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 Intra Ocular Pressure.
Vitreous Humor Flow
 Open Angle Glaucoma
■ Open angle glaucoma can be classified as a primary open angle glaucoma (POAG) and
secondary open angle glaucoma (SOAG).
■ Primary when it is not related to another underlying condition. Secondary glaucoma results
from another ocular or systemic disease, trauma, or the use of certain drugs.
Primary Open Angle Glaucoma (POAG)
■ POAG is a chronic, progressive disease that most often presents with characteristic
optic nerve (ON) damage, retinal nerve fiber layer (NFL) defects, and subsequent
visual field (VF) loss.
■ The etiology of glaucoma has been described as mechanical or vascular.
■ The mechanical process involves compression of the axons due to elevated IOP.
■ The vascular process includes events in which reduced blood flow to the posterior
pole leads to damage.
Secondary Open Angle Glaucoma
(SOAG)
■ The cause of secondary OAG can be any of a variety of substances that mechanically
block the outflow of aqueous through the trabecular meshwork, resulting in elevated
IOP.
■ Secondary OAG can also result from alterations in the structure and function of the
trabecular meshwork, due to insults such as trauma, inflammation, and ischemia.
Pathophysiology of POAG & SOAG
Idiopathic, alteration in Retinal nerve
the structure and fiber layer
function of the (NFL) defects
trabecular meshwork.

Acceleration and Elevated

exaggeration of normal Resistance within the Intra Compression
aging changes in the trabecular meshwork Ocular of the axons
anterior chamble angle, Pressure
iris and ciliary body
tissues of the eye.

Subsequent
Damage
visual field (VF)
Risk factors Optic Nerve
loss
SOAG & POAG Risk Factors
■ General :
Age, Race, Family history
■ Ocular:
Elevated or asymmetric levels of IOP, Diffuse or focal enlargement of cup portion of
optic nerve, Diffuse or focal narrowing of neuro- retinal rim, Asymmetry of cup-to-disc
ratios >0.2, Myopia, Central corneal thickness Visual field status (pattern standard
deviation)
■ Non-ocular:
Diabetes mellitus, Vasospasm, Perfusion pressure ratio.
Angle Closure Glaucoma (ACG)
■ Angle-closure glaucoma (ACG) is a group of diseases in which there is reversible
(appositional) or adhesional (synechial) closure of the anterior-chamber angle. The
angle closure may occur in an acute or chronic form.
■ In the acute form, the IOP rises rapidly as a result of relatively sudden blockage of
the trabecular meshwork by the iris via papillary block mechanism.
■ The chronic form may develop after acute angle closure where synechial closure of
the angle persists, or it may develop over time as the angle closes from prolonged or
repeated contact between the peripheral iris and the TM, which often leads to
peripheral anterior synechiae (PAS) and functional damage to the angle.
Aetiology of ACG

1. Thick cataractous lens (phacomorphic glaucoma);

2. Ectopic lens (eg, in settings of trauma, as well as Marfan’s or
Weill-Marchesani syndrome);
3. Neovascularization of the angle secondary to diabetic
retinopathy or ocular ischemia; and tumors.
 Pathophysiology of ACG

■ Angle closure occurs when the peripheral iris is in contact with the
trabecular meshwork (TM), either intermittently (appositional
closure) or permanently (synechial closure).
Pathophysiology of ACG
■ Specific mechanisms leading to angle closure can be divided into 2 categories:

1. Mechanisms that push the iris from behind. The most common reason is relative
pupillary block, but other reasons include plateau iris syndrome, enlarged or anteriorly
displaced lens, and malignant glaucoma.

2. Mechanisms that pull the iris into contact with the TM. Examples include contraction of
inflammatory membrane as in uveitis, fibrovascular tissue as in iris neovascularization,
or corneal endothelium as in iridocorneal endothelial syndrome.
Pathophysiology of ACG
■ Chronic intermittent friction between the iris and the TM can lead to progressive dysfunction
of the TM. With time, adhesions (synechiae) form between the iris and parts of the TM.

1. Eventually the TM is so dysfunctional or obstructed that aqueous outflow from the eye is
impaired and IOP rises.

2. Prolonged elevation of IOP leads anatomically to glaucomatous changes in the optic nerve
head and loss of optic nerve axons and functionally to progressive loss of the visual field.

