Case Report

MANAGEMENT OF JUVENILE GLAUCOMA

WITH TRABECULECTOMY
Zahratul Riadho*

Consultant:
Dr. dr. Hj. Fidalia, Sp.M(K)

OPHTHALMOLOGY DEPARTMENT OF SRIWIJAYA UNIVERSITY

MOH. HOESIN HOSPITAL PALEMBANG
2018
INTRODUCTION

Juvenile
Glaucoma

A rare juvenile- A rare form of

onset open-angle developmental
It occurs
glaucoma (JOAG) glaucoma
3 - 35 years old

A progressive bilateral neuropathy optic

that may lead to blindness
 Juvenile incidence is only about 0.02% of people
Glaucoma with glaucoma in the world

Clinical
Inherited as Linkage of
features
an the gene on
same as in
autosomal chromosom
Primary
dominant 1 (band
Open-Angle
trait 1q21-q1)
Glaucoma
 Treatment options for Juvenile Glaucoma

Medications

Surgery

Glaucoma Drainage Device

Treatment with medication alone usually is

not enough to control IOP
PURPOSE

AIM
To Report a Case of Juvenile Glaucoma Treated with
Trabeculectomy + 5 fluorouracil
CASE
REPORT
CASE REPORT

Identification
Ms. A, 20 yo, Outside town
Came to RSMH at August 16th, 2018

Chief Complaint
Pain on the right eye since one month ago
ANAMNESIS
1 Years Ago
Both vision were blurred and
Visual field were decreased
Headache (+), Intermitent pain on the eye(+),
Red Eye (-), Watery eye (-), Secrete (-), Cloudy
vision (-), Nausea (-)

Went to Ophthalmologist  Got eyedrops and

medicines (Timol®, Azopt®, Acetazolamide
tablet, KSR tablet) and also glasses receipt.
She didn’t use eyedrops and medicine regularly
and didn’t control routinely.
ANAMNESIS

6 Months Ago

Visual field became more decreased,

intermittent pain on the eye (+), headache (+).
Went to Opthalmologist again and was planned
for operation

After left eye operation was done,

She didn’t control again
ANAMNESIS

1 Month Ago

Pain on the Right eye (+) disturb her daily

activity, visual field became more decreased,
red eye (-), headache (-), nausea (-)

Went to ophthalmologist in RSUD Prabumulih

and then referred to RSMH for Operation
ANAMNESIS

Past History
• History in Family with same disease (-)
• History of Trauma (-)
• History of Eye surgery (+)
• History of Wearing glasses (+)
OD : Spheris - 3,00
OS : Spheris - 3,00
• History of Long term eyedrop usage (-)
• History of Long term medication (-)
• History of Hypertension (-)
• History of Diabetes Mellitus (-)
PHYSICAL EXAMINATION

Vital Sign
 Sensorium : Compos Mentis
 Blood pressure : 110/70 mmHg
 Pulse : 82 x/minute
 Respiratory rate : 20x/minute
 Temperature: 36,8o C
 Ophthalmology Status

Right Eye Left Eye

VA 6/60 ph 6/30 6/60 ph 6/21
BCVA S- 3,00 : 6/21 BCVA S- 3,00 : 6/12
IOP 44,4 mmHg 18,7 mmHg
(3 medication) (2 medication)
Eyeball position Orthoforia
Eyeball movement Good to all gaze Good to all gaze
pain (-) pain (-)
Eyelid Normal Normal
Conjunctiva Normal Normal
Cornea Clear Clear
 Ophthalmology Status
Right Eye Left Eye
Anterior Medium depth, VH gr.4 Medium depth, VH gr.4
Chamber
Iris Good appearance Iridectomy at 12 o’clock
Pupil Round, central, Ø 3 mm, Round, central, Ø 5 mm,
LR (+) LR (+)
Lens Clear Clear
Fundus Reflex (+) (+)
Papil Round, normal disc margin, Round, normal disc margin,
red color, c/d: 0.7, a/v: 2/3 red color, c/d: 0.9, a/v: 2/3
macula Nasalization (+) nasalization (+)
Retina
Foveal reflect (+) normal Foveal reflect (+) normal

