Transcript primary open angle glaucoma

PRIMARY OPEN ANGLE
GLAUCOMA
PROF.DR.ÖZCAN OCAKOĞLU
HISTORICAL ASPECTS
THE GLAUCOMA TERM IS DERIVED FROM THE OLD
GREEK WORD “GLAUKOS” WHICH MEANS “GREYISHBLUE”
HIPPOCRATES DEFINED GLAUCOMA AS “A DISEASE
OF THE ELDERLY PATIENTS IN WHICH THE PUPILLA
BECOMES BLUE”.

A PERSON WITH A SWOLLEN CORNEA AND A RAPIDLY
DEVELOPING CATARACT AND CHRONIC (LONG-TERM)
ELEVATED PRESSURE INSIDE THE EYE
c. 460 BC–c. 380 BC
WHAT IS THE INTRAOCULAR
PRESSURE?
PRESSURE INSIDE THE EYE IS TERMED ”INTRAOCULAR PRESSURE
(IOP)”
EYE PRESSURE IS MEASURED IN MILLIMETERS OF MERCURY (mmHg)
“NORMAL EYE PRESSURE” IS NOT A STABLE NUMBER(S), IT RANGES
FROM 10 to 21 mmHg
ELEVATED IOP IS AN EYE PRESSURE OF “GREATER THAN 21 mmHg”
WHAT IS GLAUCOMA?
CURRENTLY, GLAUCOMA IS DEFINED AS “A PROGRESSIVE OPTIC
NEUROPATHY WHICH CAUSES PERMANENT BLINDNESS BY
DAMAGING THE OPTIC NERVE AND THE PERIFERIC VISUAL FIELD”
GLAUCOMA AFFECTS 3% OF THE SOCIETY AND THE SECOND
FREQUENT REASON OF PERMANENT BLINDNESS (ESPECIALLY IN
DEVELOPED COUNTRIES).
THE PREVALANCE IS HIGHER IN ELDERLY POPULATION.
CLASSIFICATION OF
GLAUCOMA
VARIOUS CLASSIFICATIONS ARE AVAILABLE.
MANY CLASSIFICATIONS ARE BASED ON ETIOLOGY, ANATOMY
AND CLINICAL PRESENTATION.
CLASSIFICATION BY THE TIME OF ONSET IS AS;

CONGENITAL GLAUCOMAS

ACQUIRED GLAUCOMAS
 PRIMARY GLAUCOMAS
 SECONDARY GLAUCOMAS
CLASSIFICATION OF THE
ACQUIRED GLAUCOMAS
PRIMARY OPEN ANGLE
GLAUCOMA
•NORMAL PRESSURE GLAUCOMA
•OCULAR HYPERTENSION
SECONDARY OPEN ANGLE
GLAUCOMAS
•PSEUDOEXFOLIATION GLAUCOMA
•PIGMENTARY GLAUCOMA
•PHACOLYTIC GLAUCOMA
•SECONDARY TO OCULAR
INFLAMMATION
•SECONDARY TO HIGH EPISCLERAL
VENOUS PRESSURE
•SECONDARY TO STEROID THERAPY
PRIMARY ANGLE CLOSURE
GLAUCOMAS
•ACUTE ANGLE CLOSURE GLAUCOMA
•SUBACUTE ANGLE CLOSURE GLAUCOMA
SECONDARY ANGLE CLOSURE
GLAUCOMAS
•DUE TO PERIPHERAL ANTERIOR
SYNECHIAE
•SWOLLEN LENS OR PUPILLARY
SECLUSION ANTERIOR MOVEMENT OF THE
IRIS-LENS DIAPHRAGM
•NEOVASCULAR GLAUCOMA
• PLATEAU IRIS SYNDROME
PRIMARY OPEN ANGLE
GLAUCOMA
POAG IS DESCRIBED AS OPTIC NERVE DAMAGE FROM MULTILP POSSIBLE
CAUSES THAT IS CHRONIC AND PROGRESSES OVER TIME
A LOSS OF OPTIC NERVE FIBERS IS CHARACTERISTIC OF THE DISEASE
POAG CHARACTERISTICS ARE OPEN ANTERIOR CHAMBER ANGLE, HIGH
INTRAOCULAR PRESSURE IN THE EYE ,VISUAL FIELD ABNORMALITIES
AND CUPPING AND ATROPHY OF THE OPTIC DISC
POAG CAUSES ?
THE EXACT CAUSE OF POAG IS UNKNOWN
THE MOST IMPORTANT (AND WELL KNOWN) CAUSE OF POAG IS
INCREASED IOP
THE CAUSE OF THE HIGH IOP IS GENERALLY ACCEPTED TO BE BECAUSE
OF AN IMBALANCE IN THE PRODUCTION AND DRAINAGE OF FLUID IN THE
EYE (AQUEOUS HUMOR)
THE FLUID IS CONTINUALLY BEING PRODUCED BUT CANNOT BE DRAINED
BECAUSE OF THE IMPROPERLY FUNCTIONING DRAINAGE CHANNELS
(CALLED TRABECULAR MESHWORK)
RAISING THE IOP!!
OUTFLOW
PATHWAYS AND
RESISTANCE
POINTS
GLAUCOMATOUS DAMAGE
THE BASIS OF THE GLAUCOMATOUS
DAMAGE IS THE LOSS OF RETINAL
GANGLION CELLS.
THE GANGLION CELLS CONSTITUTING
THE RETINAL NERVE FIBER LAYER AND
THEIR AXONS DIE DURING THE
GLAUCOMATOUS DAMAGE PROCESS.
SYMPTOMS
MOST CASES ARE ASYMPTOMATIC UNTIL THE VISUAL FIELD
ABNORMALITIES BECOME PROMINENT AND AFFECT CENTRAL
VISION.
THUS, ANNUAL ROUTINE EXAMINATION IS ESSENTIAL FOR
EARLY DIAGNOSIS.
THE EVALUATION OF
GLAUCOMA PATIENTS
VISUAL ACUITY (BEST CORRECTED)
BIOMICROSCOPY (CLUES TO SPESIFIC DIAGNOSIS...)
MEASUREMENT OF INTRAOCULAR PRESSURE

