Glaucoma. Glaucoma. Optic Disc Cupping

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1 Glaucoma What is Glaucoma? Bruce James A group of diseases in which damage to the optic nerve occurs as a result of intraocualar pressure being above the physiological norm for that eye Stoke Mandeville Hospital Priestley Smith 1885 Emeritus Professor of Ophthalmology University of Birmingham Glaucoma No doubt the excavation of the disc in glaucoma is not a purely mechanical result of exalted pressure; it is, in part at least, an atrophic condition which, though primarily due to pressure, includes vascular changes and impaired nutrition in the substance of the optic disc...which may probably progress even though all excess of pressure be removed Optic Disc Cupping In glaucoma damage to the axons occurs in the lamina cribrosa of the optic nerve head leading to Retinal Ganglion Cell Death probably by a disruption of axonal transport Increased Translaminar pressure Gradient Mechanical Changes Stress on the lamina cribrosa may not necessarily lead to deformation, the scleral canal may expand and tighten the lamina Physiological Changes Interference with the delivery of nutrients to the optic nerve Increases energy required for axonal transport Burgoyne Burgoyne 1

2 Diagnosis of Glaucoma Medicine is a science of uncertainty and an art of probability William Osler As appealing as it is to have incontrovertible scientific backing for our actions in treating our patients, we often simply don t know what to do. Symptoms Chronic open angle glaucoma-none Angle closure glaucoma Pain Redness of eye Reduced Vision Caroline Wellberry The Lancet 375 May 2010 Signs Chronic Open Angle Glaucoma Reduced Visual Field Pressure may be raised Increased Optic Disc Cupping Secondary Examination» Pachymetry» Gonioscopy 2

3 How is glaucoma Classified? According to the appearance of the angle of the eye Open and Closed Angle Glaucoma Signs Meaningful interpretation, reducing uncertainty, requires accurate measurement IOP measurement The Instrument Calibration The Eye Tear film Corneal Thickness Corneal Shape Corneal abnormalities Accommodation Eye Position The Patient Increased venous pressure Orbicularis Contraction 3

4 The Technique Tonometer -Tear Contact Fluorescein Concentration Duration of Tonometer Contact Pressure on the eye by the examiners fingers Sampling Errors IOP Varies with:- Pulse Respiration Blinking Exercise Posture Time Pressure >3 mmhg in 17% of consecutive measurements by 2 different ophthalmologists Thorburn W. The accuracy of clinical applanation tonometry. Acta Ophthalmol 1978;56:1-5 Field Computerised Field Test 4

5 Disc Cupping Looking for change Disc Photography Tomography Retinal Nerve Fibre Layer Polarimetry OCT Retinal Nerve Fibre LayerLAyer Achieving a Diagnosis - Synthesis Matching the field and the disc 5

6 Achieving a diagnosis» Normal Eye» Ocular Hypertension» Glaucoma» Uncertainty» Remember the effect of the diagnosis on the patient. Family History is important. Treatment Lowering IOP will slow down or prevent further damage but will not undo the damage that has been done How can we reduced Intraocular Pressure? With eye drops With laser With surgery To reduce the production of aqueous To increase the removal of aqueous 6

7 Adapt the therapies available to the individual patient Eye Drops include:- Pharmaceutical Laser SLT Surgical Nothing? Have amended it comments appreciated B-blockers Prostaglandin analogues Alpha-adrenergic agonists Carbonic anhydrase inhibitors Parasympathomimetic agents Combination therapy Preservative free drops Problems Include Failure to achieve the target pressure Side Effects (General) Respiratory problems Cardiovascular Side Effects (Local) Ocular surface disease Allergy Intraocular inflammation Macular Oedema Laser To the trabecular meshwork (SLT laser) To the ciliary body % reduction in IOP following SLT Laser Conventional Surgery 7

8 IOP mmhg Pre and post operative IOP for each year group Starting IOP Pre-op IOP iop week 1 iop 1 year iop last fu Year Outcomes of Trabeculectomy for NTG n=11 Parameter Mean Range Age years years IOP at start 15.5mmHg 14-21mmHg IOP pre-operation 14.5mmHg 11-21mmHg CCT 472um um IOP 1 week 6.7mmHg 0-28mmHg IOP one year 7.6mmHg 4-14mmHg IOP last FU (21-31/12) 8.4mmHg 5-15mmHg VA Start 6/5-6/9 VA 1 year post op 6/6-6/12 But potential complications» Infection» Pressure too low» Pressure too high» Cataract formation MIGS Surgery (Usually at the time of or following cataract surgery)» Stents» Trabectome» Endo-Cyclodiode The Aim of Treatment Points to consider To balance treatment effectiveness and sideeffects To preserve vision until death - not caused by glaucoma treatment Age Severity Life Expectancy Cost Effectiveness 8

9 Pain Redness Reduced Vision Cloudy Cornea Dilated Pupil Very High Pressure Angle Closure Treatment Reduce IOP with intravenous Diamox Pilocarpine to constrict pupil Peripheral iridotomy Secondary Glaucoma A result of other ocular disease or trauma Treatment As with chronic open angle glaucoma Except:- Rubeotic glaucoma usually secondary to retinal ischaemia (diabetes, CRVO) anti-vegf treatment and pan-retinal photocoagulation with yclodiode laser to the ciliary body. Glaucoma Treatment is preventative Care with the diagnosis - use all available evidence but don t be too seduced by modern technology! Try to do no harm! 9

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