Glaucoma "the silent thief of sight"

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NANNM CONTINUING EDUCATION COMMITTEE FEDERAL
TEACHING HOSPITAL GOMBE

• TOPIC GLAUCOMA THE SILENT THIEF OF SIGHT.
• PRESENTER ABDULWAHAB USMAN (NOI)
• DATE12 TH APRIL,2016
• VENUE CONFERENCE HALL FTH GOMBE

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OUTLINE

• INTRODUCTION
• DEFINITION
• BRIEF ANATOMY AND PHYSIOLOGY
• CLASSIFICATION
• MANAGEMENT
• NURSING CARE
• CHALLENGES
• RECOMMENDATIONS
• CONCLUSION
• REFERENCES

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INTRODUCTION

• Glaucoma is considered to be the second largest
  cause of blindness after cataract worldwide, and
  the foremost cause of irreversible blindness.
• In 2013, the number of people with glaucoma
  worldwide was estimated to be 64.3 million ,
  increasing to 76.0 million in 2020 and 111.8
  million in 2040.
• Glaucoma is mostly refer to as the silent thief
  of sight due to its asymptomatic nature at early
  stage.
• Early detection and effective treatment are
  necessary to prevent loss of vision.

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DEFINITION

• Glaucoma is a group of ocular disease
  characterized by progressive optic neuropathy
  resulting in optic disc defect and irreversible
  visual field loss that are usually associated
  with raised intraocular pressure.

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BRIEF ANATOMY PHYSIOLOGY
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PRODUCTION AND FLOW OF AQUEOUS HUMOUR

• Aqueous humour, derived from plasma, is produced
  from ciliary process. From there, it passes to
  posterior chamber and then around iris to
  anterior chamber. From the anterior chamber, it
  either drains into schlemn's canal via trabecular
  meshwork Trabecular outflow or goes back into
  ciliary process towards venous circulation
  Uveoscleral outflow.

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CLASSIFICATION

• Congenital /developmental Glaucoma
• Primary
• Secondary

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CONGENITAL GLAUCOMA

• Congenital glaucoma is further classified as
  follows depending on the age of onset.
• True congenital glaucoma (40)
• Infantile glaucoma (55)
• Juvenile glaucoma (5)
• It affects 1 in 10,000 birth of the population .
• 70 bilateral.

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CLINICAL FEATURES

• Corneal oedema
• Lacrimation , photophobia and blepharospasm
  (Classic Triad).
• Corneal enlargement.
• Haabs striae.
• Raised IOP

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EVALUATION

• Tonometry
• Measurement of corneal diameter by callipers
• Slit lamp examination
• Ophthalmoscopy
• Gonioscopy

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MANAGEMENT

• Primarily surgical.
• Goniotomy.
• Trabeculotomy if goniotomy fails or when the
  corneal clouding prevent visualisation of the
  angles.
• Trabeculectomy.

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PRIMARY GLAUCOMA

• Primary open angle glaucoma (POAG)
• Primary angle closure glaucoma (PACG)
• PRIMARY OPEN ANGLE GLAUCOMA
• Adult onset
• An open angle of normal appearance.
• Most prevalent type of Glaucoma (1/3)
• 1 in 100 0f the population gt 40 years.

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RISK FACTORS

• Age gt 40 years
• Race develop earlier and more severe in black
  than white
• Family history
• Diabetes and Hypertension
• Myopes
• Low CCT lt 555um
• Retinal diseases
• Steroids

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CLINICAL FEATURES

• Asymptomatic at early stage
• Headache
• Eye ache
• Scotoma
• Difficulty in reading and close work
• Delayed dark adaptation
• Decrease visual acuity
• Increase IOP
• Cupping of the optic disc

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EVALUATION

• Visual acuity
• Slit lamp examination
• Tonometry
• Pachymetry
• Perimetry
• Ophthalmoscopy
• Gonioscopy

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MANAGEMENT

• Initial therapy is medical , with surgery as the
  last resort.
• Beta blockers eg Timolol maleate and Betaxolol
• Prostaglandin analogue eg Latanoprost.
• Adrenergic drugs eg Brimonidine
• Carbonic anhydrase inhibitors eg Dorzolamide and
  Acetazolamide
• Miotics eg pilocarpine
• Hyperosmotic agent eg mannitol
• SURGERY
• Laser trabeculoplasty
• Trabeculectomy

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NORMAL TENSION GLAUCOMA

• Also called low tension glaucoma, is when typical
  glaucomatous changes and visual field defects are
  associated with an IOP that is constantly below
  21mmHg
• It is believed to result from low vascular
  perfusion which makes the optic nerve head more
  susceptible to normal IOP.
• Betaxolol is the drug of choice

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OCULAR HYPERTENSION

• Also called glaucoma suspect is when a patient
  has an IOP constantly more than 21mmHg but no
  optic disc and visual field defects.
• The patient should be carefully monitored and
  should be treated as a case of POAG in the
  presence of risk factors.
• Significant diurnal variation of more than 8mmHg
  between the lowest and the highest values of IOP
• IOP constantly more than 28mmHg
• Significant asymmetry in the cup size of the two
  eyes i.e gt 0.2.

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PRIMARY ANGLE CLOSURE GLAUCOMA

• Primary angle closure disease is characterized by
  apposition of the peripheral iris against the
  trabecular meshwork, resulting in obstruction of
  the aqueous outflow.
• Primary angle closure glaucoma is used only when
  the optic disc and visual field changes are
  present.

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RISK FACTORS

• Sex More in female than male. 41.
• Hereditary
• Age More in advance age with highest frequency
  in 6th and 7th decades.
• Hypermetropics due to shallow anterior chamber
  and short axial length.
• Race More in South East Asians, Chinese and
  Eskimos than blacks.

