PRIMARY ANGLE CLOSURE GLAUCOMA

MANAGEMENT

1. Latent - asymptomatic

3. Acute

2. Subacute - intermittent angle closure

4. Chronic - ‘creeping or latent’ angle closure

• IOP may remain normal

• May progress to subacute, acute or chronic angle closure

• May develop acute or chronic angle closure

• Congestive - sudden total angle closure

• Postcongestive - follows acute attack

• Follows intermittent angle closure

5. Absolute

Classification

• No PL following acute attack

LATENT AND SUBACUTE ANGLE CLOSURE GLAUCOMA

1.MEDICAL….To reduce IOP Pilocrpine 2% : instilled every 5 min for 30

min then QID. Beta blockersPatient is advised to continue pilocarpine QID ORBeta blocker in BD dose2.LASER IRIDOTOMY / PERIPHERAL

IRIDECTOMY Fellow eye must also be treated surgically

as soon as possible.

ACUTE CONGESTIVE ANGLE CLOSURE GLAUCOMA

A: MEDICAL1.SUPINE POSITION

ALLOWS THE LENS TO SHIFT POSTERIORLY2.HYPEROSMOTIC AGENTS

20%MANNITOL….1gm/kg I/V over 30 min

3.CARBONIC ANHYDRASE INHIBITORS

ACETAZOLAMIDE….. 500 mg I/V + oral

4. ANALGESIA AND ANTIEMETICS

ACUTE CONGESTIVE ANGLE CLOSURE GLAUCOMA

5.TOPICAL AGENTS• Pilocarpine 2% to both eyes• Beta-blockers like timolol

0.5%....with caution in astrhma & COPD

• Topical -agonist (phenylephrine)• Steroids in case of inflammation.

ACUTE CONGESTIVE ANGLE CLOSURE GLAUCOMA

B.SURGICAL1.Surgical iridectomy 2.YAG laser Peripheral iridotomy……. To both eyes when cornea is clear4.Filtration operation3.Clear lens extraction by phaco with IOL.

HYPEROSMOTIC AGENTS

MODE OF ACTION: Hyperosmotic agents remain intravascular thus increase blood osmolality and cause a fluid shift from the eye into the vascular space. The subsequent osmotic diuresis reduces IOP.INDICATION:1.Acute angle closure glaucoma2.Prior to IO surgery when IOP is very high

HYPEROSMOTIC AGENTS

SIDE EFFECTS:1.Cardiovascular overloadMust be used with great caution in patients

with cardiac or renal disease.2.Urinary retention3.Headache,backache,nausea & mental confusion

HYPEROSMOTIC AGENTSS.N DRUG DOSE SIGNIFICANCE

1 MANNITOL 1gm/kg Peak of action is achieved within 30 minDuration of action is 6 hrsNot given to diabettics

2 GLYCEROL 1gm/kg Peak of action is achieved within 1 hrCan be given to well controlled diabetticsGiven with pure lemon juice to prevent nausea.

3 ISOSORBIDE Oral agent.

Can be given to diabettics without insulin cover

CARBONIC ANHYDRASE INHIBITORS

MODE OF ACTION: They reduce the formation of aqueous by

inhibiting action of CAE.Thus there is decreased formation of bicarbonates.

INDICATION:1.Systemically administered CAI are useful in short term treatment particularly in patients of acute glaucoma.

CARBONIC ANHYDRASE INHIBITORS

SIDE EFFECTS:1.Paraesthesia2.Malaise ,fatigue,depression,weight loss3.Gastic irritation,abdominal

cramps,diarrhea & nausea.4.Renal stone formation5.Steven-Johnson syndrome6.Blood dyscrasias.

CARBONIC ANHYDRASE INHIBITORS

S.N

DRUG DOSE SIGNIFICANCE

1 ACETAZOLAMIDE 500mg IV+500mg POSTAT

Immediate onset of actionPeaks at 30 min. Duration of action is 4 hrs.Only CAI available in injectable form & is very useful in emergency.

