CASE REPORT

ACUTE GLAUCOMA

Created by:

Erliana Fani 2009061258

Monika Theresa P 2009061260

Hendrawan A 2009061264

Ricky Fernando 2009061266

Gerry Wonggo 2009061272

Ido Genesio 2009061273

Supervisor : dr. Abdi Kelana, Sp.M

Fakultas Kedokteran Universitas Katolik Atma Jaya

Bagian Ilmu Penyakit Mata

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Periode 18 September 2011 – 22 Oktober 2011

CASE REPORT

Patient Identity

Name : Tn. S

Sex : Male

Age : 53 years old

Ethnic : Javanese

Religion : Moslem

Occupation : Labour

Address : Angke Indah

History Taking

Chief complaint : Sudden blurry vision since 1 day before admission

Additional complaint:

Pain, watery and redness on his right eye since 1 day before admission.

Headache since 1 day before admission.

History of present illness:

Since 1 day before admission, when patient was about to sleep, he felt a sudden blurry vision, pain, watery and redness. The blurry vision was lose his peripheral (side) vision.

Patient felt throbbing headache especially around the right eye. History of trauma was denied. Usage of topical eye drops was denied. Halo around lights was denied. Nausea and vomiting was denied. Fever was denied.

Past occular history :

History of using eye-glasses was denied.

History of past illneses

Hypertension since 5 years ago, controlled with medication (captopril)

He denied the following diseases: diabetes mellitus, allergy, asthma, and previous surgical operation, heart disease.

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Familial medical history

no previous history of

similar complaint

systemic disease

malignancy

General Status

General condition : appearing sick

Level of consciousness : fully awake

Blood pressure : 100/60 mmHg

Heart rate : 60 x/ minute

Respiratory rate : 20 x/ minute

Temperature : 36,8oC

Ophtalamic Status

Right eye Left eye Periocular appearence

Normal Normal

General condition Redness Normal Eyeball position Orthophoric Orthophoric Eyeball movement Can move to 8

directions Can move to 8 directions

Visual acquity 1/300 5/5 Light Projection Well from 8 directions Well from 8 directionsSupercilia Full symmetric Full symmetric Cilia Normal Normal Palpebra Hyperemic -

edema +tenderness -

nodule -

Hyperemic -edema -

tenderness -nodule -

Sup/Inf Margo Palpebra

Well-positioned Well-positioned

Sup/Inf Tarsal Conjunctiva

Hyperemic + Hyperemic -

Bulbar conjunctiva Injection conjunctiva +, mucoid discharge -

Injection conjunctiva -, mucoid discharge -

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Cornea- Clearness- Edema- Infiltrate- Ulcer- Crust- Destruction- Sikatriks

Clear+-----

Clear------

Anterior Chamber Mild depth Clear

Normal depthClear

Iris Darkish brownCrypt (-)

Darkish brownCrypt (+)

Pupil CenterRound 4mm

Light reflex (-)/(-)Isochoric -

CenterRound 2mm

Light reflex (+)/(+)Isochoric -

Lens Clear Clear

Tonometry Schiotz 69,3mmHg 37,2mmHg

Summary

53 y.o. male, having blurry vision on his right eye, Pain, watery and redness on his right

eye for 1 day, headache since 1 day

Ophthalmic status of right eye:

General Condition : Red and swelling

Visual acquity : 1/300

Palpebra : Edema +

Superior/Inferior Tarsal Conjunctiva : Hyperemic +

Bulbar Conjunctiva : Injection conjunctiva +

Cornea : Edema +

Anterior Chamber : Mild depth

Iris : Crypt –

Pupil : Mid dilatasi

Tonometry schiotz : 69,3 mmHg

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Ophthalmic status of left eye:

Tonometry schiotz : 37,2 mmHg

Clinical diagnosis

OD Acute Glaucoma

OS Primary Closed Angle Glaucoma Chronis

Differential Diagnosis

OD Angle Closure Glaucoma

OS Primary Open Angle Glaucoma

Treatment

Topical :

Pilocarpine 2% ED OD 1 drop/5 minutes ( for the first 1 hour), every hour

( for the first day)

Timolol Hemihydrate 0,5% ODS 2x1 drop

Oral :

Asetazolamide 3x250 mg

Kalium L-Aspartat 1x1

Asam Mefenamat 2 x500mg prn

Surgery : Laser iridotomy/peripheral iridectomy to push iris back and increase angle.

