Glaucoma acute symptoms: What are the Symptoms of Glaucoma?
What are the Symptoms of Glaucoma?
High eye pressure is a glaucoma risk factor
Glaucoma is a complicated disease in which damage to the optic nerve results in vision loss.
There are several forms of glaucoma; the two most common forms are primary open-angle glaucoma (POAG) and angle-closure glaucoma (ACG). Open-angle glaucoma is often called “the sneak thief of sight” because it has no symptoms until significant vision loss has occurred.
Symptoms of Open-Angle Glaucoma
There are typically no early warning signs or symptoms of open-angle glaucoma. It develops slowly and sometimes without noticeable sight loss for many years.
Most people who have open-angle glaucoma feel fine and do not notice a change in their vision at first because the initial loss of vision is of side or peripheral vision, and the visual acuity or sharpness of vision is maintained until late in the disease.
By the time a patient is aware of vision loss, the disease is usually quite advanced. Vision loss from glaucoma is not reversible with treatment, even with surgery.
Because open-angle glaucoma has few warning signs or symptoms before damage has occurred, it is important to see a doctor for regular eye examinations. If glaucoma is detected during an eye exam, your eye doctor can prescribe a preventative treatment to help protect your vision.
In open-angle glaucoma, the angle in your eye where the iris meets the cornea is as wide and open as it should be, but the eye’s drainage canals become clogged over time, causing an increase in internal eye pressure and subsequent damage to the optic nerve. It is the most common type of glaucoma, affecting about four million Americans, many of whom do not know they have the disease.
You are at increased risk of glaucoma if your parents or siblings have the disease, if you are African-American or Latino, and possibly if you are diabetic or have cardiovascular disease. The risk of glaucoma also increases with age.
Symptoms of Acute Angle-Closure Glaucoma
- Hazy or blurred vision
- The appearance of rainbow-colored circles around bright lights
- Severe eye and head pain
- Nausea or vomiting (accompanying severe eye pain)
- Sudden sight loss
In angle-closure glaucoma (also called narrow angle glaucoma), the angle is closed in many or most areas, causing increased eye pressure, which leads to optic nerve damage, and possible vision loss. This rise in eye pressure may occur suddenly (an acute attack of angle closure) or gradually. There are also early stages of the disease in which the angle is closed but the eye pressure may or may not be high and the optic nerve is not affected yet.
Symptoms of acute angle-closure glaucoma are very noticeable and damage occurs quickly. If you experience any of these symptoms, seek immediate care from an ophthalmologist.
If you are diagnosed with glaucoma, it is important to set a regular schedule of examinations with your eye doctor to monitor your condition and make sure that your prescribed treatment is effectively maintaining a safe eye pressure.
Article by Doreen Fazio, MD. Dr. Fazio completed her ophthalmology residency and glaucoma fellowship at Jules Stein Eye Institute, UCLA. She currently practices as an ophthalmologist at Valley Eye Center in Van Nuys, California.
Glaucoma: acute glaucoma – MyDr.com.au
What is glaucoma?
Glaucoma refers to a group of eye disorders in which there is damage to the optic nerve (the nerve that sends messages from the eye to the brain). In most cases, this damage is the result of increased pressure in the eye (intraocular pressure). It can lead to loss of vision and even to blindness.
Causes of glaucoma
An area of the eye called the ciliary body produces a fluid (the aqueous humour) that flows through the pupil into the front (anterior) chamber of the eye. Normally, this fluid drains out of the eye into the blood circulation through drainage channels located in the angle between the iris (the coloured part of the eye) and the cornea (the transparent front layer of the eye). If the drainage channels become blocked, then the pressure in the eye builds up, damaging the optic nerve at the back of the eye.
There are 4 main types of glaucoma:
- Chronic open-angle glaucoma (also known as primary open-angle glaucoma) — this is the most common form of glaucoma. The drainage channels narrow down gradually. The only symptom is gradual loss of vision, affecting the peripheral (side) vision first, leading to ‘tunnel vision’. Vision loss can be quite severe before it is noticed.
- Acute angle-closure glaucoma — the drainage angle becomes blocked suddenly by the iris, so that fluid can no longer reach the drainage channels and the pressure in the eye increases rapidly. This causes sudden onset of symptoms that are often severe. If not treated, acute angle-closure glaucoma can rapidly cause vision loss.
- Secondary glaucoma — glaucoma that develops as a result of another disease, such as a cataract, or the use of steroids.
- Congenital glaucoma — a rare form of glaucoma that is present from birth.
Symptoms of acute glaucoma
Symptoms of acute glaucoma include sudden (often severe) eye pain, a red eye, blurred vision, sensitivity to light, and seeing rainbow haloes around lights. The eyeball feels firm and tender. You may also have nausea and vomiting.
Risk factors for acute glaucoma
Acute glaucoma is more common in older people, especially those who are long-sighted, as they often have a narrow drainage angle in their eyes. It is also more common in women than men, and in people with a family history of the condition.
If your eye drainage angles are narrow, then acute glaucoma can be triggered by sudden dilation of your pupils (e.g. because of darkness or stress). The risk of acute glaucoma is also increased by some medicines, including some antihistamines and antidepressants, and rarely, some believe, by certain eyedrops used to dilate the pupils for an eye examination.
Treatment of acute glaucoma
Acute glaucoma is a medical emergency. If you have symptoms of acute glaucoma, you must seek medical attention immediately. If treatment is delayed, there can be permanent loss of vision.
Treatment is usually eye drops and medicines (either by mouth or intravenously — through a drip) to lower the intraocular pressure, followed by laser iridotomy — surgery to open a new channel in the iris to relieve the pressure.
Because people who have had acute glaucoma in one eye are at risk of an acute attack in their other eye, your doctor may suggest surgery to the other eye to prevent this happening.
1. Glaucoma Australia. What is glaucoma? http://www.glaucoma.org.au/what.htm (accessed Feb 2011).
2. Acute angle-closure glaucoma (revised Feb 2008). In: eTG complete (Internet). Melbourne: Therapeutic Guidelines Limited; Nov 2010. http://online.tg.org.au (accessed Feb 2011).
3. MayoClinic.com. Glaucoma (published 17 Jul 2010). http://www.mayoclinic.com/health/glaucoma/DS00283 (accessed Feb 2011).
