Approximately 1.

2 million nerve fibers from the retina come together and form a "cable" called the optic nerve. This nerve connects the back of the eye to the brain. When light bounces off an image and strikes the retina, it organizes and "packages" the image, and sends the electrical impulses to the brain via the optic nerve. The brain then "decodes" these electrical stimuli into what we know as vision.

GLAUCOMA
WHAT IS GLAUCOMA, AND HOW PREVALENT IS THE DISEASE? Glaucoma is a disease that causes damage to the optic nerve which threatens blindness. The optic nerve is the "cable" that connects the eye with the brain and which carries visual information from the retina (back of the eye) to the seeing centers of the brain. (See Eye Anatomy for details.) The optic nerve is composed of over one million nerve fibers and is approximately 1/16th of an inch in diameter. There are many forms and causes of glaucoma (see below) which can be extremely difficult disease to diagnose at times.

Glaucoma is considered a major health problem, and it is estimated that over 2 million Americans have the disease, and as much as half of them may be unaware of the problem. Every year, as much as 100,000 Americans develop glaucoma. According to the American Academy of Ophthalmology, in the United States alone, glaucoma of all types is the second most common cause of legal blindness, and is the leading cause of legal blindness among African Americans. Approximately 80,000 Americans are legally blind from glaucoma, and many more have visual impairment. Glaucoma is one of the most common causes of preventable blindness.

There is no cure for glaucoma. However, with proper treatment, blindness can be prevented in 90% of the cases.

2. WHAT CAUSES GLAUCOMA?

Internal Arrows)

Circulation

of

the

Eye

(Red

Aqueous (watery fluid) is made from the glands located in the ciliary body. It then circulates in the posterior chamber where it bathes the iris and lens. It flow through the pupil and into the anterior chamber where it nourishes the cornea, and finally empties back into the blood stream after passing through the trabecular meshwork and into Schemm's Canal.

The eye is a closed cavity that has its own internal fluid circulation which bathes and nourishes the internal eye. This fluid is called aqueous humor and is made by tiny glands in the ciliary body, a muscle that helps the eye focus. This muscle is located behind the iris (the colored part of the eye). Aqueous (red arrows) then flows from behind the iris, through the pupil, and into the front compartment of the eye (called the anterior chamber) where is nourishes the cornea and lens. From there, it is normally drained out of the eye through a filtering drain called the trabecular meshwork. The trabecular meshwork is situated in the angle of the eye (where the colored and white parts of the eye meet. In many cases of glaucoma, this "drain" becomes clogged such that fluid cannot leave the eye as fast as it is produced. This causes fluid

pressure to build up in the eye. Optic nerve damage in glaucoma is usually caused by this elevated fluid pressure within the cavity of the eye.

The picture to the left shows a healthy optic nerve head. Notice the pink color and the small cup. In contrast, the picture to the right shows loss of optic nerve tissue as evidenced by a large cup .

Although most cases of glaucoma are related to abnormally elevated fluid pressure in the eye, the degree of fluid pressure elevation necessary to cause optic nerve damage varies from individual to individual. Many people tolerate elevated pressures without any optic nerve damage at all. Still others can have severe optic nerve damage with normal or only mild elevations of pressure. In these types of patients, it is thought that optic nerve damage is a result of poor blood flow to the nerve making the nerve very sensitive to pressure in the high normal range. GLAUCOMAS VISUAL FIELD

WITH GLAUCOMA NORMAL EYE

ADVANCE GLAUCOMA 3. ARE THERE DIFFERENT KINDS OF GLAUCOMA? The word "glaucoma" is like the word "automobile." Many forms and types exist. Below is a discussion of the most common forms. If you have glaucoma, it is important that you know which type you have. Some forms of glaucoma, for example, can be affected by certain medications. Each of these are discussed below. Just scroll down or click on any of the items below for discussion. It will be helpful if you read the section on Primary Open-Angle Glaucoma before reading about the other types of glaucoma.

Primary Open-Angle Glaucoma (POAG) Normal or Low Tension Glaucoma (NTG of LTG) Acute Angle-Closure Glaucoma (AACG) Neovascular Glaucoma (NVG) Pigmentary Glaucoma Exfoliation Syndrome Secondary Glaucomas

PRIMARY OPEN-ANGLE GLAUCOMA (POAG) POAG is the most common form of glaucoma , and usually occurs in adults over the age of 45-50 years of age. It is a chronic problem of unknown cause resulting from increased fluid pressure within the eye which causes damage to the optic nerve and vision. This form of glaucoma is "silent" meaning that there are no early symptoms. The pressure rises slowly, and various components of the eye such as the cornea adapt well without signaling any pain. The disease often goes undetected, and patients can lose large amounts of their vision without being aware of any damage. This is because initial loss of vision occurs in the periphery. It is not until central vision becomes involved that patients realize that there is something wrong. Even then, there's a

tendency to believe that there's only a minor problem such as needed their glasses adjusted. By then, however, the damage is irreversible. There is much still to be learned about POAG. We do know that in this form of glaucoma elevated pressure causes damage and deterioration to the optic nerve. The average pressure in the normal population is 14-16 millimeters of mercury, although the normal range can vary from 8 to 21. Pressures or 22 are considered suspicious, and beyond

Open Angle Glaucoma In this type of glaucoma, aqueous produced by the ciliary body cannot exit out of the eye easily because of a blockage at the trabecular meshwork. As the ciliary body continues to produce aqueous, the fluid pressure begins to build up in the eye. This can lead to damage of the optic nerve.