APPLANATION TONOMETRY (GOLDMANN)

NONCONTACT TONOMETRY
PACHYMETRY (CENTRAL CORNEAL THICKNESS)
EVALUATION OF THE ANTERIOR CHAMBER ANGLE (GONIOSCOPY)
VISUAL FIELD TESTING
FUNDUSCOPY
TONOMETRY
TONOMETRY IS A METHOD USED TO MEASURE THE PRESSURE
INSIDE THE EYE
BECAUSE IOP VARIES FROM HOUR TO HOUR IN ANY
INDIVIDUAL (DIURNAL VARIATION), MEASUREMENTS MAY BE
TAKEN AT DIFFERENT TIMES OF DAY (MORNING AND NIGHT)

A DIFFERENCE IN PRESSURE BETWEEN MORNING AND NIGTH OF
5 mmHg OR MORE MAY SUGGEST GLAUCOMA
A DIFFERENCE IN PRESSURE BETWEEN THE TWO EYES OF 3
mmHg OR MORE MAY SUGGEST GLAUCOMA
APPLANATION TONOMETRY
THE TECHNIQUES OF
IOP MEASUREMENTS
PERRKINS HAND
HELD TONOMETER
SCHIOTZ TONOMETER
NON CONTACT TONOMETER
TONOPEN XL
PACHYMETRY
NORMAL CENTRAL CORNEAL THICKNESS IS
VARIABLE 500-520 MICRONS

THINNER CORNEA (CCT < 500 m) CAN GIVE
FALSELY LOW PRESSURE READINGS

SEVERE GLAUCOMA PATIENTS MAY BE
FAILED DIAGNOSE

A THICK CORNEA (>600 m) CAN GIVE
FALSELY HIGH PRESSURE READINGS

UNNECESSARY TREATMENTS !!
GONIOSCOPY
•GONIOSCOPY IS PERFORMED TO CHECK
THE DRAINAGE ANGLE OF AN EYE
•A SPECIAL CONTACT LENS(GONIOLENS)
IS PLACED ON THE EYE
•THIS TEST IS IMPORTANT TO
DETERMINE IF THE ANGLES ARE OPEN,
SL:SCHWALBE’S LINE
TM:TRABECULAR MESHWORK
SS:SCLERAL SPUR
CBB:CILIARY BODY BAND
NARROWED, OR CLOSED
•OPEN ANGLE: LONG TERM,SLOWLY,
INSIDIOUS DISEASE
•CLOSE(OR NARROWED): RISK OF ACUT
GLAUCOMA CRISIS
VISUAL FIELD TESTING
VF TESTING TO CHECK THE PATIENTS PERIPHERAL VISION
TYPCALLY BY USING AN AUTOMATED VISUAL FIELD MACHINE
THIS TEST IS DONE TO RULE OUT ANY VISUAL DEFECTS DUE TO
GLAUCOMA
VF DEFECTS MAY NOT BE APPERENT UNTIL OVER 40% OF THE OPTIC
NERVE FIBER LAYER HAS BEEN LOST
VF TESTING MAY NEED TO BE REPEATED