Suggested examination

Funduscopy

Visual field test

Gonioscopy

Pachymetry

Optic nerve imaging

Complications

Complete and permanent blindness

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Prevention

Regularly visit their ophthalmologist every 6 months – 1 year, avoidance ingesting large

quantities of fluid.

Prognosis

Quo ad vitam : bonam

Quo ad functionam : dubia ad malam

Quo ad sanationam : dubia ad malam

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Discussion

1. Definition

Glaucoma (after Mosby), is an abnormal condition of high pressure within an eye. It is caused by a blocking of the normal flow of the watery fluid in the space between the cornea and lens of the eye (aqueous humour).

Acute (angle-closure, closed-angle, or narrow-angle) glaucoma happens if the pupil in an eye with a narrow angle between the iris and cornea opens too wide and causes the folded iris to block the flow of aqueous humour. Chronic (open-angle or wideangle) glaucoma is much more common, often occurring in both eyes; it develops slowly and is an inherited disease.

Acute glaucoma happens with extreme eye pain, blurred vision, a red eye, and an abnormally wide-open pupil. Nausea and vomiting may occur. If untreated, acute glaucoma results in complete and permanent blindness within 2 to 5 days. Chronic glaucoma may show no symptoms except for gradual loss of side vision over a period of years. Sometimes headaches, blurred vision, and dull pain in the eye are present. Halos around lights and blind spots in the centre of the field of vision begin to occur after the condition has developed for a while.

Acute glaucoma is treated with eye drops to close the pupil and draw the iris away from the cornea, drugs that lower pressure, drugs that reduce fluid in the eye, and surgery to produce a pathway for aqueous humour. Chronic glaucoma can usually be controlled with eye drops. All adults should have their eyes examined for glaucoma every three to five years. It is also a good idea for patients who have glaucoma to wear a medical identification tag. Thus, Glaucoma is a disorder in which increased intraocular pressure leads to eventual vision impairment and possibly to degeneration of the optic nerve. It may be a primary condition, or it may be secondary to other ocular disease. Glaucoma is classified as open angle, or closed angle (Pictures below - Acute Glaucoma).

2. Causes and Incidence

The aetiology of primary glaucoma is unknown, but predisposing factors include heredity, hyperopia, and vasomotor instability. It is estimated that 1.5% to 2% of Europeans over 40 years of age have glaucoma, and more than 12% of newly diagnosed cases of blindness are attributable to glaucoma. Blacks and those with a family history are most susceptible. Ninety percent of primary glaucoma cases are the open-angle type, which occurs most often after age 65 (Picture right - Glaucoma fundus in chronic open-angle type).

3. Pathophysiology

Increased intraocular pressure (IOP) is related to an imbalance in the production, inflow, and outflow of aqueous humour. Inflow occurs through the pupil and outflow through the meshwork at the juncture of the iris

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and cornea. In secondary glaucoma the meshwork becomes clogged by blood, fibrin, or inflammatory cells produced by an underlying ocular disorder

Primary open-angle glaucoma is marked by degenerative changes to the meshwork that block outflow. In primary closed-angle glaucoma, the anterior chamber is shallow, the filtration angle is narrow, and the iris obstructs the meshwork at Schlemm's canal. Sometimes dilation of the pupil or trauma pushes the iris forward, narrowing the angle and resulting in obstruction in an acute attack. Primary or secondary glaucoma may be congenital; the condition is hereditary (primary) or is caused by foetal defects in the ocular structure or underlying congenital systemic disorders (secondary).

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4. Classification glaucoma

Open-angle glaucoma is the most common form. Some people have other types of the disease.

A) low-tension or normal-tension glaucoma, optic nerve damage and narrowed side vision occur in people with normal eye pressure. Lowering eye pressure at least 30 percent through medicines slows the disease in some people. Glaucoma may worsen in others despite low pressures. A comprehensive medical history is important to identify other potential risk factors, such as low blood pressure, that contribute to low-tension glaucoma. If no risk factors are identified, the treatment options for low-tension glaucoma are the same as for open-angle glaucoma.

