Glaucoma Overview

Glaucoma refers to certain eye diseases that affect the optic nerve and cause vision loss. Most,
but not all, of these diseases typically produce elevated pressure inside the eye, called intraocular
pressure (IOP). Normal IOP is measured in millimeters of mercury and can range from 10-21
mm Hg. An elevated IOP is the most important risk factor for the development of glaucoma.

Elevated IOP is sometimes called ocular hypertension. If your doctor diagnoses ocular
hypertension, it does not mean you have glaucoma, but it does mean you are at a higher risk for
developing the condition, and you should see an ophthalmologist (a medical doctor who
specializes in eye care and surgery) frequently.

Half of the people with glaucoma are usually unaware of it until a serious loss of vision has
occurred.

Many factors are associated with an increased risk of developing glaucoma, some of which are
elevated IOP, a family history, ethnic background, and older age.

• The two main types of glaucoma are angle closure and open angle.

o In angle-closure glaucoma, the normal drainage canals within the eye are
physically blocked. Angle-closure glaucoma can be acute (sudden) or chronic
(long-lasting). In acute angle-closure glaucoma, a sudden increase in IOP occurs
because of the buildup of fluid known as aqueous humor. Acute angle-closure
glaucoma is considered an emergency because optic nerve damage and vision loss
can occur within hours of the onset of the problem. Chronic angle-closure
glaucoma may cause vision damage without symptoms.

o In open-angle glaucoma, the drainage system remains open. Open-angle

glaucoma also may cause vision damage without symptoms.

• Normal (or low) tension glaucoma is an unusual and poorly understood form of the
disease. In this type of glaucoma, the optic nerve is damaged even though the IOP is
consistently within a range usually considered normal.

• Childhood glaucoma is rare and starts in infancy, childhood, or adolescence. It is similar

to open-angle glaucoma, and few, if any, symptoms are present in the early stage.
Blindness can result if it is left untreated. Like most types of glaucoma, this childhood
form is thought to be inherited.

• Congenital glaucoma is a type of childhood glaucoma that usually appears soon after
birth, although it may be delayed until later in the first year of life. Unlike childhood
glaucoma, though, congenital glaucoma often has noticeable signs that may include
tearing, light sensitivity, and cloudiness of the cornea. This type of glaucoma is more
common in boys and can affect one or both eyes.
 • Secondary glaucoma refers to an increased IOP that is a result of a structural problem
within the eye. This secondary type may be the result of injury to the eye or other medical
conditions. This form of glaucoma is different because treatment is aimed at treating the
underlying cause as well as lowering the increased pressure within the eye.

Glaucoma Causes

Glaucoma involves increased pressure within the eye. In the normal eye, a clear fluid called
aqueous humor is produced in the rear chamber and flows through the pupil into the front
chamber. Once in the front part of the eye, the fluid drains out of the eye through an area called
the canals of Schlemm. Aqueous humor provides structural support, oxygen, and nutrition to
tissues within the eye.

• Increased IOP results from either increased production or decreased drainage of aqueous
humor. The resulting increase in pressure within the eye may eventually damage the optic
nerve. This increase in IOP is by far the most common risk factor for vision loss due to
glaucoma, but it is not the only factor involved.

• For many years, it was believed that high IOP was the primary cause of optic nerve
damage in glaucoma. Now we know that even people with normal IOP can experience
vision loss from glaucoma. On the other hand, some people with high IOP never develop
the optic nerve damage of glaucoma. Therefore, other factors may affect the optic nerve
even when IOP is within the normal range.

• Elevated IOP is still considered a major risk factor for glaucoma, though, because studies
have shown that the higher the IOP is, the more likely the optic nerve will be damaged.

• No one knows why certain ethnic groups, such as African Americans, have higher rates
of glaucoma that lead to blindness. Primary open-angle glaucoma is the leading cause of
blindness among African Americans and Alaska Natives, occurring 6-8 times more often
than in whites, often in the earlier stages of life.

Glaucoma Symptoms

Most people with glaucoma do not notice symptoms until they begin to have significant vision
loss. As optic nerve fibers are damaged by glaucoma, small blind spots may begin to develop,
usually in the peripheral or side vision. If the entire optic nerve is destroyed, blindness results.

