GLAUKOMA

Agustian Deny
I11109090

Definition
Glaukoma

merupakan kelainan mata dimana terjadi

peningkatan TIO yang dapat membahayakan nervus
optikus.Glaucoma is a disorder in which increased
intraocular pressure damages the optic nerve. This
eventually leads to blindness in the affected eye.
Primary glaucoma glaucoma that is not caused by
other ocular disorders.
Secondary glaucoma another ocular disorder or an
undesired side effect of medication or other therapy.

Epidemiology
Worldwide, glaucoma is the leading cause of irreversible

blindness.
In fact, as many as 6 million individuals are blind in both
eyes from this disease.
In the United States alone, according to one estimate,
over 3 million people have glaucoma.

Physiology and pathophysiology of aqueous humor

circulation
The average normal intraocular pressure of 15mm Hg in

adults is significantly higher than the average tissue

pressure in almost every other organ in the body.
Such a high pressure is important for the optical imaging
and helps to ensure several things:
Uniformly smooth curvature of the surface of the cornea.
Constant distance between the cornea, lens, and retina.
Uniform alignment of the photoreceptors of the retina and the

pigmented epithelium on Bruchs membrane, which is normally

taut and smooth.

Movement of fluid in the eye

 The aqueous humor is formed by the ciliary processes

and secreted into the posterior chamber of the eye

At a rate of about 26 l perminute and a total anterior
and posterior chamber volume of about 0.20.4ml, about
12% of the aqueous humor is replaced each minute.

Classification
Glaucoma Primary (unknown etiology)
Closed angle glaucoma
Acute congestive glaucoma
Glaucoma Secondary (caused by another diseases)
Abnormality lens
Abnormality uvea
Trauma
Surgery
And the other
Glaucoma congenital
Glaucoma Absolute

Primary open angel glaucoma

EXAMINATION
METHODS

Oblique Illumination of the Anterior Chamber

The anterior chamber is illuminated by a beam of light

tangential to the plane of the iris. In eyes with an

anterior chamber of normal depth, the iris is uniformly
illuminated. This is a sign of a deep anterior chamber
with an open angle (see Fig. 1.12).
In eyes with a shallow anterior chamber and an angle
that is partially or completely closed, the iris protrudes
anteriorly and is not uniformly illuminated (see Fig.
1.12).

Slit-Lamp Examination
The central and peripheral depth of the anterior chamber

should be evaluated on the basis of the thickness of the

cornea.
An anterior chamber that is less than three times as deep
as the thickness of the cornea in the center with a
peripheral depth less than the thickness of the cornea
suggests a narrow angle.

Gonioscopy
Gonioscopy can differentiate the following conditions:
Open angle: open angle glaucoma.
Occluded angle: angle closure glaucoma.
Angle access is narrowed: configuration with imminent risk angle
of an acute closure glaucoma.
Angle is occluded: secondary angle closure glaucoma, for
example due to neovascularization in rubeosis iridis.
Angle open but with inflammatory cellular deposits, erythrocytes,
or pigment in the trabecular meshwork: secondary open angle
glaucoma.

Measuring Intraocular Pressure

Palpation
If the examiner can indent

the eyeball, which

fluctuates under
palpation, pressure is less
than 20 mmHg.
An eyeball that is not
resilient but rock hard is a
sign of about 6070
mmHg of pressure (acute
angle closure glaucoma).

Schitz indentation tonometry

The lower the intraocular pressure, the deeper the tonometer pin

sinks and the greater distance the needle moves.

Applanation tonometry
most common method of

measuring intraocular
pressure
A flat tonometer tip has a
diameter of 3.06 mm for
applanation of the
cornea over a
corresponding area
(7.35 mm2).
This method eliminates
the rigidity of the sclera
as a source of error

Pneumatic non-contact tonometry

The tonometer records the deflection of the cornea and

calculates the intraocular pressure on the basis of this

deformation.

Measuring the twenty-four-hour pressure curve

to analyze fluctuations

of the pressure level

over a 24-hour period
in patients with
suspected glaucoma
Pressure is measured
on the ward at 6:00
a.m., noon, 6:00 p.m.,
9:00 p.m., and
midnight.

Tonometric self-examination
The patient tonometer makes it possible to obtain a 24-hour

pressure curve from any number of measurements obtained

under normal everyday conditions
using the device requires a certain degree of skill on the part
of the patient.
Patients who have problems applying eyedrops are best
advised not to attempt to use a patient tonometer.
Younger and well motivated patients are the best candidates
for tonometric self-examination.

Optic Disk Ophthalmoscopy

In the presence of persistently elevated intraocular

pressure, the optic cup becomes enlarged and can be

evaluated by ophthalmoscopy
The optic nerve is the eyes glaucoma memory.
Evaluating this structure will tell the examiner whether
damage from glaucoma is present and how far advanced
it is.

 Optic disk measurement. The area of the optic disk, optic

cup, and neuroretinal rim (vital optic disk tissue) can be

measured by planimetry on two-dimensional photographs
of the optic nerve.
Optic disk tomography. Modern laser scanning
ophthalmoscopes permit three-dimensional
documentation of the optic nerve.

