Glaucoma

Clinical presentation 

Painless loss of peripheral vision leading to absolute glaucoma as the end stage

Affects mainly adults of 40 years of age and above

Cornea and conjunctiva are clear

Pupil in the affected eye does not react with direct light in advanced stage

The optic nerve is always damaged, this can be seen through fundoscopy

One eye may be affected more than the other

First degree relatives of glaucoma patients are at increased risk

Note:

• Primary  Open  Angle  Glaucoma  does  not  have  symptoms  in  early  stages,  hence  routine intraocular pressure checkup and fundus examinations should be done in all people of 40 years and above by some qualified eye care personnel on annual basis.
• All  suspected  cases  of  glaucoma  should  be  referred  to  qualified  eye  care  personnel  for confirmation of diagnosis and commencement of treatment plan
• Surgical treatment is usually preceded by medical treatment
• Refilling  of  antiglaucoma  may  be  prescribed  by  a  middle  cadre  eye  worker  but  annual monitoring should be done at a centre where there is an Ophthalmologist
• For advanced and complicated Glaucoma, patients should be referred to a health facility where there are Glaucoma Specialists
• Investigations:  Visual Acuity
• Slit Lamp bimicroscopy
• Fundoscopy
• Tonometry
• Gonioscopy

Pharmacological Treatment 

This is initiated after a diagnosis is reached by an ophthalmologist, refill of some medicines can be  done by Assistant Medical Officers in ophthalmology but with regular reviews at a health facility with  eye specialist. Medical treatment should be lifelong unless there are conditions necessitating other  interventions 

C: timolol 0.25% or 0.5%, one drop in the affected eye, instill 12hourly. 

OR 

D:  betaxolol  0.25%  or  0.5%,  one  drop  in  the  affected  eye,  instill  12hourly. Use  lower  strength in mild disease and those at risk of complications. 

In patients who comply to treatment and there is no good response 

ADD 

D: latanoprost 0.005% one drop, 2hourly in the affected eye. 

OR 

D: prostamide bimatoprost 0.03%, one drop, 24hourly in the affected eye. 

• These may be used as first-line in patients with contraindication of beta-blockers.
• They  can  be  used  as  a  second-line  drug  in  patients  on  beta-blockers  if  the  target  IOP reduction has not been reached.

In patients who are intolerant to prostaglandin analogue or are not responding give: 

D: brimonidine tartrate 0.15–0.2%, one drop, 12hourly, in the affected eye. 

OR 

S: dorzolamide 20mg/mL, one drop, 8hourly in the affected eye 

Failure to respond give: 

C: pilocarpine hydrochloride 2% or 4%, instill one drop in the affected eye 6 hourly. 

Note: Pilocarpine  causes  long-standing  pupil  constriction  so  it  should  not  be  used  unless  a  patient  is prepared for glaucoma surgery or as an alternative topical treatment for patients who are contraindicated for Timolol use. Consult a specialist before using it. 

In severe cases or while waiting for surgery, use: 

C: acetazolamide (PO) 250mg 6hourly 

Note: 

• β-blockers  are  contraindicated  to  people  who  are  known  to  have  overt  asthma  as  this group  of  medication  may  cause  an  acute  asthmatic  attack  within  a  short  time  following instillation into the eye
• Brimonidine is contraindicated in children below 12years

Laser Treatment 

• It may be indicated in addition to or instead of eye drops or surgery.
• Laser trabeculoplasty (Argon Laser Trabeculoplasty, Selective Laser Trabeculoplasty) or cyclophotocoagulation are different options among others

Surgical Treatment 

It is done in all patients with poor compliance and when medical treatment is not useful. There are  different surgical techniques depending on the age of the patients, patients’ response to surgical  treatment,  surgeons’  surgical  skills  and  availability  of  equipment.  It  is  recommended  that  all  surgeries are done by Ophthalmologists after thorough assessment of the patients.

This is also known as Congestive glaucoma and commonly affect people aged 40 years and above.  It affects more females than males. 

Clinical PresentationAcute  sudden  onset  of  painful  red eye in the affected eye

Severe  headache  and  cloudiness of the cornea

Severe elevated intraocular pressure.

