GLAUCOMA

Dr. (Prof.) Sandeep Mithal (M.S.)

Upgraded Dept. of Ophthalmology
LLRM Medical College, Meerut
1

Anatomy of Angle of
Anterior Chamber

A/C is bounded in
front by the
cornea, behind by
the iris and the
part of the
anterior surface
of the lens which
is exposed in the
pupil.

Its peripheral
recess is known
as the angle of
the A/C, bounded
posteriorly by the
root of the iris
and ciliary body
and anteriorly by
the corneoscleral
junction.
4

In the inner layers of

the sclera at this part
there lies a circular,
venous sinus called the
canal of Schlemm and
in between the canal
and A/C there lies a
loosely constructed
meshwork of tissues
called corneoscleral
trabeculae which has
got a sieve like
structure and
communicates A/C with
canal of Schlemm.
5

Aqueous Humor Its

Formation and Circulation

Aqueous is
produced by
ultrafiltration and
secretion from
ciliary processes
and passes into
the posterior
chamber.
6

From the posterior chamber it passes through the

pupillary aperture into the A/C and then through
trabecular meshwork into Schlemm canal and finally
leaves the eye through aqueous vein into the
anterior ciliary vessels.

Facility of aqueous outflow

1. Trabecular outflow - 90%

2. Uveoscleral outflow 10%

10

11

Aqueous humor leaves

the eye through a tiny
drain called the
trabecular meshwork,
which is located just in
front of the iris.

12

IOP
Normal IOP varies between 14-22
mmHg and is not maintained at a
constant level throughout the day,
because of the variations which occur
during 24 hours, so called diurnal
variation. Normal diurnal variation is
usually 3-5 mmHg.

13

IOP can be measured by:

(i) Digital method
(ii) Tonometry

14

(i) Digital method

is a rough method and gives an idea about
difference in the IOP of two eyes.
Method: Ask the patient to look down and
place both your forefingers over upper lid
above the tarsal plate and then press with
one and feel the fluctuation with the other.
This can be compared with other eye

15

(ii) Tonometry
Indentation,

Schiotz
Applanation
Goldman,

Hand -held goldman type tonometer

1.
Perkins Applanation tonometer
2.
Mackaymarg tonometer (Tonopen)
3.
Pneumatic tonometer

Non-contact puff air

16

Indentation tonometry

In indentation tonometry a plunger with a

definite weight presses over the cornea and
depending upon IOP, causes indentation of
cornea which is reflected on a scale and by
scale reading from a standard chart IOP can
be known.

17

Applanation tonometry

In applanation tonometry amount of pressure

which is required to make a small area of
cornea flat is measured and it gives reading
of IOP.
This is more accurate as factor of scleral
rigidity does not come into play in this
method.

18

Applanation tonometry

19

20

Tonometers

The Schiotz tonometer

The tono-pen.

The Goldmann tonometer.

The Perkins tonometer.

21

Tonometers

22

Definition of Glaucoma
Glaucoma is a chronic progressive
optic europathy caused by a group of
ocular conditions which lead to
damage of the optic nerve with loss of
visual function

23

Classification of Glaucoma
1. Congenital
2. Acquired : Acquired can be
(a) Primary
(b) Secondary
Primary is again divided depending upon
configuration of angle of A/C into
(i) Angle closure or narrow angle glaucoma
(where angle is less than 20) or congestive
glaucoma; and
(ii) Open angle or Chronic simple or Wide angle
glaucoma where angle is normal, i.e. more than
20.
24

ANGLE CLOSURE
GLAUCOMA

25

Aetiopathology:
Aetiopathology
Predisposing factors

Age usually occurs in fifth or sixth decade

of life.
Sex much more common in females.
Personality Particularly seen in those who
has got anxious personality and shows
instability in their vasomotor reactions.

26

The type of eye

affected is also
characteristic.
It can only occur in
eyes having narrow
angle of A/C
having shallow
anterior chamber
more common in
hypermetropes
27

How to know about the angle

of A/C ?

It is done by gonioscopic exploration of angle of

A/C.