that point, abnormal. What is not understood well is why persons with clearly elevated pressures do develop optic nerve damage, and why some others do not. This is the subject of active research. In this disease, it is thought that the drainage portion of the eye and trabecular meshwork (please see question 2 - What Causes Glaucoma?) does not allow outflow of internal fluid (aqueous) normally. The reasons for this are not clear, and there are several theories being considered. Because aqueous continues to be formed, pressure within the eye increases. Once a sufficient number of optic nerve fibers are destroyed, blind spots begin to develop in the peripheral vision. This peripheral field loss is often undetected by the patient, but can easily be mapped out by a visual field test (please click Diagnostic Services for a description of a visual field test). It is important to realize that damage at any level is permanent, and that the goal of treatment is to slow or arrest the disease so that no further damage is done. (Question

7 talks of ways your ophthalmologist has to detect problems before they lead to visual damage.) While there is no "cure" for POAG, treatment is often highly successful is slowing or arresting the disease . Many patients do not understand the necessity for lifelong treatment, especially when they sense that their vision is good, and they "feel" nothing wrong with them. It is important however that treatment is taken according to your doctor's instructions to prevent further damage. If you are having side effects from your medicines, you need to discuss this with your doctor. If you are not confident with the recommendations or diagnosis, a second opinion may be helpful. By no means should you ignore the problem because of lack of symptoms. Remember, glaucoma treatment is a very individualized process. Please see question 10 for more details about treatmen NORMAL OR LOW TENSION GLAUCOMA LTG is a form of glaucoma where there is progressive optic nerve damage and deterioration resulting in loss if vision, but in which there is no elevation of intraocular fluid pressure. This form of glaucoma can be very difficult to diagnose, and is often not recognized until some form of damage results. LTG is becoming increasingly recognized as an important type of glaucoma to look for, especially in persons with vascular disease such as hypertension, diabetes, heart disease, etc. LTG is thought to be due in part to poor circulation to the optic nerve head, making it very sensitive to any form of pressure, even pressure that is well within normal range for the general population. In these very sensitive eyes, it is thought that a pressure lower than normal is necessary to prevent further damage and visual loss. The target pressure to minimize any further optic nerve damage is different for different individuals, and treatment can never be a "cook book" approach. There is much research being done in the field of optic nerve blood flow, and much has yet to be learned about this form of glaucoma. For treatment details, please see question 10.

ACUTE ANGLE-CLOSURE GLAUCOMA (AACG)

In contrast to an open angle, a narrow angle is one in which the peripheral iris lies in very close proximity to the trabecular meshwork. In extremely narrow angles, resistance to fluid flow could lead to increased pressure behind the iris in the posterior chamber. This can result in further narrowing of the angle or even total closure, leading to dangerously high intraocular fluid pressure.

Unlike POAG where intraocular fluid pressure rises slowly, in AACG, the pressure rise is sudden and can become extremely high. This results in pain, redness, blurred vision, and may cause nausea and vomiting. The cornea often swells causing halos in addition to blurred vision. What causes an attack of acute glaucoma? Please refer to question 2 for details of anatomy. As discussed, the aqueous (red arrow) is drained through the trabecular meshwork located in the angle of the eye. The angle is where the iris (colored part of the eye) and the white

part (called the sclera or "wall" of the eye) meet. In some individuals, the angle of the eye is very narrow. This could be as a result of the way their eye is built, or it may be due to problems such as thickened cataracts which begin to crowd the front part of the eye. Under these conditions, anything that dilates the pupil will cause the iris to crowd the angle.

Angle Closure Glaucoma In some cases, the distance between the peripheral iris and the trabecular meshwork can be extremely narrow. Under certain circumstances, the iris can completely and suddenly close the angle resulting in sudden extreme pressure elevation. This is considered an emergency since vision is immediately threatened.

When crowding becomes critical, the trabecular meshwork may become completely and suddenly obstructed by iris that fluid pressure begins to build up rapidly, causing the attack. Things that can cause pupillary dilation include being in the dark, certain types of medication such as anti-histiminics, cold preparations, anti-depressants, antinauseants, and some others. Stress can cause pupillary dilation as well. Attacks usually occur in the evening or at night. AACG is an emergency, and must be treated promptly before optic nerve and trabecular meshwork damage occur. Permanent damage to these structures can result quickly. Treatment begins with a combination of drops to both constrict the pupil (thereby "pulling" the iris away from the trabecular meshwork) and decrease the eye's fluid production. Once the intraocular fluid pressure is within normal range, your ophthalmologist will perform a laser iridotomy. A laser iridotomy is a procedure in which a laser beam is used to create a small opening in the iris, near the angle. This allows pressure to equalize in the eye, and allows the aqueous to flow more freely. This laser treatment is a painless outpatient procedure, and can be done in less than 10 minutes. An attack usually occurs in only one eye, even though it is very common that both eyes have narrow angles. Therefore, most of the time, your ophthalmologist will recommend that the uninvolved eye also undergo a laser iridotomy procedure to prevent such an attack in that eye too. Routine comprehensive examinations can be helpful in determining if an individual is at risk for AACG. If your ophthalmologist is suspicious of narrow angles, he will perform a gonioscopy exam, a painless procedure in which a special mirrored lens is placed gently on the surface of the eye that allows visualization of the angle. (See Diagnostic Services page for a description of gonioscopy.) Patients with narrow angles can then be warned of symptoms. Your doctor may even recommend that you undergo laser iridotomy if he feels that the risk for attack is great.

