Glaucoma

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CLINICAL DESCRIPTION

This is an optic neuropathy with characteristic visual field defects which correspond to the pattern of optic nerve damage. 

PRIMARY OPEN ANGLE GLAUCOMA (POAG)

CLINICAL DESCRIPTION

Glaucoma with a normal (open) anterior chamber angle and raised intraocula pressure (IOP).

CLINICAL FEATURES

SIGNS AND SYMPTOMS

• Gradual loss of vision, narrowed field of vision.

TREATMENT

• Prostaglandin analogues - the first line treatment (avoid in uveitis)
  • Travopost 0.004% (Travatan) every day
  • Latanoprost 0.005% (Xalatan) every day
  • Bimatroprost 0.03% Lumigan
  • Beta adrenergic antagonists, contraindicated in Asthma
• Selective a-1 antagonists
  • Betaxolol 0.5% 12 hourly
• Non-Selective B antagonists
  • Timolol 0.5% 12 hourly
• Alpha 2 adrenergic agonists
  • Brimonidine 0.2% 8 hourly
  • Carbonic anhydrase inhibitors
  • Systemic
    • Acetazolamide 125 - 250mg 6 hourly
  • Topical
    • Brinzolamide 1% (Azopt)every 12 hourly
    • Dorzolamide 2% (Trusopt) every 8 hourly
• Parasympathomimetic (Cholinergics)
  • Pilocarpine 2%, 4% 6 hourly gel or drops
• Surgical Treatment
  • Trabeculectomy - when maximal medical treatment is suboptimal in IOP control
  • Consider transcleral cyclophotocoagulation in eye with poor visual potential
  • Consider argon laser trabeculoplasty (ALT)/selective laser trabeculoplasty(SLT) if not possible to perform trabeculectomy
  • Minimally Invasive Glaucoma Surgery (MIGS)
  • Shunt devices
• The medical and surgical treatment of POAG is also applicable to pseudo exfoliative glaucoma and pigmentary glaucoma.

 

PRIMARY ANGLE CLOSURE GLAUCOMAGlaucoma with narrowed anterior chamber angle.

Clinical Features

SIGNS AND SYMPTOMS

• Sudden blurry vision, redness, headache and eye pain, nausea, and vomiting
• Very high intraocular pressure

Treatment

• As for POAG
• Surgical treatment (definitive treatment)
  • Bilateral Nd-YAG laser peripheral iridotomy
  • Consider lens extraction and/or trabeculectomy (NB: Risk of aqueous misdirection syndrome)

 

ACUTE PRIMARY ANGLE CLOSURE GLAUCOMA 

CLINICAL DESCRIPTION

Angle closure glaucoma with abrupt onset.

CLINICAL FEATURES

SIGNS AND SYMPTOMS

• Sudden blurry vision
• Redness
• Abrupt onset of severe eye pain (usually unilateral) and headache
• Nausea and vomiting
• Very high intraocular pressure, fixed or mid-dilated pupil

TREATMENT

• Systemic
  • Acetazolamide 500mg IV stat then 250mg PO 6 hourly.
  • If IOP is not improving consider systemic hyperosmotic agent (e.g. mannitol 20% solution IV 1 – 1.5g/kg).
  • Ipsilateral eye:
  • β-blocker (e.g. timolol 0.5% stat, then every 12hrs).
  • Sympathomimetic (e.g. apraclonidine 1% stat).
  • Steroid (e.g. prednisolone 1% stat, then every 30–60min).
  • Pilocarpine 2% (once IOP <50mmHg, e.g. twice in first hour, then every 6hrs).
• Admit patient
• Surgical treatment (definitive management)
  • Bilateral Nd-YAG laser iridotomy or surgical Peripheral iridectomy.

 

NEOVASCULAR GLAUCOMA

CLINICAL DESCRIPTION

Secondary glaucoma where anterior chamber angle is closed by "new" blood vessels.

CLINICAL FEATURES

SIGNS AND SYMPTOMS

• Decreased vision, Headache and eye pain, Photophobia
• Corneal oedema, hyphema, vitreous haemorrhage, high IOP

TREATMENT

• Pan retinal photocoagulation to decrease retinal ischaemic drive.
• Consider intravitreal anti-VEGF therapy (e.g Bevacizumab)  
• Reduction of IOP and inflammation
  • Medical
    • Cycloplegic (e.g., Atropine 1% 12 hourly) + frequent topical steroids (e.g., Prednisolone acetate 1%  6 hourly) + ocular hypotensive agents as for POAG.
  • Surgical
    • Tube-shunt procedures (e.g., Ahmed valve)
    • Consider trabeculectomy
    • Cyclodestruction (e.g., Cyclodiode) if poor visual prognosis.
  • Pain control
    • Cycloplegia (e.g. Atropine 1% 12 hourly)
    • Artificial tears
    • If the eye is blind and painful, consider retrobulbar injection of absolute alcohol (96%) or Chlorpromazine 25mg , or evisceration/enucleation.