GLAUCOMA

Introduction
Glaucoma is a group of eye conditions that damage the optic nerve, the health
of which is vital for good vision. This damage is often caused by an abnormally
high pressure in your eye.
If glaucoma is recognized early, vision loss can be slowed or prevented. If you
have the condition, you'll generally need treatment for the rest of your life.
About 3 million Americans and 64 million people worldwide have glaucoma,
but only half are aware of it. Glaucoma can occur at any age but is 6 times
more common among people > age 60.
In the Philippines, the 2017 estimated number of persons who are bilaterally
blind is 332,150 of which 33% or around 109,609 is due to cataract, 25%
(83,037) due to errors of refraction (EOR) and 14%(46,501) due to glaucoma.  
 Types
Open-angle glaucoma
Open-angle glaucoma is the most common form of the disease. The drainage angle
formed by the cornea and iris remains open, but the trabecular meshwork is partially
blocked. This causes pressure in the eye to gradually increase. This pressure damages
the optic nerve. It happens so slowly that you may lose vision before you're even aware
of a problem.
Angle-closure glaucoma
Angle-closure glaucoma, also called closed-angle glaucoma, occurs when the iris bulges
forward to narrow or block the drainage angle formed by the cornea and iris. As a result,
fluid can't circulate through the eye and pressure increases. Some people have narrow
drainage angles, putting them at increased risk of angle-closure glaucoma.
Angle-closure glaucoma may occur suddenly (acute angle-closure glaucoma) or gradually
(chronic angle-closure glaucoma). Acute angle-closure glaucoma is a medical emergency.
Types
Normal-tension glaucoma
In normal-tension glaucoma, your optic nerve becomes damaged even though your
eye pressure is within the normal range. No one knows the exact reason for this. You
may have a sensitive optic nerve, or you may have less blood being supplied to your
optic nerve. This limited blood flow could be caused by atherosclerosis — the
buildup of fatty deposits (plaque) in the arteries — or other conditions that impair
circulation.
Pigmentary glaucoma
In pigmentary glaucoma, pigment granules from your iris build up in the drainage
channels, slowing or blocking fluid exiting your eye. Activities such as jogging
sometimes stir up the pigment granules, depositing them on the trabecular
meshwork and causing intermittent pressure elevations.
Risk factors
• Having high internal eye pressure (intraocular pressure)
• Being over age 60
• African Americans, Asian or Hispanic
• Having a family history of glaucoma
• Having certain medical conditions, such as diabetes, heart disease, high blood
pressure and sickle cell anemia
• Having corneas that are thin in the center
• Being extremely nearsighted or farsighted
• Having had an eye injury or certain types of eye surgery
• Taking corticosteroid medications, especially eye drops, for a long time
OBJECTIVES

• Define Glaucoma.
• Identify the signs and symptoms related with this disease.
• Know what system are affected by the disease process and to assimilate
what function of the body were altered by this condition
• Understand the pathophysiology of Glaucoma.
• Identify the risk factor contributing to Glaucoma.
• Identify Health teachings and managements regarding Glaucoma
• Formulate nursing diagnoses, with related nursing care plans.
• Identify different drugs that is administered for the disease.
Nursing Assessment

• Chronic open-angle glaucoma

• No early symptoms
• Insidious visual impairment, blurring
• Diminished accommodation
• Gradual loss of peripheral vision (tunnel vision)
• Mildly aching eyes
• Halos around lights later with elevated IOP
• Patchy blind spots in your side (peripheral) or central vision, frequently
in both eyes
Nursing Assessment
• Acute closed-angle glaucoma
• Transitory attacks of diminished visual acuity
• Colored halos around lights
• Reddened eye with excruciating pain
• Headache
• Nausea and vomiting
• Severe headache
• Eye pain
• Nausea and vomiting
• Blurred vision
• Halos around lights
• Eye redness
Diagnostics
• Visual acuity: reduced (Snellen Chart)
• Tonometry: reading of 24-32 mmHg suggests glaucoma: may be 50
mmHg or more in closed-angle glaucoma
• Opthalmoscopic exam: reveals narrowing of small vessels of optic
disk, cupping of optic disk
• Perimetry: reveals defects in visual fields
• Gonioscopy: examine angle of anterior chamber
Anatomy and Physiology
Anatomy and Physiology

• Anterior chamber: The region of the eye between the cornea and the
lens that contains aqueous humor.
• Aqueous humor: The fluid produced in the eye.
• Bruch's membrane: Located in the retina between the choroid and the
retinal pigmented epithelium (RPE) layer; provides support to the retina
and functions as the 'basement' membrane of the RPE layer.
• Ciliary body: Part of the eye, above the lens, that produces the
aqueous humor.
• Choroid: Layer of the eye behind the retina, contains blood vessels that
nourish the retina.
 Anatomy and Physiology