There  is  usually  dramatic  visual impairment  and  vomiting  may  be present

Shallow anterior chamber

Fixed and semi-dilated pupil

It  may  be  asymptomatic  if  IOP raises slowly

Note:

• Primary acute Angle Closure Glaucoma is an Ophthalmological Emergency
• Refer all patients with Congestive glaucoma to eye specialist after initial medical treatment to lower Intraocular pressure

Investigations: 

• Visual Acuity
• Slit Lamp bimicroscopy
• Fundoscopy when cornea clear up
• Tonometry

Pharmacological Treatment 

Institute  therapy  and  then  refer  the  patient  to  eye  specialist  at  the  Regional,  Zonal  or  National  Hospital for investigations and proper management. 

Try to achieve immediate IOP reduction  

First-Line Treatment 

C: acetazolamide (PO), 500mg immediately as a single dose followed by 250mg 6hourly 

AND 

C: timolol 0.25–0.5% eye drops, instill one drop 12hourly in the affected eye 

Use the above combined treatment until you have achieved your target IOP reduction, then continue  with only Timolol eye drops for life unless patient has received surgical intervention and the IOP is  reduced to normal level. 

Note: Manage the associated pain and vomiting 

Second-Line Treatment 

If the above measures fail, use as a short-term treatment, givesystemic osmotic agents: 

C: mannitol 15–20% (IV)1.5–2mg/kg body weight to run slowly over 30–60minutes 

These medicines have diuretic effects, so they are only used as a single dose. They are also used in  emergencies to prepare patients with high intraocular pressure for surgery as they lower intraocular  pressure rapidly. 

Note: Acetazolamide is a Sulphur containing medicine, do not use in patients allergic to Sulphur. 

Surgical Treatment 

This is done at a centre with Eye Specialists and necessary diagnostic and treatment equipment.  Surgical or Later Peripheral Iridectomy will create a passage for the aqueous fluid from posterior  chamber to the drainage angle.  

Referral: Management of advanced angle closure glaucoma is done by eye specialist. All patients  with Angle Closure Glaucoma should be referred to eye specialist for other management modalities

• Presents from birth to 5 years.
• It is a syndrome whereby the intraocular pressure is raised and cause abnormality of the eyeball and visual disturbances including blindness

Clinical Presentation 

• Patients  presents  with  eyes  bigger than normal for age (buphthalmos)
• Photophobia
• Tearing
• Cloudy cornea,
• Red conjunctiva though not severe.
• Decrease in visual acuity

Investigations 

For children, examination is done under General Anaesthesia 

• Tonometry
• Cornea Diameters
• Slit lamp examination

Surgical Treatment 

Treatment for congenital glaucoma is usually surgery, which is done by Pediatric Ophthalmologist or  Glaucoma specialist. 

Referral: Refer any child who has the above-mentioned signs and you suspect that he/she is having  congenital glaucoma to a specialist at the National Hospital or Zonal Referral Hospitals where there  is Paediatric Eye team.

This presents as a complication of other eye diseases such as uveitis, hypermature cataract, trauma  and retinal diseases. It may also be due to prolonged use of steroids. 

Clinical Presentation 

• Poor  vision  in  the  affected  eye associated with
• High intraocular pressure

Investigations 

• Visual Acuity
• Slit Lamp bimicroscopy
• Fundoscopy
• Tonometry
• Gonioscopy
• Optic nerve damage
• New vessels on the iris if the cause is retinal diseases
• Refraction
• Visual Field Analysis
• Fundus Photography
• Pachymetrytest
• Optical Coherent Tomography

Pharmacological Treatment  

Management of these patients depends on the cause, but it includes medical, surgical and laser.  Institute these treatment as you refer these patients: - 

C: acetazolamide (PO) 500mg immediately stat followed by 250mg 6hourly 

AND 

C: timolol 0.25–0.5% eye drops, instill one drop 12hourly in the affected eye. 

Treatment of the preexisting eye disease is highly recommended. 

Referral:  Refer  all  patients  suspected  to  have  secondary  glaucoma  to  a  qualified  eye  specialist  available  at  the  Regional,  Zonal  or  National  Hospital  for  proper  assessment  and  definitive  management.