Glaucoma - DISEASE PRESENTATION

GLAUCOMA TYPES / CAUSES/ TREATMENT/GOALS OF THERAPY/PATIENT COUNSELLING

1. DISEASE PRESENTATION ON Presented by, Kaviya AP RA1522281010017 Pharm D INTERN 2015-2021

2. GLAUCOMA Glaucoma are ocular disorders characterized by changes in the optic nerve head (optic disk) and by loss of visual sensitivity and field. This damage is often caused by an abnormally high pressure in eye.

3. CAUSES Glaucoma is the result of damage to the optic nerve. As this nerve gradually deteriorates, blind spots develop in your visual field. Elevated eye pressure is due to a buildup of a fluid (aqueous humor) that flows throughout the inside of your eye. This internal fluid normally drains out through a tissue called the trabecular meshwork at the angle where the iris and cornea meet. When fluid is overproduced or the drainage system doesn't work properly, the fluid can't flow out at its normal rate and eye pressure increases.

4. TYPES OF GLAUCOMA Open angle glaucoma Closed angle glaucoma Children glaucoma Normal tension glaucoma

5. Other Types of Glaucoma : Variants of open-angle and angle-closure glaucoma include, Secondary Glaucoma Pigmentary Glaucoma Pseudoexfoliative Glaucoma Traumatic Glaucoma Neovascular Glaucoma Irido Corneal Endothelial Syndrome  (ICE) Uveitic Glaucoma

6. Open-angle glaucoma Open-angle glaucoma is the most common form of the disease. The drainage angle formed by the cornea and iris remains open, but the trabecular meshwork is partially blocked. This causes pressure in the eye to gradually increase. This pressure damages the optic nerve. It happens so slowly that patient may lose vision before he/she even aware of a problem.

7. Angle-closure glaucoma Angle-closure glaucoma or closed-angle glaucoma, occurs when the iris bulges forward to narrow or block the drainage angle formed by the cornea and iris. As a result, fluid can't circulate through the eye and pressure increases. Some people have narrow drainage angles, putting them at increased risk of angle-closure glaucoma. Angle-closure glaucoma may occur suddenly (acute angle-closure glaucoma) or gradually (chronic angle-closure glaucoma). Acute angle-closure glaucoma is a medical emergency.

8. Normal-tension glaucoma In normal-tension glaucoma,optic nerve becomes damaged even though eye pressure is within the normal range. Reason is unknown. P atient may have a sensitive optic nerve, or may have less blood being supplied to optic nerve. This limited blood flow could be caused by atherosclerosis — the buildup of fatty deposits (plaque) in the arteries — or other conditions that impair circulation. Those at higher risk for this form of glaucoma are: people with a family history of normal-tension glaucoma people of Japanese ancestry people with a history of systemic heart disease.

9. Glaucoma in children ( C ongenital / Infantile glaucoma ) It's possible for infants and children to have glaucoma. It may be present from birth or develop in the first few years of life. This is a rare condition that may be inherited, caused by incorrect development of the eye’s drainage system before birth. This leads to increased intraocular pressure, which in turn damages the optic nerve. Symptoms of childhood glaucoma include enlarged eyes, cloudiness of the cornea, and photosensitivity (sensitivity to light).

10. Pigmentary glaucoma Pigment dispersion syndrome is a condition that happens when pigment rubs off of the back of the iris of the eye when the fibers supporting the lens rub against it. This pigment is deposited in the trabecular meshwork of the eye, where the fluid drains out. In pigmentary glaucoma, pigment granules from iris build up in the drainage channels, slowing or blocking fluid exiting eye. Activities such as jogging sometimes stir up the pigment granules, depositing them on the trabecular meshwork and causing intermittent pressure elevations.

