GLAUCOMA

Mr. Manikandan.T,
RN., RM., M.Sc(N)., D.C.A .,(Ph.D)
Assistant Professor,
Dept. of Medical Surgical Nursing,
VMCON, Puducherry.
 Definition
• It is not one disease but rather a group of
disorder characterized by
1. Increased IOP and the consequences of
elevated pressure,
2. Optic nerve atrophy
3. Peripheral visual field loss
 Etiology
• It is related to the consequences of elevated
IOP.
• A proper balance between the rate of aqueous
production and rate of aqueous reabsorption
is essential to maintain the IOP normal limits.
• When the rate of inflow is greater than rate of
outflow, IOP can rise above the normal limits.
If IOP remains elevated, permanent vision loss
occurs.
 Risk factors
• Age
• Race
• Family history of glaucoma
• Medical conditions- Diabetes mellitus,
Cardiovascular disease
• Physical injuries - Eye trauma
• Near sightedness
• Corticosteroids use
• Eye abnormalities
• • Thin cornea
 Types
1. Open angle glaucoma: Usually bilateral, but one
eye may be more severely affected than the
other. The anterior chamber angle is open and
appears normal.
2. Angle closure glaucoma: Obstruction in aqueous
humor outflow due to the complete or partial
closure of the angle from the forward shift of the
peripheral iris to the trabecula. The obstruction
results in an increased IOP.
 Open-Angle Glaucoma

1)Primary open-angle glaucoma (POAG):Optic

nerve damage, visual field defects, IOP >21
mm Hg. May have fluctuating IOPs. Usually no
symptoms but possible ocular pain, headache,
and halos.
2)Normal tension glaucoma: IOP </- 21 mm Hg.
Optic nerve damage, visual field defects.
3)Ocular hypertension: Elevated IOP. Possible
ocular pain or headache.
 Angle closure glaucoma
(Pupillary Block)
• Acute angle-closure glaucoma (AACG): Rapidly progressive
visual impairment, periocular pain, conjunctival hyperemia,
and congestion. Pain may be associated with nausea,
vomiting, bradycardia, and profuse sweating. Reduced central
visual acuity, severely elevated IOP, corneal edema. Pupil is
vertically oval,fixed in a semidilated position, and unreactive
to light and accommodation.
• Subacute angle-closure glaucoma: Transient blurring of
vision, halos around lights; temporal headaches and/or ocular
pain; pupil may be semidilated.
• Chronic angle-closure glaucoma: Progression of
glaucomatous cupping and significant visual field loss; IOP
may be normal or elevated; ocular pain and headache.
 Clinical manifestation

• chronic open-angle glaucoma :

