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Glaucoma

Glaucomas

Glaucoma is a group of eye diseases characterized by intraocular pressure-associated optic neuropathy. The two most common types are primary open-angle glaucoma and angle closure glaucoma.


Presentation

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.

Skin Lesion
  • CONCLUSION: JXG is a rare disease, characterised by yellowish skin lesions on the trunk, neck, or head. Up to 10% of cases will have ocular involvement, which is the most common extracutaneous manifestation of the disease.[ncbi.nlm.nih.gov]
Blurred Vision
  • 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]
  • A 60-year-old woman was referred for distending pain with blurred vision for more than 1 month in the right eye after cataract surgery. B-ultrasound scanner and UBM demonstrated the Intraocular Lens (IOL) was centered in the bag.[ncbi.nlm.nih.gov]
  • Abstract A 19-year-old man noticed blurred vision in his right eye. He had an intraocular pressure of 60 versus 12 mmHg in the fellow eye. He was initially diagnosed with an atypical, advanced pigmentary glaucoma.[ncbi.nlm.nih.gov]
  • Do you have blurred vision, nausea, and headaches? Do you see "halos" around bright lights? You might have glaucoma . What Is Glaucoma? Glaucoma is a group of eye diseases that can lead to blindness by damaging the optic nerve .[visionaware.org]
  • If you do notice any symptoms, they might include blurred vision, or seeing rainbow-coloured circles around bright lights. Both eyes are usually affected, although it may be worse in one eye.[nhs.uk]
Eye Pain
  • During the early Common Era, eye pain, a glaucous hue, pupil irregularities, and absence of light perception indicated a poor prognosis with couching. Galen associated the glaucous hue with a large, anterior, or hard crystalline lens.[doi.org]
  • Symptoms of closed angle glaucoma Eye pain, usually severe. Blurred vision. Eye pain is often accompanied by nausea and sometimes vomiting. Lights appear to have extra halo-like glows around them. Red eyes.[medicalnewstoday.com]
  • Acute glaucoma happens suddenly and causes severe eye pain and rapid loss of vision. It is a medical emergency that requires immediate treatment.[doi.org]
  • Here are the signs of an acute angle-closure glaucoma attack: Your vision is suddenly blurry You have severe eye pain You have a headache You feel sick to your stomach (nausea) You throw up (vomit) You see rainbow-colored rings or halos around lights[aao.org]
Loss of Peripheral Vision
  • Despite effective treatments, many people suffer some preventable loss of peripheral vision. One problem is that the disease too often goes undetected.[web.archive.org]
  • As open-angle glaucoma progresses, symptoms may include loss of peripheral vision and difficulty adjusting to low light. Risk factors for glaucoma Everyone is at risk of developing glaucoma, but some people have a higher risk.[betterhealth.vic.gov.au]
  • Doctors also perform a visual field test to determine if there is any loss of peripheral vision and utilize a procedure called Tonometry to check for eye pressure.[brailleworks.com]
  • It results in a progressive loss of peripheral vision and, in late stages, loss of central vision leading to blindness. Early treatment of glaucoma aims to prevent or delay vision loss.[ncbi.nlm.nih.gov]
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]
  • […] 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]
  • Symptoms include photophobia, blepharospasm, and excessive tearing. Typically, the diagnosis is made in the first year of life. Depending on when treatment is instituted, visual acuity may be reduced and/or visual fields may be restricted.[ncbi.nlm.nih.gov]
  • […] feels swollen Red eyes Halos around lights Nausea and vomiting Congenital Glaucoma Symptoms include: Symptoms become noticeable when child is a few months old Cloudiness in front of the eye, usually on the iris (the colored part of the eye) Red eye Photophobia[eyehealthweb.com]
Scotoma
  • […] steps, altitudinal scotomas, focal defects e.g. paracentral scotomas (2) optic disc changes - localised or generalised thinning of the neuroretinal rim, enlargement of the optic cup and increased cup to disc ratio (1) nerve fiber layer defects (3) Although[gpnotebook.co.uk]
  • Peripheral vision (1960 —) appeared in translations 51 of his term peripherische Sehen. 52 Blind spot (1870 — ) and scotoma (1880 — ) entered common parlance.[web.archive.org]
Headache
  • Other symptoms include headache, redness of the eye and swelling, sighting of multicoloured halos and uveitis.[symptoma.com]
  • She had no symptoms other than occasional, mild headaches and had no findings to suggest clinically isolated syndrome (CIS) or MS; additionally, her cerebrospinal fluid analysis was unremarkable.[ncbi.nlm.nih.gov]
  • […] variety of symptoms, depending upon type and severity, such as excavation of the optic disk, hardness of the eyeball, corneal anesthesia, reduced visual acuity, seeing of colored halos around lights, disturbed dark adaptation, visual field defects, and headaches[icd9data.com]
  • Narrow-angle glaucoma causes pain in the eye, headaches, and sometimes nausea and vomiting. The affected person may see halos around lights.[britannica.com]
  • Do you have blurred vision, nausea, and headaches? Do you see "halos" around bright lights? You might have glaucoma . What Is Glaucoma? Glaucoma is a group of eye diseases that can lead to blindness by damaging the optic nerve .[visionaware.org]
Mydriasis
  • 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]
  • In older cases the pupil will dilate and this is called mydriasis.[doi.org]
  • […] renal failure Mannitol 0.5–2.0 g/kg body weight IV over 30–45 min (may repeat 8–12 h later) Alpha- 2 -selective adrenergic agonists (topical) Apraclonidine 1 drop bid–tid Decrease aqueous production; may increase uveoscleral aqueous outflow; may cause mydriasis[merckmanuals.com]
  • 1550-1612). 8 Hunton discussed both amaurosis (1810 - ), a medical term implying poor vision, and amblyopia (1860—), which often implied a lesser visual impairment (Figure 1). 9 Hunton also discussed couching [1570-], strabismus, chemosis (1870 - ), mydriasis[web.archive.org]
  • 1550-1612). 8 Hunton discussed both amaurosis (1810 – ), a medical term implying poor vision, and amblyopia (1860—), which often implied a lesser visual impairment (Figure 1). 9 Hunton also discussed couching [1570-], strabismus, chemosis (1870 – ), mydriasis[oculistmd.wordpress.com]

Workup

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.

Treatment

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].

Prognosis

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].

Etiology

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].

Epidemiology

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.

Sex distribution
Age distribution

Pathophysiology

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.

Prevention

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.

Summary

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.

Patient Information

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. 

References

Article

  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.

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Last updated: 2019-07-11 22:47