NEOVASCULAR GLAUCOMA (NVG)

This is an uncommon form of glaucoma that is caused by NEW blood vessel growth in the iris (colored part of the eye) which leads to bleeding and scarring of the angle. When the angle scars, the aqueous cannot exit via the trabecular meshwork and Schlemm's canal causing relentness increased intraocular pressure. (See question 2 for details of the anatomy of the angle.) This is an uncommon form of glaucoma and is usually due to other problems of the eye related to its circulation or even more rare, chronic inflammation. This is considered a type of SECONDARY GLAUCOMA (see below) meaning that NVG has occurred due to another problem with the eye. There are two main circulation problems that can lead to NVG. Diabetic Retinopathy in its advanced form, if untreated, can lead to NVG. Central Retinal Vein Occlusion (CRVO) is a circulatory problem in which the main vein draining blood out of the eye becomes occluded or "stopped up," leading to a back flow of blood and hemorrhaging into the eye. If severe and untreated, NVG can develop. There are many systemic problems that are associated with CRVO such as hypertension, heart disease, diabetes, and other vascular problems. Rarely does CRVO occur in healthy persons. There are other less common causes of NVG such as carotid artery occulsive disease, chronic uveitis, and others. If caught in time, laser treatment can usually successfully treat NVG. The goal of treatment is to save the eye, not to restore vision since vision is usually permanently damaged by this time.

PIGMENTARY GLAUCOMA Pigmentary glaucoma is a type of open-angle glaucoma that is caused the shedding of iris pigment into the anterior chamber fluid (aqueous) which then accumulates into the drainage structures of the eye called the trabecular meshwork. (See question 2 for details of the anatomy of the drainage system of the eye.) With the trabecular meshwork "clogged up," aqueous produced in the cavity of the eye cannot drain out into Schlemm's canal thereby causing increased fluid pressure in the eye. Pigmentary glaucoma is relatively uncommon and occurs more in men than women. It is an inherited form of glaucoma and begins usually in the 20's or 30's. Because it begins so early in life, it represents a real threat to long term normal vision. The vast majority of cases of pigmentary glaucoma occur in nearsighted persons. It is thought that in certain nearsighted individuals, the anterior chamber is

deeper than normal causing the iris to rub up against other structures in the eye such as the lens and zonules (fibers in the eye behind the iris which hold the lens in proper position). This constant rubbing action causes the iris pigment to flake off into the aqueous. This form of glaucoma can be treated successfully (see question 10).

EXFOLIATION SYNDROME This form of glaucoma is common, and occurs in approximately 10% of persons over the age of 50. For reasons that are not clear, a whitish dandruff-like material builds up in the eye and accumulates on the lens surface. As the pupil dilates and constricts, this material along with iris pigment is literally rubbed off the lens and is dispersed in the aqueous (see question 2 for details of the anatomy). Both pigment and this exfoliative material clog the trabecular meshwork leading to a build up of fluid pressure. Not all persons with exfoliative syndrome develop glaucoma or elevated pressure. However, if you have exfoliative syndrome, your chances of developing glaucoma at some point in your life are six times higher than if you don't. It usually begins in one eye long before the other. Therefore, persons with exfoliative syndrome need to be monitored carefully for the development of glaucoma. Fortunately with this type of glaucoma, treatment is highly successful (see question 10).

SECONDARY GLAUCOMAS These types of glaucomas are generally as a result of an insult or injury to the eye. These events can fall into several categories: A. Trauma Such as a hard blow to the eye, a penetrating injury, severe lye burn, etc. These mechanical factors can cause damage to the drainage structures of the eye resulting in a build up of fluid pressure. B. Vascular A variety of diseases that cause poor circulation to the eye can lead to NEOVASCULAR GLAUCOMA (see above). C. Congenital

Glaucoma can be present at birth if the drainage channels of the eye are not well formed. Other birth defects of the eye can also lead to glaucoma. D. Medications Certain types of medications can cause glaucoma such as steroids, anti-histiminics, some types of anti-depressants, and medications for certain stomach disorders such as belladonna alkaloids. Be sure to check with your medical doctor and/or your ophthalmologist if you are taking or plan to take these types of medicines.

4. WHO GETS GLAUCOMA? It is not an understatement to say that EVERYONE, children to older adults, should be concerned about glaucoma, because early detection and treatment are the only ways to prevent irreversible blindness. See below for risk factors that place certain people at greater risk.

5. ARE THERE RISK FACTORS FOR THE DEVELOPMENT OF GLAUCOMA? There are several conditions that put some people at greater risk:

Age. Although glaucoma can occur in younger persons, the risk for glaucoma increases with age, generally beyond 40.

Family History Glaucoma can be inherited, and therefore family history is a risk factor. The Baltimore Eye Survey found that open-angle glaucoma is increased approximately 3.7 fold for individuals having a sibling with this most common form of glaucoma. However just because there is glaucoma in the family does not mean that a given individual will develop the disease.

Higher than normal intracoular pressure. Generally pressures beyond 22 represent higher than normal pressures. While elevated pressure does not mean you have glaucoma, it is the single most important risk factor for the development of glaucoma. Therefore, elevated pressures, especially if combined with other risk factors, should be closely monitored.

Race An important risk factor for open-angle glaucoma, which is found to be four to five times greater in African Americans than in other races. Also, blindness from glaucoma is 4 to 8 times more common in African Americans than in Caucasian Americans. Asian-Americans seem more prone to develop angle-closure glaucoma.

