Glaucoma

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Glaucoma

  1. 1. Glaucoma Gauri S. Shrestha, M.Optom, FIACLE
  2. 2. Introduction <ul><li>Glaucoma refers to a group of diseases characterized by </li></ul><ul><ul><li>optic neuropathy </li></ul></ul><ul><ul><li>specific pattern of visual field defect </li></ul></ul><ul><ul><li>raised intraocular pressure </li></ul></ul><ul><li>Damage to optic nerve is irreversible process </li></ul><ul><li>Normal IOP is 10-21mmHg </li></ul>
  3. 3. Aqueous production and drainage <ul><li>Secretion of aqueous humour </li></ul><ul><ul><li>ciliary body (posterior chamber ) </li></ul></ul><ul><li>Route of Drainage </li></ul><ul><ul><li>primary (90%): trabecular meshwork </li></ul></ul><ul><ul><li>uveal-scleral outflow (10%) </li></ul></ul>
  4. 4. Aqueous drainage Ciliary body Posterior chamber Anterior chamber Trabecular meshwork Schlemm’s canal Collector channels Intrascleral Venous plexus Episcleral plexus Sub- ophthalmic vein Cavernous sinus
  5. 5. Uveoscleral Ciliary body Suprachoroidal space Venous circulation of ciliary body, choroid and sclera
  6. 6. Classification <ul><li>Congenital and developmental glaucoma </li></ul><ul><ul><li>Primary congenital glaucoma </li></ul></ul><ul><ul><li>Developmental glaucoma </li></ul></ul><ul><ul><ul><li>With associated anomalies such as Rieger syndrome, peter’s anomaly, aniridian, ectopia lentis, Sturge-Weber syndrome, nanophthalmos, congenital microcornea etc., </li></ul></ul></ul><ul><li>Primary glaucoma </li></ul><ul><ul><li>Primary open angle glaucoma (POAG) </li></ul></ul><ul><ul><li>Primary angle closure glaucoma (PACG) </li></ul></ul>
  7. 7. Classification <ul><li>Secondary glaucoma </li></ul><ul><ul><li>Phacomorphic glaucoma </li></ul></ul><ul><ul><li>Phacolytic glaucoma </li></ul></ul><ul><ul><li>Glaucoma due to uveitis </li></ul></ul><ul><ul><li>Pigmentary glaucoma </li></ul></ul><ul><ul><li>Neovascular glaucoma </li></ul></ul><ul><ul><li>Glaucoma associated with intraocular tumours </li></ul></ul><ul><ul><li>Steroid induced glaucoma </li></ul></ul><ul><li>Secondary glaucoma </li></ul><ul><ul><li>Traumatic glaucoma </li></ul></ul><ul><ul><li>Ciliary block glaucoma </li></ul></ul><ul><ul><li>Glaucoma associated with intraocular haemorrhage </li></ul></ul><ul><ul><li>Glaucoma associated with iridocorneal endothelial syndrome </li></ul></ul><ul><ul><li>Glaucoma due to pseudoexfoliation syndrome </li></ul></ul>
  8. 8. PRIMARY CONGENITAL GLAUCOMA <ul><li>DESCRIPTION </li></ul><ul><ul><li>A rare condition </li></ul></ul><ul><ul><li>manifests without associated anomalies </li></ul></ul>Pathogenesis <ul><li>Classification </li></ul><ul><ul><li>True congenital glaucoma (40%). IOP becomes elevated intrauterine life and child is born with ocular enlargement. </li></ul></ul><ul><ul><li>Infantile glaucoma (50%). It manifests prior to child’s third birthday. </li></ul></ul><ul><ul><li>Juvenile glaucoma (10%). It manifests between 3-16 years. </li></ul></ul>Maldevelopment of the angle structures Impaired aqueous outflow Raised IOP
