Glaucoma

One of the most common cause of

blindness in the world.
 GLAUCOMA
What is it?

A disease of progressive optic

neuropathy with loss of retinal
neurons and the nerve fiber layer,
resulting in blindness if left untreated.
 GLAUCOMA

“Glaucoma describes a group of diseases that kill retinal

ganglion cells.”

“High IOP is the strongest known risk factor for glaucoma but it
is neither necessary nor sufficient to induce the neuropathy.”
GLAUCOMA
Currently, we define the glaucomas as an optic
neuropathy (with multifactorial risk factors
that include increased IOP, increasing age,
and genetic predisposition) characterized by
recognizable patterns of optic disc and retinal
nerve fiber structural and visual field
functional damage
GLAUCOMA
What causes it?

There is a dose-response
relationship between intraocular
pressure and the risk of damage to
the visual field.
 GLAUCOMA
How do we diagnose it?

 IOP is not helpful diagnostically until it reaches

approximately 40 mm Hg at which level the
likelihood of damage is significant.
 Visual fields are also not helpful in the early stages
of diagnosis because a considerable number of neurons must be lost
before VF changes can be
detected.
 Optic nerve damage in the early stages is difficult
or impossible to recognize.
 50% of people with glaucoma do not know it!
GLAUCOMA
Intraocular pressure is not the only factor
responsible for glaucoma!

 95% of people with elevated IOP will never have

the damage associated with glaucoma.
 One-third of patients with glaucoma do not have
elevated IOP.
 Most of the ocular findings that occur in people
with glaucoma also occur in people without
glaucoma.
 Glaucoma
Glaucoma is characterized
by three factors:
◦ Elevated Intra Ocular Pressure
(IOP)

◦ Optic nerve damage

(cupping of the disc)

◦ Progressive loss of
visual field
Glaucoma

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Intraocular Pressure
Classification
(A) Congenital Glaucoma or Developmental
1.Primary:due to primary developmental anomaly at the the
angle.
2.Secondary:associated with other ocular or systemic disorders.
(B) Acquired
1.Primary
(a) PACG
(b)POAG
2.Secondary:associated with other ocular or systemic disorders
Absolute Glaucoma
Acute Angle Closure Glaucoma
 Acute Angle Closure Glaucoma
What are findings
on physical exam?
◦ Visual acuity:
◦ Conjunctiva:
◦ Cornea:
◦ Pupil:
◦ Anterior chamber:
What is the anterior chamber
 Shallow anterior chamber
How can you
demonstrate a
shallow anterior
chamber?
OBLIQUE
FLASHLIHGHT
TEST
Estimating Anterior Chamber Depth
 Acute Angle Closure Glaucoma

What is a normal
intra-ocular
pressure (IOP)?
How do you
measure the IOP?
 Tonometers

