Aqueous humor outflow:

Vision is extremely important for human survival. More than half of sensory receptors are located in the eyes. The eye contains two main chambers the anterior cavity and vitreous chamber. Anterior cavity: the lens divides the anterior cavity into further two chambers: Anterior chamber: between the cornea and iris Posterior chamber: between the iris and zonular fibers and lens.

Both the chamber of anterior cavity is filled with aqueous humor, a watery fluid. The aqueous humor is a clear, gelatinous fluid similar to plasma, but containing low-protein concentrations. The aqueous humor is continuously formed from plasma by the epithelial cells of the ciliary processes. It is secreted into the posterior chamber, passes from the posterior chamber through the pupil into the anterior chamber, and is drained at the anterior chamber angle. Most of the aqueous drains into the venous circulation via the trabecular meshwork, Schlemm's canal, scleral collector channels, and aqueous and episcleral veins; the remainder drains into the orbit via the interstices of the ciliary muscle, the suprachoroidal space, and the sclera. Circulation of the aqueous in the anterior chamber occurs via hydrostatic phenomena, including mechanical forces caused by eyeball and head movements, thermal currents resulting from the temperature differential between the warmer vascular iris and the cooler avascular cornea, and the pressure gradients between the posterior chamber, anterior chamber, and episcleral veins. As the fluid bathes the anterior lens, iris, and corneal endothelium, its composition is altered as a result of the exchange of nutrients, cellular waste products, and other substances within these structures. The entire volume of the aqueous humor is replaced every 90 to 100 minutes.

Flow of aqueous humor:

formed from plasma by the epithelial cells of the ciliary processes.filters out of blood capillaries from ciliary process

enters in posterior chamber

flow forward between the iris and lens through the pupil

enters into anterior chamber

trabecular meshwork

canal of schlemm

scleral collector channels

aqueous and episcleral veins

Functions of aqueous humor:

Maintains the intraocular pressure and in flates the globe of the eye.
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Provides nutrition (e.g. amino acids and glucose) for the avascular ocular tissues; posterior cornea, trabecular meshwork, lens, and anterior vitreous.

May serve to transport ascorbate in the anterior segment to act as an anti-oxidant agent. Presence of immunoglobulin indicates a role in immune response to defend against pathogens.

Provides inflation for expansion of the cornea and thus increased protection against dust, wind, pollen grains and some pathogens.

For refractive index.

Glaucoma
Definition: it is a group of disorders characterized by increased intraocular pressure which leads to optic nerve atrophy and peripheral visual field loss.

Risk factors:
Age: Glaucoma is much more common among older people. People are six times more likely to get glaucoma over 40 years. Family History of Glaucoma: The most common type of glaucoma, primary open angle glaucoma, is hereditary. If members of your immediate family have glaucoma, you are at a much higher risk than the rest of the population. Family history of glaucoma increases the risk of glaucoma four to nine times. Indiscriminate use of Steroids: Studies indicate Steroids increase intraocular pressure. These could be in the form of Oral medications, Steroid Inhalers and Steroid Eye Drops used for long periods of time Injury to Eye: Injury to the eye may cause secondary open angle glaucoma. This type of glaucoma can occur immediately after the injury or years later High myopia (nearsightedness) Diabetes Hypertension Central corneal thickness less than 500 microns

Types:
1. Open-angle glaucoma
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- Primary open-angle glaucoma - Normal-tension glaucoma - Juvenile open-angle glaucoma - Glaucoma suspects - Secondary open-angle glaucoma 2. Angle-closure glaucoma - Primary angle- closure glaucoma with relative pupillary block - Acute angle closure - Subacute angle closure - Chronic angle closure - Secondary angle- closure glaucoma with pupillary block - Secondary angle- closure glaucoma without pupillary block - Plateau iris syndrome 3. Congenital glaucoma: 1. Primary 2. Rubella