2 DICHLORPHENAMIDE 50-100mg TDS

Onset of action is within 1 hrPeaks at 3 hrs. Duration upto 12 hrs.

BETA-BLOCKERS

MODE OF ACTION: They reduce the aqueous humor formation by blocking beta

receptors in ciliary body When used with alpha-2 agonist or a CAI,an additional

15% reduction is achieved. When combined with a prostaglandin analogue, reduction

is even greater 20%

BETA-BLOCKERS

SIDE EFFECTS:1.Occasional allergy,corneal punctate epithelial erosions,reduced aqueous tear secretion.2.Bradycardia & hypotension…beta-1 blocker Bronchospasm…beta-2 blockers Sleep disorders,hallucinations,confusion, depression,fatigue reduced HDL

levels. 3.Reduction of systemic absorption.

BETA-BLOCKERS

CONTRAINDICATIONS: CCF,2nd or 3rd degree heart

block,bradyucardia,asthma & obstructive airway disease.

Beta blockers must not be used at bed time as it can cause visual deterioration.

BETA-BLOCKERS

S.N

DRUG DOSE SIGNIFICANCE

1 TIMOLOL 0.5%(non-selective)

BD Good ocular hypotensive agent.,safer,highly effective,has longer duration of action & is cheap.

2 BETAXOLOL 0.5%(beta-1 selective blocker)

BD Less ocular hypotensive effect.It increases optioc disc flow bc of a Ca-channel blocking effect on microcirculation of the disc.

MIOTIC AGENTS

MODE OF ACTION: They act by stimulating muscarinic receptors in the sphincter pupillae & ciliary body.In PACG sphincter pupillae contraction causes miosis pulling the peripheral iris away from the trabeculum,thus opening the angle.It is necessary to reduce IOP with systemic

medication before miotics can take effect. It is instilled every 15 min until pupil constricts then

qid.

MIOTIC AGENTS

S.N DRUG DOSE SIGNIFICANCE

1 PILOCARPINE 2% QIDBD if used in combination with beta-blocker.

Started after 1 hr of commencment of t/m,by which time reduction of iris ischemia & lowering of IOP allows the sphincter pupillae to respond to the drug.Fellow eye is also treated prophylactically wth 1%.

2 CARBACHOL 3% TDS Good alternative of pilocarpine in resistant cases.

MIOTIC AGENTS

SIDE EFFECTS: 1.Miosis 2.Browache 3.Myopia 4.Exacerbation of the symptoms of

cataract 5.Visual field defects appear denser &

larger

ALPHA-2 AGONISTS

MODE OF ACTION: Reduces the IOP by reducing the

formation of aqueous humor.

ALPHA-2 AGONISTS

S.N

DRUG DOSE SIGNIFICANCE

1 APRACLONIDINE 1% Used topically as an adjunct in glaucomaDoes not cross BBB hence has no hypotensive effects like clonidine

2 BRIMONIDINE 0.2% BD Also has a neuroprotective effect.

ALPHA-2 AGONISTS

SIDE EFFECTS:1.Allergic conjunctivitis2.Acute granulomatous anterior uveitis3.Xerostomia,drowsiness & fatigue.

NEW DRUG

LATANOPROST 0.005%THE GOLD STANDARD PROSTAGLANDIN

ANALOGUE

Latanoprost is a prodrug of latanoprost acid

Latanoprost is hydrolysed to its active form in

cornea or in plasma

It is preferred in open angle glaucoma.

Has little systemic side effects,but may cause

ocular irritation & iris pigmentation

Latanoprost: Proven for 24 hour IOP Control

Latanoprost when instilled at 9 p.m.

effectively lowered IOP at 3, 6 and 9 a.m.

at noon at 9 p.m. and at midnight

Latanoprost compared to other agents

lead to a fairly uniform circadian

reduction in IOP

AXIAL CORNEAL INDENTATION

One technique to lower the IOP is corneal indentation, in which the gentle pressure is applied several times to the cornea with a lens or hook to open the angle. This pressure on the cornea causes a shift in the internal structures of the eye, enhances aqueous drainage, and lowers the IOP.

