40 to age 54, every one to three years
from age 55 to 64, every one to two years
after age 65, every six to 12 months
Anyone with high risk factors should be tested every year or
two after age 35. Those at higher risk include people of
African descent, people with diabetes, and people with a
family history of glaucoma. You are at increased risk if you
have a parent or brother or sister with glaucoma.
2.Know your family's eye health history
Glaucoma tends to run in families. If you're at increased risk, you
may need more frequent screening.
3. Exercise
studies have shown that moderate exercise such as walking or
jogging three or more times every week can have an IOP lowering
effect.
moderate exercise on a routine basis is recommended. Like Yoga
can be beneficial, but its best to avoid inverted positions such as
headstands and shoulderstands, as these may increase IOP.
4. Protect Your Eyes
Wearing protective eyewear is important when engaged in sports
activities or home improvement projects to prevent Eye injuries
that can result in traumatic glaucoma or secondary glaucoma
(Robert,2012)
REFERENCE
Nice.org,2009, Glaucoma: diagnosis and management,
published on april 2009, Available on
(https://www.nice.org.uk/guidance/CG85/ifp/chapter/Mo
nitoring-and-treatment-for-people-with-ocular-
hypertension-or-suspected-glaucoma)
Robert.L.Stamper, MD, 2012, What Can I Do to Prevent
Glaucoma?. Available on
(http://www.glaucoma.org/gleams/what-can-i-do-to-
prevent-glaucoma.php)
Glaucoma.org, 2013, Five Common Glaucoma Tests,
Available on
(http://www.glaucoma.org/glaucoma/diagnostic-
tests.php)