Glaucoma Associates of New York

90% of blindness from glaucoma could have been prevented with timely diagnosis and treatment.

Medications can have SIDE EFFECTS

GLAUCOMA is not a single, simple disease

3-4 million people with glaucoma in U.S. alone

SINK analogy
The GLAUCOMA HOME PAGE – www.glaucoma.net
1-800-GLAUCOMA The Glaucoma Foundation
NYGRI

Robert Ritch, MD
Shelley and Steven Einhorn Distinguished Professor of Ophthalmology
Surgeon Director and Chief, Glaucoma Services The New York Eye and Ear
Infirmary 310 East 14th Street New York, NY 10003

Medical Director and
Chairman, Scientific Advisory Board
The Glaucoma Foundation

Definition of Glaucoma

5 major types first, divide ACG and OAG. Kitchen sink analogy. ACG often curable. Treat with laser. Asians more than Caucasians.

OAG XFS most common Scandinavia, Ireland, Greece, Russia, Middle East, India, Japan

PDS/PG hereditary, Caucasian, 20-40 y/o

POAG Blacks 4-6 times as affected

LTG non-IOP-dependent risk factors

TX we lower IOP because we still have nothing else to do.

Genetics

Infectious

I. What is glaucoma
A. High pressure in the eye leads to death of optic nerve cells
1. Analogy to kitchen sink
2. How death of cells leads to loss of vision
a. Peripheral vision lost first. Central vision can remain until late stage, when 90% of optic nerve already destroyed.
3. Glaucoma usually has no symptoms aside from silent, painless loss of vision beginning peripherally
4. Low-tension glaucoma and non-pressure dependent risk factors
a. Blood supply to the eye
b. Low blood pressure
c. sleep apnea
d. Other factors
5. Fast facts
a. Glaucoma is the second leading cause of blindness in the U.S. and a leading cause in virtually every country in the world
b. Over 80,000 people in the U.S. are blind from glaucoma
c. Over 250,000 are blind in one eye
d. About 2 million more have some degree of visual damage
e. About 8 million more are susceptible
B. Risk factors
1. Blacks
2. Myopes
3. Diabetes
4. Family history
5. Hypertension
6. Smoking
C. Relationships and common questions
1. Effect of alcohol
2. Over the counter medications which have warnings about “contraindicated in glaucoma”
3. Other systemic diseases – thyroid disease
4. Steroids and glaucoma – steroid eye drops, systemic steroids
II. Definition of glaucoma – Glaucoma is an end stage, analogous to congestive heart failure or liver failure. It is a progressive optic neuropathy characterized by a specific pattern of optic nerve head and visual field damage, which represents a final common pathway resulting from a number of different conditions which can affect the eye. While elevated IOP is the most important risk factor for the development or progression of glaucomatous damage, it is still only a risk factor and not the disease itself. Some of the entities which lead to glaucoma are becoming well characterized, although most related conditions remain to be discovered or fully elucidated.

III. Diagnosis of glaucoma
A. Routine eye examination at periodic intervals (more later)
B. Tonometry, gonioscopy, ophthalmoscopy, visual fields
C. Ocular hypertension vs glaucoma suspect
D. Diurnal variation in IOP.
E. Postural variations effect of Yoga, and Valsalva, e.g. trumpet players

IV. Open-angle vs angle-closure glaucoma
1.POAG
2.High-tension vs low-tension
3.Angle-closure
4.Exfoliation syndrome – may account for 20% of all glaucoma. Most common in Caucasians, but common more or less worldwide in all races. Drain of eye gets clogged by pigment, much like coffee ground clogging your kitchen drain. Can be detected before glaucoma develops.
5.Pigmentary glaucoma – Much more common than generally realized. Maybe 250,000 people. Hereditary. Affects young people – 20’s and 30’s – often leading to blindness in one eye before discovered. Important to check family members. Can be detected before glaucoma develops.

IV. Treatment
A. Preventive – increasing recognition of conditions which can lead to glaucoma and identification of risk factors, much blindness could be prevented by identifying patients who should be followed more often.
1. Goal of therapy is not just to make IOP a certain number but to prevent clinically significant loss of vision, to minimize side effects of medications, and to maintain a reasonable quality of life.
B. Drops – turn down faucet or open drain.
Most patients don’t take drops correctly. Discuss lid closure and spacing and punctal occlusion to increase duration and effectiveness of drops and decrease systemic side effects.
1. Miotics (pilocarpine, carbachol) – drops, gel. Side effects most prominent in younger patients. Relation to retinal detachment.
2. Beta-blockers – Timoptic, Betoptic, Betagan
a. Few local side effects and effective lowering of IOP made these the drugs of choice as soon as introduced.
b. However, systemic side effects include lowered pulse and blood pressure, exercise intolerance, exacerbation of asthma and congestive heart failure, sleep apnea, memory loss, insomnia, and hallucinations.
3. Epinephrine and Propine – Usually least effective in terms of lowering IOP. High rate of allergy. Seems to be most effective in pigmentary glaucoma and possibly juvenile glaucoma.
4. Carbonic anhydrase inhibitors – drops (Trusopt) and pills (Diamox, Neptazane). Turn down faucet. High incidence of side effects in pill form – urinary frequency, paresthesias, GI problems, fatigue, depression, confusion.
5. Alpha-2 agonists – Turn down faucet. High incidence of allergy and tolerance.
6. Prostaglandin analogs – Create a new drain. Can turn hazel and green eyes brown.
7. Effect of nonsteroidal drugs on glaucoma – tranquilizers, cold tablets, antihistamines, and all those other drugs for which package inserts say “contraindicated in glaucoma” but which are almost always safe to take.

C. Laser treatment
1. Angle-closure glaucoma
2. Open-angle glaucoma
D. Surgical treatment
1. Trabeculectomy
a. Antifibrotics have greatly increased success
b. New techniques of postoperative management have significantly reduced complications.
2. Setons and valve implantation
3. Cyclodestructive procedures
4. Newer procedures – trephination, canaloplasty, Trabectome

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