Patients suffering from glaucoma may present with a wide range of symptoms. Most commonly, they present with periorbital pain and visual deficit [7]. Other symptoms include headache, redness of the eye and swelling, sighting of multicoloured halos and uveitis. Patients may sometimes complain solely of a severe headache, often accompanied with vomiting, which may be confused with intracranial hemorrhage. Primary infantile glaucoma may present as mostly bilateral but sometimes asymmetric involvement of eyes that are red, itchy and tearing. The infant is often unable to focus his or her eyes at one particular object clearly.

• Severe Pain

  A 30-year-old European man was admitted to our centre complaining about severe pain of the right eye (OD) and right part of the face, redness and no vision of the OD. [ncbi.nlm.nih.gov]

  Severe Pain – often, people wake up in the night with a very severe pain in 1 eye (although it can happen in both eyes simultaneously – this is uncommon). Redness of the eye. Blurred Vision – sometimes ‘haloes’ can be seen around bright lights. [hartmannopticians.ie]

  Symptoms include severe pain and nausea, as well as redness of the eye and blurred vision. If you have these symptoms, you need to seek treatment immediately. This is a medical emergency. [enhancedvision.com]

  In acute closed-angle glaucoma, symptoms include severe pain and nausea, as well as redness of the eye and blurred vision. In chronic closed-angle glaucoma, symptoms include periods of headaches or eye pain. [columbiaeye.org]

  However, more severe pain may be a sign of complications, so in this case, the doctor's advice should be sought. Back to top Possible side effects The most common problem after a trabulectomy is scarring of the opening. [irishhealth.com]

• Pallor

  Ophthalmological examination revealed 0.15 Snellen visual acuity, and fundoscopy revealed nearly total cupping and pallor of the optic disc and multiple retinal hemorrhagic foci in the macula in OD. Lesions spontaneously resolved over a few months. [ncbi.nlm.nih.gov]

  The eye doctor will also look for other clues such as pallor (pale color), notches in the rim of the optic nerve head, small disc hemorrhages (blood on the edge of the nerve), and thinning of the tissue surrounding the nerve (peripapillary atrophy). [emedicinehealth.com]

  It has been observed and generally accepted that sustained moderately high intraocular pressure from secondary glaucoma or prolonged angle-closure glaucoma causes reduced visual acuity, contracted visual fields, and generalized optic disc pallor in humans [doi.org]

  It manifests by cupping of the optic disc (see the image below) in the absence of other known causes of the disease. [1, 2] Advanced glaucomatous damage with increased cupping and substantial pallor of the optic nerve head. Courtesy of M. [emedicine.medscape.com]

  Certain NTG cases, those with unilateral disease, pallor of the disc, atypical defect and color defects require appropriate cardiovascular or neurological investigation. [ijo.in]

• Underweight

  Flegal KMGraubard BIWilliamson DFGail MH Cause-specific excess deaths associated with underweight, overweight, and obesity. JAMA 2007;298 (17) 2028- 2037 PubMed Google Scholar Crossref 12. [doi.org]

• Heart Disease

  To prevent eye sight damage and blindness So far the only treatment method is to lower IOP Can gradually steal sight without any warning or symptoms Incurable disease which can cause blindness if untreated Blindness is ranked 3rd (after cancer + heart [icaretonometer.com]

  Medical conditions: Some studies indicate diabetes may increase the risk of developing glaucoma, as do high blood pressure and heart disease. [alcon.com]

  Weitzman DGoldbourt U The significance of various blood pressure indices for long-term stroke, coronary heart disease, and all-cause mortality in men: the Israeli Ischemic Heart Disease study. [doi.org]

  Some types of sympathomimetics can only be used with caution in people who have: high blood pressure heart disease A type of sympathomimetic that you may be prescribed is brimonidine tartrate. [hse.ie]

  […] symptoms are apparent, be aware of these risk factors: Having high internal eye pressure (intraocular pressure) Being over age 60 Being black, Asian or Hispanic Having a family history of glaucoma Having certain medical conditions, such as diabetes, heart [mayoclinic.org]