B) In angle-closure glaucoma, the fluid at the front of the eye cannot drain through the angle and leave the eye. The angle gets blocked by part of the iris. People with this type of glaucoma may have a sudden increase in eye pressure. Symptoms include severe pain and nausea, as well as redness of the eye and blurred vision. If you have these symptoms, you need to seek treatment immediately. This is a medical emergency. If your doctor is unavailable, go to the nearest hospital or clinic. Without treatment to restore the flow of fluid, the eye can become blind. Usually, prompt laser surgery and medicines can clear the blockage, lower eye pressure, and protect vision.

C) congenital glaucoma, children are born with a defect in the angle of the eye that slows the normal drainage of fluid. These children usually have obvious symptoms, such as cloudy eyes, sensitivity to light, and excessive tearing. Conventional surgery typically is the suggested treatment, because medicines are not effective and can cause more serious side effects in infants and be difficult to administer. Surgery is safe and effective. If surgery is done promptly, these children usually have an excellent chance of having good vision.

D) Secondary glaucomas can develop as complications of other medical conditions. For example, a severe form of glaucoma is called neovascular glaucoma, and can be a result from

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poorly controlled diabetes or high blood pressure. Other types of glaucoma sometimes occur with cataract, certain eye tumors, or when the eye is inflamed or irritated by a condition called uveitis. Sometimes glaucoma develops after other eye surgeries or serious eye injuries. Steroid drugs used to treat eye inflammations and other diseases can trigger glaucoma in some people. There are two eye conditions known to cause secondary forms of glaucoma. Pigmentary glaucoma occurs when pigment from the iris sheds off and blocks the meshwork, slowing fluid drainage. Pseudoexfoliation glaucoma occurs when extra material is produced and shed off internal eye structures and blocks the meshwork, again slowing fluid drainage. Depending on the cause of these secondary glaucomas, treatment includes medicines, laser surgery, or conventional or other glaucoma surgery.

5. Symptoms

Open-angle glaucoma - Often asymptomatic; frequent changes in prescription for glasses; mild headaches, vague visual disturbances; halos around lights; difficulty adjusting to darkness (Picture below - Open-angle Glaucoma).

Closed-angle glaucoma - Severe pain in and around eye; tearing; coloured rainbow halos around lights; recurring episodes of blurring and impaired vision; mild dilation of pupils; hazy cornea; possible nausea and vomiting (Picture below - Closed-angle Glaucoma).

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6. Complications

Untreated glaucoma leads to progressively diminishing vision, degeneration of the optic nerve, and blindness. If untreated, acute glaucoma results in complete and permanent blindness within 2 to 5 days. . Chronic glaucoma may show no symptoms except for gradual loss of side vision over a period of years. Patients suspected of having Glaucoma should, therefore, be referred immediately for complete ophthalmologic evaluation. Most forms of glaucoma are characterized by high intraocular pressure. Intraocular pressure is maintained at normal levels when some of the fluid produced by the eye is allowed to flow out. The fluid (aqueous humour) is produced by the ciliary body where it flows into the anterior chamber and then out through a spongy tissue at the front of the eye called the trabecular meshwork into a drainage canal. In open-angle glaucoma, fluid cannot flow effectively through the trabecular meshwork, and this causes an increase in intraocular pressure causing damage to the optic nerve and leading to vision loss.

7. Diagnostic Tests

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1. Tonometry - To measure elevation in Intra-Ocular Pressure (IOP). measurement of pressure inside the eye by using an instrument (right) called a tonometer. Numbing drops may be applied to your eye for this test.

2. Visual field studies - To detect impairment in central and peripheral visual fields. This test measures peripheral (side vision). It helps eye care professional tell if patient have lost peripheral vision, a sign of glaucoma.

3. Gonioscopy - To detect cellular debris or adhesions and differentiate open-angle from closed-angle type.

Gonioscopic Image of The Eye

4. Pachymetry is the measurement of the thickness of your cornea. Your eye care professional applies a numbing drop to your eye and uses an ultrasonic wave instrument to measure the thickness of your cornea.