Normal vascular contour Normal vascular contour

 Ophthalmology Status

Right Eye Left Eye

 Gonioscope

Right Eye Left Eye

Right Eye I S N T Left Eye I S N T
Schwalbe’s line + + + + Schwalbe’s line + + + +
Trabecular meshwork + + + + Trabecular meshwork + + + +
Scleral spur + + + + Scleral spur + + + +
Peripheral Iris + + + + Peripheral Iris + + + +
Pigmentation - - - - Pigmentation - - - -
PAS - - - - PAS - - - -
Neovascularization - - - - Neovascularization - - - -
DIAGNOSIS

Working Diagnosis

Juvenile Glaucoma ODS

OD : IOP wasn’t controlled with Eye
drops and Medication
OS : Post trabeculectomy OS
IOP wasn’t controlled with Eye
drops and Medication
Simple Myopia ODS
TREATMENT

Informed consent
Brinzolamide ED every 8 hour OD
Timolol 0,5 % ED every 12 hour ODS
Acetazolamide 250 mg every 12 hour
Kalium tab every 24 hour
Pro Fundus Photograph
Pro OCT ODS
Pro Humphrey
Pro Rontgen thorax and Laboratory
 Fundus Photograph

Right Eye Left Eye

Round, normal disc margin, Round, normal disc margin,

Papil Papil
red color, c/d: 0.7, a/v: 2/3 red color, c/d: 0.9, a/v: 2/3
Nasalization (+) nasalization (+)

Macula Foveal reflect (+) normal Macula Foveal reflect (+) normal

Retina Normal vascular contour Retina Normal vascular contour

 HUMPREY

Interpretation : Tunnel Vision

OPTICAL COHERENCE TOMOGRAPHY

OCT RNFL
Interpretation :

(OD)
Thinning of RNFL in
superior and inferior
quadrant

(OS)
Thinning of RNFL almost
in all quadrant
 OCT (OPTIC DISC)

(OD) VCDR 0.7 (C/D ratio > 0.7) (OS) VCDR 0.9 (C/D ratio > 0.7)
FOLLOW UP (24 August 2018)
Right Eye Left Eye

VA 6/60 ph 6/30 6/60 ph 6/21

BCVA S- 3,00 : 6/21 BCVA S- 3,00 : 6/9
IOP 31,6 mmHg 14,3 mmHg
(4 medication) (3 medication)
Eyeball position Ortophoria
Eyeball movement Good to all gaze Good to all gaze
pain (-) pain (-)
Eyelid Normal Normal
Conjunctiva Normal Normal
 Right Eye Left Eye
Cornea Clear Clear

Anterior Chamber Medium depth, VH gr.4 Medium depth, VH gr.4

Iris Good appearance Iridectomy at 12 o’clock
Pupil Round, central, Ø 3 mm, LR (+) Round, central, Ø 5 mm, LR (+)

Lens Clear Clear

Fundus Reflex (+) (+)
Papil Round, normal disc margin, red Round, normal disc margin, red
color, c/d: 0.7, a/v: 2/3 color, c/d: 0.79 a/v: 2/3
Nasalization (+) nasalization (+)
macula Foveal reflect (+) normal Foveal reflect (+) normal

Normal vascular contour Normal vascular contour

Retina
 Working Diagnosis
Juvenile Glaucoma ODS
OD : IOP wasn’t controlled with Eye
drops and Medication
OS : Post trabeculectomy OS
IOP wasn’t controlled with Eye
drops and Medication
Myopia ODS

Treatment
Informed consent
Pro Trabeculectomy + 5 FU OD
with local anesthesia
Brinzolamide ED every 8 hour RLE
Timolol 0,5 % ED every 12 hour RE
Acetazolamide 250 mg every 12 hour
Potassium tab every 24 hour
Operation report of trabeculectomy OD :
1. Patient in supine position and awake
2. Aseptic dan antiseptic procedure with povidone iodine 10%
3. Operation field narrowed with eyedrape
4. Local anaesthesia – subconjunctival injection using lidocaine HCl 2%
5. Peritomy was done in limbus at 11 o’clock till 1 o’clock
6. Partial scleral thickness incision at 12 o’clock rectangular shape 3x4 mm
7. Incission was widened till anterior chamber, continue with sclerostomy using
puncture
8. Peripheral iridectomy was done at 12’o clock
9. 5-fluorouracyl applied near scleral area below conjunctiva within 3 minutes
10. Scleral flap was sutured with Nylon 10.0 adjustable suture method
11. Conjunctival was sutured with Vicryl 8.0 interrupted method
12. Subconjuntival injection of dexamethasone 1 ml + gentamycin 1 ml
13. Chloramphenicol eye ointment was applied on the right eye
14. Eye was closed with sterile patch
15. Operation was done
FOLLOW UP
FOLLOW UP (25 August 2018)
Right Eye Left Eye

