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    Diagnosis and Therapy of The Glaucomas

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    Diagnosis and Therapy of The Glaucomas

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    Tai aN Diagnosis ™ Therapy «i. Glaucomas Robert L Stamper Marc F Lieberman | > Drake MOSBY TASEVIER Ba (© 2004. Ebevier Ine AI ght worse eeweke Fist edition (96t Scorn eon 1945 Thin! eon 1970 Boum edition 1976 ; Dh elion 1983 Sisth ston 198 Seve eho: 160 [Ne part of this pultication may be reproduced or tasted in any for or by any means electonic or mechanical. including phococpy ing recon oF any informacion worage and rie mscem. wihous pension im writing fiom the Pabliher. Person ay be seg vty fom levers Rights Deparimentsphane:(71) 215 299 3064 (US) of (744) P85 43800 [UK Gx: (+44) HRS HESI3S; enmalcheshhpermisionehevtercom Vow nnay she ‘Complete your request cone vis the Elevier Web teat hpe/ ewes. oun pean Sonera ssee British Library Cataloguing ia Publication Dats A catlogue recon forts book masube fee the Britt Lirary Libeary af Congress Cataloging is Publication Dat A catng record fr this hok fs vibe tom the Library of Congress Notice Medial tnowledze & consaely changang Senin fey precaaions ‘nut be fale. bu a new fescatch an choi expetence bode eur knowledge changes interment and drug therspy may became necesiey Lor appropeite Reser ate alee ea check the mont cutest peodvet tnforaaton proved by the manaictser of eah dru o be eines avery he recomended dose the method nd duntion of administration, experience and knows ofthe pticutto Sescmne Jonge andthe bo ‘ucatwent teach india patent Neth the Pulser othe sos ssnine any lbliny for any injury sor damage to percns or propery ‘tang Goethe publcation, Phe Ph Prime in Chins Lect isthe prin nunber:9 #76 54.9.2 1 Contents Foreword vi Preface vi Listot Contributors vi ‘Acknowledgments & Dedication | x In Mermariurn si PARTI latraduction 1 Iniroduction and classification ofthe glaucomas 1 PART2 Aqueous Humor Dynamics 2 Aqueous humarformation 8 3 Aqueous humor outfiow system overview 25 omens aretance ef Murray Alennstene 4 Intraocular pressure 0 PART3 Clinical Examination of the Eye. 5 Gonioscopicanstorny 68 6 Methods of gorioscopy B 7 Clnicalinterpretation ofgorioscopic ndings 78 8 Visualfeld theory ami methods a 9 Techniquesand variablos in visulfeld testing 98 10. Visvaltied interpretation 109 T1_ Other psychophysical tests a 2 Optcnerveanatomy and pathophysiology 143 13 Cinicatevatuationof theupticnervehead 154 14 Opticnerveimaging 7 Wan theassstanceefassa Cameo and Rie Nescher 15 Primary angle closure glaucoma 188 16. Secondary angle closure glaucoma a0 17 Primary open angle glaucoma 239 48 Secondary open angle glaucoma 266 19 Developmentaland childhacd glaucoma 294 20 Genetics of glaucoma 330 PARTS Management 21 Introduction to patient management 339 22 Medicaltreatment of glaucoma: 365 general principles PARTE Medical Treatment 23 Prostaglandins 39 2% Theadreneroicsystemandadrenergic 3% agonists 25 Adrenergicantagonists 2 2 Carbonic anhydrase inhibitors 407 2 Cholinergic drugs, 420 28 Hyporasmoticagents wa PART? LaserThorapy 29 Genaralaspects of lasertherapy 436 Visnre orsatancs cf Moons Borin 30 Laser treatment for internal low black 439 Visite oxctance ef MechoeS Berin 31 Lasertreatmentfor outflow obstruction 447 Vinnie axstance of Mcrae Berin 32 Miscellaneous lserpraceduresincluding 456 laser ciliary badly therapy Wine ossatance ef MehaelS Bern PARTE Surgical Principles and Procedures 3B General surgical care 462 34 Glaucoma outfiow procedures 466 35 Surgical management of cataract and sl glsvcoma 36 Complicationsand failure offiterng surgery 508 37 Pediatric and miscellaneous procedures 532 38 New ideas in glaucoma surgery 542 PART9 Conclusion 39 Challenges forthe new century 550 Appendix 553 Hitnebeczisonse! Retort N Wen Index 561 < Foreword In 1961, Reoberr N Shaffer andl Bernard becker published the fise edison af thie hook, whicl has hecome a clssic guide for the prac tical management of glaucoma, At dhat ciate, glaucoma was gener ally believed to be a discise that could be dhagnosed by the vel ‘of intraocular pressure alone. The easly and progressive changes it the optic cise although previously described, were not widely tec ognized oF appreciate, Optic dise photography was avaible bor twas seldoin ded. Vinal Belis were exatnined By prnetitioners with varying skills, using a variery of eochaigus, but dere was 199 sand andization (a the process, Medical weatment was Tanited 10.4 few ‘eas, swhich often caused un'cannfortale oF even serious side effets Sargery for open-angle ghucoma invalved full-thickness proce cares with a common postoperative couse 0 ‘chamber, and choveichl detachment. Most importantly, deve wa no systematic approach to the dgnosis,clasiication, and manigeinent fof tiese diseases Such an approach was presented fiod, sid that nay. have Boon its greatest contributions Practitioners fdetook written by knowledgesble clinicians tbat hypotomy, it anterior she firs ex eevved could he easly understood and followed to cbrify the management cof these comple: dicascs grouped together under che heading of ghucoma, ‘Neatly 50 years later there have been seven aurliors tions of this texubook, All of the authors wste tained ar influences! lby Drs Hecker and Shaffer. All of the authors pursed the goal of a boolk that is simple so understand and can be a guile to the busy tet on epiele- rniology: genetics, pathophysiology psychophysical testing of visl function, opnc disc and nerve fiber hiyee imaging. clinical tisk, preferred practice plans, medication, and surgery. The information is updated, but the goal of the book remains the ame — a -practt= cal guide to the management of gliucorna for the practioner. We believe Drs Saniper, Lieberman, and Drake succeeded admirably in meeding this goal ew edi- pttctitionet, The eighth edition presents siew H Dunbar Hoskins, Je, MD wach A Kass, MD Preface This book hae 2 proud history 1¢ has served as a guide for eating ppatcnts with ghaicoma to ophthalmalogias and other eye care peo= wicers thoughout the world for more than four decades The book seas originally co Becker and Robert N Shaffer. It was ater reve darough anuitiple esisions by Allan Kolker and John Hetherington Je ard, more recently, by H.Donbar Hoskins Jr and Michisl A Kass. This eighth eshiions as Well is the seventh edition, is the pooduct of the aseond aid thed generation of glivcoma specialise whe tried anl/or practiced in Se Louis or Sun Francisco, and thus were privileged to be mentored by the original anchors as well as their second generation snadens We have followed the lead of our dlinieal experience with ghuconus cal way dhe current, volorninous literanre about glaucoma and its management. Our understinding of glaucoma and have undergone sificant change in the last nwo decades. In che Last eeerde alone, sg ices have been ade iat ede aiology, genicion, andl pathophysiology: Diagnosis Is been aug mented by more sophisicated inuascule prewure measurement, poychophysical testing, an Dptic Nene and the anterior segment has become widely uotized, The casification of dhe gluecomas fae beet pelted to reflect che new findings an geactics, diagnostic modalities and epidemiology; pel ng tall eo remem tk fretors andl td eteresis che diver influences on uanifestations. Treatment has undergone 1 major cltanige due to new pharmaceutical agents anal innovative