4. Shah R, Wormald R. Glaucoma. Clinical Evidence (online 19 Aug 2009). http://clinicalevidence.bmj.com/ceweb/conditions/eyd/0703/0703_keypoints.jsp (accessed Feb 2011).
Closed Angle Glaucoma – an overview
In angle-closure glaucoma, which is also called closed-angle or narrow-angle glaucoma, intraocular pressure is usually elevated due to impaired outflow of aqueous humor at the filtration angle, trapping the fluid behind the iris (see Fig. 12.6A). Patients with narrow-angle glaucoma are usually older than 40 years and often have a family history of the disorder, but they also frequently have a history of hyperopia and longstanding narrow angles. Few have had the classic symptoms, such as seeing halos around lights, preceding an attack of angle-closure glaucoma. In contrast to the relatively normal appearance of the eye in open-angle glaucoma, in acute angle-closure glaucoma the eye is red, the pupil dilated and unreactive, and the cornea hazy. Moreover, the eye and forehead are painful, and vision is impaired.
Angle-closure glaucoma is sometimes iatrogenic. For example, when pupils are dilated for ocular examinations, the “bunched-up” iris can block the angle (see Fig. 12.6B). Likewise, medicines with anticholinergic properties can precipitate angle-closure glaucoma, probably because they dilate the pupil.
The actual risk of glaucoma with tricyclic antidepressant use is low, and with SSRIs, it is almost nonexistent. However, as neurologists and other physicians prescribe tricyclics for numerous conditions – including chronic pain, headache, and diabetic neuropathy – many patients become vulnerable. In addition, other medications for neurologic diseases, particularly topiramate, can cause angle-closure glaucoma.
Whatever the cause of angle-closure glaucoma, prompt treatment can preserve vision. Topical and systemic medications open the angle (by constricting the pupil) and reduce aqueous humor production. Laser iridotomy immediately and painlessly creates a passage directly through the iris that drains aqueous humor.
Because glaucoma poses such a threat, individuals older than 40 years should have intraocular pressure measured every 2 years and those older than 65 years, every year. Most patients who are under treatment for either form of glaucoma may safely receive psychotropic medications. Glaucoma medications, such as pilocarpine (a cholinergic medicine that constricts the pupils), and ophthalmic beta-blockers, such as timolol (Timoptic), may seep into the systemic circulation and create psychologic and cardiovascular side effects, including orthostatic lightheadedness, bradycardia, and even heart block. Not surprisingly, elderly patients who use beta-blocker eye drops sometimes experience brief periods of confusion.
Children are also susceptible to systemic absorption. For example, when children receive scopolamine or other atropine-like eye drops for ocular examination, they often become agitated.
/ GlaucomaLook After Your Eyes
What is glaucoma?
Glaucoma is a group of eye diseases in which the optic nerve, which connects the eye to the brain, is damaged by the pressure of the fluid inside your eye. It can affect one or both of your eyes and can lead to sight loss if not treated. The two most common types of glaucoma are:
- Chronic glaucoma – this develops slowly. This is the most common form of glaucoma in the UK. The most common form of chronic glaucoma is primary open angle glaucoma (POAG).
- Acute glaucoma – this causes the pressure inside your eye to increase rapidly. It may be called acute angle closure glaucoma.
Who is affected by glaucoma?
Anyone can develop chronic glaucoma. But the risk increases if you:
- are aged over 40
- are very short-sighted
- are of African or Caribbean origin
- are closely related to someone with chronic glaucoma
- have raised pressure in your eye. This is called ocular hypertension (OHT)
- are diabetic
- have high blood pressure.
People at risk of developing acute glaucoma include:
- people over the age of 40
- people of East Asian or South Asian origin
- people with a family history of closed-angle glaucoma
- people who are long-sighted.
If one of your parents or children, or a brother or sister, has glaucoma, and you are over 40, the NHS will pay for your eye examination. In Scotland, all eye examinations are paid for by the NHS.
What are the symptoms of glaucoma?
There are no symptoms in the early stages of chronic glaucoma, so it is important to have eye examinations – especially if you are in the group of people at risk of getting this condition. In the later stages, you may have blurring around the outside of your vision.
Acute glaucoma causes the pressure inside your eye to increase rapidly. The increased pressure can come and go, and some people get short bursts of pain or discomfort and blurred vision. This can happen when your pupils get bigger, so you may notice it at night or when you are in a dark area (like the cinema) or when you are reading. Other symptoms include an ache in the eye which may come and go, nausea and vomiting, red eyes, or seeing coloured rings around white lights, or it can be a bit like looking through a haze or mist. If you get these symptoms it is important to act quickly. If the symptoms persist, you should go to the Accident and Emergency department immediately, so that they can reduce the pressure and get rid of the pain. Even if the symptoms appear to go away, your vision may be damaged, so you should see your optometrist as soon as possible.
How do you treat glaucoma?
If your optometrist suspects that you have chronic glaucoma, they will refer you to an ophthalmologist (a specialist eye doctor) for a diagnosis. This may involve you having more tests. There is no cure for chronic glaucoma but it can be treated effectively, normally with eye drops which you use every day. These reduce the pressure in your eye. You will not feel that anything is happening, but you must ensure that you keep using the drops, as your sight could be much worse if you stop the treatment. It is also important that you attend your follow-up appointments.
Acute glaucoma requires prompt treatment. The first step is to lower the eye pressure. This is done using eye drops and an intravenous injection. Once the pressure is lowered, your ophthalmologist will use a laser or surgery to bypass the blockage in your eye’s drainage system to prevent the problem coming back.
Glaucoma advice, information and support
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RCOphth, Understanding glaucoma
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Glaucoma Information, Symptoms, Treatment | Harper’s Point Eye
Primary Open Angle Glaucoma
The most common form of glaucoma where the anatomy of the front of the eye appears to be normal but fluid drainage in inadequate because of failure of the trabecular meshwork. While the cause of this failure is not completely understood, primary open angle is known to be highly hereditary.
Normal Tension Glaucoma
Glaucoma that develops despite having eye pressure in the normal range. This type of glaucoma is believed to associated with episodic of ongoing inadequacy of blood circulation to the nerve. Ironically, it can often be found in individuals who have blood pressure that is very low.
Acute Angle Closure or Narrow Angle Glaucoma
Acute closure of the peripheral drainage angle is characterized by a sudden increase in intraocular pressure. The iris may obstruct the eye’s drainage angle in a slow, progressive fashion or, with acute angle closure, it may close suddenly. This, less common form of glaucoma, may be associated with severe eye pain and is an eye emergency.
