Glaucoma(1)

GLAUCOMAGLAUCOMAGLAUCOMAGLAUCOMA

Harold E. Cross M.D., Ph.D.Harold E. Cross M.D., Ph.D.

10-06-09 v. 7.010-06-09 v. 7.0(Contributions by Todd Altenbernd, MD)(Contributions by Todd Altenbernd, MD)


What is it?What is it?

A disease of progressive optic A disease of progressive optic neuropathy with loss of retinal neuropathy with loss of retinal neurons and the nerve fiber layer, neurons and the nerve fiber layer, resulting in blindness if left resulting in blindness if left untreated.untreated.

GLAUCOMAGLAUCOMA

““Glaucoma describes a group of diseases that kill retinal Glaucoma describes a group of diseases that kill retinal ganglion cells.”ganglion cells.”

““High IOP is the strongest known risk factor for glaucoma High IOP is the strongest known risk factor for glaucoma but it is neither necessary nor sufficient to induce the but it is neither necessary nor sufficient to induce the neuropathy.”neuropathy.”

Libby, RT, et al: Annu Rev Genomics Hum Genet Libby, RT, et al: Annu Rev Genomics Hum Genet 6:6: 15, 2005 15, 2005


There is a dose-response There is a dose-response relationship between intraocular relationship between intraocular pressure and the risk of damage to pressure and the risk of damage to the visual field.the visual field.

What causes it?What causes it?

ADVANCED GLAUCOMAADVANCED GLAUCOMAINTERVENTION STUDYINTERVENTION STUDY



How do we diagnose it?How do we diagnose it?

IOP is not helpful diagnostically until it reaches IOP is not helpful diagnostically until it reaches approximately 40 mm Hg at which level the approximately 40 mm Hg at which level the likelihood of damage is significant.likelihood of damage is significant. Visual fields are also not helpful in the early stagesVisual fields are also not helpful in the early stages of diagnosis because a considerable number of neurons of diagnosis because a considerable number of neurons

must be lost before VF changes can be must be lost before VF changes can be detected.detected. Optic nerve damage in the early stages is difficultOptic nerve damage in the early stages is difficult or impossible to recognize.or impossible to recognize. 50% of people with glaucoma do not know it!50% of people with glaucoma do not know it!


Intraocular pressure is not the only factor Intraocular pressure is not the only factor

responsible for glaucoma!responsible for glaucoma!

95% of people with elevated IOP will never have 95% of people with elevated IOP will never have the damage associated with glaucoma.the damage associated with glaucoma.

One-third of patients with glaucoma do not haveOne-third of patients with glaucoma do not have

elevated IOP.elevated IOP. Most of the ocular findings that occur in people Most of the ocular findings that occur in people

with glaucoma also occur in people without with glaucoma also occur in people without glaucoma.glaucoma.


Population distribution of IOPPopulation distribution of IOP


IOP VariablesIOP Variables

Gender influences:Gender influences: Normal vs glaucoma:Normal vs glaucoma:

GLAUCOMAGLAUCOMA

Anatomy ofanterior chamberangle

Iris bombéIris bombé



Angle AnatomyAngle Anatomy


How do we measure How do we measure IOP?IOP?

ApplanationApplanation

TonopenTonopen

SchiotzSchiotz

AirAir

Non-contactNon-contact

GLAUCOMAGLAUCOMAGLAUCOMAGLAUCOMATonometryTonometry

ApplanationApplanationSchiotzSchiotz


Goldmann applanation Goldmann applanation tonometertonometer


TonopenTonopen


The normal visual field: an island of The normal visual field: an island of vision in a sea of darkness:vision in a sea of darkness:


Goldmann perimeterGoldmann perimeter Glaucoma visual fieldsGlaucoma visual fields

THE VISUAL FIELDTHE VISUAL FIELDHumphrey automated perimetry

GLAUCOMAGLAUCOMAGLAUCOMAGLAUCOMAVisual fields in glaucomaVisual fields in glaucoma

