some people are affected with this problem they want to know about the glaucoma causes, risk factor, pathophysiology, signs and symptoms, treatment and complication, etc and they get more knowledge and they will avoid the complication especially loss of vision.

1. R.PRIYA
PROFESSOR

2. GLAUCOMA

3. INTRODUCTION
Glaucoma has been known in medicine since Antiquity. Hippocrates
described "glaykoseis" as blindness which occurs in the elderly. The English
ophthalmologist Banister was the first to establish the connection between
increased tension of the eyeball and glaucoma. The important invention of
the ophthalmoscope by von Helmholtz (1850) made it possible to
diagnose glaucomatous changes in the fundus. In 1862, Donders
discovered that high intraocular pressure caused blindness and called the
disease "Glaukoma simplex." Further progress in the diagnosis of
glaucoma was made by the invention of the tonometer and the perimeter,
The first effective surgical treatment of glaucoma, an iridectomy, was
carried out by von Graefe in 1856. Drug treatment started in 1875 with the
discovery of pilocarpine. About 6 to 67 million people have glaucoma
globally.The disease affects about 2 million people in the United States

4. DEFINITION
A common eye condition in which the fluid pressure inside the eye rises to a
level higher than healthy for that eye. If untreated, it may damage the optic
nerve, causing the loss of vision or even blindness.

5. CAUSES
• Increased pressure in the eye,
• a family history of the condition, and
• high blood pressure, pressure more than 21 mmHg or 2.8 kPa is often used, with higher
pressures leading for years and never develop damage. Conversely, optic nerve damage
may occur with normal pressure, known as normal-tension glaucoma
• elevated eye pressure is due to a buildup of a fluid (aqueous humor) that flows
throughout the inside of your eye. This internal fluid normally drains out through
a tissue called the trabecular meshwork at the angle of the iris and cornea
meet. When fluid is overproduced or the drainage system doesn't work
properly, the fluid can't flow out at its normal rate and eye pressure increases.

6. RISK FACTOR
 Having high internal eye pressure (intraocular pressure)
 Being over age 60
 Being black, Asian or Hispanic
 Having a family history of glaucoma
 Having certain medical conditions, such as diabetes, heart disease, high blood pressure and sickle
cell anemia
 Having corneas that are thin in the center
 Being extremely nearsighted or farsighted
 Having had an eye injury or certain types of eye surgery
 Taking corticosteroid medications, especially eyedrops, for a long time

7. TYPES
1. Open-angle glaucoma
Open-angle glaucoma is the most common form of the disease. The drainage angle formed
by the cornea and iris remains open, but the trabecular meshwork is partially blocked. This
causes pressure in the eye to gradually increase. This pressure damages the optic nerve. It
happens so slowly that you may lose vision before you're even aware of a problem.
2. Angle-closure glaucoma
Angle-closure glaucoma, also called closed-angle glaucoma, occurs when the iris bulges
forward to narrow or block the drainage angle formed by the cornea and iris. As a result,
fluid can't circulate through the eye and pressure increases. Some people have narrow
drainage angles, putting them at increased risk of angle-closure glaucoma.
Angle-closure glaucoma may occur suddenly (acute angle-closure glaucoma) or gradually
(chronic angle-closure glaucoma). Acute angle-closure glaucoma is a medical emergency.

8. 3. Normal-tension glaucoma
In normal-tension glaucoma, your optic nerve becomes damaged even though your eye pressure is within
the normal range. No one knows the exact reason for this. You may have a sensitive optic nerve, or you may
have less blood being supplied to your optic nerve. This limited blood flow could be caused by
atherosclerosis — the buildup of fatty deposits (plaque) in the arteries — or other conditions that impair
circulation.
4. Glaucoma in children
It's possible for infants and children to have glaucoma. It may be present from birth or develop in the first few
years of life. The optic nerve damage may be caused by drainage blockages or an underlying medical
condition.
5. Pigmentary glaucoma
In pigmentary glaucoma, pigment granules from your iris build up in the drainage channels, slowing or
blocking fluid exiting your eye. Activities such as jogging sometimes stir up the pigment granules, depositing
them on the trabecular meshwork and causing intermittent pressure elevations.