Increased eye pressure caused by deposits of a fibrillary material that may contribute to the obstruction of the fluid drainage from the eye. Recent evidence has shown that it is more common in individuals who live further from the earth’s equator.
Associated with of unusual ocular anatomy where the iris is deeply set. Pigment is dislodged from the iris and then obstructs the eye’s drainage structures (trabecular meshwork). This type of glaucoma is associated with the finding known as pigment dispersion syndrome.
Angle Recession Glaucoma
Scar tissue from previous trauma can damage the trabeculum and obstruct the outflow of fluid. An unusual characteristic of this type of glaucoma is that it might only occur in one eye. Other glaucomas seem to occur in both.
Various disorders such as diabetes of vascular occlusion can cause blood vessels to proliferate on the iris and in the eye’s drainage structures.
Childhood Glaucoma or Pediatric Glaucoma
Childhood glaucoma, also referred to as congenital glaucoma, pediatric glaucoma or primary infantile glaucoma occurs in babies and young children. It is an extremely serious form of glaucoma that must be diagnosed early and treated aggressively.
LASIK and Glaucoma
Over 15 million Americans have had LASIK surgery. While LASIK does not cause glaucoma, it makes it more difficult to diagnose. Most eye pressure measuring devices, fail to read properly after LASIK surgery. This may cause you eye doctor to miss the fact that your eye pressure is high. After having LASIK, always let your examining doctor know that you have had it. Also, have thorough regular eye examinations.
Spector Eye Care | Glaucoma
There is a direct relationship between age and the likelihood of developing Glaucoma. The chances of developing Glaucoma increase considerably after the age of 40, and you are six times more likely to get Glaucoma if you are over 60 years of age, even if you have no other relevant family or medical history.
Race plays a significant role in the likelihood of developing Glaucoma. Glaucoma is the leading cause of blindness in the Black Community because certain genetic factors cause a six to eight-fold increase in risk for Glaucoma. People of Asian descent appear to have higher risk for developing Narrow Angle Glaucoma. In addition, people over the age of 60 in the Hispanic and Latino Communities seem to be at increased risk as well.
Certain patients who are severely nearsighted have a higher risk of developing Glaucoma due to certain anatomical features in eyes with Myopia.
- Hypertension or High Blood Pressure
It is critical that patients who have hypertension or high blood pressure take their prescribed medication on a consistent basis. However, patients who take medication for high blood pressure may be at greater risk for Glaucoma as a result of the medication lowering the blood pressure and thus decreasing circulation within the optic nerve.
Diabetes can cause general problems with circulation throughout the body, including the eye. As a result of the poor circulation, patients with diabetes are considered at greater risk for developing Glaucoma.
Any family history of Glaucoma is considered a very significant risk factor. If any members of your family have been diagnosed with Glaucoma, it increases the likelihood that you will develop Glaucoma by 4-9 times over the general population. This is particularly true for siblings of Glaucoma patients who have a 5-fold increase in risk for developing Glaucoma.
In addition to these factors, if you have had trauma to your eyes (i.e. a sports injury or car accident), or if you have been treated for Asthma for long periods of time with steroid inhalers, or if you have a corneal thickness less than .5mm, you may have an increased risk for Glaucoma.
Acute Angle Closure Glaucoma Review
A 62 year old woman presents to your Emergency Department with a chief complaint of severe right eye pain. Upon further questioning, she reveals reduced vision in the affected eye and colored halos around lights. She reports a diffuse headache and two episodes of vomiting. A quick physical exam reveals significant conjunctival injection and a fixed, mid-dilated pupil. Does your differential contain acute angle closure glaucoma?
What is Acute Angle Closure Glaucoma?
Acute angle closure glaucoma is a condition characterized by raised intraocular pressure due to impaired outflow of aqueous humor from the posterior chamber of the eye.1 In a normal eye, the aqueous humor is produced in the posterior chamber by the ciliary process and proceeds to flow through the pupil to the anterior chamber and out through the trabecular meshwork into Schlemm’s canal.2 In acute angle closure glaucoma, the flow to the trabecular meshwork is blocked by contact between the lens and the iris resulting in accumulation of aqueous humor in the posterior chamber. This is referred to as “pupillary block.”3 As pressure in the posterior chamber rises, the iris is pushed further forward and causes the angle between the peripheral iris, trabecular meshwork, and cornea to close, hence the name acute angle closure glaucoma.
With permission from Weinreb RN, Aung T, Medeiros FA. The Pathophysiology and Treatment of Glaucoma. JAMA. 2014;311(18):1901-1911.
As a result of the associated systemic symptoms, acute angle closure glaucoma carries a significant risk of being incorrectly diagnosed. A thorough history and physical examination with documented raised intraocular pressure is imperative for diagnosis.
Patients with acute angle closure glaucoma present with abrupt onset of pain in the affected eye. In addition patients may present with blurred vision, frontal headache, nausea and vomiting, photophobia, and colored halos around lights.4 Nausea and vomiting occurs as a result of autonomic stimulation, while blurred vision and colored haloes are a result of corneal edema.5 The onset is often precipitated by dilation of the pupil. When the pupil is mid-dilated, the contact between the iris and the lens is maximal and the iris thickens, which worsens pupillary block. 6 Patients often describe onset of ocular pain when transitioning from a light to dark environment. Medications that dilate the pupil have the potential to precipitate an attack; these include adrenergic agents, drugs with anticholingeric effects, sulfa-based drugs, tricyclic antidepressants, anticonvulsants, and antiparkinsonian drugs.7 Other risk factors for acute angle closure glaucoma include a family history of the condition, being of Asian descent, female gender, hyperopic eyes, eyes with shallow anterior chambers, thick lens, and narrow irido-corneal angles. 6 As people age, their anterior chamber becomes more shallow and the lens thickens and moves anteriorly, 5 which makes this condition rare below the age of forty, with the peak incidence occurring in the sixth and seventh decades of life.8
Patients with acute angle closure glaucoma present with conjunctival injection and a fixed, mid-dilated pupil measuring 5-6 mm in diameter. 9 Due to the elevated intraocular pressure, the eye may feel hard to the touch. The visual acuity is often reduced. Raised intraocular pressure is necessary for the diagnosis of this condition, and is measured using a Tonopen. A pressure that exceeds 21 mmHg characterizes elevated intraocular pressure, however the pressure may exceed 60-80 mmHg. 2 Fundoscopic examination is often difficult due to the presence of corneal edema; however, one of the most notable features is a pale, cupped optic disc. Cupping occurs due to atrophy of the optic nerve fibers that results in the central cup of the optic nerve appearing enlarged. The normal cup-to-disc ratio is 0.3, but a patient with glaucoma will have a ratio of 0.6 or greater.10 Finally, a slit lamp examination is required for a complete eye examination in patients suspected of having acute angle closure glaucoma. Slit lamp examination will reveal a shallow anterior chamber and a cloudy cornea due to edema. 10 Gonioscopy, a procedure used to measure the depth of the anterior chamber, will be conducted by the Ophthalmologist.