• Cones: The photoreceptor nerve cells present in the macula and concentrated in the fovea (the
very center of the macula); enable people to see fine detail and color.
• Cornea: The outer, transparent structure at the front of the eye that covers the iris, pupil and
anterior chamber; it is the eye's primary light-focusing structure.
• Drusen: Deposits of yellowish extra cellular waste products that accumulate within and beneath
the retinal pigmented epithelium (RPE) layer.
• Fovea: The pit or depression at the center of the macula that provides the greatest visual acuity.
• Iris: The colored ring of tissue behind the cornea that regulates the amount of light entering the
eye by adjusting the size of the pupil.
• Lens: The transparent structure suspended behind the iris that helps to focus light on the retina;
it primarily provides a fine-tuning adjustment to the primary focusing structure of the eye, which
is the cornea.
• Macula: The portion of the eye at the center of the retina that processes sharp, clear straight-
ahead vision.
Anatomy and Physiology

• Optic nerve: The bundle of nerve fibers at the back of the eye that carry visual messages from the retina
to the brain.
• Photoreceptors: The light sensing nerve cells (rods and cones) located in the retina.
• Pupil: The adjustable opening at the center of the iris through which light enters the eye.
• Retina: The light sensitive layer of tissue that lines the back of the eye.
• Retinal Pigmented Epithelium (RPE): A layer of cells that protects and nourishes the retina, removes
waste products, prevents new blood vessel growth into the retinal layer and absorbs light not absorbed
by the photoreceptor cells; these actions prevent the scattering of the light and enhance clarity of vision.
• Rods: Photoreceptor nerve cells in the eyes that are sensitive to low light levels and are present in the
retina, but outside the macula.
• Sclera: The tough outer coat that protects the entire eyeball.
• Trabecular meshwork: Spongy tissue located near the cornea through which aqueous humor flows out
of the eye.
• Vitreous: Clear jelly-like substance that fills the eye from the lens to the back of the eye.
PATHOPHYSIOLOGY
Drug Study
 DRUG NAME/GENERIC ACTION INDICATION CONTRA SIDE ADVERSE NURSING RESPONSIBILITIES
INDICATION EFFECTS REACTION
apraclonidine Apraclonidine is a For prevention or contraindicated for patients  red, swollen, itchy, apnea, arrhythmias,  Apraclonidine eye drops
  relatively selective reduction of receiving monoamine oxidase or teary eyes. asthenia, bradycardia, are only for use in the
  alpha2 adrenergic intraoperative and inhibitor therapy and for patients  eye discomfort. conduction defects, eye. Do not swallow the
  receptor agonist postoperative increases with hypersensitivity to any diminished or absent eye drops
in intraocular pressure component of this medication or 
feeling that
Generic: that stimulates
something is in the
reflexes, dryness of the  If you are
Iopidine alpha1 receptors to (IOP) before and after to clonidine. eye. mouth, hypotension, wearing contact lenses,
  a lesser extent. ocular laser surgery   hypothermia, remove them before
  when used  irregular, slow, or hypoventilation, using eye drops. Wait at
Apraclonidine has a prophylactically. Also pounding irritability, lethargy, least 15 minutes before
CLASSIFICATION heartbeat.
dual mechanism of used as a short-term miosis, pallor, replacing your contact
alpha2-adrenergic agonist action by reducing adjunctive therapy in  blurred vision. respiratory depression, lenses.
  aqueous humor patients with open- sedation or coma,  To apply eye drops, wash
 pale eyes.
production through angle glaucoma who seizure, somnolence, your hands first. To avoid
the constriction of are on maximally  dry eyes.
transient contamination, be careful
afferent ciliary tolerated medical   hypertension, and not to touch the dropper
DOSAGE/STOCK DOSE process vessels, and therapy requiring vomiting. tip or let it touch
increasing additional IOP   your eye or any other
1 drop 3x a day in both eyes for 10 days on 0.5%
Ophthalmic Solution
uveoscleral outflow. reduction.   surface
   Wait 5 minutes between
instillation of other
ophthalmic agents to
avoid washout of
previous dose; after
topical instillation, finger
pressure should be
applied to lacrimal sac
to decrease drainage
into the nose and throat
and minimize possible
systemic absorption
 
 ACTION
bimatoprost Bimatoprost imitates the
  effects of prostamides,
  specifically prostaglandin
Latisse F2α.14  pressure in patients
Lumigan  
Bimatoprost mildly
stimulates aqueous humor
outflow, relieving elevated
CLASSIFICATION intraocular pressure and
decreasing the risk of optic
Antiglaucoma drugs nerve damage.
   
