CASE SCENARIO

• A 52 year old female came to OPD with history of frequent

change of presbyopic glasses . On examination BCVA 6/12 and
6/24 in both eyes respectively.Anterior segment was within
normal limits .Fundus examination showed CDR 0.6 & 0.8 in
both eyes respectively. Whats the probable diagnosis ??
POAG
DR.KARTHIGA.I
 DEFINITION
• Glaucoma is a group of disorder characterized by a
progressive optic neuropathy resulting in characteristic optic
disc changes together with visual field defects.

• IOP is the major risk factor for the development of disease but
it is not a defining characteristic of the disease .
CLASSIFICATION
 POAG
Primary open-angle glaucoma is a chronic, progressive optic
neuropathy of adult onset. Characterized by:

• Raised IOP

• Glaucomatous optic nerve damage

• Characteristic visual field loss

• An open anterior chamber angle

• Retinal nerve fibre layer thinning

 RISK FACTORS
DEMOGRAPHIC:
OCULAR:
• European and African ethnic Elevated IOP
origin High myopia
• Older age Thin CCT
• Both sexes are equally affected Ocular perfusion pressure
Translaminar pressure gradient
• Positive family history

SYSTEMIC:
Diabetes mellitus
Hypertension
OCP
PATHOGENESIS
• Ischaemic Theory- raised IOP causes poor perfusion of ONH
leading to loss of retinal nerve fibre.

• Mechanical theory- direct compression of the retinal ganglion

cells due to raised IOP leading to the death of RGC

• Common pathway of damage – includes of ischaemic and

mechanical mechanisms disrupting the axoplasmic flow
causing insult to ONH
 CLINICAL FEATURES
Symptoms-
• Usually asymptomatic

• Insidious,slowly progressive B/L loss of vision

• Headache, eye pain

• Visual field defect

• Frequent change of presbyopic glasses

• SIGNS:
• Visual acuity – normal except in advanced glaucoma

• RAPD (in advanced cases only)

• Elevated IOP (More than 21 mm Hg) with diurnal variation

more than 5-8 mmHg

• Gonioscopy – open angle

• Optic disc changes (Progressive, asymmetric)

• Visual field defects

 OPTIC DISC CHANGES
• Normal optic nerve head- Distinct disc margins, pink in color,
vessels arising from the centre

• NRR- tissue between the outer edge of cup and disc margin.

• Pink in color.

• I>S>N>T rule

• Cup disc ratio- o.3-o.4

 GLAUCOMATOUS CHANGES
EARLY CHANGES
• Vertically oval, large cup

• Asymmetry of >0.2 btw two eyes

• Large CDR 0.6 or more

• Focal NRR thinning

• Splinter hemorrhages
• ADVANCED CHANGES:
• Marked cupping CDR 0.7 to 0.9

• Thinning of NRR

• Nasal shifting of retinal vessels

• Bayonetting sign

• Laminar dot sign

• Glaucomatous optic atrophy- end stage, all neural tissues are

destroyed and ONH appears white and deeply excavated
 VISUAL FIELD CHANGES
• Arcuate nerve fibres in the superior and inferior temporal
portions of the optic disc: Most sensitive to damage

• Macular fibres : Most resistant to damage

CENTRAL VISION IS PRESERVED TILL THE LAST IN GLAUCOMA

• Isopter contraction: Generalised field constriction

• Baring of blind spot: Non specific (Exclusion of blind spot

from central field)

Paracentral scotoma: Wing shaped and occurs above or below

the blind spot in the Bjerrum’s area (10-25 degrees from
fixation)

Is the earliest clinically significant defect

 Seidel’s scotoma: sickle shaped - Due to joining of blind spot
and paracentral scotoma

Bjerrum’s/Arcuate scotoma: Extension of Seidel’s scotoma to

reach the horizontal line.

Double arcuate/ring scotoma: Joining of two arcuate scotoma

• Roenne’s central nasal step: Sharp right angled defect at the

horizontal meridian when arcuate scotomas run in different
arcs

• Advanced defects: Tubular vision

THANK YOU