EarlyEarly

LateLate


Cup-to-disk ratioCup-to-disk ratio


NormalNormal

DISK CUPPINGDISK CUPPING

GlaucomaGlaucoma

GLAUCOMAGLAUCOMAGLAUCOMAGLAUCOMAGlaucomatous cuppingGlaucomatous cupping

GLAUCOMAGLAUCOMAGLAUCOMAGLAUCOMAThe histology of glaucomatous optic nerve The histology of glaucomatous optic nerve

cupping:cupping:

Normal:Normal:

GlaucomatousGlaucomatous::


Optic nerve signs of glaucoma progressionOptic nerve signs of glaucoma progression

Increasing C:D ratioIncreasing C:D ratio Development of disk pallorDevelopment of disk pallor Disc hemorrhage (60% will show progression ofDisc hemorrhage (60% will show progression of visual field damage)visual field damage) Vessel displacementVessel displacement Increased visibility of lamina cribosaIncreased visibility of lamina cribosa


Ocular hypertension treatment studyOcular hypertension treatment study

(OHTS study)(OHTS study)

GOALS: To evaluate the effectiveness of topical ocular hypotensiveGOALS: To evaluate the effectiveness of topical ocular hypotensive medications in preventing or delaying visual field loss medications in preventing or delaying visual field loss and/or optic nerve damage in subjects with ocular hyper-and/or optic nerve damage in subjects with ocular hypertension at moderate risk for developing open-angle tension at moderate risk for developing open-angle glaucoma (POAG).glaucoma (POAG).

POPULATION: 1636 participants aged 40-80 years with IOP 24-32 POPULATION: 1636 participants aged 40-80 years with IOP 24-32 mm HG in one eye, and 21-32 in the other, randomly mm HG in one eye, and 21-32 in the other, randomly assigned to observation and treatment groups.assigned to observation and treatment groups.


TREATMENT GOALS: Reduce pressure to less than or TREATMENT GOALS: Reduce pressure to less than or equal to 24 mm Hg with a minimum pressure reduction equal to 24 mm Hg with a minimum pressure reduction of 20% from the baseline.of 20% from the baseline.

OUTCOME MEASURES: Development of reproducible OUTCOME MEASURES: Development of reproducible visual field abnormality or development of optic disc visual field abnormality or development of optic disc deterioration.deterioration.

MEDICATIONS USED: beta-adrenergic antagonists, MEDICATIONS USED: beta-adrenergic antagonists,

prostaglandin analogues, topical carbonic anhydrase prostaglandin analogues, topical carbonic anhydrase inhibitors, alpha-2 agonists, parasympathomimetic inhibitors, alpha-2 agonists, parasympathomimetic agents, and epinephrine.agents, and epinephrine.

OHTS parametersOHTS parameters


OHTS ConclusionsOHTS Conclusions

At 60 months, the At 60 months, the probability of developing probability of developing glaucoma was:glaucoma was:

9.5% in observation group9.5% in observation group

4.4% in treatment group4.4% in treatment group


OHTS parameters that OHTS parameters that influence the risk of influence the risk of developing POAGdeveloping POAG

IOPIOP

Age Age

Cup-disk ratioCup-disk ratio

Central corneal thicknessCentral corneal thickness

GLAUCOMAGLAUCOMAGLAUCOMAGLAUCOMAPercentage of OHTS participants in Percentage of OHTS participants in

observation group who developed POAG observation group who developed POAG (mean follow-up = 72 mo)(mean follow-up = 72 mo)

IOP vs central IOP vs central corneal thicknesscorneal thickness

GLAUCOMAGLAUCOMA

Normal central corneal thickness: 545 – 550 uNormal central corneal thickness: 545 – 550 u

Add or subtract 2.5 mmHg for each 50 u Add or subtract 2.5 mmHg for each 50 u change in central corneal thicknesschange in central corneal thickness


Types of glaucomaTypes of glaucoma

I. Primary: A. Congenital B. Hereditary C. Adult (common types) 1. Narrow angle 2. Open angle II. Secondary A. Inflammatory B. Traumatic C. Rubeotic D. Phacolytic etc.

