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No End in Sight

Posted on August 18, 2018 | No Comments on No End in Sight

Glaucoma is a group of disorders considered a leading cause of blindness throughout the world and one of the top three in the Southeast Asian region. Glaucoma as a disease is characterized more commonly by an increase in pressure inside the eye or intraocular pressure (IOP).

Aqueous humor is the clear fluid in the eye, which provides structural support, oxygen and nutrition to the eye tissues. When drainage of this fluid is impeded, KW increases. It is this increase in IOP, produced by an imbalance in aqueous humor production and drainage through the angle of the eye, that causes damage to the optic nerve.

Consequently, the optic nerve, which is made of nerve fiber bundles that send vision signals to the brain, bears the brunt of increased IOP. Optic nerve damage results in characteristic scotomas or blind areas in the field of vision.

Risk Factors
If left undetected and without proper treatment, glaucoma can greatly decrease the field of vision resulting in irreversible visual impairment and blindness. Although increased IOP is the most common and only controllable risk factor of glaucoma, it is not the only factor involved in the progression of this disease.

Having a family history of glaucoma is an established risk factor for glaucoma. This, as well as the higher incidence of glaucoma in people of African and of Asian descent confirms the genetic predisposition to developing glaucoma.

Types of Glaucoma
Glaucoma may present as a painless and progressive loss of vision that may remain undetected, such as Primary Open Angle Glaucoma (POAG). As such, the need to have periodic eye evaluations with thorough history taking must be deemed indispensable in the delivery of proper health care.

Another type of glaucoma termed as Angle Closure Glaucoma (ACG) may on the other hand, produce a painful, red eye with significant blurring of vision. An acute attack of ACG may have concomitant nausea and vomiting.

Treatment
The primary goal of glaucoma treatment is the preservation of vision by attaining target 10P levels, which may preserve the integrity of the optic nerve. Unfortunately, glaucoma has no definitive cure; thus, early detection and treatment is imperative to control disease progression.

Through the decades, several treatment modalities have been discovered. The treatment of choice is dependent on the type of glaucoma, the stage at which the glaucoma is detected, and at times, the socio-economic status of the patient.
The treatment plan may either be medical, laser, surgical or a combination of these modalities to control the glaucoma. Institution of these forms of treatment must also take into consideration maintaining the patients’ quality of life. Even after the glaucoma has been controlled by the chosen treatment, periodic monitoring by the eye physician is required.

Neovascular Glaucoma
In addition to increased IOP and genetic predisposition, older age, history of eye trauma, eye surgery, and other eye and systemic diseases may be factors that predispose to developing glaucoma. A rare and devastating type of glaucoma may develop with diabetes or other vascular disorders which can compromise blood flow to the eye. This is called Neovascular Glaucoma (NVG), which is a form of glaucoma that is commonly associated with Proliferative Diabetic Retinopathy and many other conditions which result in compromised blood flow to the eye.

As a result of the reduced blood flow, new vessels form in the front part of the eye. It is also theorized that a chemical called Angiogenic Factor, is released and stimulates the growth of these new vessels in the iris and angle of the eye. These new vessels and the potential scars may cause blockage of aqueous humor drainage and consequently increase IOP.

Treatment of NVG is multifaceted because it involves diligent management of the systemic cause and as with the other types of glaucoma, IOP is con¬trolled but with much difficulty. NVG management will also entail Pan-Retinal Laser Photocoagulation (PRP). Medical treatment with eye drops is also used to lower IOP until PRP has taken effect or for additive IOP lowering.

If NVG is still uncontrolled, glaucoma filtration surgery, glaucoma drainage device implantation or cyclodestructive procedures (destroying the Ciliary Body, which is a part of the internal eye that produces aqueous humor, either by freezing or diode laser) may be used.

Because of poor prognosis, NVG management must primarily be preventive in nature. PRP must be done immediately as soon as extensive compromised blood flow is deemed present in the patients’ retina. Unfortunately, it is not always possible to predict which patients will develop NVG.

Prevention
The screening, diagnosis and management of glaucoma must be done by ophthalmologists who are doctors of medicine who have undergone specialty training in treating eye diseases and are able to perform eye surgery. Several government as well as non-government institutions and private clinics nationwide are equipped to screen and manage glaucoma. Some ophthalmologists who have undergone specialty training in glaucoma and members of the Philippine Glaucoma Society are the best qualified to treat complicated and advanced cases of glaucoma.

Glaucoma, like diabetes, requires constant monitoring and re-evaluation of the disease and the treatment plan throughout its clinical course. Ultimately, early detection and prevention, with due diligence on the part of the physician and cooperation of the patient, will stop or delay the potential devastation that these diseases may cause.

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