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CLINICAL FEATURES

• Severe pain
• Nausea , vomiting and prostration
• Red eye
• Photophobia
• Lacrimation
• Raised IOP (40-70mmHg)
• Ocular structures becomes oedematous
• Closed angle of anterior chamber
• Fixed and dilated pupils

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MANAGEMENT

• Primary angle closure disease is a serious
  ophthalmic emergency and needs to be manage
  aggressively as follows
• Immediate medical therapy to lower IOP
• Systemic hyperosmotic agents e.g Mannitol and
  Glycerol
• Systemic CAI e.g Acetazolamide 500mg t.d.s
• Topical anti-glaucoma drugs beta blockers and
  prostaglandin analogues.
• Analgesia
• Antiemetic
• Antinflammatory

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• Definitive therapy
• Surgeries i.e laser peripheral iridotomy, laser
  iridotomy and trabeculectomy
• iii. Prophylaxis of the fellow eye
• Prophylaxis surgery should be performed on the
  fellow asymptomatic eye as early as possible as
  chances of acute attack is 50 in such eye.
• iv. Long term glaucoma surveillance and IOP
  management in both eyes.

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SECONDARY GLAUCOMAS

• Depending on the cause, secondary glaucoma are
  named as follows
• Lens induced glaucoma
• Inflammatory glaucoma
• Neovascular glaucoma
• Glaucoma associated with intraocular haemorrhage
• Glaucoma associated with intraocular tumor
• Steroid induced glaucoma
• Traumatic glaucoma
• Glaucoma in aphakia
• Pseudoexfoliative glaucoma
• Pigmentary glaucoma

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NURSING CARE PLAN FOR A GLAUCOMA PATIENT
NURSING DIAGNOSIS NURSING OBJECTIVE NURSING INTERVENTION SCIENTIFIC RATIONALE EVALUATION
Disturbed visual sensory perception related to altered sensory reception as evidenced by loss of visual field/decreases visual acuity To maintain current visual field/acuity without further loss Determine type and degree of visual field loss Allow expression of feelings about loss and possibility of loss of vision Administer prescribed medications as indicated Prepare patient for surgery and care post operatively Baseline for evaluation Help reassure the patiient that vision loss cannot be restored but further loss can be prevented Control IOP and prevent further loss of vision To prevent further loss of vision Patient visual field /acuity was maintained without further loss
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NURSING DIAGNOSIS NURSING OBJECTIVE NURSING INTERVENTION SCIENTIFIC RATIONALE EVALUATION
Anxiety(actual) related to loss of vision as evidenced by negative self-talk Allay anxiety Determine level of anxiety Give accurate and honest information Encourage patient to express feelings and concerns. Identify helpful resources and people Baseline for evaluation Lessens anxiety related to unknown. Provide opportunity for patient to deal with reality of situation and clarify misconceptions. Provide reassurance that patient is not alone in dealing with problem Patient anxiety was allayed
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NURSING DIAGNOSIS NURSING OBJECTIVE NURSING INTERVENTION SCIENTIFIC RATIONALE EVALUATION
Knowledge deficit regarding disease process Patient will understand pathology and treatment of glaucoma Review pathology and lifelong need for treatment Demonstrate proper technique for administration of eye drops Discuss dietary consideration (adequate fluid and fiber intake) Identify potential side effects of treatment Provides opportunity to clarify and dispel misconception Enhance effectiveness of treatment To prevent constipation and straining during defecation May require medical evaluation and possible change in therapeutic regimen Patient understood pathology and treatment of Glaucoma
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CHALLENGES

• Late presentation
• Lack of awareness
• Delay in referral
• Lack of expertise
• Poor compliance with medical treatment
• Lack of equipments
• High cost of drugs
• Fake drugs
• Surgeons reluctance to offer surgery

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RECOMMENDATIONS

• Routine glaucoma screening to help detect the
  disease at early stage and prevent further loss
  of vision.
• Increase awareness through health talk and media.
• Early referral of patient from other health
  professionals to ophthalmic specialist.
• Training and re-training of eye care personnel.
• Provision of necessary equipments and proper
  maintenance of the little available ones.

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• Strict enforcement of regulation and supervision
  to curtail the circulation of fake drugs.
• Patient education on the need for strict
  compliance with treatment regimen.
• Government should subsidies the cost of glaucoma
  drugs.

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CONCLUSION

• Glaucoma represents a major public
• health burden and even though the challenges of
• management in developing countries are many, they
• are not insurmountable. There is need for
  concerted
• and integrated efforts involving all cadres of
  eye care
• practitioners, patients, institutions and
  governments to address this important eye disease.

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THANK YOU FOR LISTENING!
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REFERENCES

• http//www.cehjournal.org/category/glaucoma/
• http//nurseslabs.com/3-glaucoma-nursing-care-plan
  s/
• http//nursingcrib.com/nursing-notes-reviewer/medi
  cal-surgical-nursing/glaucoma/
• http//eyewiki.aao.org/Glaucoma_in_the_Developing_
  World
• http//www.cehjournal.org/article/visual-field-tes
  ting-for glaucoma-a-practical-guide/
• http//www.cehjournal.org/article/the-optic-nerve-
  head-in-glaucoma/?utm_sourcehootsuite
• http//www.nursingtimes.net/roles/older-people-nur
  ses/glaucoma-the-silent-thief-of-sight/5075669.ful
  larticle
• http//nursingcrib.com/nursing-notes-reviewer/medi
  cal-surgical-nursing/glaucoma/