Images from Glaucoma RCSI http://www.slideshare.net/hongchiong/glaucoma-rcsi
Treatment and Disposition
Prompt treatment is required for this condition, as the increased intraocular pressure can lead to optic nerve damage and vision loss. Immediate consultation with an Ophthalmologist is required. Pharmacological treatment options include:
- Miotics – Pilocarpine is the miotic agent of choice. It acts on the muscarinic receptors of the iris, causing it to contract and leading to constriction of the pupil and the movement of the iris away from the angle. 5 This subsequently facilitates the opening of the trabecular meshwork and the outflow of aqueous humor. Be aware that pilocarpine may be ineffective at causing the iris to contract in the early stages of an acute attack because the elevated intraocular pressure can cause pressure-induced ischemic paralysis of the iris. 2 It is effective only once the pressure in the affected eye is reduced, leading to controversy regarding when pilocarpine should be administered. Some experts recommend initiating pilocarpine only after the intraocular pressure falls below 40 mmHg, while others recommend initiating it immediately upon diagnosis. Most experts recommend immediate administration to ensure availability once the ischemic paralysis has resolved.8
- Beta-blockers – These agents act by reducing the production of aqueous humor and reduce the intraocular pressure by 10-20%. 5 The same pulmonary and cardiac contraindications that apply to the use of oral beta-blockers also apply to topical beta-blockers, as they can cause systemic side effects including bronchoconstriction and bradycardia. As such, topical beta-blockers should be avoided in patients with asthma, chronic obstructive pulmonary disorder, and patients with second and third degree heart blocks.
- Alpha–Adrenergic Agonists – Topical Clonidine is the agent of choice. It lowers the intraocular pressure by reducing the production of aqueous humor and by increasing the aqueous outflow.
- Steroids – Prednisolone Acetate is the steroid most commonly used in the treatment of angle closure glaucoma. These agents help to reduce intraocular inflammation and in doing so, help to minimize the damage to the optic nerve.
- Carbonic Anhydrase Inhibitors – Acetazolamide is the typical agent used, and functions by reducing the production of aqueous humor through the inhibition of the enzyme carbonic anhydrase. These agents are contraindicated in patients with a sulfonamide allergy, sickle cell anemia, renal failure, and Addison’s disease. In addition, it is important to be aware that these agents may cause a metabolic acidosis, since this enzyme normally causes the dehydration of carbonic acid. As such, caution must be exercised in people with diabetes, liver disease, and COPD. 5
- Hyperosmotic Agents – Depending on the agent used, these can be administered either orally or intravenously. These agents decrease the intraocular pressure by causing an osmotic diuresis and reducing the vitreous volume. They should be used with caution in patients with cardiac, pulmonary, and renal issues.
Given the potentially vision compromising nature of this condition, all of these medical treatments should be initiated upon diagnosis. Intraocular pressure should be reassessed hourly to monitor response to treatment. While these pharmacological agents are often effective at lowering the intraocular pressure, patients will often require more definitive management with laser treatment, or occasionally, surgical treatment.
This post was copyedited by Rob Carey (@_RobCarey) and uploaded by Jesse Leontowicz (@jleontow)
Goel M, Picciani R, Lee R, Bhattacharya S. Aqueous humor dynamics: a review. Open Ophthalmol J. 2010;4:52-59. [PubMed]
Tintinalli J E, Cline D, Ma O John, et al. Tintinalli’s Emergency Medicine Manual 7/E. McGraw Hill Professional; 2012.
Gandhewar R, Kamath G. Acute glaucoma presentations in the elderly. Emerg Med J. 2005;22(4):306-307. [PubMed]
Pokhrel P, Loftus S. Ocular emergencies. Am Fam Physician. 2007;76(6):829-836. [PubMed]
Castaneda-Diez R, Mayorquin-Ruiz M, Esponda-Lamoglia C, Albis-Donado O. Current Diagnosis and Management of Angle-Closure Glaucoma. Glaucoma – Current Clinical and Research Aspects. November 2011. doi: 10.5772/18123 [Source]
Lai J, Gangwani R. Medication-induced acute angle closure attack. Hong Kong Med J. 2012;18(2):139-145. [PubMed]
Lachkar Y, Bouassida W. Drug-induced acute angle closure glaucoma. Curr Opin Ophthalmol. 2007;18(2):129-133. [PubMed]
Jackson J, Carr L, Fisch B, Malinovsky V, Talley D. Optometric Clinical Practice Guideline: Care of the Patient With Primary Angle Closure Glaucoma. St Louis, MO: American Optometric Association; 1994.
Marx J, Hockberger R, Walls R. Rosen’s Emergency Medicine: Concepts and Clinical Practice . 8th ed. Elseveir Saunders Inc; 2014.
Reviewing with the Staff
Acute angle closure glaucoma is an important cause of headache in the adult, and can be missed if not included in your differential diagnosis. While some of the physical examination findings are admittedly difficult to appreciate, measurement of the patient’s IOP with the Tonopen is simple and essential to making the diagnosis. The pharmacologic treatments listed in the article can temporize the patient, especially if you are in a centre without quick access to an Ophthalmologist, however their administration should not delay transfer and definitive management. Acute angle-closure glaucoma is an ophthalmological emergency, and the most important thing you can do is to recognize it and arrange for emergent definitive management.
Dr Ashley Krywenky MD FRCPC
Emergency Medicine Physician and Simulation Instructor for Residency Education | Department of Emergency Medicine, The Ottawa Hospital
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Stephanie Cargnelli is a Family Medicine resident at the University of Toronto with a special interest in Emergency Medicine. She enjoys teaching and has a passion for research. When she’s not working, she can be found horseback riding and playing soccer.