10. PATHOPHYSIOLOGY

11. SIGNS AND SYMPTOMS
1.Open-angle glaucoma
There are no warning signs or obvious symptoms in the early stages. As the disease progresses,
blind spots develop in your peripheral (side) vision.
Most people with open-angle glaucoma do not notice any change in their vision until the
damage is quite severe. This is why glaucoma is called the “silent thief of sight.” Having regular
eye exams can help your ophthalmologist find this disease before you lose vision. Your
ophthalmologist can tell you how often you should be examined.

12. 2. ANGLE-CLOSURE GLAUCOMA
 severe pain in the eye or forehead
 redness of the eye
 decreased vision or blurred vision
 seeing rainbows or halos
 headache
 nausea
 Vomiting
3 . Normal tension glaucoma
 blind spots in their field of vision and optic nerve damage.

13. DIAGNOSTIC EVALUATION
 Tonometry
Tonometry measures the pressure within your eye. During tonometry, eye drops are used
to numb the eye. Then a doctor or technician uses a device called a tonometer to
measure the inner pressure of the eye. A small amount of pressure is applied to the eye
by a tiny device or by a warm puff of air.
The range for normal pressure is 12-22 mm Hg (“mm Hg” refers to millimeters of
mercury, a scale used to record eye pressure). Most glaucoma cases are diagnosed with
pressure exceeding 20mm Hg. However, some people can have glaucoma at pressures
between 12 -22mm Hg. Eye pressure is unique to each person.
 Ophthalmoscopy
This diagnostic procedure helps the doctor examine your optic nerve for glaucoma
damage. Eye drops are used to dilate the pupil so that the doctor can see through your
eye to examine the shape and color of the optic nerve.
The doctor will then use a small device with a light on the end to light and magnify the
optic nerve. If your intraocular pressure (IOP) is not within the normal range or if the
optic nerve looks unusual, your doctor may ask you to have one or two more glaucoma
exams: perimetry and gonioscopy.

14. Perimetry
Perimetry is a visual field test that produces a map of the complete field of vision. During this test, you will be
asked to look straight ahead as a light spot is repeatedly presented in different areas of your peripheral vision.
This helps draw a "map" of your vision.
Do not be concerned if there is a delay in seeing the light as it moves in or around your blind spot. This is
perfectly normal and does not necessarily mean that your field of vision is damaged. Try to relax and respond as
accurately as possible during the test.
doctor may want you to repeat the test to see if the results are the same the next time you take it. After
glaucoma has been diagnosed, visual field tests are usually done one to two times a year to check for any
changes in your vision.
Gonioscopy
This diagnostic exam helps determine whether the angle where the iris meets the cornea is open and wide or
narrow and closed. During the exam, eye drops are used to numb the eye. A hand-held contact lens is gently
placed on the eye. This contact lens has a mirror that shows the doctor if the angle between the iris and cornea
is closed and blocked (a possible sign of angle-closure or acute glaucoma) or wide and open (a possible sign of
open-angle, chronic glaucoma).
 Pachymetry
Pachymetry is a simple, painless test to measure the thickness of your cornea -- the clear window at the front of
the eye. A probe called a pachymeter is gently placed on the front of the eye (the cornea) to measure its
thickness. Pachymetry can help your diagnosis, because corneal thickness has the potential to influence eye
pressure readings. With this measurement, your doctor can better understand your IOP reading and develop a
treatment plan that is right for you. The procedure takes only about a minute to measure both eyes.

15. MANAGEMENT
• Prostaglandins. These increase the outflow of the fluid in your eye
(aqueous humor), thereby reducing your eye pressure. Medicines in this
category include latanoprost (Xalatan), travoprost (Travatan Z), tafluprost
(Zioptan), bimatoprost (Lumigan) and latanoprostene bunod (Vyzulta).
• Beta blockers. These reduce the production of fluid in your eye, thereby lowering the
pressure in your eye (intraocular pressure). Examples include timolol (Betimol, Istalol,
Timoptic) and betaxolol (Betoptic).
• Alpha-adrenergic agonists. These reduce the production of aqueous humor and
increase outflow of the fluid in your eye. Examples include apraclonidine
(Iopidine) and brimonidine (Alphagan P, Qoliana).