VA 6/60 ph (-) 6/60 ph 6/21

BCVA S- 3,00 : 6/12
IOP N+1 13,1 mmHg
(3 medication)
Eyeball position Ortophoiria
Eyeball movement Good to all gaze Good to all gaze
pain (-) pain (-)
Eyelid Normal Normal
Conjunctiva Subconjunctival bleeding Normal
at 11 o’clock
 FOLLOW UP (25 August 2018)
Right Eye Left Eye
Cornea Clear Clear

Anterior Chamber Medium depth, VH gr.4 Medium depth, VH gr.4

Iris Iridectomy at 11 o’clock Iridectomy at 12 o’clock
Pupil Round, central, Ø 6 mm, LR (+) Round, central, Ø 5 mm, LR (+)
RAPD (+)
Lens Clear Clear
Fundus Reflex (+) (+)
Papil Round, normal disc margin, red Round, normal disc margin, red
color, c/d: 0.7, a/v: 2/3 color, c/d: 0.9, a/v: 2/3
Nasalization (+) nasalization (+)
macula Foveal reflect (+) normal Foveal reflect (+) normal

Normal vascular contour Normal vascular contour

Retina
FOLLOW UP (25 August 2018)

Diagnosis Juvenile Glaucoma ODS

OD : Post Trabeculectomy with 5-FU day 1
OS : Post trabeculectomy controlled with
Eye drops and Medication
Myopia ODS
Management • Tobramycin dexamethasone ED ODS
every 3 hours
• Timolol 0,5 % ED ODS every 12 hours
• Cefixime 100 mg every 12 hours
• Mefenamic acid 500mg every 8 hours
• Acetazolamide 250mg every 12 hours
• KSR every 24 hours
FOLLOW UP (26 August 2018)
Right Eye Left Eye

VA 6/60 ph (-) 6/60 ph 6/21

BCVA S- 3,00 : 6/12
IOP N+0 14,5 mmHg
(3 medication)
Eyeball position ortophoria
Eyeball movement Good to all gaze Good to all gaze
pain (-) pain (-)
Eyelid Normal Normal
Conjunctiva Subconjunctival bleeding Normal
at 11 o’clock decreaas
 FOLLOW UP (26 August 2018)
Right Eye Left Eye
Cornea Clear Clear

Anterior Chamber Medium depth, VH gr.4 Medium depth, VH gr.4

Iris Iridectomy at 11 o’clock Iridectomy at 12 o’clock
Pupil Round, central, Ø 6 mm, LR (+) Round, central, Ø 5 mm, LR (+)
RAPD (+)
Lens Clear Clear
Fundus Reflex (+) (+)
Papil Round, normal disc margin, red Round, normal disc margin, red
color, c/d: 0.9, a/v: 2/3 color, c/d: 0.7, a/v: 2/3
Nasalization (+) nasalization (+)
macula Foveal reflect (+) normal Foveal reflect (+) normal

Normal vascular contour Normal vascular contour

Retina
FOLLOW UP (26 August 2018)

Diagnosis Juvenile Glaucoma ODS

OD : Post Trabeculectomy with 5-FU day 2
OS : Post trabeculectomy controlled with
Eye drops and Medication
Simple Myoia ODS
Management • Tobramycin dexamethasone ED ODS
every 3 hours
• Timolol 0,5 % ED ODS every 12 hours
• Cefixime 100 mg every 12 hours
• Mefenamic acid 500mg every 8 hours
• Acetazolamide 250mg every 12 hours
• KSR every 24 hours
• Outpatient, control 1 week
DISCUSSION
 Female, 20 Years Old
CC : Pain on the right eye

Anamnesis Ophthalmology Exam

• Visual field Loss • High IOP OD
• Pain of the Eye • VH gr.4 ODS
• Headache • Glaucomatous Optic
• Myopia Neuropathy ODS

Auxiliary Exam
• Gonioscope ODS – Wide Angle
• Humphrey ODS – Tunnel Vision
• OCT ODS – Thinning of RNFL

