GLAUCOMA

Vaisakh. GI Year MSc. Nursing,AIMS,kochi.

Glaucoma is a group of ocular disease characterized by,

1. Increased Intraocular pressure(IOP)

2. Optic nerve atrophy

3. Peripheral visual field loss

EPIDEMIOLIOGY

Leading cause of blindness in the World., In India, 3rd most common cause of blindness after cataract and refractive errors.

• Most prevalent among men than women.

• “Once lost vision in glaucoma it cannot normally be

recovered”

Glaucoma has been called as “SILENT THIEF”.

ETIOLOGY

• Congenital genetic malformations

• Diabetic retinopathy

• Occular trauma

• Corticosteroids

ETIOLOGY

A balance between the rate of aqueous humor production (referred to as inflow) and the rate of reabsorption (referred to as outflow) is essential to maintain the IOP within normal limits.

Normal IOP- 10 to 21mmHg> 21mmHg in Glaucoma

When the rate of inflow is greater than the rate of outflow, IOP can rise above normal limits .

The indirect theory suggest that High IOP compresses the microcirculation in the optic nerve head , resulting in cell injury and death.

http://www.ohiovalleyeye.com/eyeinfo_.htm

Angle Anatomy

Normal Physiology

90% of fluid flows out of the anterior

chamber draining through the spongy

trabecular meshwork

Canal of schelm and the episcleral veins

c - Iris outflow

a - Conventional outflow-90%b - Uveoscleral outflow

STAGES

Initiating events

Structural alterations in aqeous outflow system

Functional alterations(increased IOP and impaired blood flow )

Optic nerve damage

Visual loss

• Pressure in the anterior and posterior chambers pushes the lens back and puts pressure on the vitreous body

• the vitreous body presses the retina against the choroid and compresses the blood vessels that feed the retina

• Without sufficient blood supply retinal cells die and optic nerve atrophy and blindness

TYPES OF GLAUCOMA

Primary

• Open angle (Normal tension glaucoma)• Closed angle

Secondary

• Inflammatory• Traumatic

PRIMARY OPEN ANGLE GLAUCOMA

PRIMARY CLOSED ANGLE GLAUCOMA

PRIMARY NARROW ANGLE GLAUCOMA

SECONDARY GLAUCOMA

•Ocular or Systematic conditions that may be associated with inflammatory processes that block the outflow channels such as trauma and ocular neoplasms.

CLINICAL MANIFESTATIONS

Gradual peripheral visual lose (Tunnel

vision)

Sudden excruciating pain around eye

Nausea and vomiting

Corneal edema due to rise in IOP

Symptoms

1. Severe eye/headache

2.Blurred vision

3. Red eye

4.Nausea and vomiting

5.Halos around lights

6.Intermittent eye ache

at night

Signs

1.Red, teary eye

2.Mid-dilated, fixed pupil

3..Iris atrophy

DIAGNOSTIC EVALUATION

Gonioscopy

Visual Acuity test

Slit lamp microscopy

Ophthalmoscopy

OPTIC DISK DAMAGE

MANAGEMENT

DRUG THERAPYBeta blockers (Timolol)

Alpha – Adrenergic Agonist

Cholinergic agents

Carbonic anhydrase inhibitors

Prostaglandin Derivatives

(Xalatan,Lutanoprost)

SURGICAL MANAGEMENT

•Canaloplasty

•Trabeculectomy

• Glaucoma Drainage implant

Laser surgery

Argon Laser Trabeculoplasty

Selective Laser Trabeculoplasty

Laser peripheral iridotomy (Nd: YAG)

Diode Laser Cycloablation

Laser-assisted Nonpenetrating Deep Sclerectomy

NURSING MANAGEMENT

Health promotion

Early Detection

Ophthalmic examination for

every 4 yrs age between 60 and 64 yrs

every 1-2 yrs for >65yrs of age

Acute intervention Cold compress Calm and Quiet environment

Ambulatory home care

CATARACT

A cataract is a lens opacity or cloudiness. Cataract

rank behind arthritis and heart disease as a

leading cause of disability in older adults. Lens appears Grey or milky.