Can be helpful in cases non responsive to medication.

PERIPHERAL IRIDECTOMY

A peripheral iridectomy is the surgical removal of a portion of the iris in the region of its root, leaving the pupillary margin and sphincter pupillae muscle intact.It is used in the treatment of glaucoma.

PERIPHERAL IRIDECTOMY

In acute angle-closure glaucoma cases,it has been superseded by Nd:YAG laser iridotomy, because the laser procedure is much safer. Opening the globe for a surgical iridectomy in a patient with high intraocular pressure greatly increases the risk of suprachoroidal hemorrhage, with potential for associated expulsive hemorrhage.

Nd:YAG LASER IRIDOTOMY

Laser iridotomy uses a very focused beam of light to create a hole on the outer edge rim of the iris. This opening allows aqueous humor to flow between the anterior chamber and the posterior chamber. This opening may decrease pressure in the eye and usually prevents sudden buildup of pressure within the eye, which occurs during an episode of acute closed-angle glaucoma.

LASER IRIDOTOMY

INDICATIONS

• Treat closed-angle glaucoma after the pressure in the affected eye has been reduced with medicine or when medicines fail.

• Prevent closed-angle glaucoma in people who have narrow drainage angles and those people who have had closed-angle glaucoma in their other eye.

LASER IRIDOTOMY

SIGNFICANCE• Laser iridotomy can prevent further episodes of sudden (acute) closed-angle glaucoma.• Laser iridotomy can usually prevent slow-

forming (subacute) closed-angle glaucoma in people who are at risk for closed-angle glaucoma.

• Sometimes people can take less medicine to treat glaucoma after having laser iridotomy.

LASER IRIDOTOMY

COMPLICATIONS EARLY Brief blurred vision (common). Swelling of the clear covering (cornea) of the iris. Bleeding. Increased pressure in the eye. Closure of the new opening. A second surgery

might be needed if the new opening closes. Burn to the inner lining of the eye (retinal

burn). This is a very rare complication.

LASER IRIDOTOMY

LATE Worsening of clouding of the lens (cataract) that was present before laser treatment. Closure of the opening. Recurrent closed-angle glaucoma. Development of another type of glaucoma. Continuing need for medicines (depends on the person's condition before laser treatment). Glare from light entering through the new opening

FILTRATION SURGERY(Trabeculectomy)

INDICATIONS It is done when extensive i.e more than 50% PAS are present

In this procedure partial thickness of a part of limbus is excised under a scleral flap.

CHRONIC CONGESTIVE GLAUCOMA

As extensive PAS have been formed so miotics,PI or LI are of no use.

So first raised IOP is lowered with Beta-blockers,Acetazolamide &

Hyperosmotic agents. Then Filtration surgery is done.

ABSOLUTE GLAUCOMA

Loss of vision with absolute glaucoma is irreversible, and treatment is aimed at

1.PAIN REDUCTION Topical steroids Topical atropine 1% Retrobulbar injection of alcohol 2.PARTIAL DESTRUCTION OF CILIARY BODY Cyclodiathermy i.e applied to the sclera adjacent to the ciliary body

ABSOLUTE GLAUCOMA

Cyclocryotherpay procedure that employs temperatures as low as -112°F(-80°C) to destroy the ciliary body

PROCEDURE:

Eyelids are first retracted . A cryoprobe is applied to the outside of the eyeball in the area surrounding the iris . The probe freezes ciliary bodies in 50-60 seconds. The probe is applied to adjoining sites in a semicircle around the iris during one treatment

ABSOLUTE GLAUCOMA

3.FILTRATION OPERATION: Use of adjunctive mitomycin C or 5-FU

both cidal to fibroblasts is more helpful in lowering

tension.4.ENUCLEATION: Done in case of unbearable painful blind eye as a last resort.

THANKS