Prostaglandin analogues It is thought that
bimatoprost reduces
intraocular pressure (IOP) in
DOSAGE/STOCK DOSE humans by causing an
increase in outflow of the
Glaucoma: Adults: 1 drop aqueous humor via the
ophthalmic solution in trabecular meshwork and
conjunctival sac of uveoscleral pathways.13  brown in color
affected eyes once daily in  
the evening  
It achieves the above effects
by decreasing tonographic
resistance to aqueous
humor outflow.6
 Bimatoprost does not affect
aqueous humor production.
5
INDICATION CONTRA SIDE ADVERSE NURSING RESPONSIBILITIES
INDICATION EFFECTS REACTION
Used for the macular swelling Burning/stinging/irritation/ Hives; This drug may cause
reduction of and degeneration of redness/discomfort of the eye, Difficult breathing; temporary unstable vision.
elevated intraocular the eye Feeling as if something is in your swelling of your  
eye, face, lips, tongue, or Do not drive, use
with open-angle inflammation of the Dry eyes, throat. machinery, or do
glaucoma or ocular iris - the colored Watering eyes,   any activity that requires clear vision
hypertension. part of the eyeball Temporary unstable vision, you
These patients inflammation of the Dizziness. are sure you can
must be intolerant   perform such
to other intraocular uvea of the eye activities safely
pressure lowering absent eye lens  
medications or Possibility of
inadequately abnormal liver medication causing eyes to become
responsive to other function tests more
treatments   sensitive to
  Allergy to the drug light than they are
normally
 
Possibility of iris of eye becoming m
 
Waiting at least 5 minutes between
of two different ophthalmic prepar
to prevent second medication from
“washing out” the first one
 
Proper administration technique;
preventing contamination; not touc
applicator tip to any surface
 DRUG NAME/GENERIC ACTION INDICATION CONTRA SIDE ADVERSE NURSING RESPONSIBILITIES
INDICATION EFFECTS REACTION
timolol Beta(1)-receptor Ophthalmic timolol Hypersensitivity to More common Headache, asthenia/fatigue, and chest -Systemic absorption of drugs
  blockade by timolol is indicated for the the active component -Blurred vision pai from ophthalmic solutions
  leads to a decrease treatment of or to any of the -Burning or stinging in the   may be minimized by pressure
Timoptic in both heart rate increased ingredients eye Cardiovascular on the tear-duct immediately
and cardiac output intraocular pressure Less common Bradycardia, arrhythmia, after application. The eyes
during rest and in patients with -Patients with Arm, back, or jaw pain  hypotension,  should be kept closed for as
exercise, and a ocular hypertension bronchial blisters, hives, welts, or hypertension, syncope, heart long as possible
decrease in both or open-angle asthma/history of itching block, cerebral vascular accident, - Soft contact lenses should
systolic and glaucoma. The oral bronchial asthma, or blue lips, fingernails, or skin cerebral ischemia, cardiac failure not be used during instillation
diastolic blood form of this drug is severe chronic burning, crawling, Digestive of the drug; lenses may be
CLASSIFICATION pressure.7,8 In used to treat high obstructive itching, numbness, Nausea, inserted at least 15 minutes
beta-adrenergic antagonist
 
addition to this, a blood pressure.16,17 pulmonary disease prickling, "pins and diarrhea, dyspepsia, anorexia, and dry after instillation.
reduction in reflex  In certain cases, needles", or tingling mouth.  
orthostatic timolol is used in -Patients with feelings Skin  
hypotension may the prevention of cardiogenic shock, change in vision Alopecia and psoriasiform rash or - Inform patients that this
also occur. The migraine headaches. overt heart failure, chest pain or discomfort exacerbation of psoriasis. drug may cause blurred vision,
blockade of beta(2)   second-/third-degree chest tightness or   dizziness, fatigue, and/or
receptors by atrioventricular block, heaviness Respiratory visual disturbances, and they
DOSAGE/STOCK DOSE
timolol in the blood or sinus bradycardia confusion about identity, Bronchospasm  should avoid driving or
vessels leads to a   place, and time Urogenital operating machinery if these
decrease in continuing ringing or Retroperitoneal fibrosis, side effects occur.
Initial: 1 drop of 0.25% solution instilled in the
affected eye(s) 2 times a day peripheral vascular buzzing or other decreased libido, impotence, and  
 
Maintenance dose: 1 drop of 0.25% solution
resistance, unexplained noise in ears Peyronie's disease.  
once a day to 1 drop of 0.5% solution 2 times a
day
reducing blood coughing that sometimes    
  pressure.16,17,19 produces a pink frothy  
  sputum  
 