sorgical options, Therefore, the book hay undergone an exten sve upsting with expanded eet, bibliography and ilustestons (Du sevecieching, goal tn wei cived and writicn by Des Bernat 1d eo: fnterpret ina practh cant ad optic nerve analysis. Insaging of the ry his been to provide the reader dance in coneepmalizing the sciences of diagnosis ane in ind wichalizing che choices far treatment. Glimpece into the posable fntervention of the Future are given, We hope that the readers like ably understand what we lo and sil ti» authors, will comme to In slo not kiow about she glaucoma. In ane major aspect. this ecition differs from previous editions Because of the esponsntilly expanding knowledge base rcheed aseoais, we ditee principal sudbors tecogiized our idividail Kinitations of expertise and culled on our colleagucs foe amisance In specific areas. We wish to gtutefully acknowledge and thank [Drs Murray A Johnstone, Michael $ Berlin, John Samples, feanente x, Robert J Noecker and Larisss Camejo for their contrib tions, zspecticely, om agneots outtlow physiology, ser treatment, genetics, and optic nerve imaging. They have graciously auehored fo reviewed the respective chapters of dir expertise. Flowever, we have nied (0 maintain hae fas alvvays male the Becker-ShatTer teste 46 appealing: the coherence of aiv authored, eather thai at edited, gest, exp ora eonsudeana apply the literature and our experience te the management af patient yns,ou emphasis Bas been 10 provide, in one ns viewpoint, Asin previous c ‘comprehensive volume, information from the elint to enable am individual engaged in the rmanagement of che coms to do s0 effectively and with understanding, Ubimately, geal it ts redlice vision Tims ned improve the quay Fife ie our patients Robert L Stamper, MD Mare F Lieberman, MD List of Contributors Michael S Berlin, nip, ss Director of the Glawcorts Insaitate of Beverly Hills Profestor of Clinical Ophthslmology oles Secin Eye Insirute UCLA, Lon Angeles cA Larissa Camejo, MD Assistant Profesor Department of Ophthalmology University of Piewburgh Schisol of Medi Piesburgh PA USA Murray A Jobnstone, MD ‘Consultant in Gbucoms Swedish Mediead Seattle WA USA Robert J Noveker, MP Vice Chair, Clineal AMBiey Asociate Profewor, University of Pita Eyeand Ear Institue Picsbeargh PA. USA {h School of Mechcine Robert N Weinreb, MD Distinguished Professor of Ophthalmology Director, Hamilton Glaucoma Center Univetscy of California San Dicgor La Jolla cA USA Acknowledgments esieles the special thanks to our colleagues who helped author 3nd review specific chapters — Dee Michael Berlin, Murray Jobnetone, Robert Necker, ane! Larissa Camtsjo ~ we also wish to specifically thank Dis Peng Khaw and Harry Quigley for dheir inspiration sand gensral guichne; he Kugler amily and Dr Robert Wein For faciktating the inclusion of the World Gliicoma Avocation Consensus documents: and Joanne Scott of Elsevier for her patient atid excell editorial snstaice And ta all of our former, current ana future ophehalmology res= dlents 4¢ Cilifornia Pacific Medical Center and the University of California San Franeisco; we grateil the pleasure of learning togsthct for the benefit of all our patients, now and in she fur, Dedication We dedicate this book te our families, whose Jove, devotion, sup: port, patience aid sacrifice made this mvult-vear peoject, as well as most of our other accomplishinents, posible. Robert L Stamper tn memory of my parents Alfred and etsy, with lowe for my bheathers Victor and Elias, and with blessings for my son Michac! and his cousins Mare F Lieberman, MD To Bicmsb Drake ane! t9 Christoplace an! Sean Drake Michacl ¥ Drake Aad to our teschers, especilly Dis, Becker and Shaffer, whowe wixdom and etioouragement have been a source of inspirtion and strength: w our scudents, whe Belpy ws contoue Tearning: and te fur patients, who constantly stinulite our search for better wiys of ‘managing theie glucoma, In Memorium ROBERT N SHAFFER, mo 1912-2007 (One of the world’s great physicians and glaucomarotogiste died on Joly 13, 2007. Robere N’ Shaffer, bore: in Meadville, PA int LOL became one of the last century's Ieading glaucoma experts, cians, teachers and researchers. After receiving his medical degree and residency in ophthalmology fom Stanford University School fof Medicine while i¢ wis still an Sam Francisco, he established a practice itv San Francisco which vltimarely evolved i for eceelleice in patient care, He dedicated his eateee to Uke wuderunding and managing of the glaucomas. His keen powers ff observation led 10 11a al ges that are sili use vxbay cluding the Van Herrick-Shaffer slit lamp estimation of angle depth and the Shaffer chssification of ganioscopic angle appear ance: One of his proudest creations was the fellowalep in b that gave highly penonsl taining to many of the nest gence tion of ghucoma spedalists fons around the world: over 49 world eae in glaucoma served as fellows in his of He wat a prolific weiter. In addition to is dazent of peet- devicwell articles iin ophehalnie journals, he, together arith Dr Bomard Becker, one af the other giants of glaucoma teaching snl rescatch of the lise century, began what was to become one of the definitive textbooks on glaucoma = ‘The Diagnesé and Therapy ofthe Ghouoma This textbook, now named Hevkee-ShalfrS Ds Therapy of the Glaecomas, i» currently in its eighth edition, He also tered’ on the American, Board of Ophiiahaclogy: becoming ies hairmat and ulkimately is exceutive vice-president, “Together sith his partners, Drs John Hetheringlon aud Dunbar Hoskins, ne founded the Glicoma Rescarcl Foundation which i dedicated to gliucom rereatch am eduestion. Its mision is to find 4 care for gluucoma and toward that end ie has Funded many [promising pilot Feseatch projects. Bok was 4 consummate teacher, fa adlition to his fellows, he trained residents at the University of California San’ Francisco ashore he war on the clinical fealty for over thirsy years: They routed through is olfice, seeing first hand his very personal brand of cate as well as his clinical snd surgical approaches éo ghiicoma He lectured around the USA and the world, abyays presenting Bis material in an unverstionsl, far, and sllueninative fashion. His chilthood sweethears and wife, Virginia Shaffer, truly a life partner fn ao many of hit activites, had a hand in making his lectures 40 enjoyable and educational, as sae was hetaelf an export in public speaking and helped educate many o€ his fellows and residents it shat sil (One of his most memorable characteristics was his courtly quiet ailappable (except om tite tennis court) nsec. Hee was craly 1 geutlenan in all the very best meanings of the term, Those of us who were privileged to know him were enriched by his presence: He and his style of patient-centered care, bedside teiching and diplomacy will he sorely missed, is nd This page intentionally left blank DEFINITIONS: The concepes and definitions of gliucoma have evolved in the past 100 years and sill they retain imprceise ard subject to tech eal qualifications The word gloicma originally meant ‘clouded! in Greek: a¢ such, it may have referred either to a manure cataract ff to comeal edema that might result from clonic elevated pres sane, Today the terut docs 0 derse entity, but rather to a group of discass that differ in their clinical presenta pathophysiology. and treatment. These diseases are grouped together because they’ share cersin featires, nchading expping and