Glaucoma

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ETIOLOGY
•age (glaucoma
becomes more
likely as you get
older) – in the UK,
chronic openangle glaucoma
affects up to two in
every 100 people
over 40 years old
and around five in
every 100 people
over 80 years old

Risk Factors

•ethnic
origin – people of African
or Afro-Caribbean origin are
at increased risk of
developing chronic openangle glaucoma and people
of Asian origin are at
increased risk of developing
acute angle-closure
glaucoma

•short
sightedness
(myopia) – people
who are short-sighted
are more likely to
develop chronic openangle glaucoma

ocular
hypertension (OHT – raised
pressure in the eye) – your
optometrist will be able to diagnose
OHT (see diagnosing glaucoma),
which increases your risk of
developing chronic open-angle
glaucoma

medical
history – people
with diabetes may be at
increased risk of
developing glaucoma

family history – if
you have a close
relative, such as a
parent, brother or sister
who has glaucoma, you
are at increased risk of
developing the condition
yourself

Symptoms

chronic open-angle
glaucoma – the most common
type which often has few
symptoms
• usually no noticeable
symptoms because the
condition develops very slowly
• the first part of the eye to be
affected is the outer field of
vision (peripheral vision).

acute angle-closure glaucoma
– which often has severe
symptoms

•intense pain
•redness of the eye
•headache
•tender eye area
•seeing halos or 'rainbow-like' rings around
lights
•misty vision
•loss of vision in one or both eyes that
progresses very quickly

developmental glaucoma – a rare
condition affecting young babies

secondary glaucoma –
caused by other conditions or
eye treatments
• misty vision
• rings or halos around lights.

•large eyes due to the pressure in the
eyes causing them to expand
•being sensitive to light (photophobia)
•having a cloudy appearance to their eyes
•having watery eyes
•jerky movements of the eyes
•having a squint, which is an eye
condition that causes one of the eyes to
turn inwards, outwards or upwards, while
the other eye looks forward

Causes
What causes the pressure in your eye to
increase isn’t always known. However,
doctors believe one or more of these
factors may play a role:
• dilating eye drops
• blocked or restricted drainage in your
eye
• medications, such as corticosteroids
• poor or reduced blood flow to your optic
nerve
• high or elevated blood pressure

• Glaucoma refers to a spectrum of ophthalmic
disorders characterized by neuropathy of the
optic nerve and loss of retinal ganglion cells
which leads to loss vision

References
• Kimble, M.A.K. et al. 2008. Applied
Therapeutics: The Clinical Use of Drugs.
Philadelphia: Lippincott Williams & Wilkins.
• Burn, M.A.C. et al. 2007. Pharmacotherapy
Principles and Practice. USA: The McGraw
Hill Companies.
• Dipiro, J.T. et al. 2002. Pharmacotherapy: A
Pathophysiologic Approach. USA: The
McGraw Hill Companies.

TREATMENT OF

GLAUCOMA

PRINCIPLE OF GLAUCOMA
TREATMENT :
I. to maintain the patient’s quality of life at a
sustainable cost
II. reduction of intra ocular pressure,
III. improvement of ocular blood flow,
IV. direct neuroprotection

THERAPY







Medical
Miotics
Beta-blockers
Carbonic anhydrase
inhibitors
Prostaglandin
analogues
Alpha-2 agonists

Surgical
Argon laser trabeculoplasty
 Trabeculectomy
 Filtering procedure
 Cyclocryotherapy
 Cyclolaser ablation
 Iridotomy


GLAUCOMA ALGORITHM

• Prostaglandin analogues:
• Action: increase aqueous outflow via the uveoscleral route.
• Contra-indications: active uveitis, pregnancy and breast-feeding.
• Caution: brittle or severe asthma, aphakia (patient with no lens),
pseudophakia (patient with artificial lens); do not take within five
minutes of using thiomersal-containing preparations.
• Common ocular side-effects: change in eye colour: brown
pigmentation, thickening and lengthening of eye lashes; more
rarely: uveitis, ocular pruritus, photophobia and keratitis.
• Systemic side-effects: rarely - hypotension, bradycardia.
• Examples
(Lumigan)

include

latanoprost

(Xalatan)

and

bimatoprost

•Beta-blockers:
• Action: reduce aqueous secretion by inhibiting betaadrenoceptors on the ciliary body.
• Contra-indications: bradycardia, heart block, uncontrolled
heart failure, asthma and history of chronic obstructive
pulmonary disease (COPD).
• Caution: depression, myasthenia gravis, possible
interactions with other medication such as verapamil.
• Common ocular side-effects: irritation, erythema, dry eyes,
blepharo-conjunctivitis and allergy anaphylactic reaction
possible