“Juvenile Glaucoma”
 Working Diagnosis

Juvenile Glaucoma ODS

OD : Post Trabeculectomy with 5-FU
OS : Post trabeculectomy controlled with
Eye drops and Medication
Simple Myopia ODS

Surgical Procedure for This Case

Trabeculectomy + 5 Fluorouracil
 Medication
Management of
Surgery
Juvenile Glaucoma
Glaucoma Drainage Device

Trabeculectomy is a surgical procedure in glaucoma

to reduce IOP which involves creating a channel
through the sclera so that aqueous humor can be excreted

Antimetabolit/antifibrotic agent such as 5-fluorouracil

are used to inhibit wound healing to prevent
conjunctival scarring down on the sclera
Glaucoma Drainage Device (GDD) is the best choice for
juvenile glaucoma because the success rate in controlling IOP
for a long term but Trabeculectomy with antifibrotic agent
also is a good choice because the result is usually favorable
 Prognosis

Vitam : Bonam
Functionam :
Right Eye : Dubia ad Malam
Left Eye : Dubia ad malam

Still good Visual acuity but glaucomatous cupping

disc, tunnel vision visual field won’t returned

Patient advised to have control every month to evaluate

visual acuity, intraocular pressure, and progression of
visual field defects
CONCLUSION

A rare Juvenile-onset of Open Angle Glaucoma (JOAG)

A progressive bilateral neuropathy optic that may lead

to blindness if not well treated

Apropriate treatment and good follow-up will help the

patients to maintain their quality of vision

THANK YOU
Aquaeous Humour Drainage
Trabecular Meshwork
Trabecular Meshwork
Aquaeous Humour Drainage
Retinal Layer
Peripapillary Region & ONH
Visual Pathway
 Glaucoma

Glaucoma is an optic
neuropathy with
characteristic appearance of
the optic disc and specific
pattern of visual field
defects
That is associated frequently
but not invariably with
raised IOP
 Glaucoma
Progression
 Glaucoma
Progression
 Classification of glaucoma

Open angle glaucoma Angle-closure glaucoma childhood

glaucoma

PACG with
POAG Primary
pupillary block
congenital/infantile
glaucoma
NTG Acute angle closure

Glaucoma associated
Juvenile open angle with congenital
glaucoma subacute angle closure anomalies

Glaaucoma suspect CACG

Secondary glaucoma
Secondary angle closure In children
Secondary open angle
glaucoma with/without
glaucoma
pupillary block
 Congenital Glaucoma

• Congenital glaucoma is a rare form of glaucoma

• Affected infants may be born with a high intraocular

pressure or may develop an increased IOP within the “first
weeks of life".

• Both eyes are usually involved, but to varying severity

• Boys are affected slightly more frequently than girls.

 Congenital Glaucoma

EPIPHORA CORNEAL EDEMA

HAAB’S STRIAE HIGH IRIS INSERTION

ON GONIOSCOPY
 Infantile
Glaucoma
• Infantile glaucoma is also congenital glaucoma
• However, intraocular pressure starts to rise at some
time during the first years of life.
• The cause for this IOP increase is basically the same
as in congenital glaucoma, but it occurs later since
the anterior chamber angle is more mature than
when glaucoma is present at birth.
• The IOP may be normal during the first years of
childhood and then gradually increase.
 Juvenile Glaucoma
 A rare juvenile-onset open-angle glaucoma (JOAG)
 A rare form of developmental glaucoma
 It occurs > 3 y.o - < 40 y.o

• Most cases of Juvenile Glaucoma are inherited as an

autosomal dominant trait.

• Juvenile glaucoma incidence is estimated at only about

0.02% of the number of people with glaucoma

• Juvenile glaucoma probably occurs males = females

 There is a linkage of the gene for juvenile
glaucoma on chromosome 1 (band 1q21-q1)

 This gene, now called myocilin, codes for the

glycoprotein myocilin that is found in the
trabecular meshwork and other ocular tissues.