90,000 Signs of Glaucoma – Eye Surgery Center
In most cases, open-angle glaucoma occurs and progresses imperceptibly for a patient who does not experience any discomfort and see a doctor at a late stage of the disease, when he notices a deterioration in visual acuity. Complaints about the appearance of rainbow circles around light sources, periodic blurred vision are noted only by 15-20% of patients.It is these symptoms that appear with an increase in intraocular pressure (IOP) and may be accompanied by pain in the brow region and head.
Open-angle glaucoma usually affects both eyes, in most cases asymmetrically.
Intraocular pressure in open-angle glaucoma rises slowly and gradually as the resistance to the outflow of intraocular fluid (IVF) increases. In the initial period, it is fickle, then it becomes persistent.
The course of angle-closure glaucoma in most patients is characterized by periodic, at first short-term, and then more and more prolonged periods of increased intraocular pressure (IOP). In the initial stage, this is due to the mechanical closure of the trabecula zone by the root of the iris, which is due to the anatomical predispositions of the eye. In this case, the outflow of intraocular fluid (IVF) decreases. When the angle of the anterior chamber is completely closed, a condition called an acute attack of angle-closure glaucoma occurs.In the intervals between attacks, the corner opens.
During such attacks, adhesions are gradually formed between the iris and the wall of the anterior chamber angle, the disease gradually acquires a chronic course with a constant increase in intraocular pressure (IOP).
During the closed-angle form of glaucoma, the following phases can be distinguished:
- acute attack of glaucoma;
- chronic course of glaucoma.
Preglaucoma occurs in individuals who do not have clinical manifestations of the disease, but when examining the angle of the anterior chamber, it is found that it is either narrow or closed. In the period between preglaucoma and an acute attack of glaucoma, transient symptoms of visual discomfort, the appearance of rainbow circles when looking at a light source, and short-term loss of vision are possible. Most often, these phenomena occur with prolonged stay in the dark or emotional arousal (these conditions contribute to the dilation of the pupil, which completely or partially reduces the outflow of intraocular fluid) and usually disappear on their own, without causing much anxiety in patients.
An acute attack of glaucoma occurs under the influence of provoking factors, such as nervous tension, overwork, prolonged stay in the dark, drug-induced dilation of the pupil, prolonged work in a tilted position of the head, intake of large amounts of fluid. Sometimes an attack appears for no apparent reason. The patient complains of pain in the eye and in the head, blurred vision, the appearance of rainbow circles when looking at a light source. Painful sensations are caused by compression of nerve elements at the root of the iris and ciliary body.Visual discomfort is associated with corneal edema. With a pronounced attack, nausea and vomiting may appear, sometimes pain that radiates to the region of the heart and abdomen, sometimes imitating manifestations of cardiovascular pathology, is disturbing.
When visually examining such an eye without special devices, one can notice only a sharp expansion of the vessels on the anterior surface of the eyeball, the eye becomes “red”, somewhat with a bluish tint. The cornea becomes cloudy due to the development of edema.Noteworthy is the dilated pupil that does not react to light. At the height of the seizure, visual acuity can sharply decrease. Intraocular pressure can rise to 60 – 80 mm Hg. Art., the outflow of fluid from the eye stops almost completely. The eye is as dense as a stone to the touch.
If within the next few hours after the development of the attack, the pressure is not reduced with the help of medications or by surgery, the eye is in danger of irrevocable loss of vision !!! An acute attack of glaucoma is an urgent situation and requires emergency medical attention !!!
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90,000 Glaucoma, glaucoma symptoms
Glaucoma is a disease characterized by an increase in intraocular pressure (IOP), the prolonged course of which leads to a sharp decrease in visual acuity up to its complete loss. Vision in glaucoma decreases gradually. Changes in visual functions are most often noticed by the patient already in the advanced stage of the disease.
The blindness caused by glaucoma is irreversible as the optic nerve dies.In this case, it is already impossible to restore sight to the blind patient! Early diagnosis and treatment can compensate for the course of glaucoma, prevent damage to the optic nerve and associated vision loss. Therefore, it is very important to be regularly examined by an ophthalmologist – to check vision, measure intraocular pressure.
Causes of laucoma:
1. Intraocular fluid is formed in excessive quantities;
2. The excretion of intraocular fluid through the drainage system of the eye is impaired due to its changes.
Glaucoma can occur at any age, it affects mainly people over the age of 40. But this ailment can also affect young people (adolescent glaucoma) and even newborns (congenital glaucoma).
There are three main features of glaucoma:
increased intraocular pressure;
narrowing of the field of view;
change in the optic nerve.
Glaucoma comes in two forms: open-angle glaucoma and angle-closure glaucoma.
Open-angle glaucoma is the most common form of this disease. This is a particularly insidious type of disease in which there are no pronounced symptoms. A person may not feel in any way a moderate increase in intraocular pressure (IOP), which already has a detrimental effect on the optic nerve, leading to loss of vision
The course of angle-closure glaucoma is associated with the closure of the outflow tract of intraocular fluid.Complete closure of the outflow zone is manifested by an acute attack of angle-closure glaucoma.
Symptoms of an attack of angle-closure glaucoma
Sudden onset of visual impairment, often in low light conditions, blurred vision
Severe eye pain
Nausea and vomiting (accompanying severe eye pain)
Halo (rainbow circles) around the light source
The main goal of glaucoma treatment is to reduce intraocular pressure to an individually tolerable level, at which the optic nerve fibers will not suffer. In parallel, therapy is prescribed to improve the trophism of the optic nerve disc: vascular drugs, B vitamins, neurotrophic drugs. Direct reduction of IOP is achieved with the help of antiglaucomatous drugs, which are divided into three groups:
– Drugs that improve the outflow of high-blood fluid;
– Means that inhibit the production of high-frequency liquids;
– Preparations of combined action.
In the absence of the effect of drug therapy, laser treatment is performed. For open-angle primary glaucoma, argon or selective trabeculoplasty is used; with closed-angle forms of primary glaucoma, in most cases, basal iridectomy is performed.In the clinic “Visus-1” you will be offered treatment on the most modern laser equipment by first-class laser surgeons.
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90,000 Glaucoma: Symptoms, Treatment, Ophthalmology
What is Glaucoma?
Glaucoma is an eye disease that causes damage to the optic nerve. As a result, there is a loss of the visual field, that is, the space that is visually perceived in a straight head position.The process of damage to nerve cells is irreversible.
