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Glaucoma
Introduction
 Glaucoma refers to the Optic Nerve damage caused by a significant rise in Intraocular Pressure
 Raised intraocular pressure is caused by a blockage in Aqueous Humour trying to escape the eye
 Glaucoma is the 2nd leading cause of blindness in the world and can be classified into two main types:

o Open-Angle Glaucoma (~70%) o Closed-Angle Glaucoma

 Glaucoma frequently presents asymptomatically and may be identified on routine ophthalmic examination
o Intraocular pressure is most often elevated, however may be normal in some cases
 Optic Disc Cupping is Dx of Glaucoma  Irreversible Peripheral Vision Loss & Central Vision Loss (if
untreated)

Basic Anatomy & Physiology

 Vitreous Chamber Filled with Vitreous Humour
 Anterior Chamber [Cornea (Anterior Chamber) Iris] Both filled with Aqueous Humour
 Posterior Chamber [Lens (Posterior Chamber) Iris] providing nutrients to the cornea
 Ciliary Body produces aqueous humour which flows around the iris to the anterior chamber
o Drains via the Trabecular Meshwork (TBM) at the angle between Cornea & Iris  Canal of Schlemm
 From the canal of Schlemm it eventually enters the general circulation
 Normal Intraocular Pressure (10-21 mmHg) is generated by resistance to flow through the TBM

Open-Angle Glaucoma (OAG)

Aetiology
 A Neurodegenerative Process wherein Retinal Ganglion Cells (RGCs) slowly degenerate
 A number of genetic factors have been identified in OAG, for example:
o GLC1A Locus Mutation  Adult & Juvenile-Onset OAG
o Myocilin Mutations  Primary OAG

Pathophysiology
 The exact pathophysiology is unknown however the following is observed:
o ↑IOP  Faster RGC Degeneration
o Lamina Cribrosa Deformation/Stress
o RGC Axoplasmic Flow Compression
 Clinically, obstruction of fluid outflow via the TBM or Uveoscleral Outflow Routes is not seen, however:
o ↑Pressure Δ Across TBM: Stresses/deforms Lamina Cribrosa & RGCs  eventual destruction
o ↑IOP: RGC Axon Compression  Impaired Axonal Transport  RGC Apoptosis 2o ↓Trophic Factors
o Ischaemia: 2o to impaired retinal blood flow may contribute to cell death and eventual blindness

Optic Disc Cupping

 ↑IOP  ↑Cup-to-Disc Ratio & Loss of Peripheral Vision (assessed by Automated Visual Field Testing)
 In the centre of a normal Optic Disc is a small indent (Optic Cup), typically < ½ the size of the optic disc
o In ↑IOP, this indent becomes larger as the IOP puts pressure on that indent making it wider &
deeper
 AKA Optic Disc “Cupping” whereby an optic cup >0.5 the size of the optic disc is abnormal
 As cupping develops, disc vessels are displaced nasally  Nasal & Superior VF Loss then Temporal VF Loss
o As damage progresses, the disc pales (atrophies)
 Glaucomatous optic nerve damage affects the Anterior Visual Pathway up to the Optic Chiasm

OAG Risk Factors

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 Increasing Age  Ethnicity (Black)
 Family History of OAG  Myopia (Near-Sightedness)

OAG Presentation
 ↑IOP often Asymptomatic (long time) and Dx by routine optometry screening
 Peripheral Vision affected first which gradually closes  Tunnel Vision. OAG presents with gradual onset of:

o Fluctuating Pain o Blurred Vision

o Headaches o Halos around Lights (esp. at night)

Non-Contact Tonometry
 Most common machine for estimating IOP by opticians (less accurate but good for general screening)
 Involves shooting a puff of air shot at the cornea to measure the corneal response to it

Goldmann Applanation Tonometry

 Gold Standard IOP measurement where device mounted on a Slip Lamp in Contact with the Cornea
o Applies different pressures to the front of the cornea to get accurate IOP measurement

OAG Diagnosis
 Goldmann Applanation Tonometry: IOP Measurement
 Gonioscopy: Peripheral Ant. Chamber Configuration & Depth Assessment
 US Pachymetry: Central Corneal Thickness Measurement
 Slit-Lamp Fundoscopy: Optic Disc Cupping & Optic Nerve Health Assessment
 Visual Field Assessment: Peripheral Vision Loss Assessment

OAG Management Principles

 Aim to reduce IOP (Note: IOP control does stop visual field loss however does not reverse it)
 Start treatment when IOP >24 mmHg with close patient follow-up to assess response to treatment

Medical Management
 Prostaglandin Analogues: Rx Latanoprost Eyedrops
o ↑Uveoscleral Outflow
o Eyelash Growth
o Eyelid/Iris Pigmentation
 Beta Blockers: Rx Timolol Eyedrops
o ↓Aqueous Humour Production
o Cautionary Use in Asthma & HF
o Dry Eyes
o Corneal Anaesthesia
o ↓Exercise Tolerance
 Carbonic Anhydrase Inhibitors: Rx Dorzolamide Eyedrops
o ↓Aqueous Humour Production
 Alpha Adrenergic Agonists: Rx Brimonidine Eyedrops
o ↓Aqueous Fluid Production
o ↑Uveoscleral Outflow
 Miotics: Rx Pilocarpine Eyedrops
o ↑Uveoscleral Outflow
o Miosis
o ↓Acuity
o Brow Ache 2o to Ciliary Muscle Spasm
 Sympathomimetics: Rx Dipivefrine Eyedrops
o Cautionary use in Heart Disease, HTn & CAG
 Fixed-Dose Combination Drops: Rx Dorzolamide + Timolol
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Surgical Management: Trabeculectomy
 Channel created from the anterior chamber through the sclera to a location under the conjunctiva
o Aqueous humour drains through a bleb under the conjunctiva & reabsorbed into circulation

Acute Closed-Angle Glaucoma (ACG)

 Ophthalmologic Emergency requiring urgent treatment to prevent permanent loss of vision
 ACG is a group of diseases in which closure of the anterior-chamber angle (↑IOP) is either:
o Reversible (Appositional)
o Adhesional (Synechial)
 ACG occurs when the Iris bulges forward (Pupillary Block), sealing off the TBM from the anterior chamber
o Contact/Apposition of the Iris & Lens at pupillary margin ↑ resistance to flow of aqueous humour
 Preventing aqueous humour from being able to drain away  Sudden ↑IOP (>30 mmHg)
 IOP ↑ in the posterior chamber causing ↑ pressure behind the Iris
o With further worsening of the closure of the angle
 ↑IOP in CAG causes the pupil to become fixed and dilated with
subsequent axonal death

Primary Angle-Closure
 Occurs in patients with an anatomical predisposition

Secondary Angle-Closure
 Arises from pathological processes e.g., traumatic haemorrhage
pushing the posterior chamber forwards