Other symptoms usually are related to sudden increases in IOP, particularly with acute angle-
closure glaucoma, and may include blurred vision, halos around lights, severe eye pain,
headache, abdominal pain, nausea, and vomiting.

When to Seek Medical Care

Call your doctor right away if you have severe eye pain or a sudden loss of vision, especially loss
of peripheral or side vision.
Many of the medications used to treat glaucoma may have side effects, which may include
stinging or redness of the eyes; blurred vision; headache; or changes in heartbeat, pulse, or
breathing. Most side effects are not serious and go away without difficulty. Not everyone will
experience side effects from glaucoma medications, but notify your doctor if you experience any
of them.

With angle-closure glaucoma, a rapid buildup of IOP may lead to blurred vision, severe eye pain,
headache, abdominal pain, or nausea and vomiting. While angle-closure glaucoma is rare, it is a
serious form of the disease and, unless treated quickly, can result in blindness. If you have these
symptoms, you should seek medical attention immediately for evaluation and treatment in order
to prevent permanent vision loss.

Exams and Tests

Many different methods are used to measure pressure within the eye. Other tests determine
whether you have glaucoma and how advanced your glaucoma may be. Most diagnostic tests
need to be repeated on a regular basis to follow the presence or progression of glaucoma.

• Air puff test: The "air puff" test is the most common. This test is a way to measure the
IOP without having to actually touch the eye. For this test, you sit in front of a machine
with your chin resting on a brace. The eye doctor points a small jet directly at your eye.
This jet then delivers a quick puff of air onto the surface of your eye. By measuring the
response of the eye to the puff of air, the doctor can make a rough estimate of the
intraocular pressure. This is a good screening test for elevated IOP, but it is not very
accurate.

• Direct tonometry: Direct tonometry on the surface of the front part of the eye is a much
more accurate measurement of IOP. It, however, requires greater skill and expertise to
perform. A sensor is placed gently on the surface of an anesthetized eye, and a very
accurate IOP is measured.

• Dilation: An examination to inspect the back of the eye through dilated (widened) pupils
is required to diagnose glaucoma. To do this, drops are put into the eyes to enlarge, or
dilate, the pupils. This allows the eye doctor to see more of the inside of the eye. An eye
doctor can recognize a characteristic divot or depression in the optic nerve at the back of
the eye caused by damage from the elevated eye pressure. This enlargement is called
"cupping" of the optic nerve and means the condition may be relatively advanced.

• Perimetry: Another test, perimetry, is used to determine the presence of defects within the
visual fields, particularly vision to the side (called your peripheral vision). Because
people with glaucoma tend to lose their vision from the outer edges to the center,
checking peripheral vision is very important. In perimetry, a machine is used to test your
peripheral vision. You are asked to look at a series of blinking lights. By recording when
you see the lights, an accurate map of your peripheral vision can be made. If you have
glaucoma, you will have decreased peripheral vision. This test can be performed to
follow the progress of your glaucoma or to determine the severity of the initial diagnosis.
Medications

Beta-adrenergic blocking agents, alpha-adrenergic agonists, and prostaglandin analogues are

some of the most commonly used medications.

• Beta-blockers, such as timolol (Timoptic), can reduce the amount of aqueous humor
produced.

• Alpha-adrenergic agonists, such as brimonidine (Alphagan), decrease the production of

aqueous humor and also improve the drainage of aqueous humor.

• Another group of drugs called prostaglandin analogs have recently been used. One that
may be prescribed is latanoprost (Xalatan). They work near the drainage area within the
eye to increase the secondary route of aqueous humor outflow in order to lower IOP.

Surgery

In certain cases, surgery may be required.

• If you have angle-closure glaucoma, an operation called an iridotomy may need to be

done. During an iridotomy, a drainage hole is created in the iris in order to relieve the
increased pressure inside the eye. This technique can be performed using a laser;
therefore, an incision in the eye is not needed. You may choose to have an iridotomy after
an acute episode of angle-closure glaucoma or to prevent an attack of angle-closure
glaucoma.

• Medication normally does not work well for congenital glaucoma, so surgery is usually
required.

• Other types of surgery that are performed to help glaucoma include trabeculoplasty,
cyclophotocoagulation, and filtering. All of these procedures try to ease the drainage of
aqueous humor in the affected eye or eyes to decrease IOP. For more information on
these procedures, consult your eye doctor.