3. If untreated this process may progress to complete blindness.

 Glaukoma Kongenital

Glaukoma kongenital terjadi pada anak yang

mengalami perkembangan abnormal pada
anterior chamber angles yang mengakibatkan
terganggunya drainase cairan pada mata
sehingga terjadi penigkatan tekanan intraokular.
 Glaukoma Kongenital
Glaukoma Kongenital Primer

• Kelainan perkembangan yang terbatas pada sudut COA

Anomali Perkembangan Segmen Anterior

• Sindrom Axenfeld-Reiger
• Anomali Peters
• Keduanya disertai kelainan perkembangan iris dan kornea

Berbagai Kelainan Lain

• Aniridia
• Sindrom Sturege-Weber
• neurofibromatosis
Glaukoma Kongenital
 GLAUKOMA SEKUNDER

Glaukoma Pigmentasi
• Disebabkan oleh degenerasi epitel
pigmen iris dan korpus siliaris.
• Pigmen mengendap di permukaan
kornea posterior (Krukenberg
Spindle) dan tersangkut di jaringan
trabekular, mengganggu aliran
keluar aqueous humor.
 Sindrom Eksfoliasi
(Glaukoma Pseudoeksfoliasi)

Dijumpai endapan bahan berserat

mirip serpihan di permukaan lensa
anterior, prosesus siliaris, zonula,
permukaan posterior iris, dan
jaringan trabekula
 Glaukoma Akibat Tekanan Lensa
• Terjadi akibat trauma atau spontan (sindrom Marfan)
Dislokasi • Dislokasi anterior  sumbatan pada bukaan pupil 
Lensa iris bombe dan penutupan sudut

• Lensa yang menyerap cukup banyak air sewaktu

Intumesensi mengalami perubahan katarak, sehingga ukuran
Lensa membesar

• Katarak stadium lanjut mengalami kebocoran kapsul

Glaukoma lensa anterior  protein lensa mencair masuk COA
Fakolitik  jalinan trabekula edema dan tersumbat 
peningkatan TIO mendadak
Glaukoma Akibat Tekanan Lensa
Dislokasi Lensa
• Terjadi akibat trauma atau spontan (sindrom Marfan)
• Dislokasi anterior  sumbatan pada bukaan pupil iris
bombe dan penutupan sudut

Intumesensi Lensa
• Lensa yang menyerap cukup banyak air sewaktu mengalami
perubahan katarak, sehingga ukuran membesar
Glaukoma Fakolitik
• Katarak stadium lanjut mengalami kebocoran kapsul lensa
anterior  protein lensa mencair masuk COA jalinan
trabekula edema dan tersumbat peningkatan TIO
mendadak
Glaukoma Akibat Kelainan Traktus Uvealis

• Jalinan trabekular dapat tersumbat oleh

Uveitis sel-sel radang dari COA disertai edema
sekunder

• Melanoma traktus uvealis dapat

menimbulkan glaukoma akibat pergeseran
Tumor korpus siliaris ke anterior  penutupan
sudut sekunder

• Beberapa kelainan yang ditandai dengan

endotelium kornea yang abnormal yang
Sindrom menyebabkan derajat variabel atrofi iris,
Iridokorneoendotel galukoma sudut tertutup sekunder, dan
edema kornea.
 Uveitis

Uveal Melanoma
 Glaukoma Akibat Glaukoma
Trauma Neovaskularisasi
• Cedera kontusio bola mata • Paling sering disebabkan
dapat disertai peningkatan oleh iskemi retina yang luas,
TIO akibat perdarahan ke seperti yang terjadi pada
COA (hifema)  darah retinopati diabetik stadium
bebas menyumbat jalinan lanjut dan oklusi vena
trabekular yang mengalami sentralis retina iskemik.
edema akibat cedera.
PEMERIKSAAN
GLAUKOMA
 Pemeriksaan Papil Saraf Optik
■ Oftalmoskopi  pemeriksaan saraf mata apakah mengalami degenerasi atau atrofi serta
melihat penggaungan (cupping) papil.

TANDA  Pinggir papil temporal menipis

ATROFI PAPIL
 Ekskavasi melebar
Papil warna pucat  Diameter vertical lebih besar
TANDA
daripada diameter horizontal
Batas tepi tegas PENGGAUNGAN
 Pembuluh darah seolah
Lamina kribosa menggantung di pinggir dan
tampak jelas terdorong kearah nasal
Tonometri ( Pengukuran Tekanan Bola
Mata)
■ Tonometri aplanasi goldmann

– Cara kerja: pemantulan sinar yang dikeluarkan oleh bagian optoelektronik

kemudian akan dimonitor dan waktu yang dibutuhkan untuk penerimaan sinar yang
terbanyak akan dikonversi menjadi TIO
 Gonioskopi
■ Untuk memeriksa saluran pembuangan yaitu dengan memeriksa sudut iridokornea dengan
menggunakan lensa kontak khusus.

■ Dapat membedakan glaucoma sudut terbuka atau tertutup serta adanya perlekatan iris
bagian perifer, abnormalitas sudut dan adanya benda asing.

