Glaucoma

PRESENTED BY
JOANNA RACHEL P M
 Introduction
Glaucoma is a group of disorders characterized by
increased IOP and its’ consequences,
optic nerve atrophy,
and peripheral visual field loss.
Cont.

Glaucoma is one of the leading causes of irreversible

blindness in the world and is the leading cause of blindness
among adults in the United States.
It is estimated that at least 2 million Americans have
glaucoma and that 5 to 10 million more are at risk (Margolis
et al., 2002).
Cont.

Glaucoma is more prevalent among people older than 40

years of age, and the incidence increases with age.
 It is also more prevalent among men than women and in the
African American and Asian populations.
There is no cure for glaucoma, but research continues.
 Definition
The term glaucoma comprises a complex group of disorders
that involve many different pathologic changes and
symptoms but have in common an optic neuropathy that
damages the optic disc, causing atrophy and loss of
peripheral vision. The neuropathy often is caused by
increased IOP (National Eye Institute, 2013).
Basic physiology of aqueous humour
Cont.
 Intraocular pressure
IOP is determined by the
rate of aqueous production,
the resistance encountered by the aqueous humor as it flows
out of the passages, and
the venous pressure of the episcleral veins that drain into the
anterior ciliary vein
Cont.

When aqueous fluid production and drainage are in balance,

the IOP is between 10 and 21 mm Hg.
When aqueous fluid is inhibited from flowing out, pressure
builds up within the eye.
Fluctuations in IOP occur with time of day, exertion, diet,
and medications.
Cont.

It tends to increase with blinking, tight lid squeezing,

and upward gazing.
Systemic conditions such as hypertension and
intraocular conditions such as uveitis and retinal
detachment have been associated with elevated IOP.
Exposure to cold weather, alcohol, a fat-free diet,
heroin, and marijuana have been found to lower IOP.
 Risk factors
Family history of Migraine syndromes
glaucoma Near-sightedness (myopia)
African American race Eye trauma
Older age Prolonged use of topical or
systemic corticosteroids
Diabetes
Cardiovascular disease
Pathophysiology
Cont.

Regardless of the cause of damage, glaucomatous changes

typically evolve through clearly discernible stages:
Initiating events: precipitating factors include illness,
emotional stress, congenital narrow angles, long-term use of
corticosteroids, and mydriatics (ie, medications causing
pupillary dilation). These events lead to the second stage
Contd.

Structural alterations in the aqueous outflow system: tissue

and cellular changes caused by factors that affect aqueous
humor dynamics lead to structural alterations and to the third
stage.
Functional alterations: conditions such as increased IOP or
impaired blood flow create functional changes that lead to the
fourth stage.
Cont.

Optic nerve damage: atrophy of the optic nerve is

characterized by loss of nerve fibers and blood supply, and
this fourth stage inevitably progresses to the fifth stage.
Visual loss: progressive loss of vision is characterized by
visual field defects.
 Classification
Open-Angle Glaucoma’s
Usually bilateral, but one eye may be more severely affected
than the other.
In all three types of open-angle glaucoma, the anterior
chamber angle is open and appears normal
Contd.

Chronic open-angle glaucoma (COAG)

Optic nerve damage, visual field defects, IOP >21 mm Hg.
May have fluctuating IOPs. Usually no symptoms but
possible ocular pain, headache, and halos.
Cont.

Normal tension glaucoma

IOP ≤ 21 mm Hg. Optic nerve damage, visual field defects.
Ocular hypertension
Elevated IOP. Possible ocular pain or headache.
Cont.

Angle-Closure (Pupillary Block) Glaucoma’s

Obstruction in aqueous humor outflow due to the complete
or partial closure of the angle from the forward shift of the
peripheral iris to the trabecula.
The obstruction results in an increased IOP .
Cont.
Acute angle-closure glaucoma (AACG)
Rapidly progressive visual impairment, periocular pain,
conjunctival hyperemia, and congestion.
Pain may be associated with nausea, vomiting, bradycardia, and
profuse sweating.
Reduced central visual acuity, severely elevated IOP, corneal
edema.
Pupil is vertically oval, fixed in a semi dilated position, and
unreactive to light and accommodation.
Cont.

Subacute angle-closure glaucoma

Transient blurring of vision, halos around lights; temporal
headaches and/or ocular pain; pupil may be semi-dilated.
Chronic angle-closure glaucoma
Progression of glaucomatous cupping and significant visual
field loss; IOP may be normal or elevated; ocular pain and
headache.
 Assessment and diagnosis
The purpose of a glaucoma workup is to
establish the diagnostic category,
assess the optic nerve damage,
and formulate a treatment plan.
Cont.