Common
systemic
side-effects:
bronchospasm,
bradycardia, exacerbation of heart failure, nightmares.
•  Examples include timolol (Betimol, Timoptic) and betaxolol
(Betoptic)

• Carbonic anhydrase inhibitors:
• Action: reduce aqueous secretion by ciliary body. Weak systemic
diuresis when given orally.
• Contra-indications: renal impairment, metabolite imbalance, severe
hepatic impairment, sulfonamide sensitivity (acetazolamide), breastfeeding.
• Caution: elderly, hepatic impairment, history of renal calculi, history of
intraocular surgery, pregnancy and breast-feeding. Extravasation at
infusion site of intravenous acetazolamide can cause necrosis.
• Ocular side-effects: localised discomfort, lacrimation, topical allergy;
more rarely: superficial punctate keratitis, uveitis, transient myopia.
• Systemic side-effects: (particularly with systemic administration),
taste disturbance, nausea/vomiting, headache, dizziness, fatigue,
paraesthesia and sulfonamide-related side-effects.

• Examples include dorzolamide (Trusopt) and brinzolamide (Azopt).

• Sympathomimetics (alpha adrenergic agonist):
• Action: reduce aqueous secretion and increase outflow through
trabecular meshwork.
• Contra-indications: angle-closure glaucoma (due to mydriatic effects),
patients currently taking monoamine-oxidase inhibitors (possibility of
hypertensive crisis).
• Caution: hypertension, heart disease.
• Common ocular side-effects: mydriasis, dry eye, severe smarting and
redness of the eye.
• Common systemic side-effects: lethargy, hypotension.
• Example is Brimonidine (Alphagan) and Iopidine (Apraclonidine)

• Miotics:
• Action: open up the drainage channels in the trabecular meshwork by ciliary
muscle contraction.
• Contra-indications: situations where pupillary constriction is undesirable (such
as uveitis), presence of retinal holes.
• Caution: darkly pigmented irides require higher concentrations but
overdosage must be avoided, patients with retinal disease (especially
previous detachment), cardiac disease, hypertension, asthma, peptic
ulceration, urinary tract obstruction and Parkinson's disease.
• Ocular side-effects: miosis - this can cause blurred vision which can affect
driving and other skilled tasks, especially in the presence of a cataract.
Accommodative spasm with brow ache (often causing intolerance in patients
over 40), localised discomfort, pupillary block.
• Systemic side-effects: sweating, bradycardia, gastrointestinal disturbance.
• Example is pilocarpine (Isopto Carpine)

GLAUCOMA
GLAUCOMA
Surgical treatment of glaucoma
Filtration
Procedures
 creates an opening in the white
 Laser beam to open clogged
of the eye (sclera) and removes
channels in the trabecular meshwork
part of the trabecular meshwork
Argon laser
Trabeculoplasty

Alternative Medicine For Glaucoma
Treatment : Chinese Herbs to Drain
Dampness
Common
Name

hoelen

Source (Latin
Binomial)

Poria cocos

atractylode Atractylodes
s
macrocephala
polyporus

alisma
plantago
seed
pinellia

Part Used

whole
fungus

rhizome

whole
Polyporus umbellatus
fungus
Alisma orientale

Plantago asiatica

Pinellia ternata

rhizome

seeds

rhizome

Chinese
Name
(Pinyin)

Actions in Relation to
Glaucoma

fuling

promote diuresis,
eliminate dampness,
invigorate spleen,
alleviate phlegm retention

baizhu

invigorate the spleen,
deprive dampness and
promote diuresis

zhuling

promote diuresis, for
dampness retention
syndrome

zexie

promote diuresis,
eliminate dampness, expel
heat

chequanzi

clear away heat, promote
diuresis, improve visual
acuity

banxia

deprive dampness and
eliminate phlegm,
disperse stagnation

References
• South African Glaucoma Society. 2006.
Glaucoma Algorithm And Guidelines For
Glaucoma. Available at
http://www.sags.co.za/docs/glaucoma_document
_and_algorithm.pdf
access on: 26.04.2016
• Subhuti Dharmananda, Ph.D.,1997. Treatment
Of Glaucoma With Chinese Herbs. Institute for
Traditional Medicine, Portland, Oregon. Available
at http://www.itmonline.org/arts/glaucoma.htm
access on: 26.04.2016
• Primary Open-angle Glaucoma. Available at
http://patient.info/doctor/primary-open-angle-g
laucoma