Open angle glaucoma Primary open angle glaucoma: represents 90% of all the glaucomas. Patients with open
angle glaucoma have a gradual blockage of aqueous outflow despite a seemingly open space (chamber angle) in the front of the eye. Apparently as the eye ages, the drainage system can become clogged or the eye over-produces aqueous fluid, either of which causes pressure inside the eye to build to abnormal levels.
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Open angle glaucoma is often referred to as "the thief in the night," because it can develop gradually and go unnoticed for years, slowly robbing the victim of his or her eyesight. Because there is usually no pain experienced over the months or years of development and no other apparent symptoms, the victim is unaware of the existence of this serious eye disorder. Resistance of drainage of aqueous through the Trabecular meshwork occurs, due to: 1. Thickening of Trabecular lamellae (reduces pore size). 2. Reduction in number of lining Trabecular cells. 3. Increased extracellular material in the Trabecular meshwork spaces.

Normal tension glaucoma: Glaucoma is usually high pressure inside the eye that damages
the optic nerve and can result in permanent vision loss. Normal-tension glaucoma (also called low-tension glaucoma) is a unique condition in which optic nerve damage and vision loss have occurred despite a normal pressure inside the eye. Eye pressure, called intraocular pressure (IOP),is measured in millimeters of mercury (mm Hg). Normal eye pressure ranges from 10-21 mm Hg. Most people with glaucoma have IOP of greater
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than 21 mm Hg; however, in normal-tension glaucoma, people have IOP within the normal range. By definition, people with normal-tension glaucoma have open, normal-appearing angles. In fact, the features of normal-tension glaucoma are similar to primaryopen-angle

glaucoma (POAG), the most common form of glaucoma (see Primary Open-Angle Glaucoma). Normal-Tension Glaucoma Causes Although its cause is not completely understood, normal-tension glaucoma is generally believed to occur either because of an unusually fragile optic nerve that can be damaged despite a normal pressure inside the eye or because of reduced blood flow to the optic nerve.

Unusually fragile optic nerves may be inherited. Reduced blood flow to the optic nerve can be due to disorders of the blood vessels (called vascular diseases), including vasospasms and ischemia.
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Vasospasms are spasms or constrictions of the blood vessels. Ischemia is reduced oxygen delivered to the tissue, in this case the optic nerve, because the blood vessels are either narrowed or obstructed.

Juvenile open angle glaucoma: Juvenile open-angle glaucoma (JOAG) is a rare, often inherited condition affecting 1 in 10,000 babies. It develops after the 3rd year of life and is therefore seen in older children and adolescents. It is characterized by underdevelopment of the outflow channel of the eye (anterior chamber angle). The fluid (aqueous humour) produced behind the iris, is unable to drain through the sieve-like structure (trabecular meshwork) back into the bloodstream, which in turn causes a raise in intraocular pressure. It is also associated with nearsightedness (myopia) where light rays come into focus in front of instead of on the retina.

There is evidence that juvenile glaucoma is caused by a genetic defect, referred to as autosomal dominant inheritance. This means that both males and females are equally affected because the gene is found in one of the autosomes (any chromosome other than X or Y); means a child of a parent found to have the gene will have a 50% chance of inheriting juvenile glaucoma. It appears
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to be more common in males than females, and it affects both eyes in two-thirds of children. However, the older the child is, the more likely it is that the glaucoma will affect only one eye.

Unlike congenital glaucoma, signs and symptoms of juvenile glaucoma may go undetected until problems with vision occur.  Where there is a family history of glaucoma, regular eye checks are important from a young age. Glaucoma suspects: Glaucoma suspect describes a person with one or more risk factors that may lead to glaucoma, including increasing IOP, but this person does not yet have definite optic nerve damage or vision loss due to glaucoma. A great overlap can exist between findings in people with early glaucoma and in those who are glaucoma suspect and without the disease. Because of this, regular eye examinations with an ophthalmologist are very important to identify and treat people who are glaucoma suspect. By monitoring them for the earliest signs of glaucomatous damage, visual function can often be preserved. In individuals who are at a high risk of developing glaucomatous damage, preventive measures, including lowering the pressure inside the eye, may be needed. Secondary open angle glaucoma: This is an open angle type of glaucoma, i.e. there is no physical obstruction of the drainage angle of the eye. As its name suggests this is the name given to a group of glaucomas where there is another condition causing the raised intraocular pressure and thus the glaucoma. Different conditions may cause secondary open angle glaucoma, these include pigment dispersion glaucoma, pseudoexfoliation glaucoma, iritic glaucoma (glaucoma associated with iritis), steriod induced glaucoma and post traumatic glaucoma.

