Transcript primary open angle glaucoma primary angle closed glaucoma

PRIMARY OPEN
ANGLE GLAUCOMA
PROF.DR.ÖZCAN OCAKOĞLU
WHAT IS GLAUCOMA?
GLAUCOMA IS A DISEASE OF THE OPTIC NERVE
IT IS CAUSED BY PROGRESSIVE OPTIC NERVE DAMAGE
GLAUCOMA CAN PROGRESS TO TOTAL LOSS OF VISION
AND CAN CAUSE IRREVERSIBLE BLINDNESS
WHAT CAUSES GLAUCOMA?
GLAUCOMA IS USUALLY, BUT NOT ALWAYS, ASSOCIATED WITH
ELEVATED INTRAOCULAR PRESSURE (IOP)

THE ELEVATED IOP LEADS TO DAMAGE OF THE OPTIC NERVE
WHAT IS THE IOP?
THE PRESSURE INSIDE THE EYEBALL IS
TERMED ”INTRAOCULAR PRESSURE (IOP)”
IOP CAN BE MEASURED SEVERAL
TECHNIQUES

AS MILLIMETERS OF MERCURY (mmHg)
NORMAL EYE PRESSURE RANGES FROM 10
to 21 mmHg
ELEVATED IOP IS USUALLY “GREATER
THAN 21 mmHg”
HOW DOES IOP OCCUR?
ANTERIOR CHAMBER IS FILLED WITH
“AQUEOUS HUMOR”

THIS FLUID IS PRODUCED BY THE
PROCESSUS CILIARIS WHICH IS A PART OF
CILIARY BODY
Inflow rate is 2 µl/min
THE AQUEOUS HUMOR THEN FLOWS
THROUGH THE PUPIL AND LEAVES THE
TRABECULAR MESHWORK (TM)

TM IS LOCATED AT THE ANTERIOR
CHAMBER ANGLE WHICH IS LOCATED
BETWEEN THE CORNEA AND ROOT OF
THE IRIS.
ANTERIOR CHAMBER ANGLE?
OPEN ANTERIOR CHAMBER ANGLE
NARROW OR CLOSED ANGLE
OUTFLOW PATHWAYS
TRADITIONAL PATHWAY
TRABECULUM, SCHLEMM CHANNELINTRASCLERAL COLLECTORS-VEIN
SYSTEM
NORMAL EYES
UVEOSCLERAL PATHWAY
SPACES WITHIN LONGITIDUNAL
FIBERS OF CILIARY MUSCLES AT
CILIARY BODY
Outflow rate is 2 µl/min
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TRABECULAR
MESHWORK
THE CAUSE OF THE HIGH IOP
IS AN IMBALANCE BETWEEN THE INFLOW AND OUTFLOW OF
AQUEOUS HUMOR.
RAISING THE IOP!!
MORHOLOGICAL EFFECT OF ELEVATED
IOP
INCREASED IOP DAMAGES RETINAL
GANGLION CELLS AND THEIR AXONS
THE RESULT OF GLAUCOMATOUS
PROCESS IS EXCAVATION OF OPTIC
DISC AND EVENTUALLY OPTIC
ATROPHY
FUNCTIONAL EFFECT OF ELEVATED IOP
(VISUAL FIELD DEFECTS)
IOP RELATED OTHER CONDITIONS
OCULAR HYPERTENSION 

IN SOME CASES, GLAUCOMA MAY NOT OCCUR IN THE EYES
WITH ELEVATED IOP (Increased IOP but no disease)
 OHT IS USUALY CAUSED BY THICKER CORNEA THAN NORMAL VALUE
NORMOTENSIVE GLAUCOMA 

IN SOME CASES, GLAUCOMA MAY OCCUR IN THE EYES
WITH NORMAL IOP
 THIS FORM OF GLAUCOMA IS CAUSED BY POOR REGULATION OF
BLOOD FLOW TO THE OPTIC NERVE
WHAT ARE THE DIFFERENT TYPES OF
GLAUCOMA?
 PRIMARY GLAUCOMAS

THE PATHOLOGY IS ONLY LOCATED INSIDE THE EYE (ON
FOCUSED TM)

THE MOST COMMONEST TYPE OF GLAUCOMA

PRIMARY OPEN ANGLE GLAUCOMA

PRIMARY ANGLE CLOSED GLAUCOMA
 SECONDARY GLAUCOMAS
 CONGENITAL (OR PEDIATRIC) GLAUCOMAS
PRIMARY OPEN ANGLE GLAUCOMA
INCREASED IOP (USUALLY > 22 MMHG, RELATED CCT)
OPEN ANTERIOR CHAMBER ANGLE
VISUAL FIELD ABNORMALITIES
CUPPING AND ATROPHY OF THE OPTIC DISC
SLOWLY, LONG TERM, INSIDIOUS DISEASE !
RESISTANCE POINTS AGAINST OUTFLOW
NORMAL EYE
GLAUCOMATOUS EYE
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MAIN RESISTANCE POINTS AGAINST TO AQUEUS FLOW
1-INTERNAL WALL OF SCHLEMM CHANNEL
2-JUXTACANALICULAR PART OF TRABECULAR MESHWORK
WHAT ARE THE RISK FACTORS?
INCREASED IOP
CORNEAL THICKNESS THINNER THAN THE
NORMAL (CCT< 500 MICRONS)
GENETIC (POZITIVE FAMILY HISTORY)
AGE AND RACE (OVER 40’S, BLACKS)
NO SYMPTOMS !!!= Thief of vision
RARELY, SOME PATIENTS COMPLAINT
HEADACHE, NEAR READING DISTURBANCES,
HAZINESS OF VISION,DARK ADAPTATION
PROBLEMS BUT NO SYMPTOM DIRECTLY
RELATED POAG
IN EARLY STAGE, VISUAL FIELD DEFECTS IS
THE ONLY SYMPTOM, BUT THE PATIENTS
DOES NOT FEEL THESE DEFECTS
THUS, ANNUAL ROUTINE EXAMINATION IS
ESSENTIAL FOR EARLY DIAGNOSIS.
THE DIAGNOSE OF GLAUCOMA
PACHYMETRY
GONIOSCOPY
TONOMETRY
OPHTHALMOSCOPY
PERIMETRY
TONOMETRY
TONOMETRY IS A METHOD TO MEASURE THE PRESSURE INSIDE
THE EYEBALL
SEVERAL TYPES OF TONOMETERS ARE AVAILABLE FOR THIS TEST,
THE MOST COMMON BEING THE APPLANATION TONOMETER
PACHYMETRY
PACHYMETRY DETERMINES THE CENTRAL CORNEAL THICKNESS (CCT).
NORMAL CENTRAL CORNEAL THICKNESS IS VARIABLE 500-520 MICRONS
CCT MAY BE EFFECTED MEASURING IOP