Goldmann Perkins Schiotz

Contact applanation Portable contact applanation Contact indentation

Air-puff Pulsair 2000 (Keeler) Tono-Pen

Non-contact Portable Portable
indentation non-contact applanation contact applanation
 The Angle of Anterior Chamber
Defination
It is an angle recess formed in between posterior surface
of cornea and anterior surface of iris and bounded from
ant. to post. by schwalbe’s line ,trabecular meshwork ,
scleral spur,ant. surface of ciliary body along with root of
iris
 Development
By 7th wk angle is occupied by mesenchymal
cells from Neural crest cells to develop TM
In posterior aspect, iris is formed from
advancing bilayer optic cup
Corneal endothelium meets developing Iris at 15
wks to demarcate the angle
Angle deepening continues even after birth
 Development
By 7th wk angle is occupied by mesenchymal
cells from Neural crest cells to develop TM
In posterior aspect, iris is formed from
advancing bilayer optic cup
Corneal endothelium meets developing Iris at 15
wks to demarcate the angle
Angle deepening continues even after birth
 Anatomy
Schwalbe’s line: This marks the anterior border of
angle and represents termination of Descemet's
membrane seen as glistening white line in
gonioscopy.
(-Prominance of this line is known as Posterior
embryotoxon,seen in Axenfield Reiger’s Anomaly
-Pigments along this line are known as Sampaolesi’s
Line , seen in pigmentary glaucoma &
Pseudoexfoliation Syndrome.)
• Trabecular Meshwork:Present just behind
the schwalbe’s line and lines inner aspect
of schlemm’s canal. Pigmentation
acquired with age.
Pigmentation is prominent in inferior &
nasal angle
(blood in schlemm’s canal can be seen in
posterior TM in following situations-
1)In normal eyes especially when patient is
lying supine
2)When flow from Schlemm’s canal to
episcleral veins is hampered
3)Low intraocular pressure.
Scleral spur :lies posterior to TM and
gives attachment anteriorly to ciliary
muscle
Ciliary body: It marks the posterior most
part of the angle by its anterior surface
betn Its attachment to scleral spur and root
of iris
Blood supply:From major arterial circle of iris
root formed from long posterior ciliary artery
and anterior ciliary.
Nerve supply:
 parasympathetic from 3rd nerve
 Sympathetic from Carotid plexus
 Sensory from gesserion ganglion
Wide CBB
-Physiological in myopia and Aphakia
-Pathological in Angle recession and
Cyclodialysis
Narrow or absent CBB in hyperopia and
anterior iris insertion
Why we look for angle of AC
For classification of glaucoma
To note the extent of neovascularisation
To asses angle recession
History or evidence of inflammation
For evidence of neoplastic activity
Degenerative or developmental anomaly
For planning of treatment- iris
neovascularisation and laser procedure
Assessment of anterior chamber and its
angle
Torchlight examination
Slit lamp assessment by Von-Herrick's
technique
Gonioscopy
UBM
Ant segment OCT
Anatomy Review: Aqueous Humour
Aqueous Humour Dynamics
 Mechanisms of aqueous humor
 Aqueous is produced by
the ciliary processes

 It flows into the posterior

chamber

 Bathes the lens

 Fills the anterior chamber

Glaucoma
Aqueous Flow Dynamics
 Inflow should be equal to
the outflow

 NormalIOP is between 10 –
21 mmHg

 Normally the IOP is highest

in the morning and lowest in
the evening
◦ Diurnal curve
 Aqueous outflow
Anatomy Physiology

a - Uveal meshwork a - Conventional outflow

b - Corneoscleral meshwork b - Uveoscleral outflow
c - Schwalbe line
d - Schlemm canal c - Iris outflow
e - Collector channels
f - Longitudinal muscle of
ciliary body
g - Scleral spur
Aqueous humour is clear colourless
watery solution continuously circulated
from posterior chamber of the eye through
out the anterior chamber
Maintenance of IOP and pathophysiology
of glaucoma revolves around aq. Humour
dynamics
ANATOMY
Ciliary body
◦ Forward continuation of choroid at Ora serreta
◦ Triangular in cut section
◦ Inner side of triangle is divided into
 Pars plicata- 2-2.5mm
 Pars plana- 5mm temporally, 3mm nasaly
Continue….

◦ Microscopy
1. Supraciliary lamina- outer most condensed
part of the stroma
2. Stroma- consist of collagen tissue and
fibroblast with ciliary muscle, vasculature and
nerves
3. Layer of pigmented epithelium
4. Layer of non pigmented epithelium
5. Internal limiting membrane
Continue…

◦ Ciliary processes
 70-80 Whitish finger like projections
 2 X 0.5mm
 Composed of central capillary network with
fenestrated thin endothelium and pericytes surrounded
by stroma and two layers of epithelium and ILM
 Inner nonpigmented and outer pigmented epithelium
with juxta opposed apical surfaces
 Inner nonpigmented epi. Characterised by
mitochondria, zonula occludentes (ZO)and lateral
surface interdigitations
 The tight junctions contribute to the blood aqueous
barrier
Posterior chamber
◦ Triangular space
◦ 0.06ml of aqueous
◦ Divided into prezonular, zonular and retro zonular
space
Anterior chamber
◦ 2.5mm deep in centre,
◦ Contains 0.25ml aqueous
◦ Bounded
 ant-post surface of cornea,
 Post- anterior surface of ciliary body and iris
 Comunicates through the pupil with post. Chamber
◦ Chamber volume decreases by 0.11μl/year of life
◦ Chamber depth decreases by 0.01mm/year of life
◦ Chamber depth is shallower in hypermetropic than myopic
◦ Chamber depth is slightly decrease during accommodation
partly by lens curvature and partly by forward translocation of
lens.
Angle of Anterior chamber
Peripheral
recess of ant. Chamber
Formed mainly by TM
Formed post. To ant. By
1. Ciliary band
2. Scleral spur
3. Trabecular meshwork
4. Schwalbe’s line
Gonioscopic grading of angle width
Grade Angle width configuration Chances of Structure
closure visible on
gonioscopy
IV 35-450 Wide open Nil Schwalbes line
to ciliary body
III 20-350 Open Nil Schwalbes line
to scleral spur
II 200 Moderately Closure Schwalbes line
narrow possible to TM
I 100 Very narrow High Schwalbes line
only
0 00 Closed closed none
Shaffer’classifiction
Aqueous outflow system
Consist of two pathways
◦ Trabecular / conventional outflow
◦ Uveoscleral / unconventional outflow
Trabecular meshwork
 It is sieve like structure bridging the scleral sulcus cosist of 3 parts
1. Uveal meshwork-
 inner most, extend from iris root and ciliary body to the schwalbes line.
 The trabeculea are chord like and 2-3 layer thick.
 Arrangement creates 25-75μ
 Each trabeculae has 3 concentric layers with central collagenous core
enclosed by abasement membrane and trabecular cells.
 Ciliary process