• Hypotension

  Robert J Noecker University of Pittsburgh Medical Center, Eye and Ear Institute, Pittsburgh, PA, USA Abstract: In the last decade, numerous novel ocular hypotensive agents have been introduced for the control of intraocular pressure (IOP). [doi.org]

  In the last decade, numerous novel ocular hypotensive agents have been introduced for the control of intraocular pressure (IOP). [ncbi.nlm.nih.gov]

  Treatment Participants treated with commercially available topical ocular hypotensive eye drops. Drug: Topical ocular hypotensive eye drops. Topical ocular hypotensive eye drops. [clinicaltrials.gov]

• Pruritus

  Its most common side-effects are conjunctival hyperemia, allergic conjunctivitis, and ocular pruritus. The newest formulation of brimonidine, brimonidine-Purite 0.1%, has a higher pH to improve the ocular bioavailability of brimonidine. [ncbi.nlm.nih.gov]

• Blurred Vision

  Side-effects from some eye drops may include a stinging sensation, red eyes, blurred vision, headaches, or changes in pulse, heartbeat or breathing. [umkelloggeye.org]

  Blurred vision Seeing halos around lights Headaches [alcon.com]

  With angle-closure glaucoma, a rapid buildup of IOP may lead to blurred vision, severe eye pain, headache, abdominal pain, or nausea and vomiting. [emedicinehealth.com]

  For example: Open-angle glaucoma Patchy blind spots in your side (peripheral) or central vision, frequently in both eyes Tunnel vision in the advanced stages Acute angle-closure glaucoma Severe headache Eye pain Nausea and vomiting Blurred vision Halos [mayoclinic.org]

  A 6-year-old girl presented with blurred vision and was found to have elevated intraocular pressure (IOP) and glaucomatous optic disc damage in both eyes. [ncbi.nlm.nih.gov]

• Eye Pain

  This nearly always affects both eyes. In advanced stages, the patient has tunnel vision. Symptoms of closed angle glaucoma Eye pain, usually severe. Blurred vision. Eye pain is often accompanied by nausea and sometimes vomiting. [medicalnewstoday.com]

  With angle-closure glaucoma, a rapid buildup of IOP may lead to blurred vision, severe eye pain, headache, abdominal pain, or nausea and vomiting. [emedicinehealth.com]

  Acute angle-closure glaucoma signs and symptoms include: Severe eye pain Nausea and vomiting (accompanying the severe eye pain) Sudden onset of visual disturbance, often in low light Blurred vision Halos around lights Reddening of the eye Symptoms of [brightfocus.org]

  When to see a doctor Promptly go to an emergency room or an eye doctor's (ophthalmologist's) office if you experience some of the symptoms of acute angle-closure glaucoma, such as severe headache, eye pain and blurred vision. [mayoclinic.org]

  Symptoms of primary open-angle glaucoma include : Gradual loss of peripheral vision, usually in both eyes Tunnel vision Symptoms of acute angle-closure glaucoma include : Severe eye pain Nausea and vomiting (accompanying the severe eye pain) Sudden onset [singhealth.com.sg]

• Visual Impairment

  Abstract Diabetic retinopathy (DR) and glaucoma are emerging causes of blindness and visual impairment in India and the world. Both diseases do not have any early warning symptoms, and once the symptoms appear, the diseases are reasonably advanced. [ncbi.nlm.nih.gov]

  The disease is responsible for one in ten cases of visual impairment. [telegraph.co.uk]

  That's why the UK site Clinic Compare has created four GIFs that let us see through the eyes of the visually impaired. [news.health.com]

  Should your vision become significantly impaired, there are a number of aids which can help people with diabetes who have visual impairments. Explore Glaucoma Join the Diabetes Newsletter [diabetes.co.uk]

  According to WHO surveys this disabling condition accounts for approximately 2% of visual impairment cases and is the third cause of blindness worldwide (8% of cases). [sylentis.com]

• Excessive Tearing

  Symptoms include cloudiness of the eye(s), enlargement of one or both eyes, extra sensitivity to light, excessive tearing and red eye(s). Infants with Congenital Glaucoma typically do well as long as surgery is done early. [brailleworks.com]

  These children usually have obvious symptoms, such as cloudy eyes, sensitivity to light, and excessive tearing. [enhancedvision.com]

