GLAUCOMA

Glaucoma
• Comprises a group of ocular
disorder characterized by
increase intraocular
pressure, optic nerve
atrophy and visual field
loss.
• Incidence of glaucoma in the US is
about 1.5% and in prevalence in blacks
are at least 5 times that of white.
• In US: 2,000,000 are visually impaired
due to glaucoma
• In the Phil: diagnoses 634,130 of the
population (extrapolated data) and
317,605 undiagnosed (extrapolated
data)
• PRIMARY OPEN-ANGLE GLAUCOMA
– MORE COMMON FORM OF GLAUCOMA AMONG
CAUCASIANS, AFRICAN-AMERICANS

• PRIMARY ANGLE-CLOSURE GLAUCOMA

– MORE COMMON AMONG ASIANS
Anatomy and Physiology
 CLASSIFICATION
• Primary and Secondary
– Refers to the cause, if its cause by its own or other
condition.
• Acute and chronic
– Refers to the onset and duration
• Open and closed
– Describes the width of the angle between the
cornea and the iris.
 OPEN-ANGLE GLAUCOMA:
1. PRIMARY OPEN-ANGLE
2. NORMAL-TENSION (LOW-TENSION)
GLAUCOMA
 ANGLE-CLOSURE GLAUCOMA:
1. ACUTE
2. SUB-ACUTE
3. CHRONIC
4. PLATEAU IRIS
Angle- Closure glaucoma develops due to
blockage of drainage of aqueous humor by
apposition of iris to the trabecular meshwork.
• Acute Primary Angle-Closure Glaucoma
- occurs when IOP suddenly ↑
- results from sudden blockage of trabecular
meshwork
- manifested by pain, blurred vision, rainbow colored
haloes around lights and vomiting
• Subacute Angle-Closure Glaucoma
- characterized by episodes of blurred vision, haloes
and mild pain caused by ↑ IOP
- resolves spontaneously specially during sleep induce
miosis
- occurs periodically over days or weeks, and confused
with migraines or headache
Chronic Angle- Closure Glaucoma
- develops after acute attack in which synechial
closure persist or chamber closure closes gradually and
IOP ↑ slowly
• Plateau iris
- caused by anteriorly positioned ciliary
process that narrows the anterior chamber
recess by pushing the peripheral iris forward
- suspected if the central anterior chamber is
unusually deep and the iris plane appears flat
- iridectomy, performed to remove any
component of pupillary block
 CONGENITAL GLAUCOMA:
1. GLAUCOMA ASSOCIATED WITH OTHER
DEVELOPMENTAL OCULAR ANOMALIES (ANIRIDIA)
2. PRIMARY CONGENITAL
3. GLAUCOMA ASSOCIATED WITH EXTRAOCULAR
DEVELOPMENTAL ANOMALIES (STRUGE-WEBER
SYNDROME, CONGENITAL RUBELLA)
 Pathophysiology of Open-angle glaucoma
Predisposing factors: Precipitating factors:
• Age= >40 years old • Adult onset
• Race= African- diabetes
American and Asian • Hypertension
• Gender= male • Myopia
• Family History • Arteriosclerotic and
ischemic
• Eye trauma
• Prolonged use of
Degenerative changes in corticosteroid
trabecular meshwork and the • Emotional stress
canal of schlemm with
unknown cause

• Fluctuating IOP’s
Excessive fluid in the • Ocular pain
anterior chamber • Headache
• Halos
Nerve bundles from
the optic nerve cease
to function
 Pathophysiology of Closed-Angle
Glaucoma
Predisposing factors: Precipitating factors:
* Age= >40 years old • Adult onset diabetes
*Race= African- • Hypertension
American and Asian • Myopia
*Gender= male • Arteriosclerotic and ischemic
*Family History disease
• Eye trauma
• Prolonged use of
corticosteroid
• Emotional stress

Pupillary Dilation Enlargement of lens

Crowding of Iris into the Forward displacement of

Anterior Angle Iris

Obstruction of Aqueous
Flow
 Obstruction of Aqueous
Flow

Further Buldging of
Aqueous Flow

- Blurred Vision - Mildly dilated non-

- Ocular Pain Formation of Adhesion reactive pupils
- Haloes between Iris and Cornea - Nausea and Vomiting
- Cil;iary Injection ( Anterior Synechiae) - Corneal Edema
- Profuse Lacrimation

Closure of Angle

Atrophy of Iris and

Ciliary body
Permanent changes of
cornea

Optic Atrophy

Nerve deterioration

Total Loss of Vision

 DIAGNOSTICS
• Tonometer- measures the Intraocular
Pressure. Normal IOP 10- 21mmHg.
• Gonioscopy- examines the angle of the
anterior chamber ( the structures
between the peripheral iris and cornea
especially the trabecular meshwork.
This differentiate closed- angle from
open-angle eglaucoma.
• Visual Field Exam- Humphrey perimeter
TONOMETER
• GONIOSCOPE
Shaffer Method of grading Anterior Chamber
Angles
Grade IV The angle between is 45 degrees (normal)

Grade III The angle between is greater that 20 degrees but less than 45 degrees

Grade II The angle between is 20 degrees. Angle closure possible

Grade I The angle between is 10 degrees. Angle closure probable.