Glaucomatous changes in the optic nerve

Glaucoma produces typical changes in the shape of the

optic cup.
Progressive destruction of nerve fibers, fibrous and
vascular tissue, and glial tissue will be observable.
This tissue atrophy leads to an increase in the size of the
optic cup and to pale discoloration of the optic disk (Fig.
10.10)

Visual Field Testing

Detecting glaucoma as early as possible requires

documenting glaucomatous visual field defects at the

earliest possible stage
Glaucomatous visual field defects initially manifest
themselves in the superior paracentral nasal visual field
or, less frequently, in the inferior field, as relative
scotomas that later progress to absolute scotomas (Fig.
10.11a d).

 Computerized static perimetry (measurement of the

sensitivity to differences in light) is superior to any kinetic

method in detecting these early glaucomatous visual field
defects.
Computer-controlled semiautomatic grid perimetry
devices such as the Octopus or Humphrey field analyzer
are used to examine the central 30 degree field of vision
(modern campimetry; Fig. 10.12).

Examination of the Retinal Nerve Fiber Layer

The retinal nerve fibers have a

characteristic arrangement,
which explains the typical
visual field defects that occur
in primary open angle
glaucoma.
In addition to the early
progressive optic nerve and
visual field defects, arcshaped
defects also occur in the nerve
fiber layer. These defects may
be observed in light with red
components (Fig. 10.13).

TREATMENT OF
GLAUCOMA

Primary Open Angle Glaucoma

Primary open angle glaucoma begins in middle-aged and

elderly patients with minimal symptoms that progressively

worsen.
The angle of the anterior chamber characteristically
remains open throughout the clinical course of the
disorder.
The most type of glaucoma, and accounts for over 90%.

 Etiology : not known, although it is known that drainage of

the aqueous humor is impeded.

Symptoms :
The majority of patients do not experience any subjective

symptoms for years

headache, burning sensation , or blurred or decreased vision that
the patient may attribute to lack of eyeglasses or insufficient
correction.
perceive rings of color around light sources at night and

 Diagnostic

Diagnostic considerations
Measurement of intraocular pressure Elevated

intraocular pressure is an alarming sign

Twenty-four-hour pressure curve Fluctuations in
intraocular pressure of over 56 mmHg may occur over a
24-hour period.
Gonioscopy The angle of the anterior chamber is open
and appears as normal as the angle in patients without
glaucoma

 Ophthalmoscopy Where the optic disk and visual field

are normal, ophthalmoscopic examination of the posterior

pole under green light may reveal fascicular nerve fiber
defects as early abnormal findings.

Differential diagnosis
Ocular hypertension
Patients with ocular hypertension have significantly
increased intraocular pressure over a period of years
without signs of glaucomatous optic nerve damage or
visual field defects.
Some patients in this group will continue to have elevated
intraocular pressure but will not develop glaucomatous
lesions; the others will develop primary open angle
glaucoma.

 The probability that a patient will develop definitive

glaucoma increases the higher the intraocular pressure,

the younger the patient, and the more compelling the
evidence of a history of glaucoma in the family.

Low-tension glaucoma
Patients with low-tension glaucoma exhibit typical
progressive glaucomatous changes in the optic disk and
visual field without elevated intraocular pressure.
These patients are very difficult to treat because
management cannot focus on the control of intraocular
pressure.

 Often these patients will have a history of hemodynamic

crises such as gastrointestinal or uterine bleeding with

significant loss of blood, low blood pressure, and
peripheral vascular spasms (cold hands and feet).
Patients with glaucoma may also experience further
worsening of the visual field due to a drop in blood
pressure.

Treatment
Indications for initiating treatment
Glaucomatous changes in the optic cup: Medical treatment should
be initiated where there are signs of glaucomatous changes in the
optic cup or where there is a difference of more than 20% between
the optic cups of the two eyes.
Any intraocular pressure exceeding 30 mmHg should be treated.

 Increasing glaucomatous changes in the optic cup or increasing

visual field defects: Regardless of the pressure measured, these

changes show that the current pressure level is too high for the
optic nerve and that additional medical therapy is indicated. This
also applies to patients with advanced glaucomatous damage and
threshold pressure levels (around 22mm Hg). The strongest
possible medications are indicated in these cases to lower
pressure as much as possible (1012mm Hg).

 Early stages: It is often difficult to determine whether therapy is

indicated in the early stages, especially where intraocular pressure

is elevated slightly above threshold values.

 Patients with suspected glaucoma and risk factors such

as a family history of the disorder, middle myopia,

glaucoma in the other eye, or differences between the
optic cup in the two eyes should be monitored closely.
Follow-up examinations should be performed three to four
times a year, especially for patients not undergoing
treatment.

Medical therapy
Available options in medical treatment of glaucoma :
Inhibit aqueous humor production.
Increase trabecular outflow.
Increase uveoscleral outflow.
Medical therapy is the treatment of choice for primary

open angle glaucoma.

Surgery is indicated only where medical therapy fails.