16. • Carbonic anhydrase inhibitors. These medicines reduce the production of fluid in your eye.
Examples include dorzolamide (Trusopt) and brinzolamide (Azopt). Possible side effects include
a metallic taste, frequent urination, and tingling in the fingers and toes. This class of drug is
usually prescribed for twice-daily use but sometimes can be prescribed for use three times a
day.
• Rho kinase inhibitor. This medicine lowers eye pressure by suppressing the rho kinase
enzymes responsible for fluid increase. It is available as netarsudil (Rhopressa) and is prescribed
for once-a-day use. Possible side effects include eye redness, eye discomfort and deposits
forming on the cornea.
• Miotic or cholinergic agents. These increase the outflow of fluid from your eye. An example is
pilocarpine (Isopto Carpine). Side effects include headache, eye ache, smaller pupils, possible
blurred or dim vision, and nearsightedness. This class of medicine is usually prescribed to be
used up to four times a day. Because of potential side effects and the need for frequent daily use,
these medications are not prescribed very often anymore.

17. SURGICAL MANAGEMENT
Here are soHere are some types of laser surgery for glaucoma:
 Argon laser trabeculoplasty (ALT): This opens clogs in your eye so fluid can drain
out. Your doctor may treat half of the clogs first, see how well it works, then treat
the other half later. ALT works in about 75% of people with the most common
kind of glaucoma.
 Selective laser trabeculoplasty (SLT): If ALT doesn’t work so well, your doctor may
try this. Your doctor beams a highly targeted low-level laser at just the spots
where there’s pressure. You can do SLT a little at a time.
 Laser peripheral iridotomy (LPI): If the space between your eye’s iris (the colored
part) and cornea (the clear outer layer) is too small, you can get narrow-angle
glaucoma. Fluid and pressure build up in this area. LPI uses a laser beam to
create a tiny hole in the iris. The extra fluid can drain and relieve pressure.
 Cyclophotocoagulation: If other laser treatments or surgery doesn't ease fluid
buildup and pressure, your doctor can try this. He’ll beam a laser into a structure
inside your eye to ease pressure. You may need to repeat it over time to keep
your glaucoma in check.

18. If laser surgery or drugs don’t relieve your eye pressure, you may need a more traditional
operation.You might have to go into the hospital or surgery center, and you’ll probably
need a few weeks to heal and recover.
These procedures include:
• Trabeculectomy: The surgeon will make a small cut in the white part of your eye
to take out some of the mesh of tissue inside. This helps the extra fluid drain out.
You may need to take some medicine along with this surgery so scar tissue
doesn’t form. The procedure can be done in your doctor’s office or an outpatient
clinic.
• Drainage implant surgery: The doctor places a tiny tube inside your eye so fluid
can drain. Now there are minimally invasive implants.
• Electrocautery: In this procedure, the surgeon uses a heat device called a
Trabectome to make a tiny cut in your eye’s drainage tubes. It sends heat to the
mesh of tissue inside your eye. It can ease fluid buildup and pressure. It’s not as
invasive as trabeculectomy or drainage implant surgery.

19. AFTER CARE OF SURGERY
After surgery, rest at home for about a week. Don’t drive, read, bend over, or
lift anything heavy for up to 4 weeks. Keep water out of your eye. Your eye
may be red, sore, or watery. You may also see a little bump where the cut
was made.
Your vision might be a little blurry for about 6 weeks. Contact lenses may not
fit until the bump or swelling goes down. About half of people who get this
surgery no longer need medications to keep pressure down.