Angle closure glaucoma:

Primary angle closure glaucoma: in this there is reduction of aqueous outflow occurs due
to bulging of lens. It also occurs due to dilatation of pupils in the clients having narrow angle anatomically. Acute angle-closure glaucoma is caused by a rapid or sudden increase in pressure inside the eye, called intraocular pressure (IOP). In angle-closure glaucoma, the iris (the colored
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part of the eye) is pushed or pulled up against the trabecular meshwork (or drainage channels) at the angle of theanterior chamber of the eye. When the iris is pushed or pulled up against the trabecular meshwork, the fluid (called aqueous humor) that normally flows out of the eye is blocked and cannot drain out, thereby increasing the IOP. See Multimedia files 1-2. If the angle closes suddenly, symptoms are severe and dramatic. Immediate treatment is essential to prevent optic nerve damage and vision loss. If the angle closes intermittently or gradually, angleclosure glaucoma may be confused withchronic open-angle glaucoma, another type of glaucoma. People who are farsighted (called hyperopia) are at an increased risk for acute angleclosure glaucoma because their anterior chambers are shallow and their angles are narrow. As people age, the lens of the eye enlarges and pushes the iris forward, thus increasing the risk for angle-closure glaucoma. Angle closure may occur 2 ways:

The iris may be pushed forward up against the trabecular meshwork.

The iris may be pulled up against the trabecular meshwork. In either case, the position of the iris causes the normally open anterior chamber angle to close. Aqueous humor that should normally drain out of the anterior chamber is trapped inside the eye, thereby increasing the IOP. If the ensuing rise in pressure is sudden, pain, blurred, and nausea may occur. Optic nerve damage may also occur due to the increased IOP, either in a sudden attack or in intermittent episodes over a long period of time. Sometimes, the attack may be caused by dilation of the pupils, possibly during an eye examination.

Acute Angle-Closure Glaucoma: With acute angle-closure glaucoma, because the rise in pressure is rapid, the symptoms also occur suddenly. Understandably, people who are experiencing acute angle-closure glaucoma are extremely uncomfortable and distressed. Dramatic symptoms of acute angle-closure glaucoma include the following: Severe eye pain Nausea and vomiting Headache Blurred vision and/or seeing haloes around lights (Haloes and blurred vision occur because the cornea is swollen.)
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Profuse tearing

In acute attacks of angle-closure glaucoma, it is common for only one eye to be involved and for symptoms to worsen. Some people may experience intermittent episodes of angle closure and elevated IOP without ever having a full-blown attack of angle-closure glaucoma. This is called subacuteangle-closure glaucoma. People with subacute angle-closure glaucoma may have no symptoms, or they may experience mild pain, have slightly blurred vision, or see haloes around lights. These symptoms resolve spontaneously as the angle reopens. Sub acute angle closure glaucoma: Sub acute angle closure Glaucoma: The attacks of rise in IOP
are recurrent regular each attack lasting from a few minutes to 1-2 hours

Chronic angle closure glaucoma: Secondary angle closure glaucoma with papillary block: Secondary angle closure glaucoma without papillary block: Plateau iris syndrome:

Congenital Glaucoma Primary Congenital Glaucoma

By definition, primary congenital glaucoma is present at birth. It is usually diagnosed at birth or shortly thereafter, and most cases are diagnosed during the first year of life. However, sometimes, its symptoms are not recognized until later in infancy or into early childhood. Primary congenital glaucoma is characterized by the improper development of the eye's drainage channels (called trabecular meshwork). Because of this, the channels that normally drain the fluid (called aqueous humor) from inside the eye do not function properly. More fluid is