  9. 10. Symptoms and signs <ul><li>Symptoms </li></ul><ul><ul><li>Photophobia, Lacrimation, blepharospasm, enlarged eyeball, </li></ul></ul><ul><li>Signs </li></ul><ul><ul><li>Corneal edema, corneal enlargement more than 13mm diameter. </li></ul></ul><ul><ul><li>Sclera become thin and appers blue </li></ul></ul><ul><ul><li>Iris may show iridodonesis and atrophic patches in late stage </li></ul></ul><ul><ul><li>Lens becomes flat or subluxated </li></ul></ul><ul><ul><li>Optic disc shows increased cup/disc ratio and atrophy specially after third year. </li></ul></ul><ul><ul><li>IOP is invariably high. </li></ul></ul>
  10. 11. NURSING ASSESSMENT Child may need examination under anesthesia <ul><li>History on lacrimation, photophobia, and blepharospasm </li></ul><ul><li>Assess visual acuity and perform refraction to find out loss of vision </li></ul><ul><li>Examine cornea for edema and opacity </li></ul><ul><li>Measure IOP with hand held perkin’s applanation tonometer </li></ul><ul><li>Measure corneal diameter by calipers. </li></ul><ul><li>Perform a dilated fundus examination to evaluate the optic disc and retina </li></ul>
  11. 12. <ul><li>NURSING DIAGNOSIS </li></ul><ul><ul><li>Altered visual perception secondary to increased intraocular pressure and manifested as Profound lacrimation, photophobia, corneal haze, and buphthalmos </li></ul></ul><ul><ul><li>Loss of vision </li></ul></ul><ul><li>EXPECTED OUTCOME </li></ul><ul><ul><li>Intraocular pressure will be controlled and bring down to normal. </li></ul></ul><ul><ul><li>Lacrimation will be controlled. </li></ul></ul><ul><ul><li>Photophobia and corneal haze will be eliminated </li></ul></ul><ul><ul><li>Prevent eye from loss of vision. </li></ul></ul>
  12. 13. Intervention <ul><li>Counsel the child’s parents for urgent need of surgery </li></ul><ul><li>Prepare them psychologically </li></ul><ul><li>Check the ophthalmologic order of management plan </li></ul><ul><ul><li>Topical beta-blocker (timolol 0.25% to 0.50% b.i.d.) </li></ul></ul><ul><ul><li>Goniotomy is the first choice of surgery (Clear cornea) </li></ul></ul><ul><ul><li>Trabeculotomy </li></ul></ul><ul><ul><ul><li>corneal clouding prevents visualization of the angle </li></ul></ul></ul><ul><ul><ul><li>Failed repeated goniotomy </li></ul></ul></ul><ul><li>Monitor IOP, optic disc, and corneal diameter on regular follow up </li></ul>
  13. 14. EVALUATION <ul><li>Outcome criteria </li></ul><ul><ul><li>Cornea should be transparent; and IOP should be maintained with in normal range </li></ul></ul>
  14. 15. PRIMARY OPEN ANGLE GLAUCOMA <ul><li>Usually bilateral with asymmetry in onset. </li></ul><ul><li>Slow progressive rise in IOP (above 21mmHg), </li></ul><ul><li>Glaucomatous optic nerve damage, </li></ul><ul><li>Visual field loss </li></ul>
  15. 16. Risk-factors <ul><li>Ocular risk Factors </li></ul><ul><li>. IOP </li></ul><ul><li>. Myopia </li></ul><ul><li>. Increased cup/disc ratio </li></ul><ul><li>. Asymmetric cupping </li></ul><ul><li>. Disc hemorrhage </li></ul>
  16. 17. Risk-factors <ul><li>Non ocular risk factors </li></ul><ul><li>. Age </li></ul><ul><li>. Race </li></ul><ul><li>. Family history </li></ul><ul><li>. Diabetes and Systemic hypertension </li></ul><ul><li>. Migraine and peripheral vasospasm </li></ul><ul><li>. Alcohol consumption </li></ul><ul><li>. Cigarette smoking </li></ul>
