The goal of treatment of Glaucoma is to prevent loss of vision caused by Optic nerve Damage. Here we are giving information about recent management of glaucoma

1. Glaucoma Management:
Evolving Paradigms
DR. HABIBA SULTANA
LONG TERM FELLOW GLAUCOMA
GLAUCOMA SPECIALIST
JUNIOR CONSULTANT, DEEP EYE CARE FOUNDATION,
RANGPUR

2. We will discuss
 Aim of glaucoma management.
 When and how to treat.
 Various treatment modalities.

3. Open angle glaucoma
√ Open angle.
√ Glaucomatous
optic nerve damage.
± Elevated IOP.
± Visual field
damage.

4. Closed angle glaucoma
√ Closed angle.
± Elevated IOP.
± Glaucomatous optic nerve
damage.
± Visual field damage.

5. Glaucoma assessment checklist
 Visual acuity.
 Refractive error.
 Pupils.
 Lid/sclera/conjunctiva.
 Cornea.
 Corneal thickness.
 Intraocular pressure.

6. Contd..
 Anterior segment.
 Angle structures.
 Iris.
 Lens.

7. Contd..
 Optic nerve.
 Fundus.

8. Contd..
 Visual field.

9. How to treat

10. Indicators of unstable open angle
glaucoma:
 Elevated intraocular pressure.
 Progressive optic nerve changes.
 Progressive visual field changes.

11. How to approach

12. Angle closure
Apposition of peripheral iris against the trabecular
meshwork resulting in obstruction of aqueous
outflow.

13. By mechanism in the anterior segment
 Pupillary block
glaucoma
 Plateau iris
configuration and
syndrome.
 Phacomorphic
glaucoma.

14. By time course and presence of
symptoms
 Acute angle closure glaucoma.
 Subacute angle closure glaucoma.
 Chronic angle closure glaucoma.

15. According to clinical examination
1.Primary angle closure suspect :
Greater than 270 ITC
+
Absence of PAS
+
Normal IOP, disc & visual field

16. According to clinical examination
2.Primary angle closure :
Greater than 270 ITC With
elevated IOP & or PAS
+
Normal disc & visual field
Peripheral anterior
synechiae

17. According to clinical examination(cont.)
3.Primary angle closure glaucoma:
Greater than 270 ITC
+
Elevated IOP
+
Optic nerve & visual
field damage

18. Management plan for patients in whom
iridotomy is indicated
 Preferred surgical treatment for
acute angle closure crisis.
 In a potentially occludable angle.
 Progressive narrowing of the
angle.
 Medication required that may
provoke pupillary block.

19. Management plan for patients in whom
iridotomy is indicated(contd)
 Symptoms suggesting prior angle closure.
 Fellow eye.
 Patients occupation makes it difficult to access
immediate care.

20. Initiating closed angle care
(International recommendations)
Diagnosis Clinical Findings
Essential
Treatment
Surgical Options
Acute or
Chronic Closed
Angle (Pupil
Block)
Iris-trabecular
contact
Iris bowing
Laser Iridotomy
Or
Surgical Iridectomy
(Laser to fellow Eye)
Lens
Extraction/IOL
± Trabeculectomy
+ Mitomycin C
Closed Angle
(plateau iris)
Iris-trabecular
contact
Flat iris
Laser Iridotomy
Or
Surgical Iridectomy
(Laser to fellow Eye)
&
Laser Iridoplasty
Lens
Extraction/IOL
± Trabeculectomy
+ Mitomycin C

21. Artificial intelligence in
glaucoma diagnosis
 Also known as machine intelligence,
refers to capability of a machine to
imitate human intelligence.
 Through the use of automated
computer vision image interpretation
offer a novel method of diagnostic
imaging.
 Have potential to incorporate structural
and functional changes over time.
 Potential to provide more accurate and
timely identification of progression.

23. Surgical intervention

24. Trabeculectomy
 Gold standard.
 IOP reduction <21mmHg in 86-96%.
 Aim is to create an alternative drainage pathway for
aqueous humor to exit the eye.

26. Minimally invasive glaucoma
surgery
 Provide safer and more efficient
IOP lowering.
 Inserted through an ab interno
approach.
 Target 3 anatomical space
,schlemm cana, suprachoroidal
and subconjuntival space.

27. Glaucoma drainage devices
 Preferred surgical option for refractory
glaucoma.
 In cases where trabeculectomy failure
rate is higher (Neovascular glaucoma
,uveitic and some congenital glaucoma).

29. Cyclodiode laser
 Most widely used method of ciliary
ablation with success rate 40-80%.
 Reduced aqueous production by
destruction of ciliary epithelium and
reduced vascular perfusion.
 Indicated in painful blind eye ,NVG
and refractory glaucoma with poor
or no visual potential.

31. Referral
 If diagnosis and management is in question.
 Condition is refractory to treatment.
 Patients with significant visual impairment or
blindness.

32. Take home message
 Glaucoma should be ruled out as part of every regular eye
examination.
 Differentiating open angle or angle closure by gonioscopy is
very much essential.
 Refferral should be done if diagnosis and management is in
question.

33. Reference
 Becker-Shaffer's, Diagnosis and therapy of Glaucoma 8th
edition
 Textbook of glaucoma– M.Bruce Shields 5th
edition.
 ICO glaucoma guideline.
Preffered practice pattern of angle closure glaucoma
 www.gonioscopy.org a website dedicated to gonioscopy -
video atlas

34. Thank You All