Slit The angle between is less than 10 degrees. Angle closure very likely.

Grade 0 The iris is against the trabecular meshwork. Angle closure is present.
 Management
• GOAL: CONTROL IOP!!!
• IN GENERAL
– OPEN-ANGLE
• PRIMARILY MEDICAL MGT
– ANGLE-CLOSURE
• PRIMARILY SURGICAL MGT
–(LASER VS. FILTERING)
– CONGENITAL
• PRIMARILY SURGICAL MGT
 Medical Management
• Beta-blockers- Timolol meleate;
– given to decrease production of aqueaous humor.;
– contraindicated for asthma and COPD
– assess for bradycardia before administration
• Alpha-adrenergic - apraclonidine
– Given to decrease production of aqueaous humor.
• Oral Carbonic Anhydrase inhibitor- acetazolamide
– Inhibits production of aqueous humor
– Side effect: anorexia, tingling sensation in hands and feet
• Oral osmotic diuretics- glycerine
• Pilocarpine HCl- a miotic causing pupillary constriction to open
schlem’s canal
– May cause blurring of vision after administration
 Surgical Management

• Laser Trabeculoplasty- The use of the laser to create an

opening in the trabecular meshwork by producing scars
causing tightening of meshwork fibers thus allow increased
outflow of aqueaous humor.
• Trabeculectomy- creation of an opening through which the
aqueous fluid escapes. A half-thickness scleral flap is loosely
sutured over the created opening through which the fluid
escapes resulting in subconjuctival absorption of aqueous
humor.
• Filtering procedures like trephination, thermal sclerotomy and
sclerotomy. This procedures create an outflow channel
from the anterior chamber into the subconjunctival space.
• Iridectomy- Is the creation of a new route for the flow of aqueous
humor to the trabecular meshwork.

• Cyclodestructive Procedure- the use freezing tip or

cyclocryotherapy or cyclophotocoagulation may be used to
damage the ciliary body and decrease production of aqueous
humor.
 Nursing Diagnosis
• Acute pain related increase in intraocular pressure.
• Risk for blindness related to increase in intraocular
pressure.
• Disturber sensory perception: visual related to
blurry vision and or blindness.
• Risk for injury related visual impairment.
• Self-care deficit related impaired vision
• Anticipatory grieving related to visual impairment.
 Nursing Management
Assessment Diagnosis Planning Intervention Evaluation

• Verbal/ non- Acute Pain related After 30 min of •Provide non- At the end of 30
verbal cues of to increase in nursing pharmacologic min patient
pain intraocular intervention relief of pain like manifest relief of
• Facial grimace pressure patient report of distraction, pain
•Pain scale decrease in pain diversional and
•Guarding relaxation
behavior exercises.
•Reassess relief of
pain

•Blurry vision Disturbed Sensory Patient will •Provide Patient will be

•Blindness Perception :visual recognize and assistance in ADL able to recognize
•Halo vision related to blurry compensate with •Reorient to and compensate
vision and/ or the visual environment with visual
blindness impairment •Reorient to time impairments .
and place
•Speak out and
provide tactile
stimulation when
providing care
•Prevent injury
 Assessment Diagnosis Planning Intervention Evaluation

*IOP > 22mmHg Risk for blindness Nurse will be able Monitor sudden Nurse was able to
•Pain in orbital related to to monitor loss of vision, eye monitor condition
area increase IOP sudden loss sight, pain, nausea and of patient.
•Blurry vision nausea, or eye vomiting
•Halo vision pain and be able •Administer drugs
to administer and notify
immediate care physician

•Loss of vision Anticipatory Patient will be •Use therapeutic Patient was able
•Blurry Vision grieving related to able to express communication to to express feeling
•Haloes in visual impaired vision feeling of grief for express empathy of grief to SO
field vision Impairment towards patient
•Depressive •Allow patient to
behavior express or
communicate
feeling of grief
•Administration of
Anti-depressive
drugs
 Assessment Diagnosis Planning Intervention Evaluation

Risk for injury Nurse will be able •Modification of Patient will be

•Blurry vision related to to provide environment free of injury
•Blindness impaired vision precautionary •Assist with ADL
•Inc. IOP measures to the • Help out with
•Halo vision client. the directions and
placement of
things.