Glaucoma can go unnoticed for a long time, since the first symptoms appear only at a late stage. If untreated, the patient may remain completely blind. This disease is one of the main causes of vision loss in industrialized countries. The risk of developing glaucoma increases with age.
What are the causes of glaucoma?
Glaucoma usually results from increased intraocular pressure.However, there are forms of the disease in which intraocular pressure may be within normal limits. The increase in pressure occurs due to an imbalance between the formation and outflow of intraocular fluid.
Intraocular fluid is a clear fluid that forms in the eye in the so-called ciliary body and contains nutrients and substances necessary for immune defense. It flows through the corner of the anterior chamber of the eye, an anatomical structure consisting of the cornea (Cornea) and the iris (Iris).
If more fluid forms than it flows out, the pressure in the anterior chamber of the eye increases. Increased intraocular pressure leads to disturbances in the blood supply to neurons, which are damaged as a result.
What are the symptoms of glaucoma?
Glaucoma usually develops painlessly and goes unnoticed for a long time. Only with a very high increase in intraocular pressure, headaches can appear. The first symptoms appear only when the disease has already reached a late stage.
In scotoma, as a rule, one third of all nerve fibers are damaged.
Loss of visual field is called scotoma. In this case, the field of view narrows in an arcuate manner from the outside to the inside. Loss in the center of the visual field is rare. Other symptoms include increased sensitivity to light and colored circles in bright light, and problems with orientation.
Glaucoma is a medical emergency
In most cases, the disease develops over a long period of time. However, sometimes there are acute attacks of glaucoma. With a sudden sharp increase in pressure, the blood supply to the eyes is disrupted. In rare cases, it can even cause sudden loss of vision. This situation is always an emergency. Intraocular pressure and, accordingly, also the blood supply to nerve cells should be normalized as quickly as possible.
Glaucoma diagnosis: how is glaucoma diagnosed?
Glaucoma can develop unnoticed for many years. If the first symptoms appear in the form of loss of visual field, they are irreversible.The development and progression of the disease can be suspended or slowed down.
Early detection of glaucoma after 40 years
For these reasons, the focus is on the early diagnosis of glaucoma. After the age of 40, it is necessary to carry out regular monitoring of intraocular pressure. If there is a family history of glaucoma or diabetes, tests should be done at the age of 35.
A more detailed examination is usually carried out with early detection of glaucoma. These research methods are also used to diagnose pre-existing glaucoma.
for any ophthalmological examination, it is a standard procedure. In addition, the risk of developing glaucoma increases with severe myopia and hyperopia.
(ophthalmoscopy) the doctor examines the structures that are affected by glaucoma, namely the retina and optic nerve.
Other structures of the eye can be viewed with
… In this case, the doctor examines the eyes as if under a microscope. The narrow slit light beam of the lamp allows you to visualize the transparent areas of the eye in a section. Thus, fine structures in the anterior segment of the eye become visible and pathological changes are detected.
In conclusion, carry out
examination of the visual field
(perimetry). Other methods can be used as needed.
Glaucoma treatment: how is glaucoma treated?
The most important task in the treatment of glaucoma is considered
decrease in intraocular pressure
… In this case, the optimal intraocular pressure for each patient is determined individually.
Eye drops as a treatment for glaucoma
Medication for glaucoma is the use of eye drops. Eye drops cause either an increase in drainage or a decrease in the formation of intraocular fluid.
Glaucoma surgery: laser treatment
In severe cases, intraocular pressure can be reduced using laser or surgical procedures. Laser treatments, like drug therapy, involve two approaches. On the one hand, with the help of obliteration of the ciliary body, it is possible to regulate the formation of intraocular fluid, on the other hand, an additional outflow of intraocular fluid is provided through the formed scar.
Laser correction of the angle of the anterior chamber of the eye is aimed at improving the outflow of intraocular fluid, thereby reducing intraocular pressure.
For certain types of glaucoma, laser iridotomy is done. In this case, the laser beam creates a hole in the outer shell of the iris of the eye. The iris (Iris) separates the anterior and posterior chambers of each other. With the help of laser iridotomy, the pressure between the two chambers of the eye is equalized and, thus, the outflow of fluid is improved.
Glaucoma surgery: trabeculotomy, goniotomy, canaloplasty
Glaucoma surgery is also designed to increase the outflow of intraocular fluid, thereby lowering intraocular pressure.Trabeculotomy and goniotomy are two classic glaucoma surgeries. In this case, the trabecular network is dissected, forming an opening in the anterior chamber of the eye and thereby creating an artificial outflow path for the intraocular fluid.
A more modern method of surgical treatment of glaucoma is canaloplasty. The catheter is placed in the central channel of the outflow of intraocular fluid ─ Schlemm’s canal. This catheter keeps the channel open at all times, allowing intraocular fluid to drain.
What are the prognosis for glaucoma treatment?
Left untreated, glaucoma can lead to complete blindness as more and more nerve cells are damaged over time. Thus, early detection of glaucoma is of great importance.
Appropriate treatment, which is determined individually for each patient, can stop the progression of the disease. The damaged nerve cells cannot be repaired, however, new lesions do not arise.
What are the specialists involved in glaucoma?
Naturally, a person in need of glaucoma surgery wants the best medical care. Thus, the patient wonders where the best clinic in the field of glaucoma surgery can be found.
Since this question is difficult to answer objectively, and a reputable doctor will never claim that he is the best, you can only rely on the experience of a specialist. The more relevant operations a doctor has performed, the more experience he has.
These are ophthalmologists who specialize in the treatment of glaucoma. With their experience and many years of work as a specialist in the treatment of glaucoma, these doctors are the right choice for the patient.
Lang, G.K. Garais, O. Lang, G.E. Recker, D. Spraul, Ts.V. Wagner, P :. Ophthalmology. Stuttgart: Georg Thieme Verlag 2008.
Sachsenweger, Matthias; Clauss, Volker; Nazemann, Joachim: Duale Reihe Ophthalmology.Stuttgart: Georg Thieme Verlag, 2002
Glaucoma – Latvijas Amerikas acu centrs
What is glaucoma?
Glaucoma is a progressive eye disease that creates changes in the optic nerve with consequent changes in the visual field. The most common symptom of the disease is increased eye pressure.
Changes in the visual field caused by glaucoma
Glaucoma is one of the main signs of blindness. This disease is most often found in people over 40 years of age. Nevertheless, if glaucoma is detected in time, its further development can almost always be stopped.