Because of radius of curvature of the cornea,

light rays coming from far peripheral iris from
the angle undergo total interval reflection so
prevents the eye surgeon from examining these
structures without the use of a contact lens to
eliminate the corneal curve

28

Goniolenses

29

Total internal reflection of light

emanating from the chamber
angle

30

Mirrored gonioscopy lens

enables light from the chamber
angle to pass out of the eye.

31

Normal Gonioscopic
Findings

32

33

Angle AC

34

Normal Gonioscopic
Findings

35

Mechanism of angle closure

Mechanism of angle closure varies.
Most common sequence of events follows
pupillary dilatation.
In a normal depth A/C iris lies flatly in a
transverse plane with pupillary margins
very lightly touching the anterior surface of
the lens.

36

In an eye having a
configuration liable to closed
angle glaucoma with its
shallow A/C and anteriorly
placed iris lens diaphragm,
iris is rather more closely
opposed to the lens making
communication between
anterior and posterior
chamber through the pupil
therefore difficult so that a
condition of relative pupillary
block exists and so there is
collection of aquous in the
posterior chamber.

37

In a state of semidilatation of pupil due

to relative pupillary block relaxed iris
bellies forward resembling iris bombe
and its roots approximates the inner
surface of cornea thereby cutting
filtration at the angle.

38

Another mechanism is a crowding of the

already narrow angle of A/C by a dilatation of
pupil which can be as a result of use of
mydriatics or sometimes merely on exposure
to darkness.
Thirdly, it can be due to swelling of the root
of the iris and ciliary body as a result of
some vascular change induced by nervous
stimuli in emotional state due to congestion
of ciliary body and root of iris.

39

Clinical features

Since both eyes usually have a similar

structure, this type of glaucoma is
likely to be bilateral but one eye is
usually affected before the other.

40

The clinical course

The clinical course of the disease can be
divided into 5 stages:
(1) prodromal stage,
(2) stage of constant instability,
(3) acute congestive stage,
(4) chronic congestive stage, and
(5) stage of absolute glaucoma.

41

Prodromal stage
In this stage occasional attacks of raised
tension occurs, giving risk to following
symptoms :
Transient attacks of blurring of vision and
appearance of coloured halos around light
due to corneal oedema.
Occasionally associated with headache
also.

42

The signs in this stage are minimal. Eye is

usually white without congestion, however,
IOP may suddenly rise for short period.
Such attacks may occur intermittently
being caused by such factors as over
work, anxiety, excitement, fatigue,
particularly by such circumstances which
cause a pupillary dilatation.
43

Stage of constant
instability
In this stage intermittency in these

attacks is replaced by regularity or there

is an exaggeration in the normal diurnal
variation.
IOP usually is considerably high in late
afternoon and evening and symptoms in
the eye like blurring of vision/coloured
halos and headache become a regular
feature of almost every day but may still
be relieved by sleep or rest.
44

Acute congestive stage

Sooner or later, however, an acute congestive

attack occurs precipitated by a sudden complete
closure of the angle of the A/C.
Patient C/o an excruciating pain in the eye
developing suddenly which may radiate over the
entire distribution of 5th nerve and may be
associated with nausea or even vomiting.
Vision rapidly diminishes so much that in a few
hours only hand movements can be recognised.

45

On Examination:

lids are oedematous,

conjunctiva shows conjunctival as well as ciliary
congestion and can be chemosed.
Cornea is hazy and insensitive.
A/C is very shallow,
iris is discoloured
pupil moderately dilated and vertically oval;
reaction to light, accommodation are absent.
Fundus is not visible due to hazy media.
Eyeball is hard due to high IOP and is tender.

46

Acute congestive stage

47

48

Typical signs of
previous acute or
subacute angleclosure attacks. (a)
Patchy iris atrophy. (b)
Torsion of the iris. (c)
Subcapsular,
speckled anterior lens
opacities
(glaucomflecken).

49

4) Chronic congestive
stage

This stage is reached if the acute stage

is not relieved by treatment or may also
start in an insidious manner without an
acute episode.
Eye remains irritable and congested
with rapidly deteriorating vision.