 Medical and Surgical Management
• Medical Management
• Objective of treatment is to prevent optic nerve damage by lowering the IOP to a level
consistent with retaining vision. Treatment is almost always lifelong. Treatment also focuses on
achieving the greatest benefit at the least risk, cost and inconvenience to the patient.
• Pharmacologic therapy is the initial and principal treatment for glaucoma. Acute angle-closure
glaucoma is treated with medication (including miotics) to reduce IOP before laser or incisional
iridectomy. Commonly used agents include:
• Beta-adrenergic blockers/antagonists are the most widely used hypotensive agents. They are effective in
many types of glaucoma.
• Cholinergic agents (topical) are miotics (cause papillary constriction) and are used in short-term
management of glaucoma with papillary block.
• Alpha-2-adrenergic agonists(topical) reduce IOP by increasing aqueous humor outflow.
• Carbonic anhydrase inhibitors (systemic) and prostaglandins lower IOP by reducing aqueous humor
formation.
• Osmotic diuretics reduce IOP by increasing the osmolality of the plasma to draw water from the eye into the
vascular circulation.
Surgical Management
• Ophthalmic laser surgery is indicated as the primary treatment for glaucoma
or is required when medication therapy is poorly tolerated or ineffective in
lowering IOP.
• Conventional surgery procedures are performed when laser techniques are
unsuccessful or when patient is not a good candidate for laser surgery (eg.
Patient cannot sit still or follow instructions)
• Filtering procedures: an opening or a fistula in the trabecular meshwork
(trabeculectomy) is made to allow drainage implant or shunt surgery may be
performed
• Trabeculoplasty – Opens trabecular meshwork (open angle)
• Irodotomy – Punches hole in iris (closed angle)
 Nursing Management
• Nursing Management
• Provide information regarding management of glaucoma
• Discuss preoperative and postoperative teaching for immediate surgical opening of the eye chamber.
• Prepare to administer carbonic anhydrase inhibitors IV or IM, to restrict production of aqueous humor.
• Prepare to administer osmotic agents.
• Discuss and prepare the client for surgical or laser peripheral iridectomy after the acute episode is relieved.
• Provide information about laser trabeculoplasty, if medication therapy proves ineffective.
• Teach the client about specific safety precautions.
• Instruct the client to avoid mydriatics such as atropine, which may precipitate acute glaucoma in a client
with closed-angle glaucoma.
• Instruct the client to carry prescribed medications at all times.
• Instruct the client to carry a medical identification card or wear a bracelet stating his type of glaucoma and
need for medication.
• Instruct the client to take extra precautions at night (e.g. use of handrails, provide extra lighting to
compensate for impaired pupil dilation from miotic use).
Priority Nursing Care Plan
 CUES NURSING GOAL NURSING RATIONALE EXPECTED
DIAGNOSIS INTERVENTION OUTCOME
 
  Disturbed sensory After continuous Implement measures to Reduces safety hazards After continuous
S perception related to nursing intervention assist patient to related to changes in nursing intervention
  altered status of the patient will: manage visual visual fields or loss of the patient will:
-Blurred Vision sense organ   limitations such vision and papillary  
-Halos around lights   maintain the current as reducing clutter, accommodation to maintain the current
visual field and arranging furniture out environmental light. visual field/acuity
  acuity without of travel path; turning   without further loss
  further loss. head to view subjects;  
    correcting for dim light  
O and problems of night  
-Eye redness vision.  
    Controls IOP, preventing
Demonstrate further loss of vision.
administration of eye  
drops (counting drops,  
adhering to the  
schedule, not missing These direct-acting
doses). topical myotic drugs
  cause pupillary
  constriction, facilitating
Assist with the outflow of aqueous
administration of humor and lowering
medications as IOP.
indicated:  
   
  To prevent an increase
  in IOP, resulting in disk
  changes and loss of
Evaluation

• Upon completion of this case study, the student nurses were able to define Glaucoma,
identify the signs and symptoms associated with the disease, and know what organs of
the body are involved or affected by the disease process. The student nurses were also
able to understand the pathophysiology of Glaucoma based on the laboratory findings,
and signs and symptoms and the risk factors contributing to the occurrence of the
disease. Everything was done through a book based approach
• The student nurses were also able to identify the different medications administered or
used for the disease, including their indications, contraindications, side effects, adverse
effects and nursing responsibilities and also the different surgical procedures.
• Lastly, the student nurses were able to formulate nursing diagnoses and apply different
nursing interventions and make use of the process as a framework for the over-all care
for the patient that would enable the student nurses to render the appropriate and
effective interventions.