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continually being produced but cannot be drained because of the improperly functioning drainage channels. This leads to high pressure inside the eye, called intraocular pressure (IOP). Eye pressure is measured in millimeters of mercury (mm Hg). Normal eye pressure ranges from 10-21 mm Hg. Elevated IOP is an eye pressure of greater than 21 mm Hg. An increase in IOP can damage the optic nerve and result in vision loss and even blindness. In approximately 75% of cases, primary congenital glaucoma is bilateral, that is, it occurs in both eyes. Primary congenital glaucoma occurs more often in boys than in girls, with boys accounting for approximately 65% of cases. Primary congenital glaucoma is relatively rare. In the United States, it reportedly affects fewer than 0.05% of children. However, various studies suggest that from 2-15% of children in institutions for the blind have been diagnosed with primary congenital glaucoma. Despite the rarity of primary congenital glaucoma, the impact on a childs visual development can be extreme. Early recognition and appropriate therapy for the glaucoma by

an ophthalmologist (a medical doctor who specializes in eye care and surgery) can significantly improve the child's visual future and prevent blindness. Primary Congenital Glaucoma Causes Primary congenital glaucoma is caused by the improper development of the drainage channels (trabecular meshwork) in the eye. More fluid (aqueous humor) is continually being produced but cannot be drained because of the improperly functioning drainage channels. Therefore, the amount of fluid increases inside the eye and raises IOP. Another way to think of high pressure inside the eye is to imagine a water balloon. The more water that is put into the balloon, the higher the pressure inside the balloon. The same situation exists with too much fluid inside the eye. The more fluid, the higher the pressure. Also, just like a water balloon can burst if too much water is put into it, the optic nerve in the eye can be damaged by too high of a pressure.
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Primary congenital glaucoma is different from childhood glaucomas that are associated with other congenital abnormalities or those that develop as a result of other eye disorders, such as inflammation, trauma, and tumors. Most cases of primary congenital glaucoma occur sporadically. However, the disease may be inherited.

Rubella: A Raised intra-ocular pressure associated with decreased outflow facility, a

progressively enlarging cornea, and atrophy of the optic nerve have been described in neonatal infants born to mothers who acquired rubella during the first trimester of pregnancy.

Drug induced glaucoma: the drugs those cause glaucoma include corticosteroids, anti
cholinergic, anti psychotropic, anti depressants, anti histamines, leads to angle closure and idiopathic lens swelling as well as increased aqueous production.

Difference between the open angle and angle closure glaucoma

Open angle glaucoma onset causes Gradual Clogging of drainage system Increase production of aqueous humor Patho mechanisms Thickening of trabecular meshwork Reduction in no of lining trabecular cells Increased extracellular material in trabecular meshwork blockage Clinical manifestations At trabecular meshwork Asymptomaic at first Gradual progressive peripheral vision loss Angle closure glaucoma Sudden Anatomical narrowing of angle Dilatation of iris Iris may push forward against trabecular meshwork Iris may be pulled up against trabecular meshwork At the angle between iris and cornea

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Clinical manifestations:
Cloudy or haloed vision Nausea or headaches Light sensitivity (photophobia) Excessive blinking (blepharospasm) Crossed or out-turned eyes (strabismus) One eye becoming larger than the other Excessive tearing (epiphora) Decreased vision (amblyopia)

Open-Angle Glaucoma Symptoms The most common form of glaucoma, open-angle glaucoma does not present signs and symptoms at first. Eventually, however, the patient will begin to lose his or her peripheral vision. Because this damage is irreversible, it is extremely important to detect the condition early on through a glaucoma test. If left untreated, open-angle glaucoma will lead to a total loss of vision. Open-angle glaucoma generally affects both eyes; it begins by damaging the nerve fibers that are necessary for peripheral vision. People with advanced open-angle glaucoma can have 20/20 vision when looking straight ahead but may have blind spots (scotomas) for images located outside the center of the visual field. Eventually, the fibers needed for central vision may be lost as well, causing total blindness. Closed-Angle Glaucoma Symptoms Closed-angle glaucoma occurs when the iris blocks intraocular fluid from draining properly. Closed-angle glaucoma may progress gradually without manifesting any symptoms until long after it has set in. Unlike the open-angle form, closed-angle glaucoma sometimes also occurs as acute attacks, as IOP rises rapidly to a dangerous level. A specific form of closed-angle glaucoma called acute glaucoma progresses rapidly, and produces symptoms of severe eye pain, headache, blurred vision, nausea, vomiting, and halos. If not treated within hours, acute closedangle glaucoma can result in permanent vision loss.
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Congenital Glaucoma Symptoms An infant or young child who has congenital glaucoma may exhibit cloudy corneas, sensitivity to light, excessive tearing, and eyelid spasm. Congenital glaucoma can be difficult to recognize because children often have trouble discerning the signs and symptoms. Consult a pediatric optician if you notice a cloudy, white, hazy, enlarged, or protruding eye. Congenital glaucoma is more common in boys than girls. A pediatric optician can help you diagnose congenital glaucoma symptoms and arrange treatment.