11. Many forms of glaucoma have no warning signs.The effect is so gradual that patient may not notice a change in vision until the condition is at an advanced stage. The signs and symptoms of glaucoma vary depending on the type and stage of your condition. Open-angle glaucoma Patchy blind spots in your side (peripheral) or central vision, frequently in both eyes Tunnel vision in the advanced stages Acute angle-closure glaucoma Severe headache Eye pain Nausea and vomiting Blurred vision Halos around lights Eye redness SYMPTOMS

12. Having high internal eye pressure (intraocular pressure) Being over age 60 Being black, Asian or Hispanic Having a family history of glaucoma Having certain medical conditions, such as diabetes, heart disease, high blood pressure and sickle cell anemia Having corneas that are thin in the center Being extremely nearsighted or farsighted Having had an eye injury or certain types of eye surgery Taking corticosteroid medications, especially eyedrops, for a long time Risk factors

13. The diagnosis of open-angle glaucoma is confirmed by the presence of characteristic optic disk changes and visual field loss, with or without increased IOP. For closed-angle glaucoma , the presence of a narrow angle is usually visualized by gonioscopy. IOP is generally markedly when symptoms are present. Additional signs include hyperemic conjunctiva, cloudy cornea, shallow anterior chamber, and occasionally edematous and hyperemic optic disk. Normal tension glaucoma refers to disk changes, visual field loss, and IOP of less than 21 mm Hg. Ocular hypertension is IOP of more than 21 mm Hg without disk changes or visual field loss. Diagnosis

14. T o preserve visual function by reducing the IOP to a level at which no further optic nerve damage occurs. Goals of therapy

15. TREATMENT Treatment includes Anti glaucoma medications Surgery Medical procedures

16. Drug therapy is the most common initial treatment and is initiated in a stepwise manner, starting with a single well tolerated topical agent (Table 66-2). Historically, Beta -blockers (e.g., timolol ) were the treatment of choice and continue to be used if there are no contraindications to potential. • Newer agents are also suitable for first-line therapy. Prostaglandin analogs(e.g., latanoprost, bimatoprost and travoprost ) have the advantage of strong potency, unique mechanism suitable for combination therapy,good safety profile, and once-a-day dosing. Brimonidine has the theoretical advantage of neuroprotection, which has not yet been demonstrated in humans. Topical CAIs are also suitable for first-line therapy. • Pilocarpine and dipivefrin , a prodrug of epinephrine , are used as third line therapies because of adverse events or reduced efficacy as compared with newer agents. • Carbachol , topical cholinesterase inhibitors, and oral CAIs (e.g., acetazolamide ) are used as last-resort options after failure of less toxic options. • The optimal timing of laser or surgical trabeculectomy is controversial, ranging from initial therapy to after failure of third- or fourth-line drug therapy. Antiproliferative agents such as fluorouracil and mitomycin C are used to modify the healing process and maintain patency. TREATMENT FOR OCCCULAR HYPERTENSION & OPEN-ANGLE GLAUCOMA

17. TREATMENT FOR CLOSED-ANGLE GLAUCOMA • Drug therapy of an acute attack typically consists of an osmotic agent and secretory inhibitor (e.g., Beta - blocker, beta 2 agonist, latanoprost , or CAI), with or without pilocarpine. • Osmotic agents are used because they rapidly decrease IOP. Examples include glycerin , 1 to 2 g/kg orally, and mannitol , 1 to 2 g/kg IV. • Although traditionally the drug of choice, pilocarpine use is controversial as initial therapy. Once IOP is controlled, pilocarpine should be given every 6 hours until iridectomy is performed. • Topical corticosteroids can be used to reduce ocular inflammation and synechiae. • Epinephrine should be used with caution because it can precipitate acute closed-angle glaucoma, especially when used with a Beta - blocker.

18. Acute closed-angle glaucoma with high IOP requires rapid reduction of IOP. Iridectomy is the definitive treatment, which produces a hole in the iris that permits aqueous flow to move directly from the posterior to the anterior chamber. IRIDECTOMY

19. Selective Laser  Trabeculoplasty , or SLT, is a form of laser surgery that is used to lower intraocular pressure in  glaucoma . It is used when eye drop medications are not lowering the eye pressure enough or are causing significant side effects. It can also be used as initial treatment in  glaucoma . TRABECULOPLASTY

20. PATIENT COUNSELLING

21. Glaucoma  is a group of eye conditions that damage the optic nerve, the health of which is vital for good vision. This damage is often caused by an abnormally high pressure in your eye.  Glaucoma  is one of the leading causes of blindness for people over the age of 60. Early detection and early treatment of  glaucoma  is vital.  Glaucoma  involves lifelong treatment and monitoring. Most people with open-angle  glaucoma  respond well to eye drop medications. Surgery may be necessary if eye drops fail to reduce intraocular pressure. Disease counselling