  Symptoms may include: excessive tearing light sensitivity (photophobia) closure of one or both eyes in the light cloudy, enlarged cornea (large eye) one eye may be larger than the other vision loss If the eye pressure increases rapidly, there may be pain [stanfordchildrens.org]

  tearing or "watery eyes" Dry eyes with itching or burning; and Seeing spots, ghost-like images The following may be indications of potentially serious problems that might require emergency medical attention: Sudden loss of vision in one eye Sudden hazy [umkelloggeye.org]

• Photophobia

  A 55-year-old female was referred for a second opinion regarding her bilateral ocular pain, photophobia, and ocular hypertension. [ncbi.nlm.nih.gov]

  Bright lights might bother your eyes (you’ll hear the doctor call this light sensitivity or photophobia). Eye injuries like corneal edema, bleeding, or retinal detachment can hide glaucoma symptoms. [webmd.com]

  Symptoms may include: excessive tearing light sensitivity (photophobia) closure of one or both eyes in the light cloudy, enlarged cornea (large eye) one eye may be larger than the other vision loss If the eye pressure increases rapidly, there may be pain [stanfordchildrens.org]

  […] of medical glaucoma treatments Drug class Ocular adverse events Systemic adverse events Alpha‐agonists (e.g. apraclonidine, brimonidine) Allergic reactions Blurred vision Burning/stinging/discomfort Follicular conjunctival response Hyperemia Itching Photophobia [doi.org]

  Uveitis Inflammation of the eye and keratic precipitates due to uveitis Pronunciation U-v-itis Specialty Ophthalmology Symptoms Headaches, red eyes, blurred vision, photophobia, burning and redness of the eye Causes Behçet disease, Crohn's disease, Fuchs [en.wikipedia.org]

• Headache

  Other symptoms include headache, redness of the eye and swelling, sighting of multicoloured halos and uveitis. [symptoma.com]

  Symptoms may include headaches, eye pain, nausea, rainbows around lights at night and blurred vision. [alcon.com]

  With angle-closure glaucoma, a rapid buildup of IOP may lead to blurred vision, severe eye pain, headache, abdominal pain, or nausea and vomiting. [emedicinehealth.com]

  When to see a doctor Promptly go to an emergency room or an eye doctor's (ophthalmologist's) office if you experience some of the symptoms of acute angle-closure glaucoma, such as severe headache, eye pain and blurred vision. [mayoclinic.org]

  They can also feel nauseous, with headaches and vomiting. This is an emergency and you should seek treatment straight away so you don’t lose vision. Most people with glaucoma have few to no symptoms until their eyesight is damaged. [healthdirect.gov.au]

• Seizure

  A neurologic evaluation should be done if a patient has slowly increasing signs of mental dysfunction, new seizures, persistent headaches or evidence that there is pressure inside the skull, such as vomiting or swelling or protrusion of the blind spot [cedars-sinai.edu]

  4.5 Anticonvulsant Drugs for Various Types of Seizures Generalized grand mal seizures Partial (focal) seizures Carbamazepine Carbamazepine Valproate Phenytoin Phenytoin Valproate Phenobarbital Phenobarbital Clonazepam Generalized petit mal seizures Gabapentin [nap.edu]

  For some people, their first symptom may be a seizure, so they are seen as an emergency. [thebraintumourcharity.org]

  Depending on where the tumor is, it can cause: Constant headaches Seizures Vomiting Trouble thinking Changes in mood or personality Double or blurred vision Trouble speaking Diagnosis A neurologist (a doctor who specializes in diagnosing and treating [webmd.com]

  Other common presentation includes seizures. Glioblastoma can be difficult to treat since some cells may respond well to certain therapies, while others may not be affected at all. [abta.org]

• Mydriasis

  In older cases the pupil will dilate and this is called mydriasis. [doi.org]

  Angle closure, with palpable hardness of the eye, mydriasis, and anterior prominence of the lens, was described in greater detail in the 18th and 19th centuries. [ncbi.nlm.nih.gov]

  0.5–2.0 g/kg body weight IV over 30–45 minutes (may repeat 8–12 hours later) Alpha-2-selective adrenergic agonists (topical) Apraclonidine 1 drop two to three times a day Decrease aqueous production; may increase uveoscleral aqueous outflow; may cause mydriasis [msdmanuals.com]

Laboratory tests

• Complete blood count
• Erythrocyte sedimentation rate
• Micro-hemagglutination-Troponema pallidum (serology for syphilis)
• Tonometry

Imaging 

No specific imaging studies are available for the diagnosis of glaucoma. A CT scan may be conducted to exclude CNS involvement.

