GLAUCOM

A
Dr Jusuf Wijaya , SpM
(Glaukomatoloog)
I.P. Mata FK - UKI

Glaucoma therapy
1.
2.
3.
4.
5.

Medication
Laser treatment
Surgical treatment
Artificial drainage shunts
Cyclodestructive procedures

Glaucoma therapy
Laser treatment
1.
2.
3.

Argon Laser Trabeculoplasty (ALT)

Nd: YAG laser iridotomy
Diode laser cycloablation

Glaucoma therapy
1. Argon Laser Trabeculoplasty (ALT)
Involves the application of discrete Argon laser
burns to the trabeculum, which results in
stretching open of the trabecular spaces ,
thus enhancing aqueous outflow and
lowers IOP

Glaucoma therapy
1.

Argon Laser Trabeculoplasty (ALT)

Complications :
- Peripheral anterior synechiae
- Small haemorrhages
- Acute elevation of IOP

Glaucoma therapy
2. Nd:YAG laser iridotomy
To create an artificial opening between the
anterior chamber and the posterior
chamber at the iris periphery
Complications :
- Bleeding
- Iritis
- Corneal burns
- Glare and diplopia

Glaucoma therapy
3. Diode laser cycloablation
This procedure lowers IOP by destroying
part of the secretory ciliary epithelium,
thereby reducing aqueous secretion
Used mainly to control pain in intractable
end-stage glaucoma
Complications :
- Mild pain
- Anterior segment inflammation
- Chronic hypotony

Glaucoma therapy
1.
2.
3.
4.
5.

Medication
Laser treatment
Surgical treatment
Artificial drainage shunts
Cyclodestructive procedures

Glaucoma therapy
Surgical treatment
1. Trabeculectomy (penetrating filtration
surgery)
2. Non-penetrating filtration surgery
- Deep sclerectomy
- Viscocanalostomy

Glaucoma therapy
Trabeculectomy
A surgical procedure that lowers IOP by
creating a fistula, which allows aqueous
outflow from the anterior chamber to the
sub-Tenon space.
The fistula is protected or guarded by a
superficial scleral flap

Glaucoma therapy
1.
2.
3.
4.
5.

Medication
Laser treatment
Surgical treatment
Artificial drainage shunts
Cyclodestructive procedures

Glaucoma therapy
Artificial drainage shunts
They are plastic devices which create a
communication between the anterior chamber
and sub-Tenon space
All such devices consist of a tube attached to a
posterior episceral explant
e.g. : - Molteno
- Baerveldt

Glaucoma therapy
1.
2.
3.
4.
5.

Medication
Laser treatment
Surgical treatment
Artificial drainage shunts
Cyclodestructive procedures

Glaucoma therapy
Cyclodestructive procedures
1. Diode laser cycloablation
2.
Cyclocryocoagulation

Glaucoma

Ocular hypertension
Primary open-angle glaucoma
Normal-tension glaucoma
Primary angle-closure glaucoma
Lens-related glaucoma
Traumatic glaucoma

Glaucoma
Ocular hypertension
Refers to patients with IOP > 21 mmHg on two
consecutive occasions, in the absence of
detectable glaucomatous damage
Only 1% of individuals with ocular hypertension
will develop glaucoma
Most patients with ocular hypertension does not
require treatment

Glaucoma
Primary open-angle glaucoma (POAG)
-

Generally bilateral, can be asymetrical

Adult onset
IOP > 21 mmHg
Open angle of normal appearance
Glaucomatous optic-nerve head damage
Visual field loss

Glaucoma
Primary open-angle glaucoma (POAG)
Risk factors and associations :
Age : more common > 65 years
Race : more common in black people
Family history and inheritance (multifactorial)
Myopia
Retinal disease (CRVO)

Glaucoma
Primary open-angle glaucoma (POAG)
It is asymptomatic until significant loss of visualfield has occurred. This is because damage
occurs gradually and fixation is only involved
late in the course of the disease.
Treatment :
Prevent functional impairment of vision by
lowering of IOP

Glaucoma
Normal-tension glaucoma
-

= Low-tension glaucoma
A variant of POAG
Mean IOP 21 mmHg
Glaucomatous optic disc damage and visual
field loss
Open angle on gonioscopy
Absence of secondary causes for
glaucomatous optic disc damage