Diagnostic tests:
1. History and general examination 2. Tonometry: Tonometry is a very common test to measure the pressure inside the eye, also known as intra-ocular pressure (IOP). Having eye pressure higher than normal places a person at a higher risk for glaucoma. It is important to understand that having higher pressure than normal does not mean a definite diagnosis of glaucoma. 3. Ophthalmoscopy: Ophthalmoscopy is used to examine the inside of the eye. Ophthalmoscopy can be performed on a dilated or undilated eye. An eye doctor uses special magnifying lenses and medical devices to view the optic nerve. The color, shape and overall health of the optic nerve is important in glaucoma assessment. The doctor may also use a digital camera to photograph the optic nerve. 4. Gonioscopy: Gonioscopy is a test that uses a special mirrored device to gently touch the surface of the eye to examine the angle where the cornea meets the iris. Whether this angle is open or closed can tell the doctor what type of glaucoma is present, and how severe the glaucoma may be. 5. Visual Field Testing: Visual field testing, also known as perimetry, is a test that measures how sensitive a person's vision is. During a visual field test, you will look straight ahead at a small light or other target and will be asked to let the examiner know when you see a light flash off to the side in your peripheral vision. Most visual field testing today is computerized. 6. Nerve Fiber Analysis: Nerve fiber analysis is a newer method of glaucoma testing in which the thickness of the nerve fiber layer is measured. Thinner areas may indicate
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damage caused by glaucoma. This test is especially good for patients who may be considered to be a glaucoma suspect and also to indicate if a persons glaucoma is progressively becoming worse. 7. Pachymetry: Pachymetry is the method of measuring the thickness of the cornea. Although research is still being conducted on the importance of corneal thickness, pachymetry is starting to play a larger role in glaucoma testing. The thickness of the cornea seems to influence the eye pressure reading when tonometry is performed.

Medical management:
LOWER IOP BY: (1) Decreasing Production of Aqueous Humor (2) Increasing Outflow of Aqueous Humor 1. Beta-Blockers [levobunolol, timolol, carteolol, betaxolol] -Mechanism: Act on ciliary body to production of aqueous humor -Administration: Topical drops to avoid systemic effects -Side Effects: Cardiovascular (bradycardia, asystole, syncope),

bronchoconstriction (avoid with b1-selective betaxolol), depression 2. Alpha-2 Adrenergic Agonists [apraclonidine, brimonidine] -Mechanism: production of aqueous humor -Administration: Topical drops -Side Effects: Lethargy, fatigue, dry mouth [apraclonidine is a derivative of clonidine (antihypertensive) which cannot cross BBB to cause systemic hypotension] 3. Carbonic Anhydrase Inhibitors [acetazolamide, dorzolamide]

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-Mechanism: Blocks CAII enzyme production of bicarbonate ions (transported to posterior chamber, carrying osmotic water flow), aqueous humor thus production of

-Administration: Oral, topical -Side Effects: malaise, kidney stones, possible (rare) aplastic

