Biology AS coursework In this report, I am going to investigate the eye disease which is known today as Glaucoma.

Glaucoma exists in multiple forms but this report will try to generalise the disease, outline what the different types have in common and observe the general trends associated with glaucoma. I personally chose to identify and describe glaucoma in this report because I have a stigmatism in one of my eyes, requiring me to wear contact lenses to restore vision to a normal level. The eye is what allows us to interact and respond to the environment around us and is a fundamental part of the bodys equilibrium which would have detrimental consequences if it were to be damaged or incur a disease or infection. 1.1 As mentioned above, glaucoma refers to a faction of various diseases but what is universal to these diseases is that they are all caused by damage to the optic nerve. The optic nerve (or cranial nerve) is one of twelve nerves which branch out from the brain transmitting information to and from the brain. The optic nerve in particular transmits images from the retina to the brain and contains in excess of a million nerve fibres. It is these fibres which make up the retina which give us sight.

Source: Medicine plus. (2009) In glaucoma, the optic nerve labelled above becomes damaged because the pressure of the eye (intraocular pressure) becomes too high for the nerve to cope with. Over a prolonged period of time, the millions of nerve fibres begin to die one by one resulting in decreased vision, however in most cases, because there are so many nerve fibres, the decrease in vision over a period of time is so small that it is left undetected and when it is detected, it is too late. If glaucoma is left untreated, it will cause loss of vision and complete blindness. To this day, glaucoma has no cure. [About.com](2009)

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Biology AS coursework

At this point the question of how does the pressure build up? still remains. The answer is quite complicated. Aqueous humor is a clear liquid which is found in the front part of the eye and vitreous humor is a clear, jelly-like substance that fills the eye behind the lens and helps the eyeball keep its shape.*What causes glaucoma?+(2004) http://www.ehealthmd.com/library/glaucoma/GLC_causes.html

Source:[What causes glaucoma?](2004) Normally, aqueous humor is formed and flows around the eye before filtering out of the eye through the eyes filtration system known as the trabescular meshwork. The trabescular meshwork is a series of minuscule pores that allow the aqueous humor to flow out of the eyeball, maintaining the optimum pressure required for a healthy eye (16 mm Hg). However, in glaucoma, there are blockages in these channels, causing aqueous humor to build up, rapidly increasing the pressure in the eye. As explained before, prolonged pressure damages and may even destroy the optic nerve. It is the damage of the optic nerve caused by increased pressure in the eye caused by the blockage of channels which is known as glaucoma. 1.2 It is important to understand that there is no cure for glaucoma; however there are surgical procedures that ease the severity of its effects. One of these surgical procedures is known as trabeculectomy. This is one of the most common surgeries performed to treat glaucoma and involves removing a section of the trabescular meshwork in order to relieve the intraocular pressure. The procedure, however is not as simple as this and the biological methods used to carry out this process require years of training and enormous skill. Due to the nature of trabeculectomy, the patient is anesthetised, then the eye is held open throughout the operation using a tool called a speculum. The conjunctiva (the clear mucous membrane that covers the white part of the eye) and the sclera (the white part of the eye) are cut open and a sort of a flap is opened. The blocked trabescular meshwork is then separated allowing the aqueous humor to once again circulate, easing pressure. The flap is then sealed and the conjunctiva is closed, completing the operation. (The Glaucomas-Glaucoma therapy)

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Biology AS coursework

Despite being the most common type of surgery performed on glaucoma, trabeculectomy is associated with a certain number of risks after surgery. These risks include: High pressure in the eye, causing the anterior chamber (the front part of the eye) to collapse. This is known as malignant glaucoma as it occurs when the pressure is too high (glaucoma) and when the anterior chamber collapses (malignant). This occurring after surgery is very rare. Exceptionally low pressure (the opposite of glaucoma) resulting in the clouding of the lens (cataract) Abrupt unexpected loss of central vision Infection of the eye. Bleeding Hazy vision

Glaucoma can be a very serious problem that affects patients that suffer from the disease. Reduced vision and blindness can have a profound impact on the life of the patient. Surgery can be the patients only hope to regain vision and if further complications occur even after surgery, then the chances of regaining vision drops substantially. Due to the complications sometimes associated with trabeculectomy, an alternative treatment known as laser assisted non-penetrating deep sclerectomy is performed. Non-penetrating deep sclerectomy will be refered to NPDS from now on. Unlike in trabeculectomy where the sclera is punctured to alleviate intraocular pressure, in NPDS, the sclera is skimmed until it is so thin that aqueous humor begins to percolate slowly out of the eye, alleviating intraocular pressure without puncturing the eye. NPDS causes significantly less complications and side effects in comparison to trabeculectomy and because it is performed manually, requires great skill and patience. Another benefit to NPDS is that it is self terminating, meaning that unlike in trabeculectomy where the sclera must be stitched back into position causing scarring, in NDPS, the sclera regenerates. 1.3 A recent study in Pakistan was conducted to observe the effectiveness of trabeculectomy by monitoring and analysing changes in intraocular pressure after 3 months of having a trabeculectomy procedure. The number of patients that underwent trabeculectomy was 44 and the number of trabeculectomies performed was 50. The intraocular pressure before the operation ranged from 1260 mm Hg, (about 16 mm Hg being normal). Out of the 50 trabeculectomies, 46 were successes resulting in a 92% success rate. The intraocular pressure was measured 1, 15, 30 and 90 days after the operation and the results are presented in the table and illustrated in the graph on the next page. Department of Opthalmology, Lady Reading Hospital, Peshawar.

