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GLAUCOMA: SEPARATING FACT FROM FICTION. Mona Khandwala Consultant Ophthalmic and Oculoplastic Surgeon Maidstone and Tunbridge Wells NHS Trust. Epidemiology. Affects 3 % of the adults 10 % affected > 70 years of age Late diagnosis A mongst three most common causes of

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  1. GLAUCOMA: SEPARATING FACT FROM FICTION Mona Khandwala Consultant Ophthalmic and Oculoplastic Surgeon Maidstone and Tunbridge Wells NHS Trust

  2. Epidemiology • Affects3% of the adults • 10% affected > 70 years of age • Late diagnosis • Amongst three most common causes of visual impairment

  3. Definition Glaucoma is a form of optic neuropathy with specific visual field loss. It is usually associated with raised intra ocular pressure (IOP)

  4. Classification of glaucoma • Primary Secondary Congenital Open angle Closed angle

  5. Primary open angle • Commonest form : > 60% adults with glaucoma • Ageing of the drainage filter • IOP rises, damages the optic nerve and causes field defects • Usually asymptomatic: often picked up at routine eye tests • Needs regular eye checks after age 40 years • Variant- Normal tension glaucoma

  6. Pathophysiology of OAG

  7. Closed angle glaucoma • Can be insidious/ sudden onset • Symptoms include: coloured halos around lights Ocular pain/ headache Cloudy/hazy vision Nausea and vomiting • True ocular emergency- urgent referral • Treatment can restore vision

  8. Pathophysiology of NAG

  9. Congenital • Enlargement of the eyeball • Opacity of the cornea • Excessive eye-watering • Sensitivity to light (photophobia)

  10. Secondary drug induced glaucoma 1. Open angle Steroids: ointment, inhalers, oral 2. Closed angle (by dilating the pupil) Tricyclic antidepressants, Mono amine oxidase inhibitor, Anti Parkinsons, Antihistamines, Antipsychotics, Antispasmolytics 3. Closed angle ( by rotation of ciliary body) Sulfonamides


  12. Mechanism of drug induced glaucoma OPEN ANGLE • Increased resistance to outflow • Accumulation of glycosaminoglycans (GAG) • Decreased pinocytosis, causing decreased clearing of GAG • Accumulation of protein that blocks the trabecular meshwork

  13. Mechanism of drug induced glaucoma NARROW ANGLE • Pupillary blockage • Stimulating sympathetic / inhibiting parasympathetic activation causing pupil dilatation • Anterior rotation of the ciliary body, with choroidal effusions, resulting in a shallow anterior chamber and blockage of the trabecular meshwork


  15. Treatment modalities • Pharmacological • Laser • Surgical

  16. Topical treatment

  17. Topical treatment: Beta blockers

  18. Topical treatment: Adrenergic agonists

  19. Topical treatment: Prostaglandin analogues

  20. Topical treatment: Carbonic anhydrase inhibitors

  21. Topical treatment: Cholinergic antagonists

  22. Preservative free drops Currently only 2 true preservative free drops: 1. Tafluprost PF (Saflutan) : £17.41 2. Latanoprost PF (Monopost): £8.49

  23. Side effects of glaucoma treatment OCULAR • Hyperemia/ redness/ itching • Thickening and lengthening of lashes (hypertrichosis) • Darkening of iris colour

  24. Side effects of glaucoma treatment SYSTEMIC • Bronchospasm • Bradycardia • Paraesthesia • Depression • Impotence • Anorexia • Renal calculi

  25. Caution with B blockers • Reduction of systemic absorption may be achieved by : Lacrimal occlusion for 3 minutes Merely closing the eyes for 3 minutes • Contra indiations : Asthma, COPD, bradycardia, CCFand heart block. • Beta-blockers should not be instilled at bedtime

  26. Laser treatment • Iridotomy • Laser trabeculoplasty • Transscleralcyclodiode • Iridoplasty

  27. Laser iridotomy

  28. Laser trabeculoplasty

  29. Iridoplasty

  30. Cyclodiode laser

  31. Trabeculectomy Filtration bleb Fragment removed Valve

  32. Some glaucoma myths • Can glaucoma be hereditary? Not always. It is, however, more common among close blood relatives of affected persons • Is it present for life? Once the glaucomatous disease develops it will remain forever even if treated • Is it possible to have it in only one eye? Certainly, although both eyes are commonly affected with different degrees of severity

  33. More glaucoma myths? • Can it cause blindness? Yes, if the progression of the disease is not stopped with appropriate treatment • Is it O.K. to drive? Yes, as long as the visual function is within the limits set by the DVLA • Can glaucoma treatments improve the eyesight? No, the aim of the treatment is to prevent further deterioration of the visual function

  34. Some glaucoma myths? • When is it advisable to have a preventive eye specialist examination? Over 40 years old and have not had an eye specialist examination within the previous 5 years. • What is the vesicle that is visible by lifting the eyelid after the glaucoma operation? It is the conjunctiva raised by the aqueous humour that filters through the small valve that the surgeon has made in the eye wall. It is known as “ filtering bleb”, it may initially be uncomfortable though, usually, only temporarily.

  35. Commonly asked questions • What happens if you forget to administer the eye-drops? Best to stick to set times • If two types of eye-drops have to be administered at the same time, can you apply them together? It is necessary to wait a few minutes between drops • If you are not sure that you have applied the first eye-drop correctly, is it dangerous to apply a second one? No, although it is best to dry the eye immediately, to prevent the extra eye-drop from flowing into the tear duct

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