DRUGS THAT INCREASE AQUEOUS OUTFLOW 1. Nonspecific Adrenergic Agonists [epinephrine, dipivefrin]
-Mechanism: uveoscleral outflow of aqueous humor -Administration: Topical drops -Side Effects: Can precipitate acute attack in patients with narrow iris-corneal angle, headaches, cardiovascular arrhythmia, tachycardia 2. Parasympathomimetics [pilocarpine, carbachol, echothiophate] -Mechanism: contractile force of ciliary body muscle, outflow via TM -Administration: Topical drops or gel, (slow-release plastic insert) -Side Effects: Headache, induced miopia. Few systemic SE for direct-acting agonists vs. AchE inhibitors (diarrhea, cramps, prolonged paralysis in setting of succinylcholine). 3. Prostaglandins [latanoprost] -Mechanism: May uveoscleral outflow by relaxing ciliary body muscle -Administration: Topical drops -Side Effects: Iris color change

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Surgical management
Laser iridotomy: involves making a hole in the colored part of the eye (iris) to allow fluid to drain normally in eyes with narrow or closed angles. Laser trabeculoplasty is a laser procedure performed only in eyes with open angles. Laser trabeculoplasty does not cure glaucoma but is often done instead of increasing the number of different eyedrops or when a patient's intraocular pressure is felt to be too high despite the use of multiple eyedrops (maximal medical therapy). In some cases, it is used as the initial or primary therapy for open-angle glaucoma. This procedure is a quick, painless, and relatively safe method of lowering the intraocular pressure. With the eye numbed by anesthetic drops, the laser treatment is applied through a mirrored contact lens to the angle of the eye. Microscopic laser burns to the angle allow fluid to better exit the drainage channels. Laser trabeculoplasty is often done in two sessions, weeks or months apart. Unfortunately, the improved drainage as a result of the treatment may last only about two years, by which time the drainage channels tend to clog again. There are two types of laser trabeculoplasty: argon laser trabeculoplasty (ALT) selective laser trabeculoplasty (SLT).

ALT is generally not repeated after the second session due to the formation of scar tissue in the angle. SLT is less likely to produce scarring in the angle, so, theoretically, it can be repeated multiple times. However, the likelihood of success with additional treatments when prior attempts have failed is low. Thus, the options for the patient at that time are to increase the use of eyedrops or proceed to surgery. Laser cyclo-ablation (also known ciliary body destruction, cyclophotocoagulation or cyclocryopexy) is another form of laser treatment generally reserved for patients with severe forms of glaucoma with poor visual potential. This procedure involves applying laser burns or freezing to the part of the eye that makes the aqueous fluid (ciliary body). This therapy destroys

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the cells that make the fluid, thereby reducing the eye pressure. This type of laser is typically performed after other more traditional therapies have failed. Trabeculectomy is a delicate microsurgical procedure used to treat glaucoma. In this operation, a small piece of the clogged trabecular meshwork is removed to create an opening and a new drainage pathway is made for the fluid to exit the eye. As part of this new drainage system, a tiny collecting bag is created from conjunctival tissue. (The conjunctiva is the clear covering over the white of the eye.) This bag is called a "filtering bleb" and looks like a cystic raised area that is at the top part of the eye under the upper lid. The new drainage system allows fluid to leave the eye, enter the bag/bleb, and then pass into the capillary blood circulation (thereby lowering the eye pressure). Trabeculectomy is the most commonly performed glaucoma surgery. If successful, it is the most effective means of lowering the eye pressure. Aqueous shunt devices (glaucoma implants or tubes) are artificial drainage devices used to lower the eye pressure. They are essentiallyplastic microscopic tubes attached to a plastic reservoir. The reservoir (or plate) is placed beneath the conjunctival tissue. The actual tube (which extends from the reservoir) is placed inside the eye to create a new pathway for fluid to exit the eye. This fluid collects within the reservoir beneath the conjunctiva creating a filtering bleb. This procedure may be performed as an alternative to trabeculectomy in patients with certain types of glaucoma. Viscocanalostomy is an alternative surgical procedure used to lower eye pressure. It involves removing a piece of the sclera (eye wall) to leave only a thin membrane of tissue through which aqueous fluid can more easily drain. While it is less invasive than trabeculectomy and aqueous shunt surgery, it also tends to be less effective. The surgeon sometimes creates other types of drainage systems. While glaucoma surgery is often effective, complications, such as infection or bleeding, are possible. Accordingly, surgery is usually reserved for cases that cannot otherwise be controlled.

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Nursing management

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