  17. 18. PATHOGENESIS <ul><li>Elevated IOP in glaucoma results from increased resistance within the aqueous drainage system </li></ul><ul><li>Retinal ganglion cell death </li></ul><ul><ul><li>compromise of the microvasculature with resultant ischaemia in optic nerve head </li></ul></ul><ul><ul><li>mechanical damage due to raised IOP </li></ul></ul>
  18. 19. Symptoms <ul><li>Commonly A symptomatic </li></ul><ul><li>Detected I ncidentally </li></ul><ul><li>Mild headache, ocular pain </li></ul><ul><li>Minimal blurring of vision </li></ul><ul><li>Frequent changes in presbyopic spectacles </li></ul><ul><li>Subjective visual field defect occasionally </li></ul>
  19. 20. Signs on examination <ul><li>Minimal decrease in vision </li></ul><ul><li>Normal conjunctiva </li></ul><ul><li>Normal Cornea </li></ul><ul><li>May be afferent pupillary defect </li></ul><ul><li>Normal AC depth </li></ul><ul><li>Open angles on gonioscopy </li></ul><ul><li>Large CDR </li></ul><ul><li>Raised or normal IOP </li></ul>
  20. 21. ASSESSMENT <ul><li>History: mild headache, eyeache, poor vision at night, color haloes </li></ul><ul><li>Optic nerve: Cupping </li></ul><ul><li>Risk factors: family history, hypertension, diabetes, age and race. </li></ul><ul><li>Record the IOP measurement: Diurnal variation of 8mm Hg between the lowest and the highest values of IOP. </li></ul><ul><li>Central corneal thickness </li></ul><ul><li>Visual field testing </li></ul>
  21. 22. <ul><li>NURSING DIAGNOSIS </li></ul><ul><ul><li>Progressive loss of vision </li></ul></ul><ul><li>EXPECTED OUTCOME </li></ul><ul><ul><li>Stop progression of POAG and damage to retinal ganglion cells. </li></ul></ul><ul><ul><li>Prevent permanent loss of vision. </li></ul></ul>
  22. 25. Glaucomatous optic atrophy
  23. 27. Intervention <ul><li>Counseling: tests, retest, and examination </li></ul><ul><li>Instruct the patient to avoid conditions that will increase IOP such as emotional stress, heavy exertion, wearing tight clothes around neck. </li></ul><ul><li>Institute proper treatment advice </li></ul>
  24. 28. Medical treatment <ul><li>B-blocker: 1 st drug of choice for initial therapy </li></ul><ul><li>Mechanism of action: </li></ul><ul><ul><li>Lowers IOP by reducing the aqueous secretion by effect on beta -receptor in ciliary processes </li></ul></ul><ul><li>Preparation: </li></ul><ul><ul><li>Timolol Maleate(0.25, 0.5%) BD- non selective </li></ul></ul><ul><ul><li>Levobunolol (0.25,0.5%) BD- nonselective </li></ul></ul><ul><ul><li>Betaxolol (0.25%) BD- cardioselective </li></ul></ul><ul><li>Contraindication : bronchial asthma, chronic obstructive pulmonary disease, heart-block, congestive hearth failure, depression. </li></ul>
  25. 29. Medical treatment <ul><li>Carbonic anhydrase inhibitor </li></ul><ul><li>Preparation </li></ul><ul><ul><li>Dorzolamide 2% t.i.d </li></ul></ul><ul><li>Inhibits enzyme carbonic anhydrase -thus reduces aqueous humor formation </li></ul>
  26. 30. Medical treatment <ul><li>Prostaglandin Analogue </li></ul><ul><li>Preparation </li></ul><ul><ul><li>Latanoprost(0.005%) </li></ul></ul><ul><ul><li>Tarvoprost 0.004%: superior ocular hypotensive effect </li></ul></ul><ul><ul><li>Bimatoprost 0.3%: potentiate trabecular outflow </li></ul></ul><ul><li>Increase the uveo - scleral outflow of Aqueous and decrease episcleral venous pressure </li></ul>
