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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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glaucoma separating fact from fiction
GLAUCOMA: SEPARATING FACT FROM FICTION

Mona Khandwala

Consultant Ophthalmic and Oculoplastic Surgeon

Maidstone and Tunbridge Wells NHS Trust

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

visual impairment

definition
Definition

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

classification of glaucoma
Classification of glaucoma
  • Primary Secondary Congenital

Open angle Closed angle

primary open angle
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
closed angle glaucoma
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
congenital
Congenital
  • Enlargement of the eyeball
  • Opacity of the cornea
  • Excessive eye-watering
  • Sensitivity to light (photophobia)
secondary drug induced glaucoma
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

mechanism of drug induced glaucoma1
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
mechanism of drug induced glaucoma2
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
treatment modalities
Treatment modalities
  • Pharmacological
  • Laser
  • Surgical
preservative free drops
Preservative free drops

Currently only 2 true preservative free drops:

1. Tafluprost PF (Saflutan) : £17.41

2. Latanoprost PF (Monopost): £8.49

side effects of glaucoma treatment
Side effects of glaucoma treatment

OCULAR

  • Hyperemia/ redness/ itching
  • Thickening and lengthening of lashes

(hypertrichosis)

  • Darkening of iris colour
side effects of glaucoma treatment1
Side effects of glaucoma treatment

SYSTEMIC

  • Bronchospasm
  • Bradycardia
  • Paraesthesia
  • Depression
  • Impotence
  • Anorexia
  • Renal calculi
caution with b blockers
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
laser treatment
Laser treatment
  • Iridotomy
  • Laser trabeculoplasty
  • Transscleralcyclodiode
  • Iridoplasty
trabeculectomy
Trabeculectomy

Filtration bleb

Fragment

removed

Valve

s ome glaucoma myths
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

more glaucoma myths
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

s ome glaucoma myths1
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.

commonly asked questions
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

more questions
More questions
  • Is it dangerous to use the eye-drops more frequently than

prescribed?

No positive effects on treatment, and it could lead to side effects

  • Is it possible to use other medication in addition to glaucoma drops?

It is very important to tell the family doctor about the diagnosis of

glaucoma and the medications being used. For instance, you should

be careful when taking some tranquillisers, anti-asthmatics or

medication for the digestive system

  • How long does it take for the eyedrops to be absorbed?

A few minutes.

case study 1
Case study 1
  • 35 yoAfrican male, web designer
  • Gradual diminution of vision
  • Positive family history
  • Vision: RE- 6/60, LE- 6/18
  • IOP: RE-23, LE-21
  • Bilateral visual field defects: RE- temporal loss, LE- inf altitudinal loss
  • Colour vision: RE- 1/17, LE- 4/17
case study 11
Case study 1
  • MRI scan done- pituitary tumor
  • Post surgery good result
  • Vision : 6/6 BE
  • Colour vision: 17/17
case study 2
Case study 2
  • 48 yoCaucasian female
  • Routine optician check revealed suspicious optic discs
  • Positive history of susceptibility to cold extremities in winter, and migraine
  • Vision: RE- 6/6, LE-6/6
  • IOP- 20 mm Hg BE
  • Optic discs- CD ratio of 0.75 with inferior rim loss
  • Normal visual field tests
case study 21
Case study 2
  • No treatment started as no evidence of visual field involvement
  • Ask history of vasospasm and migraine: NTG?
  • Ask history of trauma, steroid usage, other drug history
eligibility for free eye tests
Eligibility for free eye tests
  • You are aged 60 or over
  • You have diabetes or glaucoma
  • You are 40 or over and have a close relative with glaucoma i.e. brother, sister, parent or child
  • A hospital ophthalmologist says that you are at risk of glaucoma
  • You are registered blind or partially sighted