atrophy ‘of she optic nerve eas, which fns astendane vital Field loss and is Frequently telated to the level of ustaocular pressure COP) i this tent, gticomna is defined as a disturbance of the struc ural or functional integrity of the optic nerve that can usually be arrested or diminished by adequate lowering of TOP: An innportant distinction must be noted in the criteria currently used to define primary oper-angle glaucoma (POAG), in contest to all other forms of glaucoma. Primary open-angle glaucoma is explicitly characterized as + mulifictorial optic neuropathy with ‘a charac teristic sequined atrophy of the optic nerve and loss oF retinal gan ice cals and their atius developing ma the presence of open chacacteriatic visual feld nmerior chamber angfes, and manifesting ibnosiualities Ia contest, a] ether types of glaucoms ~ invariably the secondary placentas, and closure glaucoma ~ ae defined firs and foremost by the preace of crated IOP, and nos iw reference to the opt follows sussined elevited IOP ‘Clasically the primary glauconas are not sociated with Rao focular oF systemic disorders that accoune for the increased fete orically even the primary angle~ ewropathy that ance to apieows curtlows the primary divencs ate unl bilateral sun probably zetlest genetic predipositions.” Convery, the see- ctudaty placemat are anorited with ocular or temic abnor mal- ives responsible for slevated TOP, dhe alissases ate often unilatsal and sequired. Sonic have angued that the dtinctions beween ‘p= tary’ and “secon simply rellece ove amperteet understanding of pathophysiologic events that converge in the commton final ppthway of opdc asmophy and visual Geld lon! Although: many ride feta have been asieciated wih the derclopascet of POAG (Table Te1),clevated 1OP remain the most prominent Gictor ~ saced among the primary and seeondary gaucornas ~and che erly factor contemporary ophthalmic intervention can rekably affect Inmancular presate i dessrminee by the balance beswect she rate of aqueous humiat proclctiow af the ciliary Kady. the resist snke to aqucous outtlow at the age ofthe anterior chamber, nd the level of episcleral enous presiae (Fig. 1-1), Elevated IOP is usually caused by inereated resisunge w aqueous humor out: The optic nerve and viwwal fichl changes of glavcoma are deter= mined by the resistance to damige of the optic nerve axons In most cases of glaucoma, progressive changes in the vinual field and optic nerve ate related t increnwed [OP; in some instances ortnal’ levels of JOP are too high ing. of the optic nerve axons, (The caneept of normal” rust take nts account both the range of MPs for diferent ethnic groupe as well as the eorrection factors for applanasion tononietric meas twremients inthe presence of thicker oF thinner ceuteal comeil thicknesses)*" Although there is no absolutely ‘safe? pressure that guarantees to prevent progression af POAG,”| lowering 1OP to the low-normal ringe swally arrest ar slows the progres of gla coma" If the glucoma continues to progres, it i+ posuliced that cither (1) the IOP is not low enough of aulicienlly tive of Huctuations to stabilize the disewse; or @) the optic nerve and/or ganglion cells are so damaged hat che cascade of deterioration petsss, independently of [OP levels, proper Funct EPIDEMIOLOGIC AND SOCIOECONOMIC ASPECTS OF THE GLAUCOMAS Whether manifesting a6 POAG, primary angle-closure, of con genital csesse, glaucoma is the second. leading cause of bind- ew worldwide, with 3 disproportional morbidity among women and Axams27™ Globally, POAG affects mare people then angle- clowire gluicoma (ACG) ~ with an approximate rio of 3:1, and wide variations among. populations.” Yer ACG nian nue more aggresive and debibting course (expecially among, Asian) din was cocognized a. generati ally requires moore than sridotomy alone, frequent medical or sur= gic intervention? and yet neverthelew ACG offen leads to an appalling amount of morbidity (& ACG accounts for Teas dan half of all glaucoma eves in Chins, but over P& af its glaucoma Binns) 2 In the United States, glaucoma of all rypes is the second leading came of legil Mindnes, often despite the avalabiliny of excelent longterm management.” Among white and black populations in the US, POAG accourits for neatly two-thirds of all reported gla coma eases" Ic estimated that 2.28 milion people in the US, corer the age of 40 years have POAG:,""® half of thom ae anne mmrable vial fil Jos"? Another 10 million Americans sre estiristed to hu oF other risk factors for develop of these eves will convert to POR 2g) is teatmnent as Of their disease despite the disease: appre over the course of a decide.” Wy INTRODUCTION Nn hak cipta Fig. 1-1 Antenor segment ofthe eye Aqueous ‘humors tormad bythe oltary bony epthetum. asses between the ris andltens to enterthe anterior chamber, and leaves the eye thraugh the Irabecular meshwork and Schlemms canal coupren Introduction and classification of the glaucomas “The relationship between IOP and ghucomstous optic neuropathy is comples. On the one hand, the higher the JOP, the higher che risk of POAG: conversely, | out oF 6 eyes with POAG: onstrates JOP higher chan the age-appropriate normal range" The complexity of the stuliple parameters and yariables con verging in ‘glancoma' diagnosis and prognoss hus led to a recent spectrunt of ealy and advanced disease. Many of these studies kinown by a tors, with 3 focus on clinical applicabibiy"” Although these Lange. controlled sides were comcted in Western countries their Findings are duceely applicable to addressing the muanagement of Jaucoma in the developing world as well ™ In brie both che Ocular Hypertension Tre Sandy (OHTS) and the Early Manifest Glaconta Trial (EMG) addressed the valve in 6 the OHTS study refined the porunicters of predictive risk faeoes sch 36 cen tral corneal thickiess, age, andl ife expectancy for elaboration of The EMGT stuly unequivocally demon strated that eat treatment delayed aneate progression, in contrast fo an untreated control population; and that dlceate progression rigorously derived epidemiological data ermbracing che ange oF tsk Face it acronyans ad acldeesy 3 wide ly desection and treatment of POAC trestmient secisions.* cortelated with the higher the pressuing JOP ‘The effects and parsmeters of various interventions in eyes with established glaucomatous damage were asldrewed by che Collaborative Initial Ghucoma Treament Saudy (CIGTS, the Advanced Chucoma Intervention Study (AGIS}, and. che Collaborative Normal Tension Gloveoia Simdy (CNT! CIGTS deiosstated that substantial IOP reductions (018% ‘with medications or surgery, respectively) preserved visual function in most patients." The AGIS reparts demonstrated the efficacy both of redsiced 1OP tHuctustion aid af subnionial IOPs dbelow: Mmmlig postoperatively, and reliably under [8m 6 eats follow-up) in subilizing advatced vinusl Held los Simihtly the CNTGS, in randomizing ‘lew-tension glaucoma’ patients with advanced field low eo aggressive treatment of no, Found that 9 30 although peit-nengeal cateact Vadoa lot Ui Roque JOP reduction stabikzed most visial Fields, Though the applicability of cach particular study i+ discused ity tpreatee detail in Liter chapters, itis worthwhile to discuss haw cue Lindersanding of ri is evolving RISK FACTORS A brief review of epidemiological disincsions is required to help artay of well-designed liceracure-"" A ane useful so bear ie mind”: the clinician contextualize the bewier studies