  27. 31. Medical treatment <ul><li>Miotics (pilocarpine1, 2, 4% q.i.d.) </li></ul><ul><ul><li>It mechanically increases aqueous outflow contracting ciliary muscles. </li></ul></ul><ul><li>Sympathomimetics (dipivefrin 0.1% bid, epinephrine 0.5% to 25 bid,) </li></ul><ul><ul><li>They reduce IOP by increasing aqueous outflow. </li></ul></ul>
  28. 32. Medical treatment <ul><li>Systemic carbonic anhydrase inhibitors ( methazolamide 25 to 50mg orally bid to tid, acetazolamide 125mg to 250mg po bid to qid or acetazolamide 500mg po bid) </li></ul><ul><ul><li>Contraindication: sulpha allergy and history of renal stones. </li></ul></ul><ul><ul><li>Side effects: fatigue, nausea, confusion, and paresthesia, aplastic anemia. </li></ul></ul>
  29. 33. Intervention <ul><li>Make sure patient is instructed application of medication or therapy appropriately. </li></ul><ul><li>Advise patient to visit on follow up on appropriate time usually 3 to 6 weeks. </li></ul><ul><li>Patient with carbonic anhydrase inhibitors, alpha agonist or miotics should be quickly reviewed after 3 days. </li></ul><ul><li>When damage is severe or IOP is high, patient has to be reexamined with in 3 days regularly. </li></ul><ul><li>Once IOP is reduced to desired level, patient is followed up in 3 to 6 months. </li></ul>
  30. 34. Surgical <ul><li>Argon Laser Trabeculoplasty </li></ul><ul><ul><li>Next therapeutic option if medical treatment fails </li></ul></ul><ul><ul><li>Reduces IOP in 70-80% of patients </li></ul></ul><ul><ul><li>Reduction of IOP about 30% </li></ul></ul><ul><li>Trabeculectomy </li></ul><ul><ul><li>Creating an opening or fistula at the limbus which allows aqueous to drain from AC directly or indirectly to the sub-conjunctival space, is then removed by one or more routes </li></ul></ul>
  31. 35. EVALUATION <ul><li>Outcome criteria: </li></ul><ul><ul><li>IOP is controlled to desired level so that POAG is controlled and retinal ganglion cells damage is prevented. </li></ul></ul><ul><ul><li>Vision is restored. </li></ul></ul>
  32. 36. Definition: ACG <ul><li>It is defined as an optic neuropathy which occurs as a result of high intraocular pressure due to narrow or closed angles </li></ul>
  33. 37. Primary Angle Closure Glaucoma <ul><li>Risk Factors: </li></ul><ul><ul><li>Age: after 40 yrs </li></ul></ul><ul><ul><li>Gender: Female:Male::4:1 </li></ul></ul><ul><ul><li>Race </li></ul></ul><ul><ul><ul><li>prevalence higher in South-East Asians, Chinese & Eskimos </li></ul></ul></ul><ul><ul><li>Family history </li></ul></ul><ul><ul><ul><li>first-degree relatives are at increased risk (≈ 3.5 times) </li></ul></ul></ul><ul><ul><li>Hypermetropes </li></ul></ul>
  34. 38. <ul><li>Predisposing Factors </li></ul><ul><ul><li>Anterior shifting of iris </li></ul></ul><ul><ul><ul><li>large lens size </li></ul></ul></ul><ul><ul><ul><li>narrow entrance to the chamber angle </li></ul></ul></ul><ul><ul><li>Smaller axial length </li></ul></ul><ul><ul><ul><li>Nanophthalmos & microphthalmos </li></ul></ul></ul>Primary Angle Closure Glaucoma
