Glaucoma

Fitratul Ilahi
Head of Glaucoma Division
Ophthalmology Department
Andalas University /
Dr M Djamil Hospital
Glaucoma
Glaucoma is a significant public health problem
The second leading cause of blindness worlwide , following cataract
WHO: in 2002 were 4.4 million (12.3% of people blind worldwide).
majority of glaucoma cases were undiagnosed
Pathophysiology of glaucoma
The mechanical theory

The Ischemic theory

 Depth
Angle
Schwalbe Line
Meshwork

Ciliary body band

 Pen Torch Method
Van Herricks Technique (VH 0-4 )
Gonioscopy
Ultrasound Biomicroscopy ( UBM)
Anterior Segment Optical Coherence
Tomography (AS- OCT )
Van Herick Method
Glaucoma results
from an abnormality
of the resistance
characteristics of the
outflow system
Trabecular
meshwork
 Trabecular Outflow

Uveoscleral Outflow
Glaucoma essentials examination
Visual Acuity
Vision should be tested (undilated), unaided, and with best correction
at distance and near. Central vision may be affected in advanced glaucoma.
Refractive Error
The refractive error will help to understand the risk of open angle glaucoma (myopia) or closed
angle glaucoma (hyperopia). Neutralizing the error is important to assessing visual acuity and visual
fields.
Pupils
Pupils should be tested for reactivity and afferent pupillary defect. An afferent defect may signal
asymmetric moderate to advanced glaucoma.
Lids/Sclera/ Conjunctiva
Evidence of inflammation, redness, ocular surface disease, or local pathology may point to
uncontrolled IOP due to acute or chronic angle closure, or possible glaucoma drug allergy, or other
disease.
Cornea
The cornea should be examined for edema, which may be seen in acute or chronic high IOP. Note
that IOP readings are underestimated in the presence of corneal edema. Corneal precipitates may
indicate inflammation.
 Corneal Thickness
The thickness of the cornea is measured to help interpret IOP readings. Thick
corneas tend to overestimate the IOP reading, and thin corneas tend to
underestimate the reading.
Intraocular Pressure
IOP should be measured in each eye before gonioscopy and before dilation.
Recording the time of IOP measurement is recommended to account for diurnal
variation.
Anterior Segment
The anterior segment should be examined in the undilated state and after dilation
(if the angle is open). Look for anterior chamber shallowing and peripheral depth,
pseudoexfoliation, pigment dispersion, inflammation and neovascularization, or
other causes of glaucoma.
Goldmann Applanation ; Gold
Standard
Normal IOP : < 21 mmhg
The most accuracy of IOP
measurement
Other Tonometry : Schiotz ,
Tonopen, Non Contact Tonometry
/air-puff
 Disc
Cup
Neuro retinal rim
Pembuluh darah
excavatio
Nasal displacement
Atropi peripapil

Glaucomatous Optic Neuropathy

Normal
ONH Deformation in glaucoma
Glaucomatous
Optic Disc
 The optic nerve should be evaluated for characteristic signs of
glaucoma. The degree of optic nerve damage helps to guide initial
treatment goals.
Early optic nerve damage may include a cup 0.5, focal retinal
nerve fiber layer defects, focal rim thinning, vertical cupping,
cup/disc asymmetry, focal excavation, disc hemorrhage, and
departure from the ISNT rule (rim thickest inferiorly, then superiorly,
nasally and temporally).
Moderate to advanced optic nerve damage may include a large cup
0.7, diffuse retinal nerve fiber defects, diffuse rim thinning, optic
nerve excavation, and disc hemorrhage.
 Gonioscopic
Technique :
Direct gonioscopic
use goniolens;Koeppe,Barkan,
Wurst, Swan-Jacob
Indirect gonioscopic
use goniolens; Goldmann,
Posner,Sussman,Zeiss 4mirror
Anterior Chamber Structures :
SCLERAL SPUR
This is the most anterior projection of the sclera and the site of attachment of the
longitudinal muscle of the ciliary body. Gonioscopically, the scleral spur is situated
just poste- rior to the trabeculum and appears as a narrow dense, often shiny,
whitish band. It is the most important landmark because it has a relatively
consistent appearance in different eyes.
TRABECULAR MESHWORK
This extends from the scleral spur to Schwalbe line. The posterior functional
pigmented part lies adjacent to the scleral spur and has a grayish-blue translucent
appear- ance. The anterior non-function part lies adjacent to Schwalbe line and has a
whitish color. Trabecular pigmen- tation is rare prior to puberty. In aging eyes it
involves the posterior trabeculum to a variable extent, especially inferi- orly.
Trabecular pigmentation is more marked in brown eyes.
SCHWALBE LINE
This is the most anterior structure and appears as an opaque line. Anatomically it
represents the peripheral termination of Descemet membrane and the anterior limit
of the trabeculum. In normal eyes it often can be seen in the limbal circumference as
 Perimetry
Identification visual field
deffect
Quantitative assessment of
normal or Abnormal field
Humphrey Field Analysis
Perimetry is Automated static
perimetry and gold Standard
2-3 X / year
To evaluate glaucoma
progression and management
Classification of glaucoma
Primary Glaucoma

Primary Angle Primary Open

Closure Glaucoma Angle Glaucoma
(PACG) (POAG)

Acute Angle Chronic Angle

Chronic
Closure Glaucoma Closure Glaucoma
Chronic Angle Closure Glaucoma
Lack of
symptoms

Characteristic Pupillary block is

visual field loss relatively small

Narrow angle and trabecular

meshwork inhibited only a
Progressive small portion
glaucomatous optic
nerve damage

Increased IOP,
often several years
Anterior peripheral
synechiae (PAS)
The goals of glaucoma therapy
Surgical