continuously appearing in the ophthah Few basic elarificat 1. Causation is neither always liner nor applicable to individu uis:'rih factors’ are not synonymous with ‘caves of disease 2. Pathways af risk have multiple branches, sometimes converg: ing oF diverging: © g.ggencler and ethnicity arc sist: variables; JOP and blood pressure are Jyeumic variables (which may be either interactive or independent):dlifferene dicase stags, whether eaty of ulvancedl, may reyponsl vasiablys and satstical steed ray he miore relevant to populstions than to individuals 8, Some rink estegorict are an aggregate of ummpecified variables For example,"age’ frequently 8 surrogate forall tise factors aging of tinucs; me of expose to other tisk icons; dueation of disease; and i¢ is variously presented as txne since diagnosis, oF length of follow-up, oF age of omet. Similarly “family history’ may reflect formation about ethnicir ‘or mulépfe inherited factors nay not be independent optic dise parameters; JOP slsease risks andl Ereatmeri refiactive erronsgene mutations, ete. 4. Risk Gictors for dineme inadowe are nat necenarily the Teves: cent thickness: personal habits ad attitudes toivaeds wane es hove for diene prope sis, Hypertension, for example is niet associated with develop gucoma in young, patients but 148 with older hypertensives Gpecificaly x diordered dittolic perfosion prewurey" established glascoma, systemic hypertension ix not 2 rick for diese progression. Currently there is great interest in elaborating “global risk assessments for ientifying ocule hypertensive patients convert- ng ince PAG, OF enormous public heal import for pre chctinns pragresion is ceterssining those factors combnbuting sot 10 ior for apne ep the Gomesegon inka: fp Mndee;mach fae ide advanced field los atthe tine of prcsentstisns, Affi ethnicity, an clinical won-comphance. Les well stubed are risk fictors for therapeutic responsiveness, seh as thicker corness, misle gener, and tower socioeconomic satus Table 1.1 Bete dose Factors hae have demonstrated, to 2 greater or leer ectent,tsticical corte lation with cither the development othe progeetsion of POAG. macoma, but sebich le In contrast to th thalmiie genet, about the her he controversy and confusion He parameters of Yetanacty” and "ac being devoid of distinctive genetic subssrates* Besicls the valve cof these categories a8 matkers for putteras of ride of effect iit Lager epuluions, fom whick hopefully nore precise mechanisms will fone day be elucadated, they also highlight the importance of tna vidkalizing the care of cach patient, sensitively artending to the impact of heredity and of cultare for the apecitic patient at band, Yet much of technically he epidemiological Litcratare of de pst several decades deals explicitly with the categories of race and ethnic Background, characterized by comprchensive population-based stunbies with rigorans criteria for pressite measurements angle eval= Gon anid dite and Viewal field aidetatenit? 8 These ates of whi consistently separt a prevalence rate for POAG in 1 adules However, significant rucial diferences exist. Among Blacks, f jer! These patients ate twice prevalence ie neatly 4 times 436 hele white Counterpart, abd they have the 17% lonager.2"77 These facts rellect 2 ely ca be bi ctseme neatly nly of ophnncogis wor he pate pron i cf rates have been reported anton some Caribbean populs- 1% alehough there ate lower and mare vatiable prevalence ates among the genetically hetcrogencous Affican_popolations fram shorn thewe New World populations descended" With the bie medical resources avaible in the developed wool he holy grail for clinicians ip hat all coca of Blindness from sau coma are preventable if Une disease i detected cay ad proper teat- tment is implemented. Detection depends on education — educating the public about the importance of rourine examinations. and train= ing fllow heath pratisiorak wo recegpize che sign and aymptorne of glaucoma, Screening strategic that rely only on TOP measures ant that neglect tse and vinta fehl astenment are inadequate: \when fl esting is petra it may not be concefectie.” Pending the widespread appearance of expanded and effective public health reither the p= onic.” Eve tions," ath and oven, ireervensean, the iividual clinicina eon be enrarmonsly miecentil in ing uncli.guosca gluscons,ainyply by Gxibating the ophehlano~ ghacom pens — Ingicil eunination of close relatives of existin especialy lings and oer immediate family members: INTRODUCTION CLASSIFICATION OF THE GLAUCOMAS “The most widely used chssification system of the ghucomas sep- ites sngl-clonuse: ghaicoens foi open-angle glsiconss, Thix fundamental ditineson stl holds, but with altered enaphasis regiriog th ition. Historically, angle-lasure disease hha teen variably defined in eerms of pupilary Block mechanisms (ex, Imionc induced, presenting Signy and symptoms (eg, "cone gestive), or the presimprive time-course of the condivion (eg “ubscute)-The most contemporary approach continues to ex1ph= tise the Bal pathogenic pathoesy mechsnians of irido-esberular cobsrution that resus in functional angle closure” hut abetted bby technologies that allow direct visalization of angle, Leos, and anterior cary body stroctures, the cursent sae of bath tae baikey iene tha eps pga sification 48 an i ses iiense, and ‘rete sites of dysfunction in the anterior segment (Fig, 1-2) Inv opencangle glaucoma, there is relanve impairment of tlow fof aqueous humor through the trabecular meshwork=Schle cconal-venows system: yet om gonioicopy the angle appeas to be ‘open (Fig. 1-3). But amidst all the details of elasification, one aust never lose sight of the ulsimate Final padhway in all glaucoma as ‘manifest optic nerve damage and ganghion cell dem This bate esifieation selene continutes to be helpful because 4 clarifies pathogenctse mechanisms and therapeutic approaches We propose te simplify plaucoma clawification into Hhtee major divisions, which are subdivided into primary and seeoncary eat- ‘eqories (1) angle-closure glaucoma; 2) open-angle glaucomas and nechanistic scheme focuhing: on Ai 4 Fig. 1-2 In angle-cosure glaucoma the peripheral, its covers the rabecular meshwork, abstructing aqueous humor outtow. 6) develop sal glace i manifests an the Fist years of life. The category of ‘coutbined-mechanism glaucoma’ historically referred. to either sequential of coincidental presentations of entities ftom these three asic categories, snd usually involved angle-closure mechsaienns, hence we relegate. theve idionynerstic eases smnong, the: weondary angle-clowute glaucoma. ‘A similar elawification system divides glaucoma inte conditions thae affect the internal flow, and conditions that affect the outiow ‘of aqueous humor Internal How block is caused by such conditions 4 pupillary block or malignant ghiuicoma, Quillow block accars ‘with diseases of che trabecular incsh work (eg teovaseulisization) ‘or that compromise Schlemm’ canal, cofleetor channel, and the venous system (eg,clevated episcleral venous pressure) ‘Alternative clasification systems" are bases! on other features of the g ste of the outlew obstruction, while is vided into digas that Met the provalicoular prange of qacom, humor (eg. pesterior synechiae 1 the Ten afler oeul iylanima- he trabecular How (eg. eae ‘chymotrypain), and the post-tabecalr movement of aqueous famor feigs ecemed pickers vetoes promise Bona Carotldbcuvecions sinus fistula; @) che tisue principally invalved (ey, glaucoma exused by diseases of dhe lens or diseases of the retina) (3) he proxinnal in ‘al events (e4gesteroid glaucoma) ancl (4) the age of the patient (6. “congenital, juvenile) Specific diseases haw alo heen subclssified, nach 1. in which sore anomaly of che ante dascases, eledang (1) th ma after adrmnitration of = & POAG types breed om various spperanens of the damaged optic nnewve.