The patient’s ocular and medical history must be detailed to

investigate the history of predisposing factors.
There are four major types of examinations used in
glaucoma evaluation, diagnosis, and management:
tonometry to measure the IOP,
ophthalmoscopy to inspect the optic nerve,
Cont.

gonioscopy to examine the filtration angle of the anterior

chamber,
and perimetry to assess the visual fields.
IOP is usually increased in glaucoma (normal is 10 to 21
mm Hg). In the patient with increased pressures, the
measurements are repeated over time to verify the elevation.
Cont.

In POAG, IOP is usually between 22- and 32-mm Hg. In

AACG, IOP may be more than 50 mm Hg.
While central acuity may remain 20/20 even in the presence
of severe peripheral visual field loss, visual field perimetry
may reveal subtle changes in the peripheral vision early in
the disease process, long before actual scotomas develop.
Cont.

A commonly used screening technique for early detection of

glaucoma is to measure IOP with an air tonometer.
 A puff of air is directed at the cornea, which causes a
momentary indentation while a pressure reading is taken
(National Eye Health Education Program [NEHEP], 2014)
 Medical management
The aim of all glaucoma treatment is
prevention of optic nerve damage through medical therapy,
laser or non laser surgery,
or a combination of these approaches.
Lifelong therapy is almost always necessary because
glaucoma cannot be cured.
Cont.

Although treatment cannot reverse optic nerve damage,

further damage can be controlled.
The treatment goal is to maintain an IOP within a range
unlikely to cause further damage
Cont.
1. Cholinergic (miotics) (pilocarpine,
carbachol)
2. Adrenergic agonists (dipivefrin,
epinephrine)
3. Beta-blockers (betaxolol, timolol)
4. Alpha-adrenergic agonists (apraclonidine,
brimonidine)
5. Carbonic anhydrase inhibitors
(acetazolamide, methazolamide,
dorzolamide)
6. Prostaglandin analogs (latanoprost)
1. Increases aqueous fluid outflow by
contracting the ciliary muscle and
causing miosis (constriction of the
pupil) and opening of trabecular
meshwork
2. Reduces production of aqueous humor
and increases outflow
3. Decreases aqueous humor production
4. Decreases aqueous humor production
5. Decreases aqueous humor production
6. Increases uveoscleral outflow
 Surgical management
laser trabeculoplasty for glaucoma, laser burns are applied to the
inner surface of the trabecular meshwork to open the intertrabecular
spaces and widen the canal of Schlemm, thereby promoting outflow of
aqueous humor and decreasing IOP.
The procedure is indicated when IOP is inadequately controlled by
medications; it is contraindicated when the trabecular meshwork
cannot be fully visualized because of narrow angles
Cont.

A serious complication of this procedure is a transient rise in IOP

(usually 2 hours after surgery) that may become persistent.
IOP assessment in the immediate postoperative period is essential
https://youtu.be/nqCTytnqrpo
Cont.

laser iridotomy for pupillary block glaucoma, an opening is made in

the iris to eliminate the pupillary block.
 Laser iridotomy is contraindicated in patients with corneal edema,
which interferes with laser targeting and strength.
Potential complications are burns to the cornea, lens, or retina;
transient elevated IOP; closure of the iridotomy; uveitis; and blurring.
Pilocarpine is usually prescribed to prevent closure of the iridotomy
Cont.

Filtering procedures for chronic glaucoma are used to create an

opening or fistula in the trabecular meshwork to drain aqueous humor
from the anterior chamber to the subconjunctival space into a bleb,
thereby bypassing the usual drainage structures.
This allows the aqueous humor to flow and exit by different routes
(ie, absorption by the conjunctival vessels or mixing with tears)
Cont.

Trabeculectomy is the standard filtering technique used to remove

part of the trabecular meshwork.
Complications include hemorrhage, an extremely low (hypotony) or
elevated IOP, uveitis, cataracts, bleb failure, bleb leak, and
endophthalmitis.
The outflow of aqueous humor in a newly created drainage fistula is
circumvented by the granulation of fibrovascular tissue or scar tissue
formation on the surgical site.
Cont.

Drainage implants or shunts are open tubes implanted in the

anterior chamber to shunt aqueous humor to an attached plate in the
conjunctival space.
A fibrous capsule develops around the episcleral plate and filters the
aqueous humor, thereby regulating the outflow and controlling IOP.
https://youtu.be/kCEwEJt5YyE
 Nursing management
long-term management
assess the patient’s ability to understand
and adhere to the therapy plan.
Assess the patient’s psychologic reaction to the diagnosis of
a potentially sight-threatening chronic disorder.
Include the patient’s caregiver in the assessment process
because the chronic nature of this disorder affects them too.
Cont.

Nursing diagnoses for the patient with glaucoma include:

Risk for injury
Acute pain