Treatment
TREATMENT EVALUATION
evaluation of
glaucoma

TONOMETRY
Tonometry is a test to measure the pressure
inside your eyes
 The test is used to screen for glaucoma
 Normal eye pressure range is 10 to 21 mmHg


Urinary
incontinence

POST-VOID RESIDUAL (PVR)
• Measure volume of urine left in bladder after
voiding by catheter or bladder scan
• < 50-100 Normal
• 100 - 400 Monitor until consistently less than
200cc.
• > 400cc - Insert Foley catheter
- Cystometry

Prevention
and
monitoring

Monitoring And Prevention

MONITORING (CONDITION)
If your healthcare professional thinks you're at risk of developing
glaucoma (whether you are having treatment or not), you should be
offered regular monitoring, using tests similar to those used to diagnose
glaucoma.
 If consider high risk of glaucoma,You might have to take eye drops for
your treatment – this is covered below. If you have just started taking eye
drops, or if you have recently changed your eye drops, your eye pressure
should also be tested 1 to 4 months after starting the new treatment
 If you don't need to use eye drops, your healthcare professional should
still test your eyes regularly
 If monitoring tests show that there is no deterioration in your eyes after 3
to 5 years (or earlier if tests confirm your eyes are normal), you may be
discharged because you do not have glaucoma. But you should still visit
your optician every year to be checked by the optometrist so that any
future changes can be detected.

(Nice.org,2009)


MONITORING

Regular glaucoma check-ups include two routine eye tests: tonometry and
ophthalmoscopy.
(Glaucoma.org,2013)








Tonometry
Tonometry measures the pressure within your eye.
During tonometry, eye drops are used to numb the eye
Then a doctor or technician uses a device called a
tonometer to measure the inner pressure of the eye. A small
amount of pressure is applied to the eye by a tiny device or
by a warm puff of air.
The range for normal pressure is 12-22 mm Hg (“mm Hg”
refers to millimeters of mercury, a scale used to record eye
pressure). Most glaucoma cases are diagnosed with pressure
exceeding 20mm Hg. However, some people can have
glaucoma at pressures between 12 -22mm Hg. Eye pressure
is unique to each person.















Ophthalmoscopy
This diagnostic procedure helps the doctor examine your optic nerve for
glaucoma damage.
Eye drops are used to dilate the pupil so that the doctor can see through
your eye to examine the shape and color of the optic nerve.
The doctor will then use a small device with a light on the end to light
and magnify the optic nerve.
Perimetry
Perimetry is a visual field test that produces a map of your complete
field of vision. This test will help a doctor determine whether your
vision has been affected by glaucoma
During this test, you will be asked to look straight ahead and then
indicate when a moving light passes your peripheral (or side) vision.
This helps draw a "map" of your vision.
After glaucoma has been diagnosed, visual field tests are usually done
one to two times a year to check for any changes in your vision.











Gonioscopy
This diagnostic exam helps determine whether the angle where the iris
meets the cornea is open and wide or narrow and closed
During the exam, eye drops are used to numb the eye. A hand-held
contact lens is gently placed on the eye. This contact lens has a mirror that
shows the doctor if the angle between the iris and cornea is closed and
blocked (a possible sign of angle-closure or acute glaucoma) or wide and
open (a possible sign of open-angle, chronic glaucoma).
Pachymetry
Pachymetry is a simple, painless test to measure the thickness of your
cornea -- the clear window at the front of the eye. A probe called a
pachymeter is gently placed on the front of the eye (the cornea) to
measure its thickness
Pachymetry can help your diagnosis, because corneal thickness has the
potential to influence eye pressure readings.
(Glaucoma.org,2013)

Prevention

You may not be able to prevent glaucoma.

But self-care can help you detect it early, limit vision loss or slow its progress.

