Primary open angle glaucoma has few symptoms initially but can cause vision loss and blindness. Signs include changes to intraocular pressure, the optic disc, and visual fields. Intraocular pressure may be normal initially but later rises permanently above 21mmHg. Optic disc changes include a vertically oval cup, asymmetry between eyes, and pallor of the retinal nerve fiber layer. Visual field defects begin as contraction of the visual field or scotomas and progress to advanced defects. Diurnal testing monitors intraocular pressure changes over 24 hours which can help diagnose glaucoma.

1. Primary open angle glaucoma
clinical features
By
Dr.Sampda Sharma

2. Symptoms
• Most patients -Asymptomatic
• Headache and eye ache
• Scotoma
• Difficulty in reading and close work
• Delayed dark adaptation
• Significant loss of vision and blindness

4. Signs
1. Anterior segment signs
2. Intraocular-pressure changes
3. Optic disc changes
4. Visual field changes

5. 1.Anterior segment signs
• Late stage : pupil reflex become sluggish
• Central corneal thickness (CCT)

6. 2.Intra ocular pressure changes
• Initial stage : IOP may not rise permanently
There is exaggeration of normal
diurnal variation
• Later stage : IOP permanently raised above
21mmHg (ranges btw 30-40 mmHg)

7. DIURNAL VARIATION TEST
Repeat observation of IOP (every 3-4 hr)
for 24 hr
• Most patients : IOP falls during evening
• Morning rise in IOP – 20% of cases
• Afternoon rise in IOP – 25% of cases
• Biphasic rise in IOP – 55% of cases
• Variation of IOP over
5mmHg (Schiotz)-suspecious
8mmHg – diagnostic

8. Normal slight morning rise
Morning rise in IOP – 20% of cases
Afternoon rise in IOP – 25% of cases
Biphasic rise in IOP – 55% of cases

9. 3.Optic disk changes
• Best examination technique:
 Slit lamp biomicroscopic examination
With contact or non contact lens
• Recording and documentation:
Serial handdrawings
Photography , photogrammetry
(CSLT) confocal scanning laser topography
CT ,(NFA) nerve fibre analysis
OCT (optical coherence tomography)

10. Pathophysiology of disc changes
Mechanical
effect
↑IOP forces
lamina cribrosa
backwards
Squeezes nerve
fibres within its
meshes to disturb
axoplasmic flow
Vascular
factors
Ischemic atrophy
of nerve fibres
Without
corresponding ↑
of supporting
glial tissue

11. Subtle glaucomatous changes
a) Early glaucomatous changes
b) Advanced glaucomatous changes
c) Glaucomatous optic atrophy

12. (a) Early glaucomatous changes

14. Vertically oval cup
Due to selective loss of neural rim tissue in the
inferior and superior poles

15. Assymetry of cups
Large cup : > 0.6 (N-0.3 to 0.4)

16. Splinter hemorrhage

17. Pallor areas
Atrophy of retinal nerve fibre layer
seen with red free light

18. (b) Advanced glaucomatous
changes

19. (Cup:Disk
ratio 0.7-0.9)
(BAYONETTING SIGN)

20. neuroretinal rim

21. Normally-thickest
to thinnest parts of
neuroretinal rim of OD
are
inf,sup,nasal,tempoal
(ISNT RULE)
Any variation-
glaucoma
Crescentic shaddow
adjacent to disk margins

22. •Pulsations of retinal
arterioles at disk margins
•Lamellar dot sign – pores in
lamina cribrosa are slit shaped
•Total bean-pot cupping

23. (c)Glaucomatous optic atrophy
• All neural tissue of disk is
destroyed
• Optic nerve head appears
white and deeply excaveted

25. 4.Visual field defect
• Anatomical basis of field defect
A.Distribution of retinal nerve
fibers
B.Arrangement of nerve fibers
within optic nerve head

26. Arrangement of nerve fibers within
optic nerve head

27. Nomenclature of glaucomatous field
defects
1. Isopter contraction
2. Baring of blind spot
3. Small wing shaped paracentral scotoma
4. Seidle’s scotoma
5. Arcuate or Bjerrum’s scotoma
6. Ring or double arcuate scotoma
7. Roenne’s central nasal step
8. Peripheral field defects
9. Advanced glaucomatous field defects
I C BB Wings & SAD STEPS

28. Baring of blind spot
Small wing-shaped paracentral scotoma
Seidel’s scotoma
Arcuate or Bjerrum’s scotoma
Ring or double arcuate scotoma
And Roenne’s central nasal step

29. Thank you