• Blurry vision Self-care deficit Patient will be •Assist with ADL Patient and
•Blindness related to visual able to learn to •Teach patient Family will be
•Inc. IOP impairment manage ADL and family of ADL able to do ADL
•Halo vision
•Difficulty in
doing ADL
 Journal Reading
• Clue To Normal-Tension Glaucoma
• July 27, 2009
• Adapted from the American Academy of Ophthalmology and EurekAlert!

Health conditions in normal-tension glaucoma patients differ from those in patients with the more common primary open-angle glaucoma.
For one thing, an increased incidence of silent cerebral infarct blockage in small blood vessels in the brain, is seen in brain scans of people with
normal-tension glaucoma. Also, visual field loss is often more rapid in normal-tension glaucoma patients than in those with primary open-angle
glaucoma. Researchers at The Chinese University of Hong Kong, led by Dexter Y.L. Leung, FRCS, recently investigated whether silent cerebral
infarct might be directly related to rate of visual field loss in patients newly diagnosed with normal-tension glaucoma.

They found that visual field loss was 61 percent more likely in normal-tension glaucoma patients with silent cerebral infarct. Though this study
was in newly diagnosed normal-tension glaucoma patients and results could vary in patients who have been in treatment, the results raise
important points.

"First, this study adds weight to the hypothesis that vascular factors are likely causes of normal-tension glaucoma, along with intraocular
pressure (IOP). Second, if additional studies confirm silent cerebral infarct as a risk factor for visual field loss, treatment to prevent silent
cerebral infarct might slow disease progression in normal-tension glaucoma patients. Third, brain scans of normal-tension glaucoma patients to
detect silent cerebral infarct might be deemed cost-effective. Since treating silent cerebral infarct is also known to prevent stroke, we may be
talking about saving not only vision, but lives," said Dr. Leung.

Normal-tension glaucoma is termed "normal" because the IOP, the pressure within the eye, is lower than the point at which optic nerve damage
is known to occur in primary open-angle glaucoma patients. Despite this "normal" IOP, optic nerve damage does occur in NTG patients, who
comprise about one-third of all people with glaucoma.
 Journal Reading contd.
• Researchers Discover New Target For Glaucoma Treatment
• October 5, 2009
• Adapted from the University of Toronto

Researchers at the University of Toronto, St. Michael's Hospital and Sunnybrook Health Sciences Centre have discovered a previously unidentified form
of circulation within the human eye which may provide important new insights into glaucoma, a leading cause of blindness.

For over a century, the eye has been considered to lack lymphatics, a circulation responsible for pumping fluid and waste out of tissues. The inability to
clear that fluid from the eye is linked to glaucoma, a leading cause of irreversible blindness affecting over 66 million people worldwide.

"We challenged this assumption about a lack of lymphatics and discovered specialized lymphatic channels in the human eye," said Prof. Yeni Yücel, a
pathologist-scientist in U of T's Faculty of Medicine and St. Michael's Hospital, and lead author of the study which appears in the current issue of
Experimental Eye Research.

Glaucoma is a degenerative disease believed to be caused by the death of nerve cells at the back of the eye and in vision centers of the brain. It is often
associated with elevated pressure in the eye. Current treatments for glaucoma rely on eye drops or surgery to lower eye pressure either by reducing
fluid formation or improving fluid drainage from the eye.

The lymphatic circulation, distinct from blood circulation, carries a colorless fluid, called lymph, containing extra water, proteins and antigens through
lymphatic vessels to lymph nodes and then to the blood stream. This circulation is critical for the drainage of the fluid from tissues, clearance of
proteins and immune monitoring of the tissue.

Using molecular tools and three-dimensional reconstruction, the team of researchers identified a rich network of lymphatic channels in the ciliary body
of the human eye. These studies were confirmed by electron microscopy.

The discovery of a lymphatic circulation in the eye overthrows the idea that the eye is an immune privileged site due to the lack of lymphatics and has
major implications for understanding eye inflammations and eye tumor spread, among other eye disorders. "This 'uveolymphatic' circulation plays a
role in the clearance of fluid from the eye, making it highly relevant to glaucoma. This discovery is exciting because it means we can focus on
innovative treatment strategies for patients with glaucoma by specifically targeting this new circulation to lower eye pressure," said Dr. Gupta.

Glaucoma is expected to affect 80 million people worldwide by 2020. Although the disease can affect anybody, those with elevated eye pressure, the
elderly, blacks and persons with a family member with glaucoma are at greatest risk. Other risk factors that may be associated with glaucoma include
diabetes, high blood pressure and near-sightedness.
 REFERENCES
• Black and Hawks. Medical Surgical Nursing. 7th
ed.
• Doenges. Nurse’s Pocket Guide. 9th ed.
• Wilson M.D. Practical Ophthalmology. 5th ed.
• http://www.ahaf.org/glaucoma/vanderbilt-stu
dy-shows-that.html