Gonioskopi indirek/tidak
Gonioskopi direk/langsung
langsung menggunakan
menggunakan lensa yang
cermin untuk memantulkan
membelokkan sinar
sinar
 Pemeriksaan Lapang Pandang
■ PERIMETRI

– Perimetri kinetic  menggunakan target yang bergerak dari perifer ke sentral

– Perimetri static  menggunakan target yang tidak bergerak tetapi dapat diatur kecerahan
dan durasi target tersebut

Perimetri kinetic Perimetri static

Memeriksa satu titik pada retina

Dengan menggerakkan objek
menggunakan objek yang
suprathreshold dimulai dari daerah
intensitasnya dapat diatur sedemikian
tidak terlihat kearah sentral, rupa mulai dari subthreshold
kemudian ditentukan titik dimana sehingga akhirnya didapatkan
objek tersebut pertama kali terlihat. threshold dari titik tersebut.
TATA LAKSANA
GLAUKOMA
TATA LAKSANA

Incisional
Medikamentosa Laser Surgery
Surgery
 1.TERAPI
MEDIKAMENTOSA
2. LASER SURGERY
Laser Iridotomy
Purpose : • To relieve pupillary block, equalize pressure differential between the
anterior and posterior chambers, and open the anterior chamber angle.

Indication : • This procedure is the first choice therapy in primary or secondary angle-
closure glaucoma due to pupillary block.
Laser Trabeculoplasty
Purpose : • The trabecular meshwork is irradiated with a laser in order to improve
aqueous outflow.

Indication : •Primary open-angle glaucoma, exfoliation glaucoma, pigmentary glaucoma,

primary angle-closure glaucoma following laser iridotomy, mixed glaucoma, etc.
Laser Gonioplasty (Laser Peripheral Iridoplasty)

Purpose :
• To contract the periphery of the iris by laser thermal
effect in order to open the anterior chamber angle.

Indication :
•Plateau iris glaucoma, cases where laser iridotomy
cannot be carried out due to corneal opacity in angle-
closure due to pupillary block, cases of primary open-
angle glaucoma with a narrow angle approach as a
preparation step to laser trabeculoplasty, or in eyes
following goniosynechiolysis in order to prevent
postoperative recurrence of synechia.
Cyclophotocoagulation

Purpose : •The cyclodestruction with a laser in order to suppress aqueous

production and thereby reduce IOP.

Indication : •Indicated when other glaucoma surgery such as filtering surgery

has failed, or feasible.
Laser Suture Lysis

Purpose : •To enhance filtration following trabeculectomy

Indication :
•Cases in which aqueous filtration via the scler-al flap following
trabeculectomy is insufficient and it is assessed that filtration will
not become excessive
3. INCISONAL SURGERY
Incisional Surgery

Aqueous outflow
Surgery to
Filtrating pathway Cyclodestructive
relieve pupillary
Surgery reconstruction surgery
block
surgery
A. Filtrating Surgery

Full-thickness filtrating surgery

• In this surgery, rather than preparing a scleral flap, a direct aqueous outflow pathway from the anterior
chamber is created underneath the conjunctiva.

Nonpenetrating trabeculectomy
• In this technique, a portion of the tissue is incised underneath the scleral flap to form an aqueous
outflow pathway without penetration of the anterior chamber.

Implantation surgery
• In this procedure, an aqueous outflow path- way is created between the anterior chamber and the
outside of the eye using a special implant.
Filtrating Surgery
Trabeculectomy

•A surgical procedure that lower IOP by creating a fistula, which allow aqueous outflow
from the anterior chamber to the sub-Tenon space. The fistula is protected or “guarded”
by a superficial scleral flap.
•The most common type of glaucoma surgery.
B. Aqueous Outflow Pathway Reconstruction Surgery
Trabeculotomy

•In this procedure, a trabeculotome is

inserted into Schlemm's canal under
the scleral flap and is rotated in the
anterior chamber in order to incise
the trabecular meshwork from
outside so as to promote aqueous
outflow via Schlemm's canal.
Aqueous Outflow Pathway Reconstruction Surgery

• In this procedure, goniosynechia in eyes with angle

Goniosynechiolysis closure glaucoma are lysed and aqueous outflow via the
physiological pathway is promoted in order to reduce IOP.
Aqueous Outflow Pathway Reconstruction Surgery

• Under observation with a gonioscopic lens, a knife

Goniotomy inserted via the cornea is used to incise the anterior
chamber angle from the anterior chamber side. This
procedure is indicated in developmental glaucoma.
C. Surgery to Relieve Pupillary Block
■ Peripheral iridectomy
– This procedure is conducted in glaucomas caused by pupillary block, such as primary angle-
closure glaucoma, in order to equalize the pressure difference between the anterior and posterior
chambers by incising the periphery of the iris.
D. Cyclodestructive surgery
Trans-scleral
Endoscopic laser
Cyclocryotherapy laser
cycloablation
cycloablation