When you look at an object, the optic nerve from the retina transmits it to the brain, this nerve works like an electrical wire. It consists of millions of nerve fibers and each fiber is a carrier of its own piece of information, and together they provide peripheral or peripheral vision, as well as the central vision necessary for reading.Glaucoma damages these fibers, initially creating “dark” spots in various parts of the visual field. Very rarely do people notice these “dark” spots at the “edges” of the field of view. This can happen for a long time, until serious damage appears in the optic nerve. If the entire optic nerve is damaged, the loss of vision becomes irreversible. But, if glaucoma is detected and treated in a timely manner, this rarely happens.
So, the key to preventing damage to the optic nerve and, caused by glaucoma, loss of vision is a timely examination of vision, diagnosis and treatment of the disease. This is done by an ophthalmologist.
What are the causes and symptoms of glaucoma?
There is a continuous circulation of fluid in the eye, this fluid is produced by a special gland – the ciliary body. In the tissues between the cornea and the sclera there is a drainage system through which this fluid is removed back into the circulatory system. If the ocular drainage system becomes clogged, the pressure created by the fluid builds up, which in turn can cause damage to the optic nerve.
There are 4 types of violation of these drainage passages:
- Most often, defects appear with aging of the eye and narrowing of the drainage ducts.the cause of the narrowing is various sediments accumulating in the passages over the years. This incomplete patency gradually causes an increase in intraocular pressure, which is called chronic open-angle glaucoma, as it develops gradually over several years. Most patients have this type of glaucoma. Chonic open-angle glaucoma “steals so quietly” that the patient does not notice it until serious changes have already taken place in the optic nerve. Since no visual impairment symptoms appear during this process, systematic eye exams are the surest way to prevent blindness.
- Drain passages may be malformed. This is congenital glaucoma, which is characterized by congenital defects in the drainage system. Since the shell of the infant’s eyeball is much more elastic than that of an adult, as a result of an increase in intraocular pressure, it causes an enlargement of the eyeball in the infant.As a result, the front of the eye cornea can become cloudy, like the fogged windshield of a car. The infant may be sensitive to bright light and may have severe watery eyes. Although such indications are quite rare, nevertheless, if such symptoms appear, you should immediately consult a doctor.
- Imagine that a sheet of paper is floating in the water near the drain grate, then it covers the grate with a stream of water and closes the way for the water, preventing it from passing.In the eye with such a sheet of paper, you can compare the iris, which is pressed against the drainage system and blocks it. When the fluid is blocked, it flows back and its pressure in the eye rises sharply. This phenomenon is called acute closed-angle glaucoma. Blurred vision, sharp pain in or near the eye, iridescent halo from any light source, and nausea are all symptoms that should be considered an eye doctor immediately. If these symptoms are not treated immediately, blindness can occur within 1–2 days.
- Blocked drainage ducts can be caused by injury, medication, bleeding, fever, or inflammation that increases intraocular pressure and causes secondary glaucoma.
Damage to the outflow of ophthalmic fluid and increased internal and ophthalmic yes effect
How is glaucoma diagnosed?
During an eye examination, the doctor measures intraocular pressure, which is part of the glaucoma detection process.The doctor uses an instrument called an ophthalmoscope to look at the optic nerve. Also, peripheral vision is checked and other necessary examinations are carried out.
Occasionally, the patient has an intraocular pressure higher than normal, but there are no other signs of glaucoma. There are patients in whom increased intraocular pressure does not cause loss of vision.
Factors contributing to the onset of glaucoma can be heredity, as well as diseases such as diabetes and narrowing of the arteries.
Taking all these factors into account, the ophthalmologist decides whether the patient needs immediate treatment or whether the patient will be registered for suspected glaucoma.
How is glaucoma treated?
Usually, to treat glaucoma, your doctor prescribes eye drops, which are applied 2-4 times a day. These medications lower intraocular pressure, aid in the absorption of fluid, or decrease its amount. To achieve good results, medications must be applied regularly and continuously.
Patients with any type of glaucoma require systematic eye examinations. Sometimes glaucoma progresses and the condition worsens, without the patient knowing about it. By tracking changes in the development of glaucoma, timely replacement of medications is possible.
The damage caused by glaucoma is irreversible, but the use of eye drops, capsules, as well as surgery, prevent further damage and preserve vision. Sometimes the course of treatment causes unwanted side effects. Eye drops can cause burning sensations, redness, and headache. Although very rare, the use of some eye drops affects heart rate and heart rate, as well as breathing.If these signs appear, inform your eye doctor right away.
Glaucoma and the patient.
Glaucoma can only be treated with medication if the patient strictly follows the doctor’s instructions. You and your doctor are on the treatment team. It is impossible to stop using medications without the instruction of an eye doctor. When contacting other doctors, inform them about the medications you are using.
Remember that this is your sight and you need to take care of it!
If you do not tolerate the prescribed medications or they do not lower intraocular pressure, an operation is necessary. Sometimes a laser procedure is sufficient, but sometimes surgery is necessary to create the necessary drainage channels. In these cases, the recommended surgery is a much more reliable and effective means of preserving vision than allowing glaucoma to develop and permanently lose the optic nerve.
Loss of vision is preventable. If you have already reached or crossed the 40-year mark, it is recommended to have your eyesight checked for glaucoma annually.
Acute attack of glaucoma “If the attack was caught by surprise”
Glaucoma is a chronic eye disease characterized by increased intraocular pressure. Glaucoma can occur at any age, even in children, but is most commonly found in older people. The causes of visual impairment leading to the development of glaucoma are not fully understood. However, not the least role is played by heredity, anomalies in the structure of the eye, diseases of the cardiovascular, nervous and endocrine systems. Glaucoma treatment is aimed at normalizing intraocular pressure with drops prescribed by an ophthalmologist.
An acute attack of glaucoma is a sharp increase in pressure in the eyeball, which can lead to blindness.The attack most often occurs at night or early in the morning. As a rule, it all starts with severe pain in the forehead, eye sockets, bridge of the nose and teeth. Then a stabbing pain in the eyes is added, which radiates to the shoulder and scapula. In addition, nausea, vomiting and general weakness may appear. The eye practically fades, the light is perceived as if through a dense fog. Mild swelling of the eyelids makes it difficult to open the eyes. To the touch, the eyeball becomes hard, like a stone. The iris is barely visible. The dilated pupil, if light falls on it, does not narrow.
