Mona Khandwala
Consultant Ophthalmic and Oculoplastic Surgeon
Maidstone and Tunbridge Wells NHS Trust
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Affects 3% of the adults
10% affected > 70 years of age
Late diagnosis
Amongst three most common causes of
visual impairment
Glaucoma is a form of optic neuropathy with specific
visual field loss. It is usually associated with raised intra
ocular pressure (IOP)
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Primary
Open angle
Secondary
Closed angle
Congenital
∗ Commonest form : > 60% adults with glaucoma
∗ Ageing of the drainage filter
∗ IOP rises, damages the optic nerve and causes field
defects
∗ Usually asymptomatic: often picked up at routine
eye tests
∗ Needs regular eye checks after age 40 years
∗ Variant- Normal tension glaucoma
∗ Can be insidious/ sudden onset
∗ Symptoms include:
coloured halos around lights
Ocular pain/ headache
Cloudy/hazy vision
Nausea and vomiting
∗ True ocular emergency- urgent referral
∗ Treatment can restore vision
∗ Enlargement of the eyeball
∗ Opacity of the cornea
∗ Excessive eye-watering
∗ Sensitivity to light (photophobia)
1. Open angle
Steroids: ointment, inhalers, oral
2. Closed angle (by dilating the pupil)
Tricyclic antidepressants, Mono amine oxidase inhibitor,
Anti Parkinsons, Antihistamines,
Antipsychotics, Antispasmolytics
3. Closed angle ( by rotation of ciliary body)
Sulfonamides
OPEN ANGLE
∗ Increased resistance to outflow
∗ Accumulation of glycosamino glycans (GAG)
∗ Decreased pinocytosis, causing decreased clearing of GAG
∗ Accumulation of protein that blocks the trabecular
meshwork
NARROW ANGLE
∗ Pupillary blockage
∗ Stimulating sympathetic / inhibiting parasympathetic activation
causing pupil dilatation
∗ Anterior rotation of the ciliary body, with choroidal effusions,
resulting in a shallow anterior chamber and blockage of the
trabecular meshwork
∗ Pharmacological
∗ Laser
∗ Surgical
DRUGS
Timoptol,
carteolol,
betaxolol,
levobulonol
MECHANISM OF
ACTION
Decrease of
aqueous
production
SIDE EFFECTS
Bronchospasm,
bradycardia, CCF,
depression, confusion,
impotence
DRUG
Brimonidine
( alphagan)
MECHANISM OF ACTION
Decreases
aqueous
production and
resistance to
outflow
SIDE EFFECTS
Conjunctival
hyperaemia, allergic
reactions,
headache, malaise,
SNC depression
DRUGS
MECHANISM OF
ACTION
Latanoprost, Increases
travoprost, aqueous
bimatoprost, outflow
unoprostone
SIDE EFFECTS
Conjunctival hyperaemia,
hypertrichosis, increased
iris pigmentation
DRUGS
Dorzolamide,
brinzolamide,
acetazolamide
MECHANISM OF ACTION
Decrease
aqueous
production
SIDE EFFECTS
Paraesthesia,
malaise,
depression,
anorexia, allergic
reactions, renal
calculi
DRUGS
MECHANISM OF ACTION
Pilocarpine Increases aqueous
outflow
SIDE EFFECTS
Eye/brow pain,
increased myopia,
poor vision
Currently only 2 true preservative free drops:
1. Tafluprost PF (Saflutan) :
£17.41
2. Latanoprost PF (Monopost):
£8.49
OCULAR
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Hyperemia/ redness/ itching
Thickening and lengthening of lashes
(hypertrichosis)
Darkening of iris colour
SYSTEMIC
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Bronchospasm
Bradycardia
Paraesthesia
Depression
Impotence
Anorexia
Renal calculi
∗ Reduction of systemic absorption may be achieved by :
Lacrimal occlusion for 3 minutes
Merely closing the eyes for 3 minutes
∗ Contra indiations :
Asthma, COPD, bradycardia, CCF and heart block.
∗ Beta-blockers should not be instilled at bedtime
∗ Iridotomy
∗ Laser trabeculoplasty
∗ Transscleral cyclodiode
∗ Iridoplasty
Fragment
removed
Filtration bleb
Valve
∗ Can glaucoma be hereditary?
Not always. It is, however, more common among
close blood relatives of affected persons
∗ Is it present for life?
Once the glaucomatous disease develops it will
remain forever even if treated
∗ Is it possible to have it in only one eye?
Certainly, although both eyes are commonly affected with
different degrees of severity
∗ Can it cause blindness?
Yes, if the progression of the disease is not stopped
with appropriate treatment
∗ Is it O.K. to drive?
Yes, as long as the visual function is within the
limits set by the DVLA
∗ Can glaucoma treatments improve the eyesight?
No, the aim of the treatment is to prevent
further deterioration of the visual function
∗ When is it advisable to have a preventive eye specialist
examination?
Over 40 years old and have not had an eye specialist examination
within the previous 5 years.
∗ What is the vesicle that is visible by lifting the eyelid after the
glaucoma operation?
It is the conjunctiva raised by the aqueous humour that filters
through the small valve that the surgeon has made in the eye wall.
It is known as “ filtering bleb”, it may initially be uncomfortable
though, usually, only temporarily.
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What happens if you forget to administer the eye-drops?
Best to stick to set times
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If two types of eye-drops have to be administered at the same
time, can you apply them together?
It is necessary to wait a few minutes between drops
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If you are not sure that you have applied the first eye-drop
correctly, is it dangerous to apply a second one?
No, although it is best to dry the eye immediately, to
prevent the extra eye-drop from flowing into the tear duct
∗ Is it dangerous to use the eye-drops more frequently than
prescribed?
No positive effects on treatment, and it could lead to side effects
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Is it possible to use other medication in addition to glaucoma drops?
It is very important to tell the family doctor about the diagnosis of
glaucoma and the medications being used. For instance, you should
be careful when taking some tranquillisers, anti-asthmatics or
medication for the digestive system
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How long does it take for the eyedrops to be absorbed?
A few minutes.
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35 yo African male, web designer
Gradual diminution of vision
Positive family history
Vision: RE- 6/60, LE- 6/18
IOP: RE-23, LE-21
Bilateral visual field defects: RE- temporal loss, LE- inf
altitudinal loss
∗ Colour vision: RE- 1/17, LE- 4/17
∗MRI scan done- pituitary tumor
∗Post surgery good result
∗Vision : 6/6 BE
∗Colour vision: 17/17
∗ 48 yo Caucasian female
∗ Routine optician check revealed suspicious optic discs
∗ Positive history of susceptibility to cold extremities in
winter, and migraine
∗ Vision: RE- 6/6, LE-6/6
∗ IOP- 20 mm Hg BE
∗ Optic discs- CD ratio of 0.75 with inferior rim loss
∗ Normal visual field tests
∗ No treatment started as no evidence of visual field
involvement
∗ Ask history of vasospasm and migraine: NTG?
∗ Ask history of trauma, steroid usage, other drug
history
∗ You are aged 60 or over
∗ You have diabetes or glaucoma
∗ You are 40 or over and have a close relative with glaucoma
i.e. brother, sister, parent or child
∗ A hospital ophthalmologist says that you are at risk of
glaucoma
∗ You are registered blind or partially sighted