Aq. In post. Chamber

Anterior chamber

Trabecular meshwork ciliary body

Schlemms canal suprachoroidal space

Collector channel venous circn. Cil. Body,

sclera and orbit
Episcleral veins

Trabecular outflow Uveoscleral outflow

90% 10%
Continue….

2. Corneoscleral meshwork
 From scleral spur to lateral wall of scleral sulcus
 Cosist of flat sheet of trabeculae with elliptical opening ranging from
5-50 μ become progressively smaller towards the schlemms canal
3. Juxtacanalicular meshwork
 Outermost layer connects corneoscleral meshwork to schlemms
canal
 Consists of 2-5 layers of loosely arranged cells embedded in
ECM (hyluronic acid and other GAG) lined on either side by
endothelial cells
 Offers main resistance to aqueous flow
 Outer endothelial layer of juxta canalicular meshwork comprises
inner wall of schlemms canal
 Inner endothelial layer continue with corneo scleral meshwork
Continue….

Schlemms canal
 Endothelium lined oval channel present in scleral sulcus
 Endothelial cells of inner wall are irregular and contain giant vacuoles
Collector channel
 25-35 Intrascleral aq. Vessels
 Leaving schlemms canal at oblique angles to terminate into episcleral
veins.
 Valveless, wide at their origin and taper towards the anastomosis with
venous channel.
1. Direct system-
2. Indirect system-
 Episcleral veins
 Drain ultimately in cavernous sinus via ant. Ciliary and sup.
Ophthalmic vein
Production of Aqueous humor
Formation of aqueous humor
Aqueous is derived from plasma within
the capillary network of the ciliary
process by three mechanisms
 A) Diffusion- lipid soluble substances are
transported through the lipid portions of
the cell membrane proportion to a
concentration gradient across the
membrane
B ) Ultrafiltration- water and water soluble
substances, limited by size and charge,
flow through theoratical micropores in the
cell membrane in response to an osmotic
gradient or hydrostatic pressure;
influenced by intraocular pressure, blood
pressure in the ciliary capillaries, and
plasma oncotic pressure
C) Active transport(secration) – water soluble
substances of larger size or greater charge are
actively transported across the cell membrane
, requiring the expenditure of energy ;Na-K
ATPase and glycolytic enzymes are present in
nonpigmented epithelial cells. Active
transport is decreased by hypoxia ,
hypothermia, and any inhibitor of active
metabolism. Active transport accounts for the
majority of aqueous production
 Functions of Aqueous Humor
Maintains the intraocular pressure and inflates the globe
of the eye.
Provides nutrition (e.g. amino acids and glucose) for the
avascular ocular tissues; posterior cornea, trabecular
meshwork, lens, and anterior vitreous.
May serve to transport ascorbate in the anterior segment to
act as an anti-oxidant agent.
Presence of immunoglobulins indicate a role in immune
response to defend against pathogens.
Provides inflation for expansion of the cornea and thus
increased protection against dust, wind, pollen grains and
some pathogens.
for refractive index.
Physiological properties
Volume-0.31ml
Refractive Index 1.336
Density-1.025to1.040
Hyperosmotic
Rate -2.3ul/min
Ph 7.2
Thank you