50

On Examination:

IOP is raised, gonioscopy reveals

peripheral anterior synaechia which result
due to adhesion of congested root of iris
to the back of cornea.
Visual field defects indistinguishable from
chronic simple glaucoma occur with a
concentric contraction also and in later
stages the optic disc may show
glaucomatous cupping and optic atrophy
51

5) Absolute stage

The chronic stage, if untreated with or

without the occurrence of intermittent
subacute attacks gradually passes in
the final stage of absolute glaucoma,
wherein the eye is completely blind, i.e.
even light perception is lost.
The eye is painful which may radiate to
forehead and the temple.

52

On Examination:

eye is as hard as a stone.

Anterior ciliary veins are prominent, cornea
is insensitive and bullae or filaments may be
present over its surface as a part of bullous
keratitis or filamentary keratitis.
A/C is shallow.
Iris is atrophic,
pupil dilated and fixed with ectropion of
pigment

53

D/D :

Acute Conjunctivitis
Acute iritis
Acute Glaucoma

54

Course and Prognosis

Uveal pigment at pupillary margin.

By passage of time, sclera may get thinned
under high IOP and staphyloma ciliary or
equatorial may result.
Initially end stage, the ciliary body may get
atrophied leading to hypotony.

55

Diagnosis

Diagnosis of closed angle glaucoma is

important in the prodromal stage.

In the acute and chronic congestive stage

diagnosis is quite obvious but has to be
differentiated from acute iritis and acute
conjunctivitis.

56

Acute
conjunctivitis

Acute iritis

Acute glaucoma

Discharge

Moderate to
profuse

None

None

Vision

Normal

Blurred

Markedly blurred

Pain

None

Moderate

Severe

Congestion

Conjunctival

Circumcorneal

Circumcorneal

Cornea

Clear

Usually clear. KPs may

be present at the back

Steamy

A/C

Normal in depth

Normal in depth with

aqueous flare

very shallow

Angle of A/C
by
gonioscopy

Normal

Normal

Narrow or closed

Iris and pupil

Normal

Iris is muddy and small

irregular pupil

Iris appears discolored

due to hazy cornea,
pupil semidilate vert.
oval

IOP

Normal

Usually normal , may be

low or even high

Always raised
57

In the prodromal stage diagnosis depends

upon:
H/o seeing coloured halos
Presence of narrow angle of the A/C (By
Gonioscopy)
Provocative tests

58

A H/o seeing coloured halos around the light

particularly if associated with periodic
demonstration of constriction of pupil and
headache should arouse strong suspicion.
Finchams test

59

The anatomical structure of angle of A/C is of

great importance and in this type of glaucoma
it is invariably found narrow when explored
gonioscopically.

60

The demonstration of a rise in tension is

often difficult in the prodromal stages
since the periods of raised tension are
transient when immediate recording of
IOP may not be possible because of the
fact that it often occurs at inconvenient
times.
However, patient should always be
instructed to report to the doctor for
recording of IOP whenever he or she sees
colored halos around the light.
61

If this is not possible then provocative

tests should be carried out which are all
designed to test the capability of the eye
to regulate IOP under conditions of stress

62

Provocative tests

Dark room test

Priscol test,
Mydriatic test
Water drinking test

63

Dark room test

(8 mm in hr):
Patient is placed in a dark room for half an
hour so that pupil dilates. But he must
remain awake.
IOP is recorded before and after placing
the patient in dark room for an hour a
rise in IOP of more than 8 mm of Hg is
considered pathological.
64

Mydriatic test

(5 mm

n 1 hr):
In mydriatic test pupil is dilated by a mild mydriatic
such as phenylepherine or tropicamide but if these
give a negative result even homotropine can be
used but always with a caution.
Tonometric readings are taken every 15 minutes
for 1 hour a rise of IOP of more than 5 mm of Hg
is pathological.
After mydriatic test is over it should always be
ascertained by the surgeon that full vision of the
pupil has been achieved.

65

Priscol test

(14 mm in 1 hr):
In priscol test, 10 mgm of prisol is injected
S/C
A rise of IOP greater than 14 mm of HG
within 60 minutes is pathological.

66

Water drinking test

(more than 6 mm):

In this test patient is asked to drink a litre of water
in 5 minutes time on overnight empty stomach in
the morning as first thing in order to lower osmotic
concentration of blood.
IOP is recorded before giving water to patient and
subsequently after every 15 minutes.
A rise of IOP of more than 6 mm of Hg is
pathological.
But this test is more specific for chronic simple
Glaucoma rather than angle closure glaucoma.
67

If any of these tests are positive it is

significant but negative test does not
exclude prodromal stage or a possibility of
an acute attack developing in the
immediate future.