® or clsifiction of diese sages by vinual fel danaage” ‘or the angle-osire ghauconas, uscd on {OP levels an gonoscopic configurations a correlated with ulrasonic biomicroscopy charter Introduction and classification of the glaucomas | 1 Fig. 1-3 in open-angleplaucoma there impaired four of aqueous humor through the traecular meshwork-Sctiemen’s canal-venous system. “The reader is cautioned that all classification schemes are arbi- ‘6, Postetior polymorphous dystrophy trary and limites. Some cases do not fit neatly into one category Ah Epithelial dowsngroweh fof another. The chesfication that flows iz not meant to be all- © Fibrous imgrowth inclusive, but to be an aid in thinking about pathogenesis snd F. Flat anterton chamber ueaument, © Inlanmasios fh. Penetrating keratoplasty 1. Angle-closure glaucoma 4. Anica AA. Primary angle-closare disease 2. Posterior ‘pushing mechanism! Inidesotecular coc isthe fra common putheeyy of angle sere The iiss pusked fro hy some condition in the pestevon sliscase,absinating agucous cules ican be comeepnailized i nas segment, Off the clery holy i etsted ates slewing the cornplinentary sme est cvne ford se 1. Natural history. 4 Ciliary block glaucoma (malignant glaucoma) a. Primary angle elosine spect 1b. Cysts of the iris and esliary body Is Primary angle disur «. Intesscular tumors € Pritnary aungle-clonire glamconea 4. Nanoplihataios 2. Amterior seysnent mechanisns of clos © Suprachoroidal hemorrdage 14 Iris-popil obstruction (& pupillary block’) Intravitreal air jection (4. retinal pacumopexy) by Ciliary body anomalies c.."plat y & Cillochoroidh effusions (eg. panretimal © Levi pupil Mock (2g. phacemorplie block’ fewallen photacosgulation) lens or anicrosphesophakia)) (@) Lnflammation {ey ,posertor slerits) TB. Sceandary angle-clonunes @)Central retinal vein occlusion 1 Anterior “pulling saccharin” Ih, Seleral buckling procedure The si is pulled fanned by some proves in the age, fle by 4. Retralental ibeoplasias ihe sovenition ofa oonbrene erpscpheel maciarayreritae th Otuangle neem a. Neoraeulae glaucoma A. Primary open-sngle glauema 1a, Iridocornen! endothelial apadromes (e.g. Chandler's 1. LOD higher dhan ‘normal range synalrome) 2. FPS within ‘normal range" Glowtension INTRODUCTION 1b, Secondary open angle glaucoma 6, 10. Pigncntary glaucoma Pycudaexfoliation glaucoma Steroid ghineoma Lens-induced glaucoma 3. Phacalytic glaicoma by Lens particle glaucoma & Phacoanaphylaxis scams after cataract sangery 3. @-Chysmotrypsin glascoma Ih. Glanicoma with viscoclastice © Glaucoma with pigment dispersion and intragcular len d. UGH syndrome (uveitis + glaucoma + yphema) © Glyscoms aller neodymianytinian-alansiniam= _gamet (N&:YAG) laser posterior capmalotomy Ihucoma with vitreous in anterior chamber Glascoms after avin a. Chemical burns. bb Electric shocks © Radiation dd. Pence hans . Contusion injuey Glaucoma associated with intrsocular hemorrhage a. Ghose cell glaucoma bk Hemolytic glaucoma 5. Hemosideronis (Cluucow associated with retinal detachinent Glaucoma after vitrectomy 8. Intraocular ge b Glaucoma with wveit traacular silicone oil 4. Fuchs'heterochnonte inilocyelitie 1B. Glaucomatoeyeliic crisis (Pusnet-Schlessnan) . Precipitates on trabecular meshwork (rabeculits) al Heepes simples & Hexpes teiter fopulaton beot naly Sarcoidosis & Jaw 1 Syphilis Hassan inom 1, Glau 2. Malignant melanoma le dheumatoid ardhriis 1 virus (HIV) 1b, Metastatic lesions e. Leukemis and Iymphonis A Benign lesions (ex. juvenile sant neurofiromatosis) 12, Amyloidonis 13. Increased episeleral venous presure 4. Obstruction of venous draitige (cag. superion vena cava nbsiruction) bh. Artertowenous Fistula (eu nrotid cavernous) Genter ephcleral rena ancien (eas See Weber sudrome) ML, Deyelopancial Anolis of the anacronseonent are presen at bith, Glaucoma ‘may be present at his or may apgesr inte fit decades of Mi 6ce Ch, 20 for detailed classification of poise glauca diseases) A. Prinary congenial (infontil) glaucoma 1, Congenital ghucorna 2. Autosomal dominant juvenile glaucoma 3. Glancoma associated with systemic abo 4. Glaucomts associated with ocular abnorinlitice B. Secondary glavcomns 1. Trauevatie glaucous 2. Glaueoms with intraocular necphasan 3. Uveitis glaucoma 4. Leneinduced glauco 5. Glaweonaa after congenial cat 6, Steroid-incluced glaucoma 7. Neavascula glaucoma 8, Seconchiry angle-closure glaucoma 9, Glaveain with elevated episleral Yenous pressure 10, Glaucaina ascimdaey to antrdoculie infection camngcey een Suv Opens 27 lorabis ofp A. Klis ecto Pteree ef ghey The Bence foto the Noten File inane Dam fe Se nk stie -19, , Scratenasde rj Ophir 19,200 6, DisteaiVingtiig Wale REST le Klong anon sls afr en ange aici + tnd alder act ate The Hence Dam ye Sed “meth 884.10, dee of anc aa pacaee tao bard ey a eg ‘poe gssara Pe eae Tow ye Sad Fath Acton FPoeste¥E hc Amb Ola! tthe ‘Orley ante, 98 2h enim Acnaay of Optatrsogy:frnay ent bon 18 Dinian yee Poy pence Aine sca Pd Ptr fabs Sanson, 1, Lnke Mera Ra tr ope eesti found dikes antics tbe The Atsdoa 8 [dawoma te Baad Eye Se teenie popu Te Roney So 5 va, Denna om sa iil tt Pet Opsaadaaagy Lm rms cemted spelt anny age of Ineeeatn feoein unseen rani 4 Feta ed gna T Claas a Geren drm root Ihe pert ety pepon Tex ora Son ‘he dcusin fe Hick Sich rapa Frente mays Opting 138 195, ‘lone The sci 2 fn 3 Lo Mls erry sous fuses papain aoa Mudra ota shen as fsa issn Fao sierra toek chee and cee 5. nie )OComea hike ie wor temenng, 1. SM, RL on open ‘et cited FOE] Glace 13338 200, eget i sient Cas Opa Ove ‘Diane opal te yim Cnt sn eke ai fame tye ts, fae 8 Teel rd yperendon pian rei 4 2 pe Gpehadmot 8 Introduction and classification of the glaucomas ™ en a ‘catanve Norbi-Te on Ganon Say ‘inate etre tuted fre hatin he weatnere of wes ‘Guocoma. | Opberdd 13048, 1 seamed lions tee mane Sady (AGH T The ttn tere ct isc posal unl Yd Bas Sora ‘The MES lees en} Ope! 182, Se ghnscomoo sal ld proce ‘Oph ity 1981007, 2006 oocoms nogrnte Wenn Re Cmte ne aan ABs eae Tie legeeskogea pr ea Se Quer HA nn of paps saws ‘ike, Ue Opt TH HE Tits Sr AD Te gtd st of daca. Ball Worn eh Orn 7229, 178 ‘Gutser th tomon Neeer pene wi. fdmctma wertwade nia S028} Cqtitdmst oe 38 Jobemon hier H:The scone f:Jbmon Eh 9 Meade Rol ‘ideology fey Aue, Snpps2 So 3008 try speak icewn mae ops oplhaedgy 0.300, S00, Ciptnn crea erty wt pry ae “lone vane aang Cte, hae wl Wick epeiscens Opin nogy to on Shiner sg anno { eiottee phason matey pn] Opus! Sens rst oer ote Gao ae Ca tow pete He} Ophaia 85-1277 591 ‘Mung eeat Loot avons a Ata ates 2a pty secu bho Pingel se a ‘Nog et slVia tld oa oe pry Tracie danenalacerorare eit? Oqlitinciog tietede une (Olver Ee nds ol tose» rons Dah rom memaiaey eer ‘Raku Jot Doane j pening {Sak pment om be Hol Oc ge ‘Ripinysndibe Regery stim ee ‘etiaoy Arte pete! Sant Sap 7-986 ‘rsh Mt a Bn nee el epries sasescanatan popu The tae ye Sete Ah Opal Take 1981 ‘Alingur 0 Schan Garate cinemas thela, lnere ‘Slaer gle gavcoma soa nasa the OS Mien taa Tekh) ca Raval on mente praleee pein oper-inge acon Te ents ye Sep JAMA toe302 19 ‘hig HA. Wiles Neo apr (dewcoma evecare abe Ute Stes me al VS 98, 7 Fredo Do rele persnge ‘imme ag tans th ed Se Ak Ogun 2882 301 ‘Qhidey ts Rk Gan the seeps ‘tabecinor Sent bel bo mover Tipe Anche dnd 1120 ” Sonnet nT. Ke esto eatery Iara penai ain open ae ‘Shcrra meng wives Nak Auer (tact 2 819 Senet A Digi sa cee of he {Snuceren Commun Ee Hrsh, 19H Fils PeClawed wis aco ede ae bennd ope cm Pie iret Who ‘Willi yy 73-1, sr Bes Win SAR we hn ae Feo the nr crn esl eae br hn ‘cron Sve 135-198 Stier eecarframensefsaiie ypaneatca Stan nee menroierecrniiere mined varied ede BR 3803206 oman Nt pst am tent fon whcomtonrk opimen mar tnpemetocrcerdwngand orataetnn sed ‘eset Opal! 148326 [eles el ah at he es open At) Cao! Ds Fine tebwon Ama fo he OFFTS.An phic FS Women He Slur 2 Kumar RS ance thi wr opm Grice aap Secames ca Sind sents Cat Oni Snndeentdl cermin tan ped cv Igpmemive med do oy peti tbe oe Ursoae Antecpitsin (1-08, 2908, Grete Rca The Oct Hypertree egiew Tal hacho tron tha prs he Ses PONG. Aa Opiate! 