If, within the next hours after the onset of the attack, the pressure is not relieved with medication or surgery, permanent loss of vision is threatened. Therefore, as soon as you notice these symptoms in yourself, urgently call an ambulance.
Before the arrival of the doctor
1. Since the pain during an attack of glaucoma is very strong, take an anesthetic (analgin, pentalgin, spazmalgon).
2. Take any diuretic available in your medicine cabinet, such as furasemide.
3. Wrap your feet with a towel moistened with hot water, or better place them in a basin of hot water. Instead of foot baths, you can put mustard plasters on your shins for 15-20 minutes.
4. Sit or lie down more comfortably with a high pillow under your head, and wait for an ambulance without panic (!).
Further relief of an attack is carried out in a hospital by specialists. If, despite all the measures taken, intraocular pressure does not decrease within 18-20 hours, surgical intervention will be required.Don’t give up on the operation. The fate of the eye is literally decided by the clock, delay is fraught with loss of vision, which then cannot be returned. Dear Patients! Protect your eyesight. Even with mild discomfort in the eyeball, consult an ophthalmologist.
Ophthalmologist V.V. Nasonov
90,000 Glaucoma treatment at home in St. Petersburg by an ophthalmologist
A whole group of diseases (about sixty) are united by one name “glaucoma” because of the main reason that causes them – a constant or periodic increase in pressure inside the eye.The uncontrolled development of this pathology ends with the death of the optic nerve and blindness. That is, without detection of the disease at an early stage and complex therapy that slows down the development of the disease, the forecasts, unfortunately, are always pessimistic.
If the symptoms described by the patient suggest exactly this pathology, then the diagnosis of glaucoma at home, first of all, requires measuring the pressure of the fluid inside the eye. It is important to know that although not too often, there are still acute attacks of glaucoma caused by severe hypertension.In these cases, the patient needs to be assisted in the next few hours – delay with a high probability will lead to irreversible loss of vision.
In our medical center “Dynasty”, you can call any specialist by phone around the clock and an ophthalmologist’s consultation on glaucoma at home is no exception to the rule.
How to detect glaucoma?
- In many cases, glaucoma develops without noticeable changes or discomfort to the person. The patient turns to the optometrist only when the visual acuity is significantly reduced or the field of vision is disturbed. And this, unfortunately, is too late.
- The appearance of an iridescent halo around light sources, as well as temporary vision as if in a fog, is observed in about a quarter of patients with this disease, and can also be a symptom of other diseases.
- The most indicative sign of the initial stage of glaucoma is a change in the visual field, which is imperceptible to the person himself and is detected only during special examinations.
Therefore, in order to catch such a dangerous disease at the very beginning and with the help of doctors to slow down its development as much as possible, it is necessary to regularly undergo preventive examinations with an ophthalmologist.Diagnosis of glaucoma by an ophthalmologist at home is as accurate as in the walls of a polyclinic office.
Choose a branch “Dynasty” on Novocherkassk avenue, Krasnogvardeisky district “Dynasty” on Lenina, Petrogradsky district “Dynasty” on Repishcheva, Primorsky district “Dynasty” in Vsevolozhsk
Cost of glaucoma diagnostics by an ophthalmologist at home
|Service description||Price in rubles|
|Calling an ophthalmologist at home (St. Petersburg, within the Ring Road) on weekdays||
|Calling an ophthalmologist at home (St. Petersburg, within the Ring Road) on weekends and holidays||
|Calling an ophthalmologist at home (distance from the ring road up to 10 km) on weekdays||
|Calling an ophthalmologist at home (distance from the ring road up to 10 km) on weekends and holidays||
|Calling an ophthalmologist at home (distance from the ring road from 11 to 30 km) on weekdays||
|Calling an ophthalmologist at home (distance from the ring road from 11 to 30 km) on weekends and holidays||
|Calling an ophthalmologist at home (distance from the ring road from 31 to 50 km) on weekdays||
|Calling an ophthalmologist at home (distance from the ring road from 31 to 50 km) on weekends and holidays||
|Call an ophthalmologist at home (distance from the ring road from 51 to 80 km) on weekdays||
|Calling an ophthalmologist at home (distance from the ring road from 51 to 80 km) on weekends and holidays||
|ADDITIONAL MANIPULATIONS WHEN LEAVING THE HOUSE|
|Rinsing of the lacrimal ducts (visit of an ophthalmologist to the house is paid separately)||
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90,000 types, symptoms, diagnostics in Moscow – modern methods of glaucoma treatment, operations
Glaucoma is a dangerous pathology in which the patient’s pressure constantly or periodically increases and the blood circulation of the eyes is impaired.If glaucoma is left untreated, these disorders contribute to the gradual death of the optic nerve, which sooner or later causes blindness.
As a rule, at the very beginning of the disease, a person is not worried about anything. Visual impairment occurs when more than half of the optic nerve is affected. At this stage, glaucoma is accompanied by discomfort in the eye (pain, heaviness, fogging, pain, the appearance of a “mesh”), patients complain of deterioration of vision in the dark.
Most often, a person comes to the doctor when most of the vision has already been lost. Rarely, with a sudden increase in intraocular pressure, acute symptoms appear: severe and sharp pain in the eye, redness, vomiting. Such an attack indicates the development of angle-closure glaucoma and requires immediate medical attention and medicinal or surgical pressure reduction.
To avoid such conditions and prevent loss of vision, our doctors recommend that you be attentive to the condition of your eyes and, after 40 years, undergo regular examinations by an ophthalmologist, and if even minor changes appear, you should be urgently examined.
Causes of glaucoma
The main reason for the development of primary glaucoma is age-related changes that appear after 40 years. Hypertension, coronary heart disease, diabetes mellitus, and the use of hormonal medications (for example, in case of thyroid dysfunction) also contribute to the onset of the disease. Regular examinations are also necessary if your close relatives have suffered or are suffering from glaucoma.
A disease that was detected on time is much easier to treat, including medication, and laser or surgical operations allow you to avoid complete loss of vision.
Diagnostics of glaucoma
The complex of procedures includes:
- examination of visual acuity;
- study of intraocular pressure and eye hydrodynamics;
- examination of the fundus;
- biomicroscopy of the anterior part of the eye;
- examination of the peripheral and central visual fields;
- assessment of the condition of the optic nerve head.