68

Course and Prognosis

Before the stage of acute attack, visual acuity

remains unimpaired.
If acute stage persists - total abolition of vision
may result in single attack.
Otherwise after each attack visual acuity is
always depressed to some extent.
In chronic congestive state vision rapidly falls
and chronic stage if untreated gradually passes
into absolute stage wherein the eye is
completely blind
69

Treatment

Treatment of prodromal stage and stage of

constant instability:
Early diagnosis of closed angle glaucoma stage
and its treatment in this early stage is very
important, since treatment in this stage is easy
and prognosis excellent.
Here main aim is to prevent occurrence of an
acute attack till surgery is taken up .....................
and side by side keep IOP controlled.
70

Medical treatment

Medical treatment consists of use of miotic

drops locally such as Pilocarpine 0.5 to 2% 2
to 3 times a day or one of its substitutes.
Drops should be instilled in both the eyes at
the time of rise of tension which can be found
out by maintaining record of IOP over 24
hours or prophylactically also, when fatigue,
excitement or darkness is anticipated.
But ideal treatment is surgical in the form of
peripheral iridectomy before anterior
peripheral synaechia have formed or simple
laser iridotomy.
71

It establishes a free communication between

anterior and posterior chambers thereby
preventing any possibility of iris bombe or
angle closure and results in a complete
cessation of the disease without involving any
visual disability or any other risk.

72

Treatment of acute
congestive stage : Medical
and
Surgical
Medical
treatment

In case of acute congestive glaucoma

medical treatment is always a preparation for
surgery and its main aim is to reduce IOP
and also pain before surgery, in order to
avoid the difficulties of operation on a
congested chemosed eye and the danger of
opening the eye under high IOP.

73

(i) Sedation and analgesia

Strong analgesics are

recommended as it is an extremely
painful condition

74

ii) Miotics

Constrict the pupil by intensive miotic

therapy either by Pilocarpine 4% alone (one
drop every 5 minutes for 15 minutes; every
15 mts for 1 hour and then 1 hourly till pupil
constricts and then 4 to 5 hour a day) or if
Pilocar alone is not sufficient eserine can also
be added to miotic therapy.

75

(iii) Lowering of IOP by

other
means
(a)
Acetazolamide

Orally in a dose of 500 mgm stat and then 250

mgm tab 6 hourly for first 2 days, then reducing it
to 8 hrly; then 12 hrly till surgery is undertaken.

It is a carbonic anhydrase inhibitor and reduces

aqueous secretion by as much as 60%
Potassium chloride 1 gm with each tablet and 250
mg should be given to cover hypokalaemia
produced by it. Otherwise patient will complains of
cramps in calf muscles, loss of appetite, tingling
and numbness.

76

(b) Systemic hyperosmotic therapy:

(a) Glycerol 1.5 gm/kg body weight orally with
lime or other fruit juices;
(b) Urea 1.5 gm/kg body weight by I/V route;

c) Mannitol 20%

77

Surgical Treatment

Medical treatment should be tried for 12 hours or at

the most up to 24 hours.
If acute attack is controlled by medical means within
this period (which is indicated by improvement in
general condition of the patient, pain is reduced,
congestion is less, cornea clear, pupil get constricted
and tension lowers down) it is better to wait until the
eye is free of congestion before operating;
but if attack is not controlled even in 24 hours by
medical treatment then patient should be transferred
to OT and surgery should be undertaken as an
emergency measure.

78

Peripheral Iridecomy or laser

iridotomy

Peripheral Iridecomy or laser iridotomy is the

operation of choice if extensive anterior
peripheral synaechia have not formed which can
be found out by gonioscopy.
But if extensive ant. Peripheral synaechiae have
formed involving more than 2/3rd of angle then a
filtering operation should be done,

79

Peripheral Iridecomy or laser

iridotomy

80

Peripheral Iridecomy or laser

iridotomy

81

Full thickness filtering procedures:

Schieis
Trephine
Iridencleisis
Guarded filtering procedures:
Trabeculectomy
Subscleral trephine
Subscleral thermosclerostomy

82

Treatment of the fellow

eye

In all cases of closed angle glaucoma, other

eye should be operated upon by a
prophylactic peripheral iridectomy or simple
laser irodotomy if the angle is narrow even if
IOP is normal.

