The document discusses glaucoma, its types, classifications, and management strategies. It covers congenital and primary glaucoma, secondary glaucoma, and primary angle closure glaucoma, detailing symptoms, diagnostic approaches, and treatment options including medications and surgical interventions. The document emphasizes the importance of controlling intraocular pressure to prevent vision loss and outlines nursing assessments and patient care related to glaucoma.

1. Glaucoma Gauri S. Shrestha, M.Optom, FIACLE

2. Introduction Glaucoma refers to a group of diseases characterized by optic neuropathy specific pattern of visual field defect raised intraocular pressure Damage to optic nerve is irreversible process Normal IOP is 10-21mmHg

3. Aqueous production and drainage Secretion of aqueous humour ciliary body (posterior chamber ) Route of Drainage primary (90%): trabecular meshwork uveal-scleral outflow (10%)

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. Uveoscleral Ciliary body Suprachoroidal space Venous circulation of ciliary body, choroid and sclera

6. Classification Congenital and developmental glaucoma Primary congenital glaucoma Developmental glaucoma With associated anomalies such as Rieger syndrome, peter’s anomaly, aniridian, ectopia lentis, Sturge-Weber syndrome, nanophthalmos, congenital microcornea etc., Primary glaucoma Primary open angle glaucoma (POAG) Primary angle closure glaucoma (PACG)

7. Classification Secondary glaucoma Phacomorphic glaucoma Phacolytic glaucoma Glaucoma due to uveitis Pigmentary glaucoma Neovascular glaucoma Glaucoma associated with intraocular tumours Steroid induced glaucoma Secondary glaucoma Traumatic glaucoma Ciliary block glaucoma Glaucoma associated with intraocular haemorrhage Glaucoma associated with iridocorneal endothelial syndrome Glaucoma due to pseudoexfoliation syndrome

8. PRIMARY CONGENITAL GLAUCOMA DESCRIPTION A rare condition manifests without associated anomalies Pathogenesis Classification True congenital glaucoma (40%). IOP becomes elevated intrauterine life and child is born with ocular enlargement. Infantile glaucoma (50%). It manifests prior to child’s third birthday. Juvenile glaucoma (10%). It manifests between 3-16 years. Maldevelopment of the angle structures Impaired aqueous outflow Raised IOP

10. Symptoms and signs Symptoms Photophobia, Lacrimation, blepharospasm, enlarged eyeball, Signs Corneal edema, corneal enlargement more than 13mm diameter. Sclera become thin and appers blue Iris may show iridodonesis and atrophic patches in late stage Lens becomes flat or subluxated Optic disc shows increased cup/disc ratio and atrophy specially after third year. IOP is invariably high.

11. NURSING ASSESSMENT Child may need examination under anesthesia History on lacrimation, photophobia, and blepharospasm Assess visual acuity and perform refraction to find out loss of vision Examine cornea for edema and opacity Measure IOP with hand held perkin’s applanation tonometer Measure corneal diameter by calipers. Perform a dilated fundus examination to evaluate the optic disc and retina

12. NURSING DIAGNOSIS Altered visual perception secondary to increased intraocular pressure and manifested as Profound lacrimation, photophobia, corneal haze, and buphthalmos Loss of vision EXPECTED OUTCOME Intraocular pressure will be controlled and bring down to normal. Lacrimation will be controlled. Photophobia and corneal haze will be eliminated Prevent eye from loss of vision.

13. Intervention Counsel the child’s parents for urgent need of surgery Prepare them psychologically Check the ophthalmologic order of management plan Topical beta-blocker (timolol 0.25% to 0.50% b.i.d.) Goniotomy is the first choice of surgery (Clear cornea) Trabeculotomy corneal clouding prevents visualization of the angle Failed repeated goniotomy Monitor IOP, optic disc, and corneal diameter on regular follow up

14. EVALUATION Outcome criteria Cornea should be transparent; and IOP should be maintained with in normal range

15. PRIMARY OPEN ANGLE GLAUCOMA Usually bilateral with asymmetry in onset. Slow progressive rise in IOP (above 21mmHg), Glaucomatous optic nerve damage, Visual field loss

16. Risk-factors Ocular risk Factors . IOP . Myopia . Increased cup/disc ratio . Asymmetric cupping . Disc hemorrhage

17. Risk-factors Non ocular risk factors . Age . Race . Family history . Diabetes and Systemic hypertension . Migraine and peripheral vasospasm . Alcohol consumption . Cigarette smoking

18. PATHOGENESIS Elevated IOP in glaucoma results from increased resistance within the aqueous drainage system Retinal ganglion cell death compromise of the microvasculature with resultant ischaemia in optic nerve head mechanical damage due to raised IOP

19. Symptoms Commonly A symptomatic Detected I ncidentally Mild headache, ocular pain Minimal blurring of vision Frequent changes in presbyopic spectacles Subjective visual field defect occasionally

20. Signs on examination Minimal decrease in vision Normal conjunctiva Normal Cornea May be afferent pupillary defect Normal AC depth Open angles on gonioscopy Large CDR Raised or normal IOP

21. ASSESSMENT History: mild headache, eyeache, poor vision at night, color haloes Optic nerve: Cupping Risk factors: family history, hypertension, diabetes, age and race. Record the IOP measurement: Diurnal variation of 8mm Hg between the lowest and the highest values of IOP. Central corneal thickness Visual field testing

22. NURSING DIAGNOSIS Progressive loss of vision EXPECTED OUTCOME Stop progression of POAG and damage to retinal ganglion cells. Prevent permanent loss of vision.