  35. 39. <ul><li>Precipitating Factors </li></ul><ul><ul><li>Dim illumination </li></ul></ul><ul><ul><li>Emotional Stress </li></ul></ul><ul><ul><li>Trauma/illness </li></ul></ul><ul><ul><li>Intense concentration </li></ul></ul><ul><ul><li>Pharmacological pupil dilatation </li></ul></ul>Primary Angle Closure Glaucoma
  36. 40. Pathogenesis of Attack: <ul><li>Mid dilatation of pupil (4-6 mm) </li></ul><ul><li>Maximum pupillary block and relaxation </li></ul><ul><li>of peripheral iris allowing </li></ul><ul><li>forward displacement of iris </li></ul><ul><li>Angle closure attack </li></ul>
  37. 41. Pupil Block: <ul><li>Increase in physiological </li></ul><ul><li>pupil block </li></ul><ul><li>Dilatation of pupil renders peripheral </li></ul><ul><li>iris more flaccid </li></ul><ul><li>Increased pressure in posterior </li></ul><ul><li>chamber causes iris bombe </li></ul><ul><li>Angle obstructed by peripheral iris </li></ul><ul><li>and rise in IOP </li></ul>
  38. 42. Symptom <ul><li>presents at emergency unit </li></ul><ul><li>sudden onset of acute pain in eye / head </li></ul><ul><li>diminution of vision </li></ul><ul><li>colour halos around the bulb </li></ul><ul><li>lacrimation / lid oedema </li></ul><ul><li>anxiety and fatigue - nausea & vomiting </li></ul>
  39. 43. Signs on Examination: <ul><li>Reduced visual acuity </li></ul><ul><li>Acute red eye </li></ul><ul><li>hazy cornea </li></ul><ul><li>vertically oval & mid-dilated pupil </li></ul><ul><li>closed angles on gonioscopy </li></ul><ul><li>high IOP over 60 or 70 mm Hg </li></ul><ul><li>cellular reaction in anterior chamber </li></ul>
  40. 44. Management: <ul><li>Principle of therapy is to bring down the IOP as quicker as possible </li></ul><ul><li>Admit the patient </li></ul><ul><li>Counsel the patient to make her anxiety free as far as possible </li></ul><ul><li>Give IOP lowering drugs </li></ul><ul><li>Reduce inflammation </li></ul><ul><li>LASER therapy </li></ul>
  41. 45. Medical Therapy: <ul><li>IV Acetazolamide (Inj Diamox, 500mg IV) followed by (250 mg tablet TID) </li></ul><ul><li>Beta-blockers </li></ul><ul><li>Miotics </li></ul><ul><li>Steroid Eye drops </li></ul>
  42. 46. Medical Therapy: <ul><li>If IOP is still more than 50mmHg </li></ul><ul><li>Hyperosmotic agents: </li></ul><ul><ul><li>Mannitol 20% </li></ul></ul><ul><ul><ul><li>1-2 gm/kg given I/V within 30-45 minutes </li></ul></ul></ul><ul><ul><li>Oral Glycerol 50%-----1-1.5 gm/kg </li></ul></ul><ul><li>Raise serum osmotic pressure and withdraw fluid from the eye specially from vitreous </li></ul><ul><li>Vitreous dehydration allows the lens to fall back deepening the AC </li></ul>
  43. 47. Fellow eye? <ul><li>Fellow eye should be treated with Pilocarpine eye drops 1drop QID </li></ul><ul><li>To be followed by prophylactic LASER Peripheral Iridotomy </li></ul>
  44. 48. Nursing management of glaucoma <ul><li>Measures taken to relieve pain </li></ul><ul><li>Reassure patient that pain and other signs and symptoms should subside with reduction of IOP </li></ul><ul><li>Provide reassurance and calm to reduce anxiety and fear </li></ul><ul><li>Provide preoperative care </li></ul><ul><li>Post operative care </li></ul>
  45. 49. THANK YOU !

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