In this PPT it included defination, etiology, classification, pathophysiology, diagnostic procedure and variuos medical and surgical management of glaucoma. A students from diploma or master can easily understand this presentation.

1. INVESTIGATION OF
GLAUCOMA
PANKAJ KUMAR VERMA
B-Optom – 3rd yr.

2. WHAT IS GLAUCOMA ?
• A chronic,progressive optic neuropathy
caused by a group of ocular condition
(increased I.O.P.)which lead to damage of
Optic Nerve with loss of Visual function

3. PATHOGENESIS
• Increase in IOP occurs due to decease in
aq. outflow facility
• Due to increased resistance to aq. outflow
caused by thickening & sclerosis of the
trabeculae
• Due to synechial angle
closure or mechanical
occlusion of the angle

4. TYPES OF GLAUCOMA
• Primary adult Glaucoma-
1) POAG
2) PACG
• Secondary Glaucoma
• Congenital / Developmental Glaucoma

5. WHY INVESTIGATIONS ARE
IMPORTANT??
• Diagnosis of Glaucoma
• Stage of Glaucoma
• Treatment modality
• Risk of future Glaucoma

6. GLAUCOMA
INVESTIGATIONS
• Intra Ocular Pressure ( I.O.P.)
• Gonioscopy
• Fundus Examination
• Visual Fields

7. Intra Ocular Pressure

8. Instrumentation
• Applanation Tonometer –
1) Goldmann Tonometer
2) Perkins Tonometer
• Schiotz tonometer
• Tono-Pen
• Noncontact Tonometer

9. Applanation Tonometer
• Based on Imbert Flick
Law-
For an ideal dry thin
walled sphere, the
pressure inside the sphere
(P) equal to the force
necessary to flattened its
surface (F) divided by the
area of flattening (A)
P= F/A

10. GOLDMANN TONOMETER

11. PROCEDURE
• Topical anesthesia
• Flurosine staining
• Goldmann prism is applied axially to the
corneal surface
• A pattern of semicircle is seen
• Align the inner margins of the
semicircle
• Reading on the dial *10 equals to IOP

12. POTENTIAL ERROR
• Inappropriate fluorosine pattern
• Pressure on globe
• Incorrect calibration
• Corneal pathology
like corneal oedema. distortion & abnormal
thickness

13. APPLANATION TONOMETER
• Displaces little aqueous
• Relatively inexpensive
to buy and operate
• Compact
• Hand held models
available
• No electronics, reliable
with little maintenance
• Rarely needs calibrated
• Requires topical
anesthetic
• Poor results with
edematous cornea
• Influenced by external
pressure
• corneal abrasions
possible

14. PERKINS TONOMETER

15. SCHIOTZ TONOMETER
• It measures the depth of indentation of the
anaesthetized cornea ,produced by a
weighted stylet & is measured by a lever
which travels over a scale

17. TONO-PEN

18. NONCONTACT TONOMETER

19. IN RELATION TO
GLAUCOMA
• IOP permanently raised > 21 mm of Hg –
Glaucoma Diagnostic
• IOP = 20-21 mm of Hg – Glaucoma
suspect
• Diurnal variation
> 5 mm of Hg – Glaucoma suspect
> 8 mm of Hg – Glaucoma Diagnostic

20. PROVOCATIVE TEST
• Done in Patients having Glaucoma suspect
• Water Drinking Provocative Test
• Prone Dark Room Test
• Mydriatic (Phenylephrine/Tropicamide)
Test

21. FUNDUS EXAMINATION

22. Retinal Nerve Fibers
saf
iaf
pmb
srf
irf

23. Optic Nerve Head
1)Posterior scleral foramen -
• Small cannal – small optic disc(Hyperope)
• Large cannal – large optic disc ( Myope)
2)Lamina Cribrosa –
• Series of plates of colagenous connective
tissue having 200-400 pores containing
bundle of retinal nerve fibers

24. Cont…
• Slight damage – Small pores
• Moderate damage – Oval pores
• Severe damage – Slit like pores
3) Optic Cup –
• Pale depression in the center of the Optic
Nerve Head which is not occupied by
neural tissue
• Small disc – Small cup
• Large disc – Large cup

25. Normal Optic Nerve Head
1) Cup Disc ratio ( C:D ) = 0.3 :1
2) Neuroretinal Rim –
• Tissue between outer edge of the cup &
the disk margin
• Normal rim has an Orange or pink color
• Width of rim I>S>N>T
3) Normal blood vessels

26. OPTIC NERVE HEAD

27. INSTRUMENTATION
• Direct Ophthalmoscope
• Indirect Ophthalmoscope
• +78 D or +90 D lens with S/L

28. INDIRECT
OPHTHALMOSCOPY

29. +78 or +90D lenses with S/L

30. Glaucomatous Damage
1) Retinal Nerve Fiber Damage –
• Leads to change in Optic Disc,Visual field
2) Optic Disc Damage –
• Increased C:D ratio
• Thinning of Neuroretinal rim
3) Vascular Changes – Hemorrhages
Tortuosity of Retinal vessels
Nasal shifting of Retinal vessels

31. Nerve fiber damage
• RNF defect may be
diffuse or localized
• Early localized damage
is characterized by slit
or wedge shaped
defects in RNF
• Defect increases as the
Glaucomatous changes
progresses
• At End stage – Total
atrophy of NFL

32. Optic Disc Damage
• Differentiation from
Physiological cupping
is important
• Asymmetry of cups
>0.2
• Large cup > 0.6
• Assessment of
thickness, symmetry
& color of NRR is
important

33. Early Glaucomatous changes
• Vertically Oval Cup
• Asymmetry of the Cups
> 0.2
• Large Cup > 0.6
• Splinter haemorrhages
on or near Optic disc
margin
• Pallor areas on the Disc
• Atrophy of retinal nerve
fibre

34. Advanced Glaucomatous
Changes
• Marked Cupping >0.7
• Thinning of neural
rim
• Bayonetting sign
• Pulsation of retinal
arterioles may be seen
in very high IOP
• Lamellar dot sign

35. Glaucomatous Optic Atrophy
• All neural tissue of
the disk is destroyed
• Optic nerve head
appears white &
deeply excavated

36. Progression of Disc changes

37. Imaging techniques
• Heidelberg Retinal Tomography ( HRT)
• Optical Coherence Tomography (OCT)
• Scanning Laser Polarimetry ( Nerve Fibre
Analyzer)

41. References
• Clinical ophthalmology
– Jack J. kanski
• Parsons Diseases of the Eye
– Ramanjit sihota
– Radhika tandon
• Optometric instrumentation
– David Hansen
• Shield’s Text Book of Glaucoma
- R . Rand Allingham
• Text Book of Glaucoma
- Dr. M.R. Jain
• Google .com