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Biology AS coursework

Since the aim of trabeculectomy is to relieve intraocular pressure by removing the trabescular meshwork and surrounding structures, it can be said that the solution is effective to address the problem (glaucoma). Before the operation, the intraocular pressures ranged between 12-60mm Hg mercury. The normal intraocular pressure is about 16 mm Hg and from the trabeculectomy, the pressure was brought down to an average of 10.7mm Hg. This lower pressure of 10.7 mm Hg of mercury was present after 3 months of the surgery and showed signs that the pores in the trabescular meshwork are no longer blocked and that the aqueous humor is now circulating normally. Trabeculectomy has an edge over the old drainage procedures due to the fact that although complications do occur trabeculectomy is associated with a smaller chance of post operational complications like a shallow anterior chamber, infections and drainage failure than most other operations with the same goal. Trabeculectomy is a better option than medical treatment in many cases as it is a safe procedure and effective in over 90% of the cases.

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Biology AS coursework In June of 2010, a study similar to the one in Pakistan was conducted in Greece, this time using non penetrating deep sclerectomy to treat glaucoma instead of trabeculectomy. In this study, 33 patients underwent NDPS with a total of 37 sclerectomies being performed. The intraocular pressure in the eye before the operation was an average of 24.48 mm Hg of mercury and the pressures were observed over a much wider time period than the study in Pakistan. Here, the intraocular pressures was measured immediately a day after NDPS, 7 days after NDPS, 1,3,6,12,18,36 and 42 months after NDPS. This observation provides a detailed insight into the effectiveness of NDPS due to the prolonged time over which it was observed. Department of ophthalmology, Medical school, University of Ionnina, Greece A graph illustrating these values,

The total successes were 35/37 with a success rate of 94.6 %. Only 2 procedures resulted in complete failure (5.4%). Post operative mean intraocular pressure was 17.46 m Hg which is lower in comparison to pre-operational pressure which was 24.48 mm Hg. Non penetrating deep sclerectomy continues to be performed worldwide as an alternative to classic trabeculectomy due to minimal surgical intervention being required, quick recovery time and the absence of a scar that would normally be present from treatment with trabesculectomy. Nonpenetrating deep sclerectomy is a modern and very effective type of glaucoma surgery that successfully relieves intraocular pressure to a more moderate pressure than other surgeries. The surgery allows patients to sustain a healthy pressure in the eye and therefore a suitable level of vision, minimising the detrimental effects of glaucoma.

2.1

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Biology AS coursework Glaucoma has been nicknamed the silent thief of sight and is one of the largest causes of blindness worldwide with an estimated of 6 million people blind from the disease. Glaucoma has caused devastation to societies, especially in the developing world where regular and thorough eye examinations do not take place. Where poverty is already a major cause to social deprivation, glaucoma can steal the only thing people in third world have left and render them vulnerable to a calamity of new problems. In order to prevent glaucoma, frequent eye tests need to be conducted by a fully trained optometrist and once a patient has been diagnosed with the disease then they must prepare for complicated surgery which may cost thousands of pounds. Even in the UK, where an efficient health service like the NHS prevails, the cost can be overwhelming. It is important to note that there is no cure for glaucoma, only treatments to reduce the effects so even if surgery is successful, the patient will have to invest in medicines, physician visits and vision rehabilitation costs. 2.2 One problem of glaucoma is that it is incurable, surgery can only halt the process of deterioration of sight but sometimes glaucoma is never diagnosed because symptoms never persist. In the developing world, the majority of blindness caused by glaucoma are in the rural areas while the surgical service delivery network is concentrated in the urban areas. Thus a large proportion of patients in the rural areas continue to remain blind. This situation has many social implications. There is loss of productivity, collapse of interpersonal relationships and communicational skills, depressive mood, lack of self respect and a large number of sufferers lead a secluded embarrassing life. Patients lack information on the available services and continue to remain blind for years even after being diagnosed as operable. This is unfortunate because most operated patients, irrespective of the surgical technique, are immensely satisfied with the level of visual rehabilitation after surgery. One positive to emerge from the high cases of blindness caused by glaucoma is that there is increased awareness. For example, the world health organisation (WHO) created a programme for prevention of blindness and created a blindness data bank in 1978. In 1993, work was undertaken in collaboration with the world bank to measure the global burden caused by blindness. They concluded that glaucoma is the third largest contributor to blindness and responsible for 15% of blindnesss worldwide. Journal of TNOA, glaucoma in developing countries. This resulted in an increase in donations to these countries which are desperately in need of money to fund for treatments because their economy is in decline. Increased awareness even catches the attention of western government organisations which can contribute massively. This has caused a slight decrease in occurrences of glaucoma lead blindness although it still occurs in massive numbers. It is necessary for a glaucoma sufferer to retain the intraocular pressure in their eye post surgery and there is a large outlay associated with this. Firstly the cost of surgery which may rise to thousands of pounds and even more if complications occur post surgery, then there is a need for medication. Beta blockers, glaucoma eye drops and prostaglandins are just some of the medications glaucoma sufferers are expected to use on a regular basis. This medication only maintains the (mostly poor) vision a patient has after surgery. In the current economic climate, patients have less money than ever to cope with the effects and challenges that glaucoma imposes on society.