Glaucoma
Normal-tension glaucoma
Treatment :
Medical treatment ; Betaxolol is the drug of
choice
Trabeculectomy
Systemic calcium channel blockers;
Nifedipine
Monitoring of systemic blood pressure

Glaucoma
Primary angle-closure glaucoma (PACG)
A condition in which elevation of IOP occurs as a result
of obstruction of aqueous outflow by partial or
complete closure of the angle by the peripheral iris
Risk factors :
Age : 60 years
Gender : : = 1 : 4
Race : more common in South-East Asians,
Chinese & Eskimos
Family history : increased risk for first-degree
relatives

Glaucoma
Primary angle-closure glaucoma (PACG)
Anatomical predisposing factors :
Relative anterior location of the iris-lens
diaphragm
Shallow anterior chamber
Narrow entrance to the anterior chamber

Glaucoma
Primary angle-closure glaucoma (PACG)
It can be divided into five overlapping stages :
Latent
Subacute (intermittent)
Acute congestive
Postcongestive
Absolute

Glaucoma
Latent PACG
-

No symptoms
Shallow anterior chamber
Occludable angle

Treatment :
Prophylactic peripheral laser iridotomy

Latent PACG

Latent PACG

Glaucoma
Subacute (intermittent) PACG
-

Intermittent pupillary block resulting in subacute

angle-closure
Attacks precipitated by physiological mydriasis
(watching television in a dark room), or by
physiological shallowing of the anterior chamber
when the patient assumes a prone or semiprone
position (when sewing or reading)
Emotional stress may occasionally be a precipitating
factor

Treatment :
Prophylactic peripheral laser iridotomy

Glaucoma
Acute congestive PACG
Symptoms :
Rapidly progressive unilateral visual loss
Periocular pain & congestion
Nausea & vomitting
Signs :
Ciliary injection
Corneal oedema
Shallow anterior chamber with peripheral iridocorneal
contact
Flare & cells
Vertically oval pupil, fixed in the semi-dilated position
IOP is severely elevated (50-100 mmHg)

Acute congestive PACG

Acute congestive PACG

Acute congestive PACG

Acute congestive PACG

Glaucoma
Acute congestive PACG
Treatment :
1. Acetazolamide 500 mg IV & 500 mg PO
2. Topical ;
- Pilocarpine 2% ( 2 drops in each eye)
- Dexamethasone q.i.d.
- Beta blocker

3. Analgesia & anti-emetics

4. Patient in supine position

Glaucoma
Postcongestive PACG
It refers to the aftermath of an attack of Acute
congestive PACG

Absolute PACG
It refers to the end stage of Acute congestive
PACG in which the eye is completely blind

Postcongestive PACG

Postcongestive PACG

Postcongestive PACG

Postcongestive PACG

Glaucoma
Lens-related glaucoma
1. Phacolytic glaucoma (lens protein glaucoma)
- A secondary open-angle glaucoma, occuring in association
with hypermature cataract
- Trabecular obstruction is caused by high- molecular-weight
lens proteins which have leaked through the intact capsule
into the aqueous humour. Lens protein-laden macrophages
may also contribute to trabecular blockage

Treatment :
Once IOP is controlled medically, flushing out of
proteinaceous material & cataract surgery should be
performed.

Phacolytic glaucoma (lens protein glaucoma)

Phacolytic glaucoma (lens protein glaucoma)

Phacolytic glaucoma (lens protein glaucoma)

Glaucoma
Lens-related glaucoma
2. Phacomorphic glaucoma
An acute secondary angle-closure glaucoma
precipitated by an intumescent cataractous lens
Treatment :
Initially similar to acute PACG. Cataract surgery is
performed once the eye is quiet.

Phacomorphic glaucoma

Glaucoma
Traumatic glaucoma
1. Red cell glaucoma
Traumatic hyphaema may cause an elevation of IOP due to trabecular blockage by
red blood cells. Pupillary occlusion by blood clot may superimpose an angle-closure
component.
Treatment :
1. Medical : Beta-blockers and/or systemic carbonic anhydrase inhibitors
Topical steroids and mydriatics
2. Surgical evacuation of the blood

Glaucoma
Traumatic glaucoma
2. Angle recession glaucoma
It involves rupture of the face of the ciliary body (the portion that lies between the
iris root and the scleral spur) due to blunt
Treatment :
1. Medical : frequently unsatisfactory
2. Trabeculectomy
3. Artificial drainage shunt if trabeculectomy fails

Red cell glaucoma

Angle recession glaucoma