A LOW RISK OF GLAUCOMATOUS DAMAGE, THE TEST MAY BE PERFORMED
ONCE A YEAR

A HIGH RISK OF GLAUCOMATOUS DAMAGE, TEST MAY BE PERFORMED AS
FREQUENTLY AS EVERY 2 MONTHS
DIFFERENT STAGES OF GLAUCOMATOUS
VISUAL FIELD DEFECTS
AUTOMATED VISUAL FIELD ANALYZER
NORMAL VF
EARLY STAGE
MODERATE STAGE
END STAGE
OPTIC NERVE HEAD EXAMINATION
EACH OPTIC NERVE HEAD IS EXAMINED FOR ANY DAMAGE OR
ABNORMALITIES
THIS MAY REQUIRE DILATION OF THE PUPILS TO ENSURE AN
ADEQUATE EXAMINATION OF THE OPTIC NERVES
FUNDUS PHOTOGRAPHS,WHICH ARE PICTURES OF YOUR
OPTIC DISC ARE TAKEN FOR FUTURE REFERENCE AND
COMPARISON
DIFFERENT IMAGING STUDIES MAY BE CONDUCTED TO
DOCUMENT THE STATUS OF OPTIC NERVE AND TO DETECT
CHANGES OVER TIME
FUNDOSCOPIC CHANGES
NORMAL OPTIC DISC
GLAUCOMATOUS OPTIC DISCS
CONFOCAL SCANNING LASER
OPHTHALMOSCOPY
NORMAL OD
GLAUCOMATOUS OD
HEIDELBERG RETINA TOMOGRAPHY
TWO DIFFERENT SITUATION
NORMAL TENSION (OR
LOW TENSION) GLAUCOMA
PEOPLE CAN HAVE OPTIC
NERVE DAMAGE WITHOUT
HAVING ELEVATED IOP
THE MAIN REASON OF THIS
CONDITION IS VASCULAR
INSUFFICIENCY (OCULAR
ISCHEMIA?)
OCULAR HYPERTENSION
PEOPLE CAN HAVE ELEVATED
PRESSURES WITHOUT SIGNS
OF OPTIC NERVE DAMAGE OR
VISUAL FIELD LOSS
THEY ARE CONSIDERED AS A
RISK FOR GLAUCOMA
THESE PEOPLE ARE KNOWN AS
GLAUCOMA SUSPECT
GENERAL TREATMENT
OPTIONS FOR GLAUCOMA
THE GOAL OF GLAUCOMA TREATMENT IS
REDUCE THE PRESSURE BEFORE IT CAUSES
GLAUCOMATOUS LOSS OF VISION
MEDICAL THERAPY
LASER THERAPY
SURGICAL THERAPY
MEDICAL THERAPY
AQUEUS SUPPRESANTS
•ADRENERGIC ANTAGONISTS
(BETA BLOCKERS)
•NONSELECTIVE
TIMOLOL, LEVOBUNOLOL,
CARTEOLOL (ISA+), METIPRANOLOL
•SELECTIVE
BETAXOLOL
•ADRENERGIC AGONISTS
(SELECTIVE ALPHA-2 AGONISTS)
•APRACLONIDINE
•BRIMONIDINE
•CARBONIC ANHYDRASE INHIBITORS
•SYSTEMIC
•ACETOZOLAMIDE
•TOPICAL
•DORZOLAMIDE
•BRINZOLAMIDE
OUTFLOW FACILITATIVE
DROGS
•CHOLINERGICS
•PILOCARPINE
•PROSTAGLANDINS
•LATANOPROST
•TRAVOPROST
•BIMATOPROST
FIXED COMBINATIONS
TIMOLOL MALEAT
+
+
+
Dorzolamide Latanoprost Travoprost

COSOPT

XALACOM
DOUTRAV
LASER THERAPY
LASER TRABECULOPLASTY

ARGON LASER TRABECULOPLASTY
(ARGON LASER)

SELECTIVE LASER TRABECULOPLASTY
(ND:YAG)
ARGON LASER
TRABECULOPLASTY
CYCLOPHOTOCOAGULATION

TRANSSCLERAL (ND:YAG, DIODE)

TRANSPUPILLARY (ARGON)

TRANSVITREAL (DURING VITRECTOMY)

ENDOSCOPIC (ARGON)
DIODE LASER TRANSSCLERAL
CYCLOPHOTOCOAGULATION
DIODE LASER
CYCLOPHOTOCOAGULATION
SURGICAL THERAPY
FILTRATION SURGERY
(TRABECULECTOMY)
NON PENETRATING
SURGERY
SHUNT (IMPLANT) SURGERY
(AHMED GLAUCOMA VALV)
TRABECULECTOMY
NON PENETRATING SURGERY
AHMED GLAUCOMA VALVE