130713012 [er Be inom Wk ton Hera omen Soa (neshuomarin. cue on eye! eA et:Meteiometwxpocab pesure tcp en atte Ely Meee Gc Thal Ach Oybritial Lae Ata Face fr none region sl de eBctoftcna decoy noe ‘Dnnamassntchnb Ophea 13400, Fete erin dane onto feds or srg Ophtge 1 pao Cotean Astaro pes ftnnan a cou ant ar son ea pepe haw nmol presen she seed vom iene se onan HAS [AGE The Atm Giuncoma aero Sey (Act6} 7 Tha wkd betwen cova ot Irmsces pean and wun od donee The AHS enon Aas HOt Es ain Calbnaie era Teas Gasp tol wor om {Gphttng 24,3 tortulsnann aucnsn Am) Opto Jac Fome A: Parence in dence st ‘Henintea vit inparnesc lfc ‘tin ae Ryton The deel oF fps oma, Arp aE Staumian ingen ean rina (hele Joh on 6 Anson Wee Raton Thespoleminogyofey heme, Lond Atak proved ans Shiu ntCrsescinad ube ecb 0, ‘nia Bede loan Tle epdealage oy domed, Are 2-5, on Lacon Sad 22. Lobe MC Cresent an coor ike: Jerse Manin 2 le Rees The lenoly ster one Lada, rab rea, co Sher Rs Chai fon, Nain [kee er The endorse fre ee Louden Area pp 72-47 30n, 28 Quigg HA Rid fiom Gor opem ane gan Instr onthe nc Rive Coney ncn Gaetan New Opti logy Gare Obes ‘hexeny Ophtinelogy 34 Sesion. (es Nanauer}Dy The Hager Rage ge Badin LQ poy HA: Re det sade mde aon esienion tal trdeaton Jose Ins 3% ‘aoagpoe Sparen coh cas epee fan jOptininetpeve-ten tase Predie ital ecicbewd amsnaest of fo tc the pean ol nae pei "Bu gaucomn Any Opti 1983192008 “iy een Peres EN Zs CML ogee eos ete focwsnocy 2h fk Mconersen fot cele bperndon ts cs, (aka H1S98I—3N Hyrum Eee eer Opi an {Be den of ory Arch pial HSS 30 FA. Wha] een coages aghncors Aen 4 Wathen 3 pent Eat eres Ipprcmees prisear onan entero CievOqe Opindial toa sh 38, Carey ase trnaltne nfgcoms fhe wot Aandi} pure 240 8, Tren yN Tie pertain cea of pe sei etm a popelans owed penpesee am iRorirnte Hearn 33, te 7. Qildey HA te Mode of operate [Banta prrnce nd cen be Unie Sn nen phat Vise IRB 7 7A Javan Preemie Atari th ee fGraje heh eciton Sav Opataa 8. 7), Mom RA Kowa EM MBG Staley fe prslone seh tom crate SiLGH Mle lie Pun rove fog, pany 960, Sager ance mesons Ach ill EAE Hlsaprek Spotl, tt A Hang A. flere wintry acon New Yah per seins se Siuuner 2 Epentaoyy st mites weeng ‘Sr aneonaSaey Opin 38th 9 nA Mer CC ec ccna ein open gle aca} led eon iristatie Ist Now RL je SG Tall Ltr, aoe fran with Fla ch pe ‘Banos Orluhsamtngy i128 308 x Seman ern encore Wiclbau ifeceren sichutnntese see {Bono he Nom neo furne acon Ssernng Se He Open 5%, oe Reenter Canrtepithars iat agen geese Fhe Hee Reger 7. Spach GL new dame of dances ining er Opt Uh A Badene DL eo Peta Caen the ‘gr fc ne fun ema en ap ‘ene: 1) Oph 1213190 300 9 ino HAR Cain eo cae he tases ncn Sere Orbe io FUNCTION OF AQUEOUS HUMOR. lly thought to be stagnant, It was not luntil 1921 that Seidel proved that the aqueous sas, indeed, cir cculiring Using a needle, Seidel connected a reservoir contsining: a blue dye toa rabbit eyes When the reservoir was lowered, clear uid frou the anterior chamber entered the tub ‘steoir Was raised the dye entered the sys and eventually appeared in the blood of the episeeral venous plexus." Seidel concluded thae aqueous humor mse be contintiausly formed and drained, Theo decades Later, Ascher showed that aqueous humor enters the venious system at the firnbus through the agucous veins and frst Flows alongside che bloodstream in 4 laminar fadaion before mixing. completely with the blood in the veins.* Ashton studied neoprene ‘cass of Schlerim’s canal and the aqueous veins and demonstrated a dircet connection henween these nwo steuctures+ From the work ‘of the last half exmtury i is clear that agueous humor da eeltively celles, protein-fice Muid that i formed by the ciliary body epi thelium in. the posterior chamber. It then passes berweew the itis nal the Jens, enters the anterior chamber through the pupil. and ‘etic the eye at the anterior chamber angle through the tabsculsr mecork, Schlenm’s can, and the aquemus veins, In the ante= Jor chutuber, the aqueous humor is subject ta thermal currence when the re Deeatse of the temperature difference between the iris and the 1 clone to the warmer iris and descends elose: ent nay cay ‘Esedlly soos thie ate dell oe pipiens the a ‘cornea: agsteoes to the cooler cornea. This ¢ tod liaboes and explains the relatively inferior location of pigment depasition (Krak ‘of the come, ‘During ite pasage through the eye, the aequesue humor serves 2 ‘sisahot oP enpostane Maschipea We ete in fiom ofa aul cyst for dhe normally aviscular uractutes ofthe eye, eluding the comes, Tens, and trabceular wal eye essential nutrients, such 25 oxygen, glucose, and amino acich,” and removes metabolites and potennally toxic evbstances, wach a lnetc acid sic ‘carbon dioxide,” Aqueous humor provides the proper shernical nt far the tinates of the antes provides an optically clear medium tallow good visa furietion. Ik intates the glabe andl maintains intraocular presure (JOP), bath of which are importane for the stractorsf and opscal integrity of the ‘eve, In many species, including humans, aqueous Inintor contains 1 concentestion of ascorba berg spindle) and Keratie precipitates ov the inner susfaee ishwork, fe rings eo the inte oF segaicnt of the eye and awry bi shi yy act to scavenge Fice radicals andl protect the eye againnt the effets of uluaviolet and ‘other radiation, Under adverse condisions (egg, inflammation, infec ion), ir facilitates cellular and humoral immune responses. Paring, inflammation, the rate of aqueous humor formation decrease, and ite compotion is altered to pet mnediaors (Bas 2-1), Several risk factors probubly contribute to dau nerve with is resultant vial Los in. glacoma. Intraocular pressure that iv too high for the continued health of the nerve is univer- silly accepted a6 one nf the most important of those ride factors Therefore the study af those cleneuts thut conteibure to the crea sion, maintenance, and variation of IOP is merial to the ander stunding,of the pathophysiology of dis disease. Aqueous formation (F9, facility of ourtlow (Cp. and episceral venous pressure (, the major intraocular determinants of LOB. These ficeors are rebated to one another by the Goldaann equation sit accumulation of imamine =F +P, ‘or if solving for F Fe = Re in which Po isthe FOP in dhe wacisturbed eye in min aqueous formation isin l/min, the faciey of outtlow as in /anin mm ig, aid the pieces! venout peeauire at ime shimbly, Front the equi- fioasit is evident that JOP yrill inereree when the aquecue Raemio- tion