5. Visual acuity test. This eye chart test measures how well you see at various distances.

6. Ophthalmoscopy - To visualise optic nerve. In this exam, drops are placed in eyes to widen, or dilate, the pupils. Your eye care professional uses a special magnifying lens to examine your retina and optic nerve for signs of damage and other eye problems. After the exam, your close-up vision may remain blurred for several hours.

A normal optic nerve on the left has a much smaller 'cup', or empty

space in the middle of the optic nerve, than in acute glaucoma on the right.

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8. Treatments

Immediate treatment for early-stage, open-angle glaucoma can delay progression of the disease. That’s why early diagnosis is very important.

Glaucoma treatments include medicines, laser trabeculoplasty, conventional surgery, or a combination of any of these. While these treatments may save remaining vision, they do not improve sight already lost from glaucoma.

a) Medicines

Medicines, in the form of eyedrops or pills, are the most common early treatment for glaucoma. Taken regularly, these eyedrops lower eye pressure. Some medicines cause the eye to make less fluid. Others lower pressure by helping fluid drain from the eye. Glaucoma medicines need to be taken regularly. Many medicines are available to treat glaucoma. Because glaucoma often has no symptoms, people may be tempted to stop taking, or may forget to take, their medicine. Regular use is very important.

Ocular implants for some complex forms of glaucoma.

Drugs - Open-angle: beta-adrenergic blockers and diuretics to reduce production of

aqueous humour, miotics to reduce pressure, and adrenergics to increase aqueous

outflow.

Closed-angle: hyperosmotic agents, carbonic anhydrase inhibitors, and miotics to

reduce pressure or abort acute attack; narcotic analgesics for pain.

General - Open-angle: avoidance of tobacco use, fatigue, emotional upset, and

ingesting large quantities of fluid; instruction in instillation of eye drops, and long-

term use of medications and their side effects.1

b) Laser trabeculoplasty

Laser trabeculoplasty helps fluid drain out of the eye. The laser makes several evenly spaced burns that stretch the drainage holes in the meshwork. This allows the fluid to drain better. Like any surgery, laser surgery can cause side effects, such as inflammation. If the patient have glaucoma in both eyes, usually only one eye will be treated at a time. Laser treatments for each eye will be scheduled several days to several weeks apart.

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c) Conventional surgery

Conventional surgery makes a new opening for the fluid to leave the eye. Conventional surgery often is done after medicines and laser surgery have failed to control pressure.

Conventional surgery, called trabeculectomy, is performed in an operating room. A small piece of tissue is removed to create a new channel for the fluid to drain from the eye. This fluid will drain between the eye tissue layers and create a blister-like “filtration bleb.” For several weeks after the surgery, the patient must put drops in the

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eye to fight infection and inflammation. These drops will be different from those you may have been using before surgery.

Conventional surgery is performed on one eye at a time. Usually the operations are four to six weeks apart. Conventional surgery is about 60 to 80 percent effective at lowering eye pressure. If the new drainage opening narrows, a second operation may be needed. Conventional surgery works best if the patient have not had previous eye surgery, such as a cataract operation.

Sometimes after conventional surgery, vision may not be as good as it was before conventional surgery. Conventional surgery can cause side effects, including cataract, problems with the cornea, inflammation, infection inside the eye, or low eye pressure problems.

9. Preventions

Regularly visit their ophthalmologist at the following intervals:

• Age 20-29 years: At least once during this period.

Those with risk factors for glaucoma (people of African descent or those who

have a family history of glaucoma) should be seen every 3-5 years.

• Age 30-39 years: At least twice during this period.

Those with risk factors for glaucoma (people of African descent or those who

have a family history of glaucoma) should be seen every 2-4 years.

• Age 40-64 years: Every 2-4 years.

• Age 65 years or older: Every 1-2 years. 3

Source :

1. Dr. Lance Liu MBBS (Melb), FRANZCO. GLAUCOMA. Royal Victorian Eye & Ear Hospital

2. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of

Health National Eye Institute

3. Glaucoma information and treatment Michigan Medical, P.C. Ophthalmology Dr.

Marko Habekovic

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