Test results

On the basis of history and physical examination, along with supportive evidence from laboratory tests results, a diagnosis can be made and treatment should be immediately begun.

Medication

Medications are used to primarily reduce the IOP with causing minimal adverse effects. Drugs that are commonly used include non selective beta adrenergic blockers like levobunolol, timolol and carteolol, selective beta 1 antagonists like betaxolol and metipranolol, and Alpha-2 adrenergic agonists like brimonidine. Carbonic anhydrase inhibitors like dorzolamide and acetozolamide as well as prostaglandin analogs like latanoprost and tafluprost are also used. Diuretics, such as mannitol and isosorbide dinitrate may also be necessary in cases with very high IOP.

Surgery

• Open-angle glaucoma

When a patient is on maximum tolerated medical therapy (MTMT) but still in worsening condition, surgery is indicated. Commonly used procedures include Argon laser trabeculoplasty (ALT) and selective laser trabeculoplasty (SLT). ALT has a higher rate of reoccurrence of symptoms than SLT.

If ALT or SLT has failed, trabeculectomy may be performed. The worst complication of this procedure includes loss of vision. Attendant risk factors such as split fixation on visual fields prior to surgery, preoperative number of quadrants with split fixation, and postoperative choroidal effusions with eventual resolution are possible [8]. If repeated trabeculectomy fails, a drainage shunt may be placed to help relieve pressure. If all else fails, the patient may have to undergo ciliary body ablation to treat the disease. The ciliary body epithelium can be destroyed by cyclocryotherapy, diathermy, ultrasound, transscleral Nd:YAG or diode laser (known as cyclophotocoagulation), or a newer endoscopic laser [9].

• Closed-angle glaucoma

If conservative therapy fails, a corneal indentation (CI) may be performed. It provides a temporary relief from raised IOP. The definitive treatment of closed-angle glaucoma is Argon laser peripheral iridoplasty (ALPI) along with anterior chamber paracentesis (ACP). An alternative procedure is lens replacement. The exact role of this procedure is unclear but it offers a therapeutic advantage for individuals with coexisting cataracts [10].

Glaucoma is a progressive, chronic condition. It may begin with mild, reversible symptoms like headache and redness of the eyes but may progress to lasting, irreversible ocular damage. Peripheral vision loss occurs first, but if glaucoma is untreated, central vision loss and complete blindness can occur [6].

Glaucoma is a collective term used for conditions that lead to an increased intraocular pressure (IOP) resulting in visual deficits. Open-angle glaucoma is primarily due to conditions and diseases that result in a high IOP. These include hypertension, vascular defects, renal disease and diabetes. Immune mediated nerve damage, excessive production of retinal glutamate and oxidative stress may also contribute. Some people are genetically predisposed to this condition.
Acute closed-angle glaucoma can be due to narrow anterior chamber, thin ciliary body, thin iiris, short axial length of the eyeball, lens swelling and narrow anterior chamber angle.
Other factors such as blood supply, nerve metabolism, and extracellular matrix likely play a role in the progressive optic neuropathy of glaucoma [2].

Incidence

Glaucoma is a common condition and it is the 2nd most common cause of blindness worldwide (the 1st is cataracts). Exact incidence varies in accordance with the type of glaucoma.

Age

Peaks according to age depend upon the type of glaucoma. The onset of signs and symptoms of infantile glaucoma occurs at birth in 40 percent of affected patients and before one year of age in 86 percent [3]. Peak incidence of closed-angle glaucoma is in the 6th and 7th decade of life. In primary open-angle glaucoma, incidence is highest in the 4th decade and above, but it may also occur in younger patients.

Sex

Acute close-angle glaucoma is more common in females while primary open-angle glaucoma has an unclear sex predilection.