tate increases, the episclenl venous pressure ineteases, of the ute fei ty dcereaes. More recently, wi [presture-indepenident euttlow mechanisms) (the uveoscteral path= ‘say boing she main one), the equation haz had to he modified and the discovery of a is better stated Wa Pye + U sohere By is the cam of the external prewure wich as episclral ‘venous presure and other dase prenures outside te eye, and U i che suru of the presune-independent outflow puthoays? commen Aqueous humor formation 2 ANATOMY OF THE CILIARY BODY STRUCTURE The ciliary body i the portion of che wves! tract thar hex herween the itis and the chorosd (Fig. 2-1). On cossscetion, the cary body his the supe of « sight uiangle. It ix atached anteriody fo the scleral spur, creating 4 poteathl space (uuprciary space) beeen selfs the sclera. The iets inserts inte che short anterior side oF the ciary bo scleal spur, “The ens is asached to the eiary body by the zonule, which sep rate the vitreous compartnent posteriorly from the aqueaus cos partment anteriorly (Fig, space into the posterior and anterior chambers. The punction of che sclera, aud comes i called the anterior chamber angle ‘The ciliary body is composed of muscle, vascular tise, and epi tg. £1 Ligntimacrograph o!tne anterior segment oF tne eye showngt “Tenens capsule: 2 epislera, 3 stera:4 lamina lusca5 elbary body {6 Sehiemms canat and? peripheral cornea. {Courtesy of Wilts H Spencer MO) sete mbar dengan h Selera tong the circular (phincteric), The longitudinal mincle attaches anteri= fly to the scleral spar and wabecular meshwork and posteriorly to the suprachoroidal lamina, with some fbers connecting to the choroid and selera as far posteriorly as the equator of the globe: When the longitudinal musele contracts, it pulls oper: the mabec- ilar meshwork and Schl run parallel io the Hinbus. When these fibers contract they relax the zonules, slowing the Tens t change shape. The radial musele conncets the longitudinal and circular racial manele is nat entirely clear, but it is postulated that contrac= sion of the radial fers may widen the uveal trabecular spaces. Ie fs possible chat some or all of the insertions of these ciliary ruse le teradons are into. an clastic Fibrillac network which usskes the resultant actions dificult to sorcout? The ethary body shsuice of approsimately 6mm (we Fig, 2) of the ciliary body has s relatively da inner surfice and i named ehe pits plana, The anterior portion ofthe eiiry body Ins approximately 70 to Bt radial ridges (he atiary processes) on its inner surface and fcmamed the pars pleats (Pig 2-3). The cary processes are appro mately 2am in length (Sm in wie, and 019mm in heighe. “The srfice arca of the pars plieats is eximated to be 5.7 ene? in rab bic" ancl Gene io humans? Thus the pars plicata has large su fice areca (approximately five times the surface area of the come! endothelium) for both active tid transport and wlrafilation ecause of the invagination of the embryonic optie vesicle, the nner surfaces of both the pars plana ans she pars plicss are Hined By te Layers of epiteliuun ~ an outer paganented layer that i cou fimuous with the retinal pigment epithelium, and an pigmented layer thar is continuous with the retina «Pig. 2-4), The two layers of the epithelium have cheir apical surfaces in apposition mi canal, The circular emule bers useles.The function of the ss from the scleral spur to the ora serrata, ‘The powerior person ULTRASTRUCTURE OF THE CILIARY PROCESSES Each ciliary proces is composed! of a central core of soma and cellars covered by s double layer af epithelium (eee Fug. 2-48).!" “The capillary endothelium is thin and has tiny fenestrae that fare toward the pigmtented ciliary epithelium. The capillary endothe= Hum is surrounded by a basearent membrane that contains mural edlls (pericytes) sine Fig. 22 Schematic view ofthe zonules ‘Separating tha vlreous cat from the posterior chamber and thes separating {he anterior and posterior chambers, AQUEOUS HUMOR DYNAMICS ‘The yatcular tue is surrounded by a thin stroma composed of grotnd substance, collagen Abrile: and océusionl wandering ™ hve supugested that systemic vara corticosteroid levels may account for the eicadian changes in 1OP.A low-dose epinephrine infusion will incresse nocturnal aqusoi secre about 27942" Using a selective Badrenergic agonist, terbutae Tine, Gharagoztow and comworkers? showed that exogenously administered S-agonits exert their: maxima effect of inereasin aasicous secretion during deep and had bitle oF mo eect daring waking hours, Since endogenous epinephrine secretion is at is ninimunn during sleep some correlation may be inferred fron the reduced nocturnal agucous formation and the status of creating {adrenergic agonist. ee huss by «a You have either reached a page thatis unavailable for viewing or reached your viewing limit for this book. «a You have either reached a page thatis unavailable for viewing or reached your viewing limit for this book. «a You have either reached a page thatis unavailable for viewing or reached your viewing limit for this book. ‘Agueous humor formation 1s, ‘tT ei an Con aes aah Sersndees Bunar-en bate [ese wt Teather ge va er Pn ng lon ata. 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Lge AIE-EnerbstrJEVA moons a te of lo the nner roe Shed dead eye ne sb at Gslahimal 292 1a Get nin ey Setacl cami Policy fon meee Ara Opt Muri owt J Besuaranr fee (Oe Nile palsy dyn to cbs ee ee Pap, Witton toe Thee Spun The tke ses beeline deveirsor hath afte fncaicneeenperinae sod micaetie ap Eye ite psn a si 1 NOV etn 6 Pee a Saag of rw endeace fe ancbestiond tne new Opes 499, 168, Hii EH Rime VE The at tow of ane Tana the taf appease ot iicligpar oid ade Morea at ‘ake mine Deck Gr syncs oan Mikes] phhdnel 3897 1 Sema Bannon fete td adi me mm, Hyestowe Amer HL uher Ai Merhoik a weve koe Ermboew ne Panterenen er Kanmenaeer ehnake Opsduabicbiss tise 1 Ande MTae MBean ea revere hres ers Eo Sphdaed S,a 2 eudel by onl Bronscrn hon) Opbtidnel Notun Mehen Opwtedenogrs NarvnsDe Opis rz 1998 gat Stow anon yma ot ee ‘ynansae were ema Ips) thane Naat 5, Mo Score ior dia In dascomubreyeite enue tine Opin 3a 1078 pve Rnios CEE Agee torus oer Shad Moutder it Canetanl ote eco cance f Oph S218, rm ne Cpanel atu KE Meter |W Brsboee The ‘ee of ely ecto escapee sad coun os Cp Vn em I ‘Cone Ble RE Tenens eae sn rig ase ps, Dplatinal sees 975 Daley eer I ourae WAL Te ee eile al aed othe ra Sons orm por Bon jer. Af Jes AH Abance OME New maths fo Foam Exp Eye Ron S08. ee Udy Mitel RK Cid etd of erring shmes a he oo her of me Grovehc hus ee Morice) eepiscomery mes Opies Ns St Shoo ra ee DS Forge Je Broker BE Eee of hams eu Eafe Re 8330 14, Nouosiiniske Ri-eaty eit ‘papi at aon Geto ma oun ee Onis 218, Nop Baler REPEC psn oa dimcre Won ean a ent Bete ho Balad We ene ‘Rene atter RP The when of Cette rei peso are Inve Opndent assert ner ice Pow nphonin ey ot serine and laste er Sptcatwane 21 eae Ser PAE Car meres Bw ried by turoptotoneny Ta phen Sec UK Tomei Mobi RP erase ees quien ov acoe fers he taal Ihen te skthenie Wy fc (phd 128 Weer EninnaeBe¥ ype Feeder dace bomewe eoe Dplabimnges 28838, 183 Weare RO Bren RE Arno ae Syumiestbasenesofpicen wth hed meme 9, wr Horner patie J Orbit 929 hate Iino Rance 19 A yng meta of Inet acento Sa ch Fates shan Exp yee 797901088, Oppel WW enureneyt ogee ub ey fos a et chaser reticence eed ber ‘ee of crn cele ra Sptahdentecrs Hever The meaner often aque ow i het Opn 13202 Tine walt twas) Opt 