22. Consuming a high trans fatty acid diet can result in damaging the optic nerve. You should avoid foods like  baked goods  such as cookies,  cakes , donuts or fried items like  French fries  or  stick margarine  to steer clear from worsening your glaucoma. It may also improve your eye health. Cut Trans fatty acids from your diet Diet counselling

23. Identify and avoid food allergens If you have food allergies, you may be at a higher risk of glaucoma. Work with your physician to supplement foods that cause allergic reactions. Generally, foods that cause allergies include soy, dairy, wheat and corn. Foods high in saturated fats should also be on your things to avoid list. They not only worsen glaucoma but also cause increase in weight. A  study on the effects of Body Mass Index on Intraocular pressure  suggested that obesity may be associated with higher risk of glaucomatous injury with high IOP. Steer clear of saturated fats

24. Coffee has been recorded to increase IOP, leading to optic nerve damage. You can substitute coffee with a warm beverage like green tea, which is a much healthier choice given it is full of antioxidants. It also lowers your cholesterol and blood pressure, which are 2 known factors that worsen optic nerve damage. Say ‘NO’ to coffee

25. Carbohydrates raise the body’s insulin level. When you have glaucoma, keeping a normal insulin level is cruicial because an increase in insulin level causes an increase in IOP and blood pressure. The more complex the carbohydrate is, the less it will raise your insulin level.  Foods such as beans and vegetables contain rich amount of complex carbohydrates. You can supplement these for simple carbohydrates found in foods like: Potatoes Rice Bread Pasta Cereal Baked Goods Simple Sugars Find complex carbohydrates

26. Follow these steps to make it easier to put in eye drops: Preparing the Drops Always wash your hands before handling your eye drops or touching your eyes. If you’re wearing  contact lenses , take them out — unless your ophthalmologist has told you to leave them in. Shake the drops vigorously before using them. Remove the cap of the eye drop medication. Do not touch the dropper tip. Putting in Eye Drops Tilt your head back slightly and look up. Some people find it helpful to focus on a specific point on the ceiling. Use one hand to pull your lower  eyelid  down, away from the eye. This forms a pocket to catch the drop. Hold the dropper tip directly over the eyelid pocket. Squeeze the bottle gently and let the eye drop fall into the pocket. Don’t touch the bottle to your eye or eyelid. This can give bacteria or other contaminants a chance to grow in your eye drops. Drug counselling

27. After You’ve Put in Eye Drops: Close your eyes and do not blink. Apply gentle pressure to your  tear ducts , where the eyelid meets the nose. Hold the tear ducts closed for a minute or two—or as long as your ophthalmologist recommends—before opening your eyes. This gives the drop time to be absorbed by the eye, instead of draining into your nose. Wipe any unabsorbed drops from your closed lids with a tissue. Repeat the same procedure with the other eye, if necessary. Wash your hands after handling medication and touching your face.

28. More Tips for Using Eye Drops If you need to take more than one type of eye drop at the same time, wait three to five minutes between the different kinds of medication. Use your drops exactly when and how your doctor tells you to. Ask your ophthalmologist or pharmacist if it’s OK to keep the drops in the refrigerator. When the drops are cold it might be easier to feel the drop when it hits the eye, so you can tell where it has landed. If you have a lot of trouble putting in your eye drops, ask a caregiver or family member to help. Several kinds of eye drop assistance devices are available. They can help with aiming the drop, squeezing the bottle and even keeping the eye open. Ask your eye care professional about what options might be right for you.

29. These self-care steps can help you detect glaucoma in its early stages, which is important in preventing vision loss or slowing its progress. Get regular dilated eye examinations.   Regular comprehensive eye exams can help detect glaucoma in its early stages, before significant damage occurs. As a general rule, the American Academy of Ophthalmology recommends having a comprehensive eye exam every five to 10 years if you're under 40 years old. Know your family's eye health history.  Glaucoma tends to run in families. If you're at increased risk, you may need more frequent screening. Exercise safely.  Regular, moderate exercise may help prevent glaucoma by reducing eye pressure. Talk with your doctor about an appropriate exercise program. Take prescribed eyedrops regularly.  Glaucoma eyedrops can significantly reduce the risk that high eye pressure will progress to glaucoma. To be effective, eyedrops prescribed by your doctor need to be used regularly even if you have no symptoms. Wear eye protection.  Serious eye injuries can lead to glaucoma. Wear eye protection when using power tools or playing high-speed racket sports in enclosed courts. Life style modifications

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