GLAUCOMA

PRESENTED BY
APRINDO DONATUS
I4061152018
 DEFINITION
Glaucoma is an acquired chronic optic neuropathy
characterized by optic disk cupping and visual field loss.
PHYSIOLOGY OF AQUEOUS HUMOR
 CLASSIFICATION
A. OPEN-ANGLE GLAUCOMA
1. Pretrabecular Membrane
Neovascular glaucoma, epithelial downgrowth,
iridocorneal endothelial (ICE) syndrome
2. Trabecular Abnormalities
Primary open-angle glaucoma, congenital
glaucoma, pigmentary glaucoma, exfoliation
syndrome, steroid-induced glaucoma, hyphema,
angle contusion and/or recession, anterior
uveitis (iridocyclitis), phacolytic glaucoma
3. Posttrabecular Abnormalities
Raised episcleral venous pressure
B. ANGLE-CLOSURE GLAUCOMA
1. Pupillary Block (Iris Bombe)
Primary angle-closure glaucoma, posterior
synechiae (seclusio pupillae), intumescent lens,
anterior lens dislocation, hyphema
2. Anterior Lens Displacement
Ciliary block glaucoma, central retinal vein
occlusion, posterior scleritis, following retinal
detachment surgery
3. Angle Crowding
Plateau iris, intumescent lens, mydriasis for
fundal examination
4. Peripheral Anterior Synechiae
Chronic angle closure, secondary to flat anterior
chamber, secondary to iris bombé, contraction
of pretrabecular membranes
 PRIMARY OPEN ANGEL GLAUCOMA
• The chief pathologic feature of primary open-angle glaucoma is a
degenerative process in the trabecular meshwork, including
deposition of extracellular material within the meshwork and beneath
the endothelial lining of Schlemm’s canal.
• Since intraocular pressure is the only treatable risk factor, it remains
the focus of therapy
• Advisable to reduce the intraocular pressure as much as possible,
preferably to less than 15 mmHg
 ACUTE ANGLE-CLOSURE GLAUCOMA
• Acute angle closure is an ophthalmic emergency!
• Acute angle closure (“acute glaucoma”) occurs when sufficient iris
bombé develops to cause occlusion of the anterior chamber angle by
the peripheral iris
• This blocks aqueous outflow, and the intraocular pressure rises
rapidly, causing severe pain, redness, and blurring of vision
• Intravenous and oral acetazolamide—along with topical agents, such
as betablockers and apraclonidine, and, if necessary, hyperosmotic
agents—will usually reduce the intraocular pressure
 CHRONIC ANGLE-CLOSURE GLAUCOMA
• Chronic glaucoma with anterior chamber being occlusion
permanently caused by peripheral anterior synechiae.
• Pupil mid-dilatation condition cause the iris become loose and results
the end of iris adhere to pupil
• After chronic episode, this situation lead to peripheral anterior
synechiae which was resulted from compensated due to elevated
intraocular pressure in posterior chamber.
 PATHOPHYSIOLOGY
• The major mechanism of visual loss in glaucoma is retinal
ganglion cell apoptosis, leading to thinning of the inner
nuclear and nerve fiber layers of the retina and axonal loss in
the optic nerve.
• The optic disk becomes atrophic, with enlargement of the
optic cup.
• So far, 11 genes and multiple loci have been identified to
contribute to the development of glaucoma with their
effects being influenced by age and environment.
 CLINICAL ASSEMENT IN GLAUCOMA

TRIAS GLAUCOMA PHYSICAL EXAMINATION

• Raised of Intraocular Pressure
• Cupping Diskus Optikus
• Visual Field Loss
• Intraocular Pressure Assesment
• Anterior Chamber Angle Width
Examination
• Optic Disk Assesment
• Visual Field Examination
 TONOMETRY
• Measurement of intraocular pressure.
• Corneal thickness influences the accuracy of measurement.
• Normal range of intraocular pressure is 11–21 mm Hg.
• Type: Schiotz tonometer, Goldmann applanation tonometer, and
noncontact tonometer.
 ANTERIOR CHAMBER ANGLE WIDTH
EXAMINATION
• The anterior chamber angle is formed by the junction of the peripheral
cornea and the iris, between which lies the trabecular meshwork.
• Estimated by: oblique illumination with a penlight, slitlamp observation,
and gonioscopy
• Gonioscopy interpretation:
 Open angle: possible to visualize the full extent of the trabecular
meshwork, the scleral spur, and the iris processes
 Narrow Angle: able to see only Schwalbe’s line or a small portion of the
trabecular meshwork.
 Closed Angle: unable to see Schwalbe’s line.
ANTERIOR CHAMBER ANGLE WIDTH
EXAMINATION
 OPTIC DISK ASSESMENT
• The earliest sign of glaucoma is thinning of the retinal nerve fiber
layer in the region surrounding the optic disk.
• Performed by: direct ophthalmoscopy
 VISUAL FIELD EXAMINATION
• Glaucomatous field loss involves mainly the central 30° of field.
• Visual field defects are not detected until there is about 40% retinal
ganglion loss.
 MEDICAL TREATMENT
1. Facilitation of Aqueous Outflow
2. Suppression of Aqueous Production
3. Reduction of Vitreous Volume
4. Miotics, Mydriatics, and Cycloplegics
 FACILITATION OF AQUEOUS OUTFLOW
• Prostaglandin analogs (Increase uveoscleral outflow
ofaqueous): bimatoprost 0.003%, latanoprost 0.005%,
tafluprost 0.0015%, and travoprost 0.004% solutions, each
once daily at night, and unoprostone 0.15% solution twice
daily
• Parasympathomimetic agents increase aqueous outflow by
action on the trabecular meshwork through contraction of
the ciliary muscle
• e.c.: pilocarpine 1-4% solution four times daily
 SUPPRESSION OF AQUEOUS PRODUCTION
• Beta-adrenergic blocking agents
• Betaxolol 0.25% and 0.5%, carteolol 1%, levobunolol 0.5%,
metipranolol 0.3%, and timolol maleate 0.25% and 0.5% solutions
twice daily
• timolol maleate 0.25% and 0.5% gel once daily in the morning are the
currently available preparations
 REDUCTION OF VITREOUS VOLUME
• Hyperosmotic agents render the blood hypertonic, thus drawing
water out of the vitreous and causing it to shrink. This is in addition to
decreasing aqueous production
• Oral glycerin (glycerol), 1 mL/kg of body weight in a cold 50% solution
mixed with lemon juice
 MIOTICS, MYDRIATICS, AND CYCLOPLEGICS
• Constriction of the pupil is fundamental to the management
of primary angleclosure glaucoma and the angle crowding of
plateau iris
• Cycloplegic/mydriatic agents (cyclopentolate and atropine)
are used to relax the ciliary muscle and thus tighten the
zonular apparatus in an attempt to draw the lens backward
 SURGICAL & LASER TREATMENT
• Peripheral Iridotomy, Iridectomy, and Iridoplasty
• Laser Trabeculoplasty
• Glaucoma Drainage Surgery
• Cyclodestructive Procedures
Terima Kasih~