83

Treatment of chronic
congestive stage

1.
2.

Treatment of chronic congestive stage is

depending upon presence or absence of
anterior peripheral synaechia
PI
Filtering surgery
In the meantime surgery is undertaken,
miotic, if require acetazolamide should be
given to control IOP.

84

Treatment of absolute
stage
Main symptom here is pain, though eye has got

no vision
Cyclodestructive procedure
1.
Cyclodiatheramy
2.
Cyclocryotherapy
3.
Laser cyclophoto-coagulation can be done to
reduce IOP.

Alternatively retrobulbar injection of alcohol

can be given to relieve pain.

If these procedures do not relieve pain, it is

best to do cryoablation.
85

Chronic simple
glaucoma or open
angle or wide angle
glaucoma

86

Primary open-angle glaucoma

(POAG)

Primary open-angle glaucoma (POAG) is a

progressive optic neuropathy with
characteristic optic nerve excavation and
corresponding visual field defects

87

Narrow angle

Open angle

Age

In 5th or 6th decade

Occurs a decade later

Sex

Common in male

No special pre....... to any sex.

Personality

Anxious personality
with an unstable
vasomotor system

Can occur in anybody

Type of eye

Specifically seen in
narrow angled eye

Can occur in eye with any

type of angle

Symptoms
and course

Symptoms are ............

and disease runs an
acute course

No symptoms are
experienced generally and
disease runs a slowly
progressing course.

Field defect
and cupping

Appears late and

develop rapidly.

Develop early and progresses

insidiously.
88

Both types of glaucoma, however, ultimately

end in same stage, i.e. absolute stage or in
both types condition is almost always
bilateral.

Treatment: .................

89

Aetiopathogenesis

The mechanism of chronic simple glaucoma is

inadequately understood, however it seems that
there are some degenerative changes in the
trabecular meshwork of mucinous nature impending
passage of aquous through the trabecular
meshwork or there is sclerosis in fine vessels drain
aquous from canal of schlemm

There is impaired drainage or impairment can be as

a result of disturbance of neurohormonal control of
ocular vasculature
90

Clinical fatures

Symptoms

Chronic simple glaucoma unlike narrow angle

glaucoma is usually free from all symptoms
especially in the early stage.
There is no pain, etc except for a very very slowly
progressive painless visual loss.
Sometimes patient may also come c/o increasing
difficulty in near work seeking frequent change in
presbyopic glasses or some intelligent patients
may also c/o taking more time in adapting in dark,
i.e. light minimum is raised.

91

Normal vision

The same scene as it

might be viewed by a
person with glaucoma

92

Signs:
Triad of signs is present :
(1) Increased IOP,
(2) Glaucomatous cupping of optic disk,
(3) Visual field loss.

93

(1) Increased IOP:

In early stages the IOP in chronic simple glaucoma

requires careful study over a period of 24 hours for
which hospitalization is required.
The initial change is not so much a rise of tension
as an exaggeration of the normal diurnal variation.
Since 20% of cases show the rise in tension in the
morning, 25% in the afternoon and the majority
shows a triphasic curve rising at both times.
In most cases, however, contrary to what happens
in closed angle glaucoma, tension falls during the
evening.

94

At first between the phasic rises, the tension

usually returns to normal (so a single reading of
IOP should never be relied upon which may be
recorded at the time of normal IOP between
phasic rises) but as time goes on the variation
increases and the normal level is never attained.
The difference between peak pressure and the
base pressure thus diminished and a
permanent elevation occurs usually however
retaining some of the phasic element.

95

96

2) Cupping of the optic

disc:

When IOP remains raised for quite sometime

optic disc becomes cupped partly due to the
mechanical effect of raised IOP and partly
due to vascular sclerosis with subsequent
anaemic atrophy of the optic nerve.
Glaucomatous cup has to be differentiated in
early stages from a deep physiological cup.