PREVENTION

Know your
family's eye health
regular eye exams
history
Prevention
Exercise

Protect Your Eyes

PREVENTION
Regular eye exams
. are the best form of prevention against significant glaucoma
damage.
. Early detection and careful, lifelong treatment can maintain vision
in most people. In general, a check for glaucoma should be done:
. before age 40, every two to four years
. from age 40 to age 54, every one to three years
. from age 55 to 64, every one to two years
. after age 65, every six to 12 months
. Anyone with high risk factors should be tested every year or two
after age 35. Those at higher risk include people of African descent,
people with diabetes, and people with a family history of glaucoma.
You are at increased risk if you have a parent or brother or sister
with glaucoma.
1.

2.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.
3. Exercise
 studies have shown that moderate exercise such as walking or
jogging three or more times every week can have an IOP
lowering effect.
 moderate exercise on a routine basis is recommended. Like Yoga
can be beneficial, but it’s best to avoid inverted positions such as
headstands and shoulderstands, as these may increase IOP.
4. Protect Your Eyes
 Wearing protective eyewear is important when engaged in sports
activities or home improvement projects to prevent Eye injuries
that can result in traumatic glaucoma or secondary glaucoma

(Robert,2012)

REFERENCE
Nice.org,2009, Glaucoma: diagnosis and management,
published on april 2009, Available on (
https://www.nice.org.uk/guidance/CG85/ifp/chapter/Moni
toring-and-treatment-for-people-with-ocular-hypertensi
on-or-suspected-glaucoma
)
 Robert.L.Stamper, MD, 2012, What Can I Do to Prevent
Glaucoma?. Available on (
http://www.glaucoma.org/gleams/what-can-i-do-to-prev
ent-glaucoma.php
)
 Glaucoma.org, 2013, Five Common Glaucoma Tests,
Available on
(http://www.glaucoma.org/glaucoma/diagnostic

STUDY CASE
Skenario
 Pak Taufik, usia 60 tahun, datang ke apotek dengan
membawa salinan resep. Pak Taufik berkonsultasi
dengan apoteker dan meyakini bahwa salah satu obat
yang ia konsumsi mempengaruhi penglihatannya. Ia
meminta Anda sebagai seorang apoteker untuk
mengidentifikasi obat tersebut yang menyebabkan
gangguan penglihatan yang dialaminya.
 Pak Taufik pernah menderita Chronic Obstructive
Pulmonary Disease (COPD) dan inkontinensia urin.
Pada catatan pengobatannya diketahui Pak Taufik
menggunakan tetes mata Latanoprost untuk
mengobati glaukoma yang telah diberikan selama 6
bulan yang lalu.






Berikut ini adalah catatan pengobatan Pak
Taufik saat ini:
a. Seretide 500 Accuhaler, satu hisapan dua kali
sehari
b. Salbutamol inhaler, dua hisapan p.r.n.
c. Salbutamol nebuliser solution 5 mg, satu
setiap 3–4 kali sehari
d. Ipratropium bromide nebulising solution 500
micrograms/2 mL, satu setiap 3–4 kali sehari
e. Tolterodine 2 mg dua kali sehari
f. Tetrasiklin 250 mg dua kali sehari
g. Hypromellose 0.3% drops p.r.n.

Berikut ini adalah riwayat pengobatan Pak Taufik:
 a. Latanoprost 50 micrograms/mL, satu tetes setiap malam
 b. Tolterodine, pertama kali diresepkan pada 6 bulan yang lalu untuk
mengatasi inkontinensia urin dari urologis






Pasien dengan COPD dapat dikontrol dengan kombinasi inhaler dan
nebuliser. Pak Taufik menggunakan salbutamol dan ipratropium 2-3 kali
sehari, akan tetapi ketika COPD terasa lebih parah, Pak Taufik
meningkatkan penggunaan obat tersebut menjadi 4-6 kali sehari.
Inkontinensia urin sudah terkontrol saat ini akan tetapi Pak Taufik
mengalami kondisi mulut dan mata kering yang ekstrim. Pada mingguminggu ini, Pak Taufik menyadari penurunan penglihatan yang
signifikan dengan adanya sedikit kemerahan pada kedua mata. Pak
Taufik meyakini bahwa perubahan ini dikarenakan faktor usia saja.
Akan tetapi, Pak Taufik dijadwalkan konsultasi dengan konsultan mata
dalam waktu 6 bulan lagi. Kunjungan yang terakhir kira-kira 6 bulan
yang lalu. Konsultan memutuskan untuk menghentikan tetes mata
Latanoprost dan meyakinkan Pak Taufik bahwa semuanya dalam
kondisi yang normal.

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