Clinical features of juvenile glaucoma same as in

primary open-angle glaucoma
OAG Pathophysiology
Goldman Applanation
Tonometry
Goniosco
py
Shaffer’s Grading System
 Gonioscopy
Grading
• Grade 4 (35-45o) is the widest angle, characteristic of myopia and
aphakia, in which the ciliary body can be visualize with ease.
• Grade 3 (25-35o) is an open angle in which at least the scleral spur
can be identified.
• Grade 2 (20o) is a moderately narrow angle in which only the
trabeculum can be identified.
• Grade 1 (10o) ia a very narrow angle in which only Schwalbe line,
and perhaps also the top of the trabeculum, can be identified.
• Grade 0 (0o) is a closed angle due to iridocorneal contact and is
recognized by the inability to identify the apex of the corneal
wedge.
Funduscopy
Funduscopy
N. Opticus yang glaucomatous:
 Pucat
 Ekscavatio
 Cup Disc ratio membesar >0.6
 Nasal displacement pembuluh darah
 Bayonet sign
Funduscopy
Funduscopy
Funduscopy
Funduscopy
Funduscopy
Funduscopy
Funduscopy
Perimetry
Normal Visual Field – Automated
Perimetry
83
84
85
OCT in Glaucoma
OCT in Glaucoma
OCT in Glaucoma
OCT in Glaucoma
OCT-A in Glaucoma
 OCT-A
Discriminant
Treatment Modalities in glaucoma
• Medical
• Laser
• Surgery – Trabeculectomy
Combined surgery
 PRINSIP TERAPI
• Tekanan intra okuler diturunkan dengan obat obatan
secara bertahap berupa :
• Timolol 0,25% -0,50% dua kali sehari
• Bila dengan obat pertama TIO yang diharapkan belum
tercapai dapat ditambah dengan obat lain , maksimal
sampai 3 macam obat tetes.
• Apabila tekanan lebih dari 30 mmhg dapat diberikan terapi
sistemik dengan carbonik anhidrase inhibitor dengan dosis
125 mg 4x sehari , harus disertai pemberian obat preparat
kalium.

• Bila dengan terapi medikamentosa belum memberikan

hasil yang memuaskan sebaiknya dipertimbangkan untuk
terapi bedah.
 Beta Blockers
• Β blockers
• Decreases IOP by decreasing aqueous secretion
• Contra indications:
• Congestive cardiac failure
• Heart block
• Bradycardia
• Bronchial asthma
Ocular Systemic

Side allergy Bradycardia, Hypotention

effect SPK’s Broncho spasm
s tear secretion Hallucination, head ache
nausea, dizziness
 Alpha 2 Agonists

• Brimonidine, apraclonidine
• Mechanism:
• Decreases aqueous secretion
• Increases uveo scleral outflow
• Side Effects:
• Allergic conjunctivitis
• Xerostomia
• Drowsiness and headache
 PROSTAGLANDIN ANALOGUES
• Mechanism
• Decreases IOP by increasing uveoscleral outflow
• Latanoprost F2 α analogue.005%
• Travoprost 0.004%
• Bimatorpost 0.3%
• Unoprostone 0.15% BD

• Conjunctival hypereamia
Side • Eye lash growth and hyperpigmentation of
effec periorbital skin
ts • Anterior uveitis
• Cystoid macular edema
 MIOTICS

• Pilocarpine 1% 2% 3% 4% QID
• Parasympathomimetic stimulates muscarinic
receptors in sphincter pupillae & ciliary body
• In POAG – increases aqueous outflow
• In PACG – opens the angles

• Miosis
Side • Browache
effec
ts • Myopic shift
• Visual field defect
 Carbonic Anhydrase Inhibitors
• Inhibits aqueous secretion target menurunkan 15-20%
• Topical CAI
• Dorzolamide (Trusopt)
• Brinzolamide (Azopt)
• Systemic CAI
• Acetazolamide 250mg BD

• Parasthesia
Side • Malaise
effec
ts • GI upset
• Renal Stone
 Hyper Osmotic Agents
• Glycerol 1g / kg in 50% solution
• Mannitol 1-2g/kg in 20% solution
• Side Effects:
• Cardiac or renal failure
• Urinary retention
• Head ache, nausea
Laser Trabeculoplasty
Glaucoma Surgery
• Trabeculectomy:
• Conventional filtering procedure creates a new channel
for aqueous outflow between the anterior chamber
and subtenons space without the use of an artificial
device
• Partial thickness
• Full thickness
Trabeculectomy
Trabeculectomy Procedure
 Antimetabolite in Filtering Surgery
Antimetabolites are usually used during
trabeculectomy surgery to prevent bleb failure due to
scarring by the wound healing process.

The most commonly used antimetabolites are 5-

fluorouracil (5-FU) or mitomycin C (MMC).

