GLAUCOM

A
Dr Jusuf Wijaya , SpM
(Glaukomatoloog)
I.P. Mata FK - UKI
Curriculum Vitae
1994 : Dokter Umum , Vrije Universiteit
Brussel (Belgia)
1999 : Dokter Spesialis Mata , Vrije
Universiteit Brussel (Belgia)
2001 : Fellow Ilmu Bedah , Foundation Eye
Care Himalaya (Belanda Nepal)
2002 : Fellow di bidang Glaukoma ,
Rotterdam Eye Hospital (Belanda)
2004 : Adaptasi (penyesuaian) , Universitas
Sam Ratulangi (Manado)
Glaucoma
= Optic Neuropathy with :
1. characteristic appearances of the optic
disc and
2. specific pattern of visual field defects

3. associated frequently but not invariably

with raised IOP
Glaucoma
Aqueous Production
Aqueous humor is actively secreted (Na+/K+-
ATPase pump dependant) by the non-
pigmented epithelium of the ciliary processes ,
which secretes Na+ ions into the posterior
chamber (water follows passively along the
osmotic gradient)
Passive secretion plays a minimal role in the
genesis of aqueous humor.
 Glaucoma
Aqueous Production
Independent of the level of Intraocular Pressure
(IOP)
Diminished by :
- Hypoxia
- Hypothermia
- Drugs (-blockers, -mimetics, CAI)
- Cyclodestructive procedures (cyclocryotherapy
& laser ablation)
- Ciliary body shutdown (ciliary body detachment,
inflammation of the ciliary body)
 Glaucoma
Aqueous (Out)flow
posterior chamber pupil anterior chamber
> Trabecular (conventional) route (90%) :
trabeculum Schlemm canal episcleral veins
> Uveoscleral (unconventional) route (10%) :
ciliary body & iris suprachoroidal space
venous circulation in the ciliary body, choroid &
sclera
Glaucoma
Glaucoma
Glaucoma
= Optic Neuropathy with :
1. characteristic appearances of the optic
disc and
2. specific pattern of visual field defects

3. associated frequently but not invariably

with raised IOP
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
OCT (Optical Coherence Tomography)
Provides high resolution cross-section
imaging of the retina using light
Longitudinal / axial resolution of 10
microns
Measures NFL (Nerve Fiber Layer)
thickness
Glaucoma
HRT (Heidelberg Retinal Tomograph)
Provides three-dimensional images of the
optic nerve head using confocal
ophthalmoscopy ; multiple optical slices
are taken of the retina by the laser
scanner, and built into a three-
dimensional image by the use of
appropriate computer software
Glaucoma
= Optic Neuropathy with :
1. characteristic appearances of the optic
disc and
2. specific pattern of visual field defects

3. associated frequently but not invariably

with raised IOP
Glaucoma
The visual field may be described as an
island of vision surrounded by a sea of
darkness
The outer aspect of the visual field extends:
50 superiorly, 60 nasally, 70 inferiorly
and 90 temporally
Visual acuity is sharpest at the very top of
the hill (the fovea)
A scotoma : an area of visual loss
surrounded by vision
Glaucoma
Visual field could be evaluated by perimetry
Two types of perimetry :
1. Kinetic perimetry ; involves the
presentation of a moving stimulus from a
non-seeing area to a seeing area until it
is perceived
2. Static perimetry ; involves the
presentation of non-moving stimulus of
varying intensity in the same position to
obtain a vertical boundary of the visual
field
Glaucoma
= Optic Neuropathy with :
1. characteristic appearances of the optic
disc and
2. specific pattern of visual field defects

3. associated frequently but not invariably

with raised IOP
Glaucoma
Tonometry is the objective measurement of
IOP
Different types of tonometers :
- Goldmann tonometer !
- Schiotz tonometer
- Air-puff tonometer
- Pulsair (Keeler) tonometer
Glaucoma
Gonioscopy
involves the examination and analysis of the
anterior chamber angle (the angle
between the posterior corneal surface
and the anterior surface of the iris)
Glaucoma therapy
1. Medication
2. Laser treatment
3. Surgical treatment
4. Artificial drainage devices
5. Cyclodestructive procedures
Glaucoma therapy
Medication
1. Beta-blockers
2. Alpha-2 agonists
3. Prostaglandine analogues
4. Miotics
5. Carbonic anhydrase inhibitors
6. Hyperosmotic agents
Glaucoma therapy
1. Beta-blockers
Reduce IOP by decreasing aqueous secretion
e.g. : Timolol (Timoptol)
Betaxolol (Betoptic)
Levobunolol (Betagan)
Carteolol (Teoptic)
Glaucoma therapy
Beta-blockers
Ocular side effects :
Allergy, reduced tear secretion, corneal erosions
Systemic side effects :
Bradycardia and hypotension
Bronchospasm
Depression
Decreased libido
Glaucoma therapy
2. Alpha-2 agonists
Decrease IOP by both decreasing aqueous
secretion and enhancing uveocleral outflow
e.g. : Brimonidine (Alphagan)
Apraclonidine (Iopidine)
Glaucoma therapy
3. Prostaglandine analogues
Reduce IOP by enhancing uveocleral outflow
e.g. : Latanoprost (Xalatan)
Travoprost (Travatan)
Bimatoprost (Lumigan)
Unoprostone isopropyl (Rescula)
Glaucoma therapy
4. Miotics
Parasympathomimetic drugs that act by
stimulating muscarinic receptors in the
sphincter pupillae and ciliary body
e.g. : Pilocarpine 1%, 2% & 4%
Glaucoma therapy
5. Carbonic anhydrase inhibitors
Topical preparations
Dorzolamide (Trusopt)
Brinzolamide (Azopt)
Systemic preparation
Acetazolamide (Diamox)
Glaucoma therapy
6. Hyperosmotic agents
Lower IOP by creating an osmotic gradient
between blood and vitreous so that water is
drawn out from the vitreous
e.g. : Glycerol
Isosorbide
Mannitol