Other risk factors include:

Diabetes Myopia (nearsightedness) Blunt injury to the eye Steroid medication use Hypertension

6. WHAT'S THE DIFFERENCE BETWEEN A GLAUCOMA SUSPECT AND A GLAUCOMA PATIENT? Glaucoma can be extremely difficult to diagnose, particularly in the early stages. An example of a glaucoma suspect would be a person who may have elevated pressures, but a normal optic nerve exam and visual fields. Elevated pressure alone does not mean glaucoma , although it is an important risk factor (see question 5). Such a person would be monitored on an appropriate basis, and even perhaps treated if the pressure were high enough to be a significant risk.

Another confusing scenario would be a patient with suspicious looking optic nerves, but with normal visual fields and pressure. Normal-tension glaucoma in this case may be suspected, but still difficult to diagnose If your doctor tells you that your optic for sure. Being a glaucoma nerve cups are large, don't panick. Not suspect basically means that all large optic nerve cups are abnormal. a potential problem may have This optic nerve head happens to be been caught in the very early normal even though the cup is large. stages and can be watched or Telling the difference between a normal treated early to prevent and abnormal large cup can be damage. challenging and requires experience as well as attention to detail. By contrast, a glaucoma patient by definition means that damage has occurred, either in the way of optic nerve damage, or damage to the vision as demonstrated by visual field testing. This means that optic nerve fibers have already undergone irreversible damage, and that treatment will be necessary to prevent any further damage to the nerve or to your vision.

7. HOW CAN I TELL IF I HAVE GLAUCOMA? The vast majority of cases of early glaucoma have no symptoms. Except for acute forms of glaucoma, there generally is no pain or discomfort. Most patients are totally unaware that there is anything threatening their vision. In advanced glaucoma, patients may complain of generally blurred vision or loss of peripheral vision. In acute glaucoma, pain is prominent with other symptoms and signs such as red eye, halos, light sensitivity, and headache. The intensity of pain can vary from a low grade brow ache to intense aching. The best method for diagnosing glaucoma is through a comprehensive examination. This should be done regardless of age, but especially if

risk factors (see question 5) are present. Your ophthalmologist has a variety of diagnostic tools available in the investigation for possible glaucoma (see question 9). Remember too that there are many other causes of blurred vision and ocular pain.

8. IS GLAUCOMA PAINFUL? Glaucoma is usually a painless disease. Pain is more related to the rate of pressure rise (as seen in the acute forms of glaucoma) and less related to the level of pressure itself. It is well known that high levels of pressure that occur slowly over a period of time have little or no symptoms of discomfort. We've seen patients with intraocular pressures of 50 millimeters of mercury (upper limits of normal - 22) and didn't have a clue that anything was wrong. It is as though the eye acclimates and compensates. With sudden rises in pressure, however, discomfort may occur with pressures far below that level.

9. HOW IS GLAUCOMA DIAGNOSED? Most cases of glaucoma are "silent" meaning that there are no warning signs that specifically point to glaucoma. Except in advanced cases where there may be profound visual loss, glaucoma generally goes undetected. An eye examination is the best method of glaucoma detection (see question 13 for details). During the course of an examination, if your ophthalmologist becomes suspicious of glaucoma, he may perform other tests to clarify or stage the level of disease that a person may have. These tests are listed below:

APPLANATION TONOMETRY This test is a routine part of a complete eye examination. It is a painless method of measuring fluid pressure or intraocular

pressure (IOP) of the eye, and is the preferred method used by Davidson Eye Associates. Elevated IOP is the single most important risk factor for glaucoma (see question 5 for details of risk factors). During this part of the examination, your ophthalmologist will put yellow numbing drops in the eye. (S)he will then shine a blue light into the eye, while gently placing a measuring guage against the cornea to determine the pressure in the eye.

This method is a highly accurate IOPdetermination and is completely painless.

form

of

Applanation tonometry is the most common method of IOP determination. There are other less common forms of pressure determination. For example, air puff tonometry reads IOP by blowing a puff of air against the eye. Because nothing touches the eye, numbing drops are not needed. Patients are aware of air being blown into the eye, however.

GONIOSCOPY This is a "non-routine" but extremely important test that allows examination of the angle of the eye (see question 2 for details),

and it is done only when there is suspicion of glaucoma or other problems. During this test, numbing drops are placed into the eye. The ophthalmologist will then gently lay a special lens against the eye that will allow visualization of the drainage channels and other structures located in the angle. This procedure is completely painless and takes only a minute or so to do in most cases.

OPHTHALMOSCOPY This is a normal part of a full eye examination where the optic nerve is examined under high magnification. The optic nerve, color, circulation, and surrounding tissue can be evaluated for abnormalities (see question 2 for details).