EPIDEMIOLOGY Cataract is leading cause of blindness in the world. - WHO- Cataract affects nearly 1 in every 6 peoples of age above 40yrs.

By 80yrs of age, more than half of all have cataract.

Most cataracts are age related called as “SENILE CATARACT”

ETIOLOGYAge related- Senile cataractAltered metabolic process leads to accumulation of Yellow- brown pigments and alterations in the lens fiber structure.

Other causes areo Blunt or Penetrating Injuryo Maternal Rubellao Radiation (or) UV Light Exposureo Systemic Corticosteroidso Patients with Diabetes Mellitus

TYPES OF SENILE CATARACT

.

Nuclear cataract

Cortical Cataract

Posterior subcapsular

cataracts.

Nuclear cataract

Nuclear cataract is associated with genetic component.

It causes central opacity of lens.

Myopia worsens when cataract

progresses.

Eye glasses can be used.

Cortical cataractIt involves the anterior, posterior or equatorial

cortex of the lens. It doesnot interfere with passage of light through the center of the lens and has little effect on vision.

• Vision is worse in light.

• Peoples with highest levels of sunlight

exposure have twice the risk of developing

cortical cataracts.

Posterior subcapsular cataract

It occurs infront of the posterior capsule. Common in younger adults. Associated with prolonged use of corticosteroids use, DM, occular trauma.

Near vision is diminished and eye is

extremely sensitive to glare from bright light.

CLINICAL MANIFESTATIONS

Decrease in vision

Abnormal color presentation

Glare worsens at night when pupils dialates

Brunescens color values shift to Yellow-brown.

DIAGNOSTIC EVALUATIONOphthalmoscopic examination or Slit Lamp microscopic examination.

A totally opaque lens creates the appearance of white pupil.

MANAGEMENT No nonsurgical medications, eyedrops, eyeglasses treatment cures cataract.

In the earlier stages of cataract development- glasses, contact lenses, bifocal magnifying lenses may improve vision.

Surgical management is the treatment of choice….

SURGICAL MANAGEMENT

Intracapsular Cataract Extraction

Extracapsular Cataract Extraction

Extracapsular cataract extraction

1. Anterior capsulotomy

2. Completion of incision

3. Expression of nucleus

4. Cortical cleanup

6. Polishing of posterior capsule, if appropriate

5. Care not to aspirate posterior capsule accidentally

8. Grasping of IOL and coating with viscoelastic substance

Extracapsular cataract extraction ( cont. )

7. Injection of viscoelastic substance

9. Insertion of inferior haptic and optic

11. Placement of haptics into capsular bag

10. Insertion of superior haptic

12. Dialling of IOL into horizontal position

and not into ciliary sulcus

Phacoemulsification

Phacoemulsification

1. Capsulorrhexis 2. Hydrodissection

3. Sculpting of nucleus 4. Cracking of nucleus

5. Emulsification of each quadrant

6. Cortical cleanup and insertion of IOL

Lens Replacement Surgery

NURSING MANAGEMENT

• Preoperative care

• Intraoperative care

• Postoperative care

• Followup care

COMPLICATIONS

Retinal detachment

Endophthalmitis

Corneal edema and Crystoid macular edema

Posterior capsular opacification

RELATED RESEARCH STUDYData from two case control studies in Oxfordshire were

combined and analysed by in oxfordshire by J J Harding and M Egerton on Diabetes, glaucoma, sex and cataract. This study covered 1940 subjects 723 cases and 1217 controls,– reveals that Diabetes was shown to be a powerful risk factor for cataract with a relative risk of 5.04. More than 11% of cataracts was attributable to Diabetes and also found that relative risk of glaucoma as a risk factor for cataract.

Glaucoma is a powerful and independent risk factor for cataract in both sexes and may be responsible for 5% of all cataracts .

CONCLUSION

SUMMARY

REFERENCE