25. Glaucomatous optic atrophy

27. Intervention Counseling: tests, retest, and examination Instruct the patient to avoid conditions that will increase IOP such as emotional stress, heavy exertion, wearing tight clothes around neck. Institute proper treatment advice

28. Medical treatment B-blocker: 1 st drug of choice for initial therapy Mechanism of action: Lowers IOP by reducing the aqueous secretion by effect on beta -receptor in ciliary processes Preparation: Timolol Maleate(0.25, 0.5%) BD- non selective Levobunolol (0.25,0.5%) BD- nonselective Betaxolol (0.25%) BD- cardioselective Contraindication : bronchial asthma, chronic obstructive pulmonary disease, heart-block, congestive hearth failure, depression.

29. Medical treatment Carbonic anhydrase inhibitor Preparation Dorzolamide 2% t.i.d Inhibits enzyme carbonic anhydrase -thus reduces aqueous humor formation

30. Medical treatment Prostaglandin Analogue Preparation Latanoprost(0.005%) Tarvoprost 0.004%: superior ocular hypotensive effect Bimatoprost 0.3%: potentiate trabecular outflow Increase the uveo - scleral outflow of Aqueous and decrease episcleral venous pressure

31. Medical treatment Miotics (pilocarpine1, 2, 4% q.i.d.) It mechanically increases aqueous outflow contracting ciliary muscles. Sympathomimetics (dipivefrin 0.1% bid, epinephrine 0.5% to 25 bid,) They reduce IOP by increasing aqueous outflow.

32. Medical treatment 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) Contraindication: sulpha allergy and history of renal stones. Side effects: fatigue, nausea, confusion, and paresthesia, aplastic anemia.

33. Intervention Make sure patient is instructed application of medication or therapy appropriately. Advise patient to visit on follow up on appropriate time usually 3 to 6 weeks. Patient with carbonic anhydrase inhibitors, alpha agonist or miotics should be quickly reviewed after 3 days. When damage is severe or IOP is high, patient has to be reexamined with in 3 days regularly. Once IOP is reduced to desired level, patient is followed up in 3 to 6 months.

34. Surgical Argon Laser Trabeculoplasty Next therapeutic option if medical treatment fails Reduces IOP in 70-80% of patients Reduction of IOP about 30% Trabeculectomy 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

35. EVALUATION Outcome criteria: IOP is controlled to desired level so that POAG is controlled and retinal ganglion cells damage is prevented. Vision is restored.

36. Definition: ACG It is defined as an optic neuropathy which occurs as a result of high intraocular pressure due to narrow or closed angles

37. Primary Angle Closure Glaucoma Risk Factors: Age: after 40 yrs Gender: Female:Male::4:1 Race prevalence higher in South-East Asians, Chinese & Eskimos Family history first-degree relatives are at increased risk (≈ 3.5 times) Hypermetropes

38. Predisposing Factors Anterior shifting of iris large lens size narrow entrance to the chamber angle Smaller axial length Nanophthalmos & microphthalmos Primary Angle Closure Glaucoma

39. Precipitating Factors Dim illumination Emotional Stress Trauma/illness Intense concentration Pharmacological pupil dilatation Primary Angle Closure Glaucoma

40. Pathogenesis of Attack: Mid dilatation of pupil (4-6 mm) Maximum pupillary block and relaxation of peripheral iris allowing forward displacement of iris Angle closure attack

41. Pupil Block: Increase in physiological pupil block Dilatation of pupil renders peripheral iris more flaccid Increased pressure in posterior chamber causes iris bombe Angle obstructed by peripheral iris and rise in IOP

42. Symptom presents at emergency unit sudden onset of acute pain in eye / head diminution of vision colour halos around the bulb lacrimation / lid oedema anxiety and fatigue - nausea & vomiting

43. Signs on Examination: Reduced visual acuity Acute red eye hazy cornea vertically oval & mid-dilated pupil closed angles on gonioscopy high IOP over 60 or 70 mm Hg cellular reaction in anterior chamber

44. Management: Principle of therapy is to bring down the IOP as quicker as possible Admit the patient Counsel the patient to make her anxiety free as far as possible Give IOP lowering drugs Reduce inflammation LASER therapy

45. Medical Therapy: IV Acetazolamide (Inj Diamox, 500mg IV) followed by (250 mg tablet TID) Beta-blockers Miotics Steroid Eye drops

46. Medical Therapy: If IOP is still more than 50mmHg Hyperosmotic agents: Mannitol 20% 1-2 gm/kg given I/V within 30-45 minutes Oral Glycerol 50%-----1-1.5 gm/kg Raise serum osmotic pressure and withdraw fluid from the eye specially from vitreous Vitreous dehydration allows the lens to fall back deepening the AC

47. Fellow eye? Fellow eye should be treated with Pilocarpine eye drops 1drop QID To be followed by prophylactic LASER Peripheral Iridotomy

48. Nursing management of glaucoma Measures taken to relieve pain Reassure patient that pain and other signs and symptoms should subside with reduction of IOP Provide reassurance and calm to reduce anxiety and fear Provide preoperative care Post operative care

49. THANK YOU !