VISUAL FIELD ANALYSIS This is a computerized analysis of the field of vision, and is the hallmark of glaucoma detection and follow up. This test is extremely important because it can pick up early visual loss from glaucoma and can measure the degree of damage to your vision. Damage usually begins in the periphery (your side vision) where it is not noticed early on. In fact, loss of central (straight-ahead) vision occurs late in the disease and usually after wide spread peripheral vision loss. This explains why glaucoma often goes undetected by the patient until advanced disease occurs. This test also tracks whether your field loss is progressing or stabilized at its current level while under your doctor's treatment plan. During this test, you will be seated in front of the visual field machine that your doctor uses. Your head will be positioned before a white screen with your chin comfortably resting on a chin rest. Within this white screen will be a target that the testing eye (other eye will be covered) will fixate on. When the test begins, you will see spots of light of varying intensities flash one by one in different parts of your side vision. You simply press a button each time you happen to see a light stimulus. The computer then takes these responses and uses the information to form an analysis of your visual space. Sophisticated programs can then compare your responses with what is statistically normal for someone your age and level of vision. The test is easy and is of course painless since it is a visual test. Testing programs have become much more refined and do not

take near the time or require the concentration that programs in the past did. There are other tests that have become available for early glaucoma diagnosis, which concentrate on detecting early optic nerve disease. These technologies are still being developed and refined. They include the Heidelberg Retinal Tomograph, the GDx, and the Optical Coherence Tomography System. 10. WHAT IS THE TREATMENT FOR GLAUCOMA? Glaucoma is generally treated "medically" (observation in suspect cases, eye drops, and/or rarely pills). Surgery (laser, traditional surgery) is generally reserved for cases that cannot be controlled medically. Some surgeons however are using laser treatment as the first line of treatment in an attempt to avoid daily use of eyedrops. Rarely in this country is a traditional glaucoma operation performed before trying medical or laser treatment. Some countries however do traditional glaucoma surgery as their first line of treatment and claim good results. There are studies that are looking into which is the best initial treatment of glaucoma. Treatment however often includes a combination of methods.

EYE DROPS In the USA, this generally represents the first line defense against glaucoma. Different drops, however, act differently upon the eye. Some lower intraocular pressure (IOP) by causing the eye to make less aqueous. Others help open up the drainage

channels in the angle (see question 2 for details) to allow more fluid to exit the eye. There are many types of eye drops used in glaucoma, and advances in pharmacology (the study of drugs) has greatly revolutionized the way glaucoma is treated. Depending upon the

medication, drops may be used from once to four times per day, and may be used in combination with other drops. All eye drops cause a certain level of stinging and burning, which should be very short-lived. Also, just like other medication, eye drops may uncommonly cause other side affects, such as blurred vision, redness, and even problems such as insomnia, irritability, shortness or breath, heart rhythm disorders, and others. Your ophthalmologist should advise you of possible side affects of the drops that you're on. Also, make sure that (s)he knows what other medication you are taking. To minimize absorption into the bloodstream and maximize absorption into the eye, close your eyes for a minute or so and press against your tear ducts located in the nasal corners of your eyes. Your ophthalmologist can demonstrate proper eye drop technique for you. HOW DOES LASER TREATMENT WORK FOR GLAUCOMA? IS THE TREATMENT PAINFUL? When medication does not achieve the desired results, loses their effects, or is intolerable due to side affects, then your ophthalmologist may recommend laser treatment. There are basically two techniques of laser treatment used in the glaucomas. For acute glaucoma (see question 3), laser iridotomy is considered the treatment of choice after stabilization with medication. For open angle glaucoma and most other forms of chronic glaucoma, laser trabeculoplasty is the technique of choice. See below for a description of both techniques.

At Davidson Eye Associates, laser treatment is performed in an office setting. Generally, patients come in an hour before the procedure to have some preparatory eye drops instilled. Just before the treatment begins, numbing drops are instilled which may cause short-lived stinging. Laser Surgery During the laser procedure, patients will see bright flashes of Davidson Eye Associates has nearly light but will experience no pain 20 years of experience with laser for glaucoma. This otherwise. The procedure takes surgery between ten and twenty minutes. treatment is highly effective for both acute and chronic forms of glaucoma. After the treatment, we will monitor the eye and its pressure for the first hour or two. Most patients can then resume their normal activities at home, although the vision in the treated eye may be blurred for several hours. There may be some minor discomfort for a few hours after the procedure. Initial follow up visit is then scheduled which can range from one day to one week after the treatment. In acute glaucoma (see question 3 for details and pictures of a narrow angle), pressure can build up rapidly in the eye causing visually threatening damage to the optic nerve. In doing a laser iridotomy, an opening in the iris allows equalization of pressure in the posterior and anterior chambers. This allows pressure to flow directly into the angle for drainage, and also allows the peripheral iris to "fall back" or

relax, creating a wider angle for better fluid flow. Laser iridotomy is generally curative in preventing attacks of acute glaucoma. For those who have suffered an attack of acute glaucoma, this technique can prevent further attacks but will not restore any vision that may have been lost. Example of Laser Iridotomy. Sometimes a "back-up" iridotomy will be done in case one closes. For open angle glaucoma and other forms of nonacute glaucoma (see question 3 for details), laser trabeculoplasty can be done to add control. Here, the laser beam heats up the trabecular meshwork causing it to "stretch open," and allowing fluid to drain out more earily. In laser trabeculoplasty, approximately 80% of patients respond well enough to laser treatment to avoid surgery (see question 12). It may take several weeks to see the full effect, however. Although some patients find that the laser treatment allows control of their pressure without the use of eye drops, most find that eye drops at some level are still necessary. Remember, the goal of laser treatment is control of pressure, not the elimination of eye drops. Laser surgery for glaucoma is generally considered a low risk operation, which is why it has become a common form of glaucoma treatment. An uncommon complication is a pressure spike which can usually be managed with medication and rarely necessitates emergency surgery. The risk for visual loss from pressure spike or macular swelling is also rare. Laser surgery for glaucoma does not cause cataracts. Sometimes laser treatment has no affect on the pressure. Even with successful treatment with a good pressure response, glaucoma must be monitored since the treatment can lose its effect over time.