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 (ACA)
A SPECIAL CONTACT LENS (GONIOLENS)
IS USED
THIS TEST DETERMINES THE ANGLES
WHICH ARE OPEN, 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 TPYCALLY BY
USING AN AUTOMATED VISUAL FIELD MACHINE
THIS TEST IS DONE TO RULE OUT ANY VISUAL DEFECTS DUE TO
GLAUCOMA
NORMAL VF
EARLY STAGE
MODERATE STAGE
END STAGE
OPTIC NERVE HEAD EXAMINATION
OPTIC NERVE HEAD IS EXAMINED WITH OPHTHALMOSCOPICALLY
FOR GLAUCOMATOUS CHANGES
CUPPING, WHICH IS AN EXCAVATION OF THE OPTIC DISC, CAN BE
CAUSED BY INCREASED INTRAOCULAR PRESSURE.
NORMAL OPTIC DISC
GLAUCOMATOUS OPTIC DISCS
GENERAL TREATMENT OPTIONS
FOR GLAUCOMA
THE GOAL OF GLAUCOMA TREATMENT IS REDUCE THE
PRESSURE BEFORE GLAUCOMATOUS LOSS OF VISION
MOST CASES CAN BE CONTROLLED WELL WITH TREATMENTS,
THEREBY PREVENTING FURTHER LOSS OF VISION
EARLY DIAGNOSIS AND TREATMENT IS THE KEY TO PRESERVING
SIGHT IN PEOPLE WITH GLAUCOMA
GOALS OF GLAUCOMA TREATMENT
THE THERAPIES AIMED
INCREASING
OUTFLOW
THE THERAPIES AIMED
DECREASING
AQUEOS
PRODUCTION
MEDICAL TREATMENT
LASER
TEDAVISI
LASER TREATMENT
SURGICAL TREATMENT
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 (SLT/ALT)

LT IS PERFORMED ONLY IN EYES WITH
OPEN ANGLES.
 MICROSCOPIC LASER BURNS TO THE ANGLE
ALLOW FLUID TO BETTER EXIT THE
DRAINAGE CHANNELS.

LT DOES NOT CURE GLAUCOMA BUT IS
LASER TRABECULOPLASTY
OFTEN DONE TO DECREASING NUMBER OF
ANTIGLAUCOMATOUS EYE DROPS
ALT BURNS
SLT BURNS
LASER CYCLOPHOTOCOAGULATION
 THIS THERAPY DESTROYS CILIARY BODY
THEREBY REDUCING PRODUCTION OF
AQUEOUS HUMOR
 THIS TYPE OF THERAPY MAY BE DANGEROUS
BECAUSE OF THE RISK OF PHITISIS BULBI
 GENERALLY RESERVED FOR PATIENTS
SUUFERING FROM SEVERE FORMS OF
GLAUCOMA WITH POOR VISUAL ACUITY AND
SERIOUS EYE PAIN
SURGICAL THERAPY
FILTRATION SURGERY
(TRABECULECTOMY)
NON PENETRATING
SURGERY
SHUNT (IMPLANT) SURGERY
(AHMED GLAUCOMA VALV)
TRABECULECTOMY
TRABECULECTOMY IS THE MOST COMMONLY
PERFORMED GLAUCOMA SURGERY
THE AIM IS TO CREATE AN OPENING
BETWEEN ANTERIOR CHAMBER AND THE SPACE
UNDER CONJUNCTIVA
THE SURGERY PRODUCES A NEW DRAINAGE
PATHWAY FOR AQUEOUS HUMOR TO EXIT THE
EYE THEREBY LOWERING THE EYE PRESSURE
AQUEOUS SHUNT DEVICES
(GLAUCOMA IMPLANTS OR TUBES)
THE ARTIFICIAL DRAINAGE DEVICES IS
USED TO LOWER THE EYE PRESSURE.
THEY CONTAIN A TUBE ATTACHED TO A
RESERVOIR (OR PLATE)
THE RESERVOIR IS PLACED BENEATH THE
CONJUNCTIVA , TUBE IS INSERTED
ANTERIOR CHAMBER
GENERALLY, IT USES TO TREAT THE
DIFFICULT GLAUCOMA CASES
AQUEOUS PASSES THE INSIDE TUBE
LUMEN AND COLLECTS UNDER THE
RESERVOIR