97

Enlarged cup

98

99

Glaucomatous cupping of the

optic nerve.

100

Asymmetry of cup

101

End-stage ``bean pot"" cup

102

103

Glaucomatous

Deep physiological

excavation reaches up to
edge of the disc

Usually horizontally oval

and excavation never
reaches the edges

+
Usually vertically oval and

2 Sides are very steep

Not so

3 Vessels disappears at the

Continuity in vessels is
not proper at disc
margins and no parallex
can be elicited.

margins to reappear at
base again and definite
parellex can be elicited

104

3) Visual field loss

Visual field of an eye is the space within

which an object can be seen while the eye
remains fixed upon some one point. It varies
with size and colour of the test object,
illumination and upon several other factors.
But under standard conditions for a white
test object of 0.5 mm it is 55 upwards, 60
nasally, 75 downwards and 90 temporally.

105

A scotoma is a defect within the visual

field and can be negative or positive.
A positive scotoma is the one which
patient can appreciate and is due to
changes in the media usually, while a
negative scotoma is the one which patient
cannot appreciate as such and can be
detected by examination of the visual
field.

106

This can be pathological, as in various

conditions of eye , e.g. glacuoma,AION,
Brain Tumors or even physiological, the
e.g. of which is blind spot which is due to
the optic nerve head and is situated 12 to
15 temporal from the point of fixation and
slightly below the horizontal meridian.

107

There are several methods of testing

visual fields a rough but still useful
method is confrontation test, but
accurate field charting can be done
on any of the large number of
parameters available and the
investigation is called perimetry.

108

For more accurate investigation of details

compumetry is done which shows fields of
central or paracentral area only (up to 30
isopters from point of fixation) and is
carried out on Bjerrums screen (manual)
which can be of 1 or 2 meter size or
automated computerised perimetery.

109

Field defects in chronic simple glaucoma

usually run parallel to the changes in optic
disc characteristically there is a progressive
loss of the peripheral visual fields with a
gradual spread towards the fixation area
which can be recorded by perimetry.
But recording of central fields on Bjerrums
screen is more important as changes in the
central fields are quite typical of chronic
simple glaucoma.
110

The earliest sign is frequently a localized

constriction of the central field so that instead
of skirting the 30 isoptre concentrically, the
field becomes deformed, curving inwards
temporally to exclude the blind spot, known
as baring of the blind spot.

111

A second early sign is the

appearance of one or more
small scotomas in the same
isoptre as the blind spot
above or below the disc.
Then there is a sickle
shaped extension of blind
spot above or below or both
with concavity of the sickle
directed towards the fixation
point (Seidels sign).

112

At a later stage this enlarging blind spot

become confluent with scotomas lying in
same isoptre forming an arcuate scotoma
either above or below the horizontal meridian
known as Bjerums scotoma.

113

If arcuate scotoma is
formed above or below
horizontal meridian
simultaneously then a
ring scotoma may be
formed.
formed

114

Sometimes at an early
stage and sometimes only
late in the disease defects
appear in the peripheral
field.
The upper nasal field
particularly shows a
sectorial defect having a
sharply defined horizontal
edge, called Roennes
nasal step.
In later stages there is
more generalised
contraction of fields and
eventually only temporal
inland a paracentral patch
of the temporal field
persists, central vision
being abolished.
115

116

Automated perimetry

117

Other than triad of signs

pupil can be slightly

larger in size and
sluggishly reacting to
light
hemorrhage over the
disc
In late stage
peripapillary atrophy.
118

Diagnosis

Diagnosis mainly depends upon triad of signs

of raised IOP, glaucomatous cupping of optic
disc and visual field loss.
Water drinking provocative test , bulbar
pressure test, tonography are other very
helpful tests in early stages of the disease.

119

OCT

Gross glaucomatous damage

Optic nerve head analysis

120

Course and Prognosis

Course is slowly progressive and if not
treated it ultimately passes into stage
of absolute glaucoma, having no
vision.

121

Treatment:

Treatment of chronic simple glaucoma unlike

closed angle glaucoma is ideally medical and
surgery is advocated if medical treatment is
insufficient to control the condition or there is
default in medical treatment........?????