5-Fluorouracil is a pyrimidine analogue which blocks

DNA synthesis.

MMC is a DNA cross-linker which inhibits fibroblast

proliferation.
This can be applied to the surgical site by soaking a surgical sponge and
placing it onto the scleral surgical site prior to creation of the ostomy,
before or after creation of a scleral flap.

5-FU can be injected into the subconjunctival space intraoperatively or in

the early postoperative period.
5-FU acts in several ways, but principally as a thymidylate
synthase (TS) inhibitor.

Interrupting the action of this enzyme blocks synthesis of the

pyrimidine thymidine, which is a nucleoside required for DN
replication.

Thymidylate synthase methylates deoxyuridine monophosphate

(dUMP) to form thymidine monophosphate (dTMP).

5-fluorouracil (5-FU)

Administration of 5-FU
causes a scarcity in dTMP, so
tissue rapidly undergo cell
death via thymineless death.
Complication of Filtering Surgery
 Failing bleb
SIGNS
• Injection
• Vascularisation
• Thickening
• Localization
• High domed Bleb
• Normal / High IOP
• Low IOP

Initial few weeks critical

 Failing filter – High IOP
Low localized Bleb
External - Subconjunctival fibrosis
- Tight scleral flap sutures
Internal - Sclerectomy obstruction
 Failing filter – High IOP
High domed bleb – encapsulated bleb or Tenon’s cyst
 Failing filter - Low IOP
Elevated diffuse bleb
Low bleb - Bleb leak
Over Filtration hypotony
 Bleb
Failure
• Argon laser suturolysis
0.2sec 50µ 500-700mw
• Digital massage
• Topical steroids
• 5FU injection
• DF Nd yag laser
• Needling of tenons cyst
Internal Filtration Surgery
Glaucoma Drainage Device
 Preoperative Considerations
Patient Selection
Glaucoma drainage devices are typically reserved for patients
with severe uncontrolled glaucoma who have failed previous
glaucoma surgery.

In addition, the devices appear to be advantageous as a primary

procedure in patients with a high likelihood of trabeculectomy
failure, including neovascular and uveitic glaucomas.
Clinical Examination
Careful preoperative examination and planning are essential for
successful surgical outcomes.

Clinicians should assess mobility of the conjunctiva to determine

the best quadrant for drainage implant insertion.
Selection of Glaucoma Drainage Device
For a beginning surgeon, valved devices may be preferred as the surgical
technique is simpler with localization to one quadrant without manipulation
of the adjacent rectus muscles. IOP control in the early postoperative period is
more predictable with these devices because of flow-restricting mechanisms.

In patients with poor compliance with postoperative medication use and

follow-up visits, valved implants may be preferred because they usually
require less postoperative follow-up and care.

Anesthetic Considerations
The choice of anesthesia for inserting a glaucoma drainage device depends on
the presence of other medical co-morbidities, the cooperation level of the
patient, and the comfort of the surgeon.

The most commonly used anesthesia is a peribulbar or retrobulbar block

A sub-Tenon injection is also a good alternative.

Site of Implantation
With the exception of the two-plate implants, most glaucoma implants are
placed in a single quadrant. Whenever possible, single-plate implants should
be placed in the supero-temporal quadrant. This area provides the easiest
access for the surgeon to implant the plate and is least likely to produce
motility disturbances.

Postoperative
Glaucoma drainage Course
devices can be associated with various postoperative complications.
Following
The glaucoma complications
early postoperative drainage implant
are similarsurgery, the patient
to other filtration is seen
procedures on
including
postoperativeflatday
chambers,
1, and hypotony,
attentionand suprachoroidal
is paid to the tubehemorrhage
position[ and wound
architecture.

A topical antibiotic and steroid are started four times daily and continued for 4
to 6 weeks. Initial follow-up is at 1 week, and the frequency of visits depends
on the clinical status of the eye. For valved implants, preoperative glaucoma
medications are discontinued to prevent hypotony. For nonvalved implants,
the glaucoma medications are usually continued until a fibrous capsule forms
around the plate.
 PROGNOSIS
• Prognosis baik jika ditemukan pada stadium dini.
• TIO terkontrol secara adekuat oleh obat atau
tindakan bedah
• Kepatuhan pasien untuk kontrol TIO dan kepatuhan
memakai obat
• Penemuan kasus glaukoma pada keluarga .