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By ULY CLINIC

 

Glaucoma

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Introduction

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Glaucoma is a syndrome characterized by optic nerve damage and peripheral visual field loss which may be associated with raised intraocular pressure. The main classes of glaucoma are open angle glaucoma and angle closure glaucoma.  

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Note: Glaucoma may be congenital, primary or secondary to other ocular conditions

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Primary Open Angle Glaucoma

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Diagnostic Criteria

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  • 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 

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  • Primary Open Angle Glaucoma does not have symptoms in early stages, hence routine intraocular pressure check up and fundus examinations should be done in all people of 40 years and above by a qualified eye care personnel

  • All suspected cases of glaucoma should be referred to qualified eye care personnel for confirmation of diagnosis and treatment plan

  • Surgical treatment is usually preceded by medical treatment 

 

Pharmacological Treatment

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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 life long unless there are conditions necessitating other interventions

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  • Timolol 0.25% or 0.5%, one drop in the affected eye, instill 12 hourly. 

OR 

  • Betaxolol 0.25% or 0.5%, one drop in the affected eye, instill 12 hourly. 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, 24 hourly in the affected eye.

OR

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

  • These may be used as first-line in patients with contraindication of betablockers. 

  • 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:

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  • Brimonidine 0.15–0.2%, one drop, 12 hourly, in the affected eye. 

 

Failure to respond give: 

  • Pilocarpine hydrochloride 2% or 4%, instill one drop in the affected eye 6 hourly.  

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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. 

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In severe cases or while waiting for surgery, use:

  • Acetazolamide tablets (PO) 250 mg 6 hourly 

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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 

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Laser Treatment

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 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. 

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Angle Closure Glaucoma

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This is also known as Congestive glaucoma and commonly affect people aged 40 years and above. 

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Diagnostic Criteria

  • Patients presents with acute sudden onset of painful red eye in the affected eye

  • Severe headache and cloudiness of the cornea

  • Shallow anterior chamber

  • Fixed and semi-dilated pupil

  • Severe elevated intraocular pressure.

  • There is usually dramatic visual impairment and vomiting may be present

  • It may be asymptomatic if IOP raises slowly 

 

Note:  

  • Primary Angle Closure Glaucoma is an Ophthalmological Emergency

  • Refer all patients with Congestive glaucoma to eye specialist after initial medical treatment 

 

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

  • Acetazolamide tablets, 500mg PO immediately as a single dose followed by 250 mg 6 hourly  

AND

  • Timolol 0.25–0.5% eye drops, instill one drop 12 hourly 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    

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Second-Line Treatment

 

If the above measures fail, use as a short term treatment, give systemic osmotic agents:

  • Intravenous 15–20% Mannitol 1.5–2mg/kg body weight to run slowly over  30–60 minutes 

OR

  • Glycerol syrup (PO) 1–2 g/kg body weight, 50% solution as a single dose  immediately.  

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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. 

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Note: 

  • Acetazolamide is a sulphur containing medicine, do not use in patients allergic to sulphur. 

  • Glycerol is a concentrated sugar solution, it should not be given in diabetic patients. 

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Referral

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Management of advanced angle closure glaucoma is done by eye specialist. Hence, all patients with Angle Closure Glaucoma should be referred to eye specialist.

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Childhood Glaucoma

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  • Presents from birth to 5 years.

  • It is a syndrome where by the intraocular pressure is raised and cause abnormality of the eyeball and visual disturbances even blindness. 

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Diagnostic Criteria

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  • Patients presents with eyes bigger than normal for age (buphthalmos)

  • Photophobia

  • Tearing 

  • Cloudy cornea, 

  • Red conjunctiva though not severe. 

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Surgical Treatment

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

 

Referral

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Refer any child who has the above mentioned signs and you suspect that he/she is having congenital glaucoma to a specialist at a Paediatric Eye Tertiary Centre (National Hospital and Zonal Referral Hospitals).

 

 

Secondary Glaucoma

 

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.   

 

Diagnostic Criteria

  • Poor vision in the affected eye associated with

  • High intraocular pressure

  • Optic nerve damage

  • New vessels on the iris if the cause is retinal diseases 

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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 :- 

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  • Acetazolamide tablets, 500mg PO immediately as a single dose followed by 250 mg 6 hourly 

AND

  • Timolol 0.25–0.5% eye drops, instill one drop 12 hourly 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.

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Updated on, 30.10.2020

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References

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1. STG 

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