12.WHEN IS GLAUCOMA?

SURGERY

NECESSARY

FOR

TREATMENT

OF

In this country, surgery is considered as a last resort when other treatments such as medication and laser surgery have failed. There are several types of glaucoma operations performed world-wide. The most common performed procedure, however, is called a trabeculectomy.

This surgery involves removing a portion of the trabecular meshwork (see question 2 for details) which allows the aqueous to drain out of the eye more easily resulting in lower intraocular pressure (IOP). Glaucoma surgery is generally done as an outpatient procedure under local anesthesia with sedation. Unless there are complications, patients go home an hour or so after their surgery. Patients are seen the next day for a post-surgical evaluation of the eye, vision, and for measurement of the IOP. It can take several weeks for vision to get back to its baseline following the operation. Postoperative medications generally include an antibiotic drop, an anti-inflammatory drop, and a cycloplegic drop (keeps the pupil dilated and helps manage pain). Glaucoma drops may be continued at some level depending upon what your ophthalmologist feels is needed. The postoperative period generally lasts two to three months. The majority of patients do well with surgery, and most find that surgery controls them without the use of medication. There are risks to the procedure, especially in advanced glaucoma. Risks can include visual loss, cataract development from the procedure, or a failed procedure necessitating a re-operation.

13. HOW OFTEN SHOULD I HAVE MY EYES CHECKED FOR GLAUCOMA? Routine eye examinations are a vital part of maintaining ocular health and detecting silent disease. Recommendations for eye examinations vary. For the detection of glaucoma, Davidson Eye Associates recommends the following schedule as a guideline. Precisely how often a patient should be seen will depend upon their circumstances and risk factors. Davidson Eye Associates Recommended Guidelines

NO RISKFACTORS RISK FACTORS Under 30 yrs Every 4 years age 30 - 45 yrs age Every 2 - 4 years Over age 45 yrs Every 6 months to 2 years* Every 6 months to 2 years* Every 6 months to 2 years*

Every 1 - 2 years

Risk Factors Age Family History Elevated IOP Race Diabetes Hypertension Blunt Injury Prolonged use of steroid medication

STRABISMUS

Strabismus is misalignment of the eyes, which produces deviation from the parallelism of normal gaze. Diagnosis is clinical, including observation of the corneal light reflex and use of a cover test. Treatment may include correction of visual impairment with patching and corrective lenses, alignment by corrective lenses, and surgical repair. Strabismus occurs in about 3% is caused by refractive errors or retinoblastoma or other serious Left untreated, about 50% of visual loss due to amblyopia Children: Amblyopia). of children. Although most strabismus muscle imbalance, rare causes include ocular defects and neurologic disease. children with strabismus have some (see Eye Defects and Conditions in

Several varieties of strabismus have been described, based on direction of deviation, specific conditions under which deviation occurs, and whether deviation is constant or intermittent. Description of these varieties requires the definition of several terms. The prefix eso refers to nasal deviations, and the prefix exo refers to temporal deviations. The prefix hyper refers to upward deviations, and the prefix hypo refers to downward deviations (see Fig. 1: Eye Defects and Conditions in Children: Ocular deviations in strabismus. ). Manifest deviations, detectable with both eyes open so that vision is binocular, are designated as tropia. Tropia can be constant or intermittent and may involve one eye or both eyes. Latent deviation, detectable only when one eye is covered so that vision is monocular, is designated as phoria. The deviation in phoria is latent because the brain, using the extraocular muscles, corrects the minor misalignment. Deviations that are the same (amplitude or degree of misalignment remains the same) in all gaze directions are designated as comitant, whereas deviations that vary (amplitude or degree of misalignment changes) depending on gaze direction are referred to as incomitant.

Ocular deviations in strabismus.

Strabismus involves both eyes; the left eye is shown here. The direction of the deviation is designated by the prefixes eso-, exo-, hyper-, and hypo-. When the deviation is visible is indicated by the suffixes -tropia and -phoria.

Etiology Strabismus may be congenital (the term infantile is preferred, because detection of strabismus at birth is uncommon, and infantile permits inclusion of varieties that develop within the 1st 6 mo of life) or acquired (includes those that develop after 6 mo). Risk factors for infantile strabismus include family history (1st- or 2nddegree relative), genetic disorders (Down syndrome and Crouzon syndrome), prenatal drug exposure (including alcohol), prematurity or low birth weight, congenital eye defects, and cerebral palsy. Acquired strabismus can develop acutely or gradually. Causes of acquired strabismus include tumors (eg, retinoblastoma), head trauma, neurologic conditions (eg, cerebral palsy; spina bifida; palsy of the 3rd, 4th, or 5th cranial nerves), viral infections (eg, encephalitis, meningitis), and acquired eye defects. Specific causes vary depending on the type of deviation.