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Biology AS coursework Despite the fact that glaucoma costs the National Health Service (NHS) billions of bounds every year, positive implications still exist. Large numbers of patients pay for surgery and there is a high demand for medicinal and other treatments for the disease. This increases the circulation of money in that particular segment of the economy and results in affordability of advanced equipment and technology which keeps the hospitals and health centres of the UK up to date with state of the art facilities for efficient diagnosis and treatment. It is easier than ever for patients to receive treatment and advice on how to cope with the disease because of the readily available amenities which countries like the UK take for granted. Developing countries lack these amenities and this causes increased incidence of uncontrollable glaucoma. The NHS Health Technology Assessment programme is currently funding a project evaluating cost effectiveness of screening for glaucoma in the United Kingdom. This is a timely task that will inform policy making as to whether population screening could be effective in reducing glaucoma blindness. Department of ophthalmology, Grampian unit, University of Aberdeen, UK 2.3 In section 1.2, relatively old surgical methods were described and explained. New medical advances have lead to an evolution in surgical procedures and a new form of process to tackle glaucoma. One of these includes laser surgery. In laser surgery, an argon laser beam is aimed and concentrated at the trabescular meshwork which stimulates and encourages the opening of the pores within the trabescular meshwork to allow secretion of aqueous humor. This particular method is known as Argon Laser Trabeculoplasty or ALT. This is an example of a non penetrative surgery because the eye is not penetrated during the operation unlike in trabesculectomy. In this procedure, a low frequency laser beam is concentrated on the whole of the trabescular meshwork and is less effective than a new variation of the procedure. Selective Laser Trasbeculoplasty or SLT is a newer version trabeculoplasty which uses a beam that is cold (non thermal) which stimulates the seepage of the trabescular meshwork. The advantage to this procedure over ALT is that the laser beam is of a much higher frequency which can selectively aim at the part of the trabescular meshwork which causes secretion of aqueous humor (the melanin pigment in the trabescular meshwork cell). Due to the fact that in ALT whole trabescular meshwork is exposed, the operation can only be repeated once, whereas SLT may be repeated three to four times. Laser surgery, Wikipedia.

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Biology AS coursework 3.2 About.com, 2010. What Is Glaucoma? [online] Available at: http://vision.about.com/od/eyediseases/p/Glaucoma.htm [Accessed 7 December 2010] A, Azuara-Blanco. J, Burr.,2006. The rising cost of glaucoma drugs, 90,(2), p 130-131. EHealth MD, 2004. What causes Glaucoma? [online] Available at: http://www.ehealthmd.com/library/glaucoma/GLC_causes.html [Accessed 7 December 2010] Hanan, F. Shah, Mir Ali. Javaid, M. Mohammad,Shah., 2007. Effectivness of trabeculectomy in glaucoma, 21,(5), p.209-211. Kitsos, G. Aspiotis, M. Alamanos, Y. Psilas, K., 2010. Results of a modified non-penetrating deep sclerectomy in the treatment of open angle glaucoma with or without cataract, 4, p 695-701. Laser surgery, 2010. Glaucoma [online] Available at: http://en.wikipedia.org/wiki/Glaucoma#Surgery [Accessed 15 December 2010] Medline Plus, 2009. Image Of Retina. [online] Available at: http://www.nlm.nih.gov/medlineplus/ency/imagepages/9695.htm [Accessed 7 December 2010] N.N Sood. M, Burmi.,1996. Magnitude of glaucoma blindness in developing countries, 34, (4), p 1115. Robert, R. Bruce, S. and Theodore, K. 1996. The Glaucomas-Glaucoma therapy. (Second edition). St. Louis, Mosby: N Engl J Med.

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