122

Medical treatment

1. Drugs which increases facility of aqueous

outflow: e.g. Pilocarpine 1-4%, Eserine 0.25 to
1.0% Phospholine iodide 0.3 to 0.25%, DFP
0.01 to 0.1%.
But timolol and Pilocarpine are still the sheet
anchor of treatment and is used as drops 0.25 ro
0.50 BD or 1 to 4% every 6 hrly. The optimum
strength is the weakest that will control the
condition.
123

The criteria of control is that IOP should

remain within normal limits and repeated
field charting and fundus examination
should not show any further deterioration
If pilocarpine alone cannot control the
condition it can be tried in combination
with other drugs, but even then if condition
is not controlled then surgery should be
undertaken.
124

125

Method of choice for chronic simple

glaucoma is trabeculectomy but other
filtering operations like Scheis, Trephine,
Iridenclesis, Cyclodialate give good results

126

Filtering procedures
GUARDED:
trabeculectomy
Subscleral trephine
Subsclero thermal sclerostomy
FULL THICKNESS:
Schies
Trephines

127

WOUND MODULATION
Can be done in intractable cases of
Glaucoma
Trabeculectomy with Mitomycin C
5FU
LASER PROCEDURES
helps in chronic simple glaucoma
Laser trabeculolasty
128

Laser trabeculolasty

129

TRABECULECTOMY

Isolated trabeculectomy
Combined with cataract extractionPhacotrabeculectomy

130

Phacotrabeculectomy

131

Seton in filtration
glaucoma

patient has a tube

which enters the
anterior chamber
through the limbus
region. This is a seton
used for
glaucoma operation.
Molteno's tube is the
most commonly used.

132

BUPHTHALMOS OR
CONGENITAL
GLAUCOMA

133

It is defined as glaucoma which is present at

birth or develops during the first three years
of life.
Aetiology and pathogenesis:
It develops as a result of a developmental
anomaly of the tissues of the angle of A/C,
which leads to obstruction to outflow of
aqueous thereby giving rise to raised IOP.

134

Developmental anomalies may

be :

Nonseperation of root of iris from the cornea

Canal of Schlemm may be deficient or absent
Absence of aqueous veins
Or the whole angle may remain closed by
persistent embryonic tissue.
Both eyes are usually affected, condition is
more common in boys than in girls.

135

Clinical features
Symptoms:
(1) Epiphora
(2) Photophobia,
(3) Corneal haze or
(4) Enlargement in the size of the cornea or the
eye

136

Congenital glaucoma

137

Signs:
1. Blepharospasm due to corneal involvement;
2. Circumcorneal congestion may be present;
3. Cornea
enlargement in its diameter (normal 8-9 mm),
strong suspicion should arise when more than
11.5 mm, can be as large as 16-18 mm in
diameter.

Oedema of the cornea and later corneal

opacities due to rupture in descemets
membrane

Corneal sensitivity may be diminished

4. A/C is deep.
5. Iris is tremulous and may show atrophic
patches.
138

6. Pupil may be semidilated and sluggishly

reacting to light.
7. Lens may be sublaxated and tremulous.
8. Eye ball is large in size and myopic in refraction
but myopia is less in comparison to
enlargement in size of eye ball due to flattening
and posterior displacement of the lens.
9. Sclera is thinned out due to stretching and
appears bluish white in colour.
10. Fundus examination reveals cupping which is
reversible in early stages in buphthalmos

139

140

141

142

Megalocornea

Buphthalmos

Involvement

Always bilateral

Can be unilateral sometimes

Heredity

Dominant in a familial disease

Recessive

Sex

Only males are affected

Though more common in males but

females are also affected

Symptoms

No photophobic or lacrimation

Present

Cornea

Clear

Opaction and ...........

IOP

Normal

Raised

Angle

Has got normal structure

Anomalous

Disc

No cupping

Size

No generalised enlargement of
eye ball

Generalised enlargement of eye

ball present of
143

Treatment Medical /
Surgical

Medical Treatment is ineffective and can be

taken help of preoperatively only in the form
of Diamox and beta blockers

144

Surgical

Earlier the surgery is done better is the

prognosis and visual results.
Trabeculotomy (ab externo), Goniotomy(ab
interno) and Goniopuncture are operations of
choice.
Other filtering procedures like
Trabeculectomy, Schies, Iridentesis,
Trephine, etc are also effective but have to be
repeated.
145

SECONDARY GLAUCOMA

Secondary glaucoma may occur in a wide

variety of conditions usually as a result of
mechanical inerference of the circulation of
aqueous humour.