309%, Opinhiact set Ite Tet a al tae ei a Iprekoas tengo > (he nal were ap EYE REST tates, abu A scat [ornhononwtar, ment Opi St 138. AR “opps Meter A Es omc ected Srarstiae Sree ec opaisl vase acs, dete tage ‘nc precio pola oy Sp eric! epitiancef peasiAne Jepbindal 7313103 Linger Dic Fncrond orpoier of he Ln ep ieee eden uae perf ines mich Sg Schimae to TMMACTHo eet fac pen dad ie relecls snide efter of bert aor hme Chai? (908, rai eve shAtuence DM Avant ‘Seo the qc fore sat Soeecenc npn] Opin ester Linen: Fle af et ‘hstomsesienan te agen Aac e Hala rem J Oped 9, 8K. las ME Ck DY yf Morophosneetc eof he fi of en ier ‘edetlopagy swat hun as A Opimhtsl¥are to, Tew J rsa REA stay fhe ton teen tra ere mis Tar ow the peers neon Opindciogy eect 196 Wersth hmnkary Napa § Herter “etry ove Opt We So 2741, E80 ovr sme Espen tora thal efe oul gas afasenon ‘emda gro hare Ey ‘ates oy mens oftonextphy bal Soon Ses tne Axk Opbatlnal 347 17.188 Tihter ceric ni ate mince esuag eae cok tet eu ps alk th cery poten IU Te elect fmt ation sd eration) igumaneconh edorsid Once of Ae ciser breee ee mee a Feel Scand Sa 1 «a You have either reached a page thatis unavailable for viewing or reached your viewing limit for this book. «a You have either reached a page thatis unavailable for viewing or reached your viewing limit for this book. «a You have either reached a page thatis unavailable for viewing or reached your viewing limit for this book. coapren Aqueous humor outflow system overview 3 Fig. 3-3 (A) Schematieview ofthe system before plocarpine treatment (B) Administration af plocarpine contracts the eliary muscle, which puis the steral pur posteriorly ang nternaly opening te incertrabecsiar eytoctala the SCHLEMM'S CANAL ENDOTHELIUM/ TRABECULAR MESHWORK: A RESISTANCE UNIT Stuudies of cellular bioutechanics point to Schlemunis canal inner ‘wall cridotheliaun aud the trabecular mestwork acting as a unified PRINCIPLES OF BIOMECHANICS METHODOLOGY TO IDENTIFY TIS: RESISTANCE ‘The principles of biomecka geometry, swe composition, laboratory effets of timue loading, ba effects of tise load fry, hoster dascased pre and posable responses > reqqize, tx turn, study of tinue ulary conditions, sa, fel 261 Fiswe comparition and ge couily an dhs chapter, ceterrume cust of the tates to external forces Tinwe loading studies subject tissues wo normally encouneered ce to determine force-induced respomves. Load-bearing sera tun elements respond by characteristic changes tn configuration In other word, tastes caning: the resiwance are the anes tht ludergo configuration changes appropriate tw the loading frees they experience’? The applicable loading force in the squcous ‘velo: system JOP, Boundary censitions ctins she maxim Innit of tiwue responses to induced forces Invi date loading responses are discued in a Liter section and ape the most crucial test of the validity of eauclusions from the Inboratary =" TISSUE LOADING STUDIES Tissue loading induced! by TOP, both or etme and i ently demomtater pragrensve dite mm of Schlemm’ earl wlotlelium that correlates svith IOP increases." POON Evidence Grom these saute studies follows, ing that the TOP-induced Toad on the endothelin listribuited (0 the entire trabecular amesinwork (ee inner wall ® then Fig 3-4). “Ta induce tiaue loading, the prone gradient i systernatically raised above zero Gin in living eyes, presure abowe episecral ¥ Schlemm® inner wall Begins ss euoward distention when the pret sure graccat is a3 fow a $ mmHg" Distention of Scilenm’ canal Joner wall continues progrewively both within the physiologic pre sure cange ann! beyond, Consomitendy, inner wall intention causes the justaea OHI ay much a8 two- to three-fold. wir anchoring attachments to the distending wall of Schlemm’ canal endothehum, rabecu= Lor Limtllse move progresively outward toward Schlem' eanal huncn, thes deceloping. progtesively increased spacing henxeen Lanellse? 27295 Cyeoplasmie processes throughout the mesfinork undergo progsewive changes fom panel to a pete pendicular orientasion.”*"" The procenie. initially short and stubs undergo elongation and shinaing?"=" both in the justacanahewr and interiabecube spices. A more pronounced Jongitxlital oe tation of die sytosks tal flumsnt of the proses develops ay 1OP ‘At the celular fev, Scemm' canal endothelial ett and cyiophemic contents, a¢ ell a6 the nuclear envelope and i ogc shape in a progresive fishion from a spherical in ypatony to an elongated plate-tke comtigusa- PLAGE Ay cell process origins the cytoplasm and nucleus reorganize fiom a neutral wo an elongated cone-shaped configuration in response Justcanaicube cells wulergo 4 change in configuration iavoling the cell menbea the eytoplasen, the nucleae envelope, aid the auileat contents ll of which develop a progrestively more **" Useoscleral outflow is imereased significanaly” by prostaglandins." Prostaglandins in low dose are among the most potees. [OP-lowering. agents sail?! ‘As mentioned above, pilocarpine decreases and atropine inereases tuveoiclesl How" This is consent wit a age Bad of work, indicating that de thexapeutic effet of plosarpine in mos waucomna putients reflects increased trabecular outflow (caused by contraction ff the ary mince) 2 Some saudi have sown that pilo~ carpine anagonizes therapeutic prowaglndin agents." hu clinical expetience is mised im this area272% A fow studies indicate hae epinephrine may loner FOR, i large pact by increasing wweoxcleral fom." Cycldiayss is an operation designed to lower 1OP by ‘detaching a portion af the silary body fom the scleral spur-Thete is evidence that eyclokalysts acts to increase uveosceral ow!" rmacle, Factors that contract th METHODS FOR MEASURING FACILITY OF OUTFLOW FACILITY OF OUTFLOW CALCULATIONS The Goldmann equation can be rearranges! to give a simplified view of the factors thar determine the este with which agusnut bun or leaves the eye by couventianal outflow: F 1% -P, c G1) In this equation, © the feihey of outtlow qal/min/mmtighe F is the aqueaus humor production (l/min), Py. it the intraocular preture (JOD) int the wndisturbed eye (wily), and I, tthe «pie leral venous prewure (aumlg)-The factor referred to aC i often expressed as its reciprocal, RL, which is the resistance to outtlow Comb X mies X jl, There are three consrnon method used to aneasure Facey of buatiow ~ ranegranhhy perfusion, ail sictio exp. Iti also possible fo calculate the resstanice to ontHow From the Goldavann equation by measuring aqusows lmmor formation and IOP as discwsed iy Chapeer 2 Tonography Tomography has been the most widely aned clinical technique For measuring Facility of outilow: Although mest clinicians wo longer Lise Conography aa rooting chiical test itis appropriate (0 discuss this technique i some detail heoasse it has taght i mich about the pathophysiology of glaucoma and the meehanisiy of action of various trestment miedblities."” Ds rea for a few minutes. The weight af the ronan ng tonography, a Schiote tonometer is placed on the cor= fer mecreases [OP and also increas the outflow of aqueous humor above its normal ng, device that measures the subsequent decline of FOP over time Using che Friedenwall tables, the ange am che IOP readings allows the clinician 10 mer the ‘olume of ayuicous hun placed fromm the eye [fthe anaimption is made that the diphace— rent of Hud om the eye, AV, isthe only Factor anolved in the {611 of [OP during the test then the follow ing

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