Discussed below is the pathogenesis of 3 common types of glaucoma:

Open-angle glaucoma

In open-angle glaucoma, optic nerve damage results in a progressive loss of retinal ganglion cell axons, which is manifested initially as visual field loss and, ultimately, irreversible blindness if left untreated [4]. Increased intraocular pressure causes the axons of the optic nerve, where they exit the eyeball at the optic disc, to become compressed. Studies reveal that it is this compression that blocks axonal flow of cytoplasm from the neuronal somas (cell bodies) of the retina into the optic nerve fibres that lead to the brain. As a result, optic fibres start to gradually die out due to lack of nutrients. Another pathway which may add to this neuronal damage or may occur alone is compression of the retinal artery which enters the eyeball at the optic disc. In this case too, the nutrient supply to the neurons is decreased and eventually completely cut off which leads to blindness.

Closed-angle glaucoma

The anterior chamber angle provides a pathway for the aqueous humor to drain. If this angle is narrowed or closed off, the humor is unable to drain out and IOP starts to rise. In acute episodes of closed-angle glaucoma, pressures are often 30 mm Hg or higher [5].

Infantile glaucoma

It may be present at birth, called congenital glaucoma, or it may develop in the first few years of life, called infantile glaucoma. It is a rare autosomal-recessive condition but in some patients, there are multifactorial causes of disease development.

Controlling predisposing factors such as hypertension, diabetes mellitus and taking particular care in case of renal disease may somewhat help in preventing occurrence of glaucoma.

Glaucoma is defined as an optic neuropathy involving a characteristic atrophy of the optic nerve head, often accompanied by typical visual field defects [1]. Glaucoma is a disease of the eye in which the intraocular pressure becomes very high, sometimes as much as 60-70mm Hg during acute attacks. Intraocular pressure greater than 25-30mm Hg, if maintained for a long period is enough to cause blindness, whereas extremely high pressures may cause blindness within a few hours or days. Indeed, glaucoma is one of the most common causes of blindness worldwide.

Definition

Glaucoma is a term used to define conditions and diseases that result in increased fluid (aqueous humor) in the eye which leads to raised intraocular pressure.

Cause

It may be present from birth due to family inheritance or it may develop later on in life due to old age, vascular compromise, hypertension, small eyeball size, trauma, etc. 

Signs and symptoms

Common symptoms include pain around the eyeballs and headache, redness and swelling of eyes and disturbed vision. There may also be nausea, vomiting, double vision and dizziness. 

Treatment

Initial treatment is conservative, with oral medications and eye drops. If after optimum medical treatment symptoms are not alleviated, surgery is indicated. 

1. American Academy of Ophthalmology. Primary angle closure, preferred practice pattern. American Academy of Ophthalmology, San Francisco 2005. 
2. Kwon YH, Fingert JH, Kuehn MH, Alward WL. Primary open-angle glaucoma. N Engl J Med 2009; 360:1113. 
3. Yanoff M, Fine BS. Glaucoma. In: Ocular Pathology, 2nd ed, JB Lippincott, Philadelphia 1982. p.74.
4. Weinreb RN, Khaw PT. Primary open-angle glaucoma. Lancet 2004; 363:1711. 
5. Pokhrel PK, Loftus SA. Ocular emergencies. Am Fam Physician 2007; 76:829.
6. Kipp MA. Childhood glaucoma. Pediatr Clin North Am 2003; 50:89.
7. Rahim SA, Sahlas DJ, Shadowitz S. Blinded by pressure and pain. Lancet. Jun 25-Jul 1 2005;365(9478):2244. 
8. Francis BA, Hong B, Winarko J, et al. Vision loss and recovery after trabeculectomy: risk and associated risk factors. Arch Ophthalmol. Aug 2011;129(8):1011-7 
9. Allen RC, Netland PA, eds. Glaucoma Medical Therapy: Principles and Management. American Academy of Ophthalmology; 1999.
10. Foster PJ, Buhrmann R, Quigley HA, Johnson GJ. The definition and classification of glaucoma in prevalence surveys. Br J Ophthalmol. Feb 2002;86(2):238-42.