Congenital GlaucomaCongenital GlaucomaCongenital GlaucomaCongenital Glaucoma

Onset: antenatally to 2 years oldOnset: antenatally to 2 years old

SymptomsSymptoms IrritabilityIrritability PhotophobiaPhotophobia EpiphoraEpiphora Poor visionPoor vision

Signs Elevated IOP Buphthalmos Haab’s striae Corneal clouding Glaucomatous cupping Field loss


Buphthalmos and cloudy corneasBuphthalmos and cloudy corneas


Buphthalmos, glaucomatous cupping, and cloudy cornea OD

Normal OS

Haab’s striae

Narrow Angle GlaucomaNarrow Angle GlaucomaOnset: 50+ years of ageOnset: 50+ years of age

SymptomsSymptoms Severe eye/headacheSevere eye/headache painpain Blurred visionBlurred vision Red eyeRed eye Nausea and vomitingNausea and vomiting Halos around lightsHalos around lights Intermittent eye acheIntermittent eye ache at nightat night

SignsSigns Red, teary eyeRed, teary eye Corneal edemaCorneal edema Closed angleClosed angle Shallow ACShallow AC Mid-dilated, fixedMid-dilated, fixed pupilpupil “ “Glaucomflecken”Glaucomflecken” Iris atrophyIris atrophy AC inflammationAC inflammation


Angle anatomyAngle anatomy

Grade I Grade 0 Grade III Grade IIGrade I Grade 0 Grade III Grade II

GLAUCOMAGLAUCOMAGLAUCOMAGLAUCOMAAnatomy of Angle Closure GlaucomaAnatomy of Angle Closure Glaucoma

Narrow Angle GlaucomaNarrow Angle Glaucoma

Mid-dilated, fixed pupilMid-dilated, fixed pupil

Narrow Angle GlaucomaNarrow Angle GlaucomaTreatment: Peripheral Treatment: Peripheral IridotomyIridotomy

Open Angle GlaucomaOpen Angle GlaucomaAka: chronic simple glaucoma (CSG)Aka: chronic simple glaucoma (CSG)

and primary open angle glaucoma (POAG)and primary open angle glaucoma (POAG)

Onset: 50+ years of ageOnset: 50+ years of age

SymptomsSymptoms

Usually noneUsually none May have loss of central May have loss of central and peripheral visionand peripheral vision latelate

SignsSigns Elevated IOPElevated IOP Visual field lossVisual field loss Glaucomatous disk changesGlaucomatous disk changes

HISTORY:HISTORY: Positive family Positive family

historyhistory African American African American

backgroundbackground History of traumaHistory of trauma History of steroid History of steroid

useuse

Open Angle GlaucomaOpen Angle GlaucomaRisk factorsRisk factors

EXAMINATION:EXAMINATION:C/D 0.6 or greaterC/D 0.6 or greaterVertical Vertical elongation of disc elongation of disc

Inf. rim thinnerInf. rim thinner than sup.than sup.

C/D asymmetry >C/D asymmetry > 0.2 0.2


TreatmentTreatment

MedicalMedical SurgicalSurgical

MioticsMiotics Beta-blockersBeta-blockers Carbonic anhydraseCarbonic anhydrase inhibitorsinhibitors ProstaglandinProstaglandin analoguesanalogues Alpha-2 agonistsAlpha-2 agonists

Argon laser trabeculoplastyArgon laser trabeculoplasty TrabeculectomyTrabeculectomy Filtering procedureFiltering procedure CyclocryotherapyCyclocryotherapy Cyclolaser ablationCyclolaser ablation IridotomyIridotomy

GLAUCOMAGLAUCOMAGLAUCOMAGLAUCOMATreatmentTreatment

GLAUCOMAGLAUCOMAGLAUCOMAGLAUCOMASurgical treatment of glaucomaSurgical treatment of glaucoma

Argon laserArgon lasertrabeculoplastytrabeculoplasty

FiltrationFiltrationproceduresprocedures


Filtration blebsFiltration blebs

THANK YOU ALL FOR LISTENING!THANK YOU ALL FOR LISTENING!

Glaucoma(1)

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