1. Loss of peripheral vision due to compression
of retinal rods and nerve fibers .
2. Halos around lights as a result of corneal
edema.
3. Mild aching in the eyes caused by increased
IOP
4. Reduced visual acuity, especially at night, not
correctable with glasses.
 C/M
acute angle-closure glaucoma
1. Inflammation, Red, painful eye caused by an abrupt elevation of
IOP.
2. Sensation of pressure over the eye due to increased IOP.
3. Moderate papillary dilation nonreactive to light.
4. Cloudy cornea due to compression of intraocular components
5. Blurring and decreased visual acuity due to aberrant neural
conduction.
6. Photophobia due to abnormal intraoccular pressures.
7. Halos around lights due to corneal edema.
8. Nausea and vomiting caused by increased IOP.
 Diagnostic evaluation
• History collection.
• Physical examination.
• Visual acuity examination .
• Tonometry .
• Ophthalmoscopy.
• Slit lamp microscopy.
• Gonioscopy – it is performed with the head positioned in the slit
lamp (the special microscope used to look at the eyes). After
numbing the eye with drops, a special contact lens is placed directly
on the eye and a beam of light is used to illuminate the angle. ...
Examination of both eyes typically takes a few minutes
• Visual field perimetry .
• Fundus photography.
 Management
• Lifelong therapy is almost always necessary because glaucoma
cannot be cured.
Drug therapy:
1. Beta blockers - timolol
2. Alpha adrenergic agonist- brimonidine
3. Cholinergic agents – pilocarpine – increases A.Q outflow
4. Carbonic anhydrase- acetazolamide
5. Adrenergic aganost - Epinephrine, to reduce I0P by improving
aqueous outflow
6. Prostaglandins - latanoprost, to reduce intraocular pressure.
 Cont.,
Treatment for acute angle-closure glaucoma is an ocular
emergency requiring immediate intervention to reduce high IOP
including:
1. I.V. mannitol (20%) or oral glycerin (50%), to reduce IOP by
creating an osmotic pressure gradient between the blood and
intraocular fluid
2. Steroid drops- to reduce inflammation
3. Acetazolamide, a carbonic anhydrase inhibitor, to reduce IOP by
decreasing the formation and secretion of aqueous humor
4. Pilocarpine - to constrict the pupil, forcing the iris away from the
trabeculae and allowing fluid to escape
5. timolol, a beta-blocker - to decrease IOP.
6. Narcotic analgesics, to reduce pain if necessary.
 Surgical therapy
• Argon laser trabecuoplasty : laser burns are applied to the inner
surface of the trabecular meshwork to open the intratrabecular
spaces and widen the canal of Schlemm, thereby promoting
outflow of aqueous humor and decreasing IOP.
• laser iridotomy : for pupillary block glaucoma, an opening is
made in the iris to eliminate the pupillary block.
 Filtering procedures- Trabeculectomy
• Trabeculectomy is the standard filtering technique used to remove part of
the trabecular meshwork. Surgeon used to create an opening or fistula in
the trabecular meshwork to drain aqueous humor from the anterior
chamber to the subconjunctival space into a bleb (fluid collection on the
outside of the eye), thereby bypassing the usual drainage structures. This
allows the aqueous humor to flow and exit by different routes (ie,
absorption by the conjunctival vessels or mixing with tears).
 Drainage implants or shunts
• Drainage implants or shunts are open tubes implanted in the
anterior chamber to shunt aqueous humor to the episcleral
plate in the conjunctival space.
• These implants are used when failure has occurred with one
or more trabeculectomies in which antifibrotic agents were
used. A fibrous capsule develops around the episcleral plate
and filters the aqueous humor, thereby regulating the outflow
and controlling IOP.
 Trabectome
• trabectome surgery stabilizes the optic nerve
and minimizes further visual field damage.
The surgery is performed through a small
incision and does not require creation of a
permanent hole in the eye wall or an external
filtering bleb or an implant.
 Glaucoma complication
Blindness
• Nursing intervention
1. Encourage patient compliance by teaching the
patient about medications, as ordered, to dilate
the pupil and protect the affected eye .
2. Administer pain medication as ordered .
3. Encourage the patient to be ambulatory
immediately after surgery.
• Nursing process:
• The patient with Glaucoma.
 Nursing Assessment
• The patient should be assessed for loss of
both central and peripheral vision, discomfort,
understanding of disease and compliance with
treatment regimen, and ability to conduct
activities of daily living.
 Nursing Diagnosis.
• Nursing diagnoses may include the following:
• Acute pain related to increased intraocular pressure .
• Disturbed sensory perception: visual related to altered
sensory reception.
• Self-care deficit related to decreased vision.
• Anxiety related to partial or total visual loss.
• Risk for injury related to decreased vision.
• Impaired home maintenance related to decreased vision.

• Deficient knowledge related to medical regimen, disease

process due to no prior experience.
 Nursing planning
• Planning for nursing interventions needs to take
into account the patient’s level of understanding
of disease process and medical regimen and
ability to comply with the time-consuming
medication regimen.
• The goal of nursing care for the glaucoma patient
is to prevent further visual loss and to promote
comfort if the patient is experiencing pain as in
acute glaucoma.
• The patient who needs surgical intervention has
additional goals.
 Nursing Intervention
• The patient is taught how to administer medications and performs a
return demonstration to ensure that eye drops are administered
properly.
• If the patient has trouble with a steady hand when administering
eye drops, teach the patient to rest his or her hand on the forehead
to steady the hand.
• If the patient is unable to see the label on the eye drop bottle,
consider large-print labels or audiotaped directions.
• For patients with multiple medications, consider using large,
multicolored dot stickers placed on medication bottle with a
corresponding direction card with a matching colored dot.
• Patients are taught the need for having regular eye examinations
through dilated pupils.
 Evaluation
 Patient goals are met if the patient does the following:
Maintains an acceptable level of comfort
1. Has no further loss of vision
2. Is able to care for self with assistance if needed
3. Expresses concerns and anxieties
4. Does not suffer injury as a result of the visual impairment
5. Is able to manage home maintenance with assistance if
needed
6. Demonstrates correct instillation of eye medications
7. Is able to verbalize understanding of condition and
treatment.