20. COMPLICATION OF SURGERY
•Eye pain or redness
•Eye pressure that’s still too high or even too low
•Loss of vision
•Infection
•Inflammation
•Bleeding in your eye

21. NURSING CARE PLAN
Altered sensory reception: altered status of sense organ
NursingInterventions Rationale
Determine type and degree of visual loss.
Affects choice of interventions and
patient’s future expectations.
Allow expression of feelings about loss and
possibility of loss of vision.
Although early intervention can prevent
blindness, the patient faces the
possibility or may have already
experienced a partial or complete loss
vision. Although vision loss cannot be
restored (even with treatment), a
loss can be prevented.
Implement measures to assist patient to
manage visual limitations such as reducing
clutter, arranging furniture out of travel
path; turning head to view subjects;
correcting for dim light and problems of
Reduces safety hazards related to
changes in visual fields or loss of vision
and papillary accommodation to
environmental light.

22. ASSsist with administration of medications
as indicated:
These direct-acting topical myotic drugs
cause pupillary constriction, facilitating the
outflow of aqueous humor and lowering
IOP. Note: Ocusert is a disc (similar to a
contact) that is placed in the lower eyelid,
where it can remain for up to 1 wk before
being replaced.
Stress the importance of meticulous
compliance with prescribed drug therapy:
To prevent an increase in IOP, resulting in
disk changes and loss of vision.
•Chronic, open-angle glaucoma Pilocarpine
hydrochloride (Isopto Carpine, Ocusert
[disc], Pilopine HS gel)
Beta-blockers decrease the formation of
aqueous humor without changing pupil size,
vision, or accommodation. Note: These
drugs may be contraindicated or require
close monitoring for systemic effects in the
presence of bradycardia or asthma.

23. •Timolol Maleate (Timoptic), betaxolol
(Betoptic), carteolol (Ocupress),
metipranolol (OptiPranolol), levobunolol
(Betagan)T
Carbonic anhydrase inhibitors decrease the rate of
production of aqueous humor. Note: Systemic adverse
effects are common, including mood disturbances, GI
upset, and fatigue.
•Acetazolamide (Diamox), methazolamide
(Neptazane), dorzolamide (Trusopt)
Contracts the sphincter muscles of the iris, deepens
anterior chamber and dilates vessels of outflow tract
during an acute attack or before surgery.
•Narrow-angle (angle-closure) type Myotics
(until the pupil is constricted); Carbonic
anhydrase inhibitors like acetazolamide
(Diamox); dichlorphenamide (Daranide);
methazolamide (Neptazane);
Decreases secretion of aqueous humor and lowers IOP.

24. Provide sedation, analgesics as necessary.
Acute glaucoma attack is associated with sudden
pain, which can precipitate anxiety and agitation,
further elevating IOP. Medical management may
require 4–6 hr before IOP decreases and pain
subsides.
•Prepare for surgical intervention as
indicated:Laser therapy such as argon laser
trabeculoplasty (ALT), trabeculectomy or
trephination
Filtering operations (laser surgery) are highly
successful procedures for reducing IOP by creating
an opening between the anterior chamber and the
subjunctival spaces so that aqueous humor can
bypass the trabecular mesh block. Note:
Apraclonidine (Lopidine) eye drops may be used in
conjunction with laser therapy to lessen or prevent
postprocedure elevations of IOP.
•Iridectomy
Surgical removal of a portion of the iris facilitates
drainage of aqueous humor through a newly
created opening in the iris connecting to normal
outflow channels. Note: Bilateral iridectomy is
performed because glaucoma usually develops in
the other eye.

25. Postoperative care after peripheral iridectomy
includes cycloplegic eye drops.
To relax the ciliary muscle and to decrease
inflammation, thus preventing adhesions.
Cycloplegics must be used only in the affected
eye. the use of these drops in the normal eye
may precipitate an attack of acute angle-closure
glaucoma in this eye, threatening the patient’s
residual vision.
•Malento valve implant
Separates ciliary body from the sclera to facilitate
outflow of aqueous humor.
•Cyclocryotherapy Used in intractable glaucoma.
•Diathermy or cryosurgery
If other treatments fail, destruction of the ciliary
body reduces the formation of aqueous humor
•Aqueous-venous shunt
Experimental ocular implant device corrects
and prevents scarring over or closure of drainage
sac created by trabeculectomy.