GLAUCOMA

Dr Jusuf Wijaya , SpM

(Glaukomatoloog)
I.P. Mata FK - UKI
Glaucoma therapy
1. Medication
2. Laser treatment
3. Surgical treatment
4. Artificial drainage shunts
5. Cyclodestructive procedures
Glaucoma therapy
Laser treatment
1. Argon Laser Trabeculoplasty (ALT)
2. Nd: YAG laser iridotomy
3. 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. Medication
2. Laser treatment
3. Surgical treatment
4. Artificial drainage shunts
5. 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. Medication
2. Laser treatment
3. Surgical treatment
4. Artificial drainage shunts
5. 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. Medication
2. Laser treatment
3. Surgical treatment
4. Artificial drainage shunts
5. 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 visual-
field 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