The common causes are :

146

Diseases of the cornea

Keratitis and hypopyon, corneal ulcer as a

result of obstruction to the drainage channels
by purulent fibrinous masses present in the
aqueous.
Perforation of Corneal ulcer or perforating
injury of cornea due to formation of anterior
peripheral synaechiae.

147

Diseases of the Uvea

Hypertensive uveitis.
In iridocyclitis due largely to uveal engorgement and
partly to clogging of the drainage channel by the
turbid aqueous and inflammatory exudate.
Due to Sequelae of Iridocyclitis:
As a result of occlusio or secclusio pupillae there is
pupillary block leading to iris bombs and formation
of anterior peripheral synaechia which in turn leads
to raised IOP.
Essential atrophy of the iris is a degenerative
condition of obscure aetiology and is associated
with IOP.
148

149

Tumours

Tumours of iris, ciliary body and choroid are

often associated with IOP mainly due to
mechanical obstruction of the angle.

150

Diseases of the Lens

(phacogenic)

Size of the lens (phacomorphic).

Due to intumescence of the lens as during

cataract formation or due to injury of the
lens.
Position of the lens.

Anterior dislocation leads to IOP as a

result of blockage of angle or due to
pupillary block.

Posterior dislocation leads to IOP by

producing irritation of ciliary body.
151

152

(i) Phacolytic

due to leakage of lens material in A/C either

as a result of hypermaturity or injury, lens
material actually blocks the trabecular
meshwork.

153

Phacolytic acute glaucoma

154

(ii) Phacoanaphylactic.

Lens protein is a foreign protein to the body

and as during hypermaturity due to repeated
leakage of lens proteins there is antibodies
formation leading to severe anaphylactic
reaction in the eye causing IOP.0

155

(iii) Glaucoma capsulare

(Pseudo-exfoliative of lens

capsule)
In this condition, flake like deposits takes

place on the lens surface, ciliary body,

zonules of lens and posterior iris surface and
on trabecular meshwork, obstructing the
drainage of aqueous.
Previously this flake like material was
presumed to be exfoliative from lens capsule
but probably it comes from anterior uvea as a
result of degenerative changes.
156

Pseudoexfoliative
glaucoma

157

Diseases of the Retina

1.Central retinal vein thrombosis or 90 days

glaucoma which occurs roughly 90 days after
an episode of central retinal vein thrombosis
and is due to neovascularization of the angle.
2.Retinal detachment. Sometimes in late
stage of retinal detachment patient may have
IOP, exact mechanism of which is not
understood.
3.Tumour of the retina. Retinoblastoma in its
2nd stage is associated with tension.
158

Neovascular glaucoma

159

PRP for NVG

160

Trauma

1.Massive hyphaema. In massive hyphaema

due to organized clots and breakdown
products of blood due to mechanical
obstruction of angle can lead to IOP.
2.Vitreous haemorrhage, also can give IOP.
(Ghost cell glaucoma).
3.Angle contusion glaucoma due to the effect
of blunt injury on angle of anterior chamber,
there can be tear in ciliary body giving rise to
IOP.
161

162

Follwing Intraocular
Surgery

1.Delayed reformation of A/c leads to

formation of anterior peripheral synaechia
leading to IOP.
2.Epithelialization of A/C. When, after catarct
Surgery there is faulty coaption of the edges
it may be due to ingrowth of conjunctival
epithelium into A/C angle and surface of iris
leading to IOP.

163

Others

like secondary rise of IOP in diabetes due to

neovascularization of angle of A/C,
secondary rise of IOP due to local use of
corticosteroids

164

Treatment should be directed towards cause

of glaucoma. In the meantime IOP should be
controlled with the help of Diamox and other
drugs which reduces secretion of aqueous. In
intractable cases sometimes glaucoma
surgery becomes necessary

165

THANK YOU

166