Esotropia is commonly infantile. Infantile esotropia is considered idiopathic, although an anomaly of fusion is the suspected cause. Accommodative esotropia, a common variety of acquired esotropia, develops between 2 yr and 4 yr of age and is associated with hyperopia. Sensory esotropia occurs when severe visual loss (due to conditions such as cataracts, optic nerve anomalies, or tumors) interferes with the brain's effort to maintain ocular alignment. Esotropia can be paralytic, so designated because the cause is a 6th (abducens) cranial nerve palsy, but it is an uncommon cause. Esotropia can also be a component of a syndrome. Duane's syndrome (congenital absence of the abducens nucleus with anomalous innervation of the lateral rectus extraocular muscle by the 3rd [oculomotor] cranial nerve) and Mbius' syndrome (anomalies of multiple cranial nerves) are specific examples. Exotropia may be intermittent and idiopathic. Less often, exotropia is constant and paralytic, as with 3rd (oculomotor) cranial nerve palsy. Hypertropia can be paralytic, caused by 4th (trochlear) cranial nerve palsy that occurs congenitally or after head trauma or less commonly, as a result of 3rd cranial nerve palsy. Hypotropia can be restrictive, caused by mechanical restriction of full movement of the globe rather than neurologic interference with eye movement. For example, restrictive hypotropia can result from a blowout fracture of the orbit floor or walls. Less commonly, restrictive hypotropia can be caused by Graves' ophthalmopathy (thyroid eye disease). Third cranial nerve palsy and Brown syndrome (congenital or acquired tightness and restriction of the superior oblique muscle tendon) are other uncommon causes. Symptoms and Signs Unless severe, phorias rarely cause symptoms. Tropias sometimes result in symptoms. For example, torticollis may develop to compensate for the brain's difficulty in fusing images from misaligned eyes and to reduce diplopia. Some children with tropias have normal and equal visual acuity. However, amblyopia frequently develops with tropias; it is due to cortical suppression of the image in the deviating eye to avoid confusion and diplopia.

Diagnosis

Physical and neurologic examinations at well-child checkups Tests (eg, corneal light reflex, alternate cover, cover-uncover) Prisms

Strabismus can be detected during well-child checkups. History should include questions about family history of amblyopia or strabismus and, if family or caregivers have noticed deviation of gaze, questions about when the deviation began, when or how often it is present, and whether there is a preference for using one eye for fixation. Physical examination should include an assessment of visual acuity, pupil reactivity, and the extent of extraocular movements. Neurologic examination, particularly of the cranial nerves, is important. The corneal light reflex test is a good screening test, but it is not very sensitive for detecting small deviations. The child looks at a light and the light reflection (reflex) from the pupil is observed; normally, the reflex appears symmetric (ie, in the same location on each pupil). The light reflex for an exotropic eye is nasal to the pupillary center, whereas the reflex for an esotropic eye is temporal to the pupillary center. Vision screening machines operated by trained personnel are being introduced to identify children at risk. When performing the alternate cover test, the child is asked to fixate on an object. One eye is then covered while the other is observed for movement. No movement should be detected if the eyes are properly aligned, but strabismus is present if the unoccluded eye shifts to establish fixation once the other eye, which had fixed on the object, is occluded. The test is then repeated on the other eye. In a variation of the cover test, called the cover-uncover test, the patient is asked to fix on an object while the examiner alternately covers and uncovers one eye and then the other, back and forth. An eye with a latent strabismus shifts position when it is uncovered. In exotropia, the eye that was covered turns in to fixate; in esotropia, it turns out to fixate. Tropia can be quantified by using prisms positioned such that the deviating eye need not move to fixate. The power of the prism used to prevent deviation quantifies the tropia and provides a measurement of the magnitude of misalignment of the visual axes. The unit of measurement used by ophthalmologists is the prism diopter. One prism diopter is a deviation of the visual axes of 1 cm at 1 m. Strabismus should be distinguished from pseudostrabismus, which is the appearance of esotropia in a child with good visual acuity in both eyes but a wide nasal bridge or broad epicanthal folds that obscure

much of the white sclera nasally when looking laterally. The light reflex and cover tests are normal in a child with pseudostrabismus. Prognosis and Treatment

Patching Contact lenses or eyeglasses Topical agents Eye exercises Surgical repair to align eyes

Strabismus should not be ignored on the assumption that it will be outgrown. Permanent vision loss can occur if strabismus and its attendant amblyopia are not treated before age 4 to 6 yr. As a result, all children should have formal vision screening in the preschool years. Treatment aims to equalize vision and then align the eyes. Children with amblyopia require patching or penalization of the normal eye; improved vision offers a better prognosis for development of binocular vision and for stability if surgery is done. Patching is not, however, a treatment for strabismus. Eyeglasses or contact lenses are sometimes used if the amount of refractive error is significant enough to interfere with fusion, especially in children with accommodative esotropia. Topical miotic agents, such as echothiophate iodide Some Trade Names PHOSPHOLINE IODIDE 0.125%, may facilitate accommodation in children with accommodative esotropia. Orthoptic eye exercises can help correct intermittent exotropia with convergence insufficiency. Surgical repair is generally done when nonsurgical methods are unsuccessful in aligning the eyes satisfactorily. Surgical repair consists of loosening (recession) and tightening (resection) procedures, most often involving the rectus muscles. Surgical repair is typically done in an outpatient setting. Rates for successful realignment can exceed 80%. The most common complications are overcorrection or undercorrection and recurrence of the strabismus later in life. Rare complications include infection, excessive bleeding, and vision loss.

What is strabismus? Strabismus is a visual disorder where the eyes are misaligned and point in different directions. This misalignment can occur part of the

time (intermittent) or all of the time (constant). Strabismus is classified according to the direction of misalignment. When one eye is looking straight ahead, the other eye may turn inward (esotropia or convergent), outward toward the ear (exotropia or divergent), downward (hypotropia) or upward (hypertropia).

Strabismus occurs in approximately 2% of children under 3 years of age and about 3% of children and young adults, affecting boys and girls equally. Normal alignment of both eyes during childhood allows the brain to fuse the two pictures into a single 3-dimensional image. This allows a high degree of depth perception. In children, when the two eyes fail to focus on the same image, the brain may learn to recognize the stronger image and ignore the weaker image of the amblyopic eye, to avoid double vision. If this is allowed to continue, the eye that the brain ignores will never see well. This loss of vision is called amblyopia . Amblyopia results if vision from one eye is consistently suppressed and the other eye becomes dominant. Among children with strabismus, one-third to one-half develop amblyopia. If strabismus develops for the first time in adulthood, the affected individual usually experiences double vision. Because the brains of adults are already developed for vision, the problems associated with amblyopia, in which the brain ignores input from one eye, do not occur with adult strabismus.

What causes strabismus? The exact cause of the eye misalignment that leads to strabismus is not fully understood. However, strabismus is certainly more common in families with a history of the disorder. Six eye muscles control eye movement an are attached to the outside of each eye. To focus both eyes on a single target, all eye muscles must work together with the corresponding muscles of the opposite eye. The brain coordinates these eye muscles. It is important to understand that it is usually not just one eye that is deviated, but rather, the eyes are misaligned in relation to one another. In essence, both eyes are usually at fault, although one eye may appear to be the "crooked' one. Acquired strabismus in adults can be caused by injuries to the orbit of the eye or brain, including closed head injuries and strokes. People with diabetes often have loss of circulation causing an acquired paralytic strabismus. Loss of vision in one eye from any cause will usually cause the eye to gradually turn outward (exotropia). Strabismus can be caused by problems with the eye muscles, with the nerves that control the eye muscles or with the brain, where the signals for vision are processed. Strabismus can accompany some illnesses such as high blood pressure, multiple sclerosis, myasthenia gravis, or thyroid disorders. Signs and Symptoms Newborns often appear to have crossed eyes due to a lack of developed vision, but this disappears as the infant grows. True strabismus does not disappear as the child grows. Strabismus can often be recognized by a casual observer. In fact, most cases of strabismus are first noted by a parent or the child's pediatrician prior to examination by an ophthalmologist. Children should be monitor ed closely during infancy and the preschool years to detect potential eye problems, particularly if a relative has strabismus. Symptoms of strabismus include :

Eyes that look misaligned. Eyes that did not appear to move together Frequent blinking or squinting, especially in bright sunlight Tilting the head to look at things Faulty depth perception

Double vision

Diagnosis The doctor will evaluate the alignment of your child's eyes, looking for evidence of uncoordinated eye movements. In infants and young children with limited ability to cooperate, the doctor will test alignment by comparing the position of a light reflecting off each eye. However, this test may not detect intermittent strabismus unless the strabismus is occurring at the time of testing. In children who are able to cooperate, both intermittent and constant strabismus can be detected using the "cover-uncover" and "alternating cover" tests. In these tests, the child stares at an object and the examiner watches the response of each of the child's eyes when the other is covered and uncovered. Some ophthalmologist screen for vision problems with a special camera that takes instant pictures of a child's eyes. The patient may be asked to look through a series of prisms to determine the extent of eye divergence. The eye muscles will be tested to determine the strength of the extraocular muscles. A comprehensive eye exam, including a retinal evaluation, is needed to rule out pathological causes for the eye turn. A measurement also is taken to obtain the best vision correction with glasses. Additional testing may be needed depending on the cause of the eye turn. Children should be monitor ed closely during infancy and the preschool year to detect potential eye problems. The earlier the diagnosis and treatment, the better the visual results. Treatment The treatment goal for strabismus is to preserve vision, to straighten the eyes, and to restore 3-dimensional vision. Treatments vary, depending on the type and cause of strabismus. If your child's strabismus has caused amblyopia, treatment will aim at bringing the vision up to normal in the "lazy" eye first. Glasses may help straighten the eyes. A patch can be worn over the preferred eye to force the child to use the weaker or suppressed eye.

 Eye drops are used to temporarily blur the vision of the preferred eye for the same purpose. Exercises may be prescribed to strengthen specific eye muscles. Forcing a child to use the weaker eye can improve sight by reinforcing the connection between the eye and the brain. Surgery on the eye muscles may be necessary, especially when glasses are not enough to straighten the eyes. It's important to understand that strabismus surgery does not resolve amblyopia. However, the majority of children with strabismus will eventually require strabismus surgery to better align the eyes. This shot operation typically is done under general anesthesia and may involve one or both eyes. Strabismus surgery commonly entails recessions of eye muscles if weakening of muscles is required, and resections of eye muscles when strengthening of eye muscles is required. Recession of an eye muscle requires disinsertion of one of the six muscles attached to the eye, and reattachment of the muscle further back on the eye, thereby causing weakening.

Resection of an eye muscle requires disinsertion of the muscle from the eye, excising a portion of the distal end of the muscle, and subsequent reattachment to the eye, thereby resulting in a stronger muscle.

Which eye muscles are repositioned during the surgery depends upon the direction the eye is turning. During the surgery the eye is never removed! Recovery time is rapid and the patient is usually able to resume their normal activities within a few days. Over-or-under correction can occur and further surgery may be needed. As with any surgery, eye muscle surgery has certain risks which include infection, bleeding, excessive scarring, and other complications that can lead to loss of vision. In some cases, surgery can be avoided by using a relatively new technique in which a drug botilinum) is injected into one or more eye muscles to temporarily paralyze the muscle. While one muscle is relaxed, the opposing muscle can tighten, shifting the alignment of the eye. Although the effect of the medication eventually wears off, the opposing muscle that has tightened remains that way, often making the correction permanent.