Glaucoma

U.S. Department of Health and Human Services Public Health Service National Institutes of Health

WHY YOU SHOULD KNOW THE FACTS ABOUT GLAUCOMA:

You may be among the two million adult Americans who have glaucoma. If you have this eye disease, you need treatment to prevent loss of vision. Although glaucoma cannot be cured, it can be controlled if detected and treated early.

Unfortunately, people who have glaucoma may not be aware that something is wrong with their eyes until it is too late to prevent visual impairment and even blindness. To guard against visual loss from glaucoma, people should have regular eye examinations - so their eye specialist can look for signs of this disease and determine if treatment is needed.

Regular eye check-ups are particularly important for people whose risk of glaucoma is higher than average. This includes black people, who are more likely than whites to develop glaucoma. It also includes everyone over 40, because glaucoma usually begins in middle age or later. Scientists do not yet know why aging makes a person more susceptible to glaucoma, but it is clear that the risk rises in the later decades of life. Also, there is an increased risk of glaucoma in people with diabetes or high blood pressure, and in those with a family history of glaucoma. This brochure is mainly about the most common kind of glaucoma, which is called Open-Angle Glaucoma. Other kinds of glaucoma are described briefly. In the back of the brochure, you will find out where to go for more information on glaucoma. WHAT IS OPEN-ANGLE GLAUCOMA? In open-angle glaucoma, gradual changes within the eye lead to an internal fluid pressure that is high enough to damage delicate structures essential to vision. These changes occur in several stages:

.Fluid pressure inside the eye (intraocular pressure) begins to rise. This happens because the fluid that normally fills the inside of the eyeball flows in at the usual rate but drains too slowly. This fluid, called Aqueous Humor, is a clear liquid made continuously by cells inside the eye. Aqueous helps maintain the shape of the eyeball and bathes and nourishes the lens and cornea, transparent tissues located near the front of the eye (see eye diagram). Aqueous leaves the eye through a spongy meshwork of tissue located at the "angle" where the cornea and iris meet.

When aqueous cannot exit fast enough, intraocular pressure rises. Why this happens is not known for certain, although scientists think the problem relates to changes in the drainage meshwork that are triggered by aging and by other factors that are still not understood. Although someone who has high intraocular pressure usually cannot feel it, an eye care specialist can detect and measure it with an instrument called a Tonometer.

.Higher than normal intraocular pressure begins to destroy the tiny, delicate nerve fibers that make up the Optic Nerve at the back of the eye. Because the optic nerve relays visual messages from the eye to the brain - where seeing actually takes place - the health of this nerve is essential to sight.

Under prolonged high pressure, the optic nerve deteriorates and the patient's field of vision gradually gets narrower. Surprisingly, most people don't notice these changes until there is extensive loss of side vision.

.If optic nerve damage is not halted, glaucoma leads to tunnel vision and blindness. This can happen in just a few years. Glaucoma-induced vision loss is permanent and cannot be restored by treatment.

Therefore, to be fully effective, treatment must begin before there is serious damage to the optic nerve. That is why early detection is critical, for an eye specialist can detect what the glaucoma patient cannot; abnormalities of the optic nerve and subtle changes in the visual field. It is these key diagnostic signs, rather than elevated pressure, that indicate the presence of glaucoma. Although glaucoma is not contagious, if one eye is affected, the other eye will almost certainly develop the condition.

HOW IS OPEN-ANGLE GLAUCOMA CONTROLLED?

The goal of treating open-angle glaucoma is to preserve vision by lowering intraocular pressure and preventing optic nerve damage. Here are some facts about the main forms of treatment in use today:

.Drugs for open-angle glaucoma are the most widely used method of treating this disease. These medications are taken as eyedrops or pills. Some improve fluid drainage, while others lower pressure by inhibiting fluid formation. Most cases of glaucoma can be controlled with one or more medications, and a majority of patients tolerate these drugs well.

However, in a few patients intraocular pressure is not adequately controlled by medications. Also, some people find that the drugs' side effects - such as stinging in the eye, blurred vision, or headaches - do not go away after the first few weeks of use but continue to be a problem. The patient may have trouble adhering to the prescribed dosage schedule and may be tempted to stop taking the medication or cut back on the dosage. In this situation, the patient should contact his or her eye doctor to discuss the problem and the best means of dealing with it. Changing the treatment plan without proper medical advice may allow intraocular pressure to rise again, and the patient may suffer needless visual loss as a result.

So, in spite of the fact that glaucoma can be controlled by medications in a majority of patients, other forms of treatment also play an important role in glaucoma therapy. These are described below:

.Conventional surgical techniques are intended to help fluid escape from the eye, and thus reduce pressure. Thirty years ago, before glaucoma drugs were available, surgery was the only effective treatment for glaucoma. Now ophthalmologists generally reserve surgery for patients whose glaucoma cannot be controlled by medications and for those who are unable to tolerate the side effects of these drugs. During the operation, the surgeon makes an opening to create a new drainage pathway so that aqueous can leave the eye more easily. After surgery, a few patients still need to use medication to keep their pressure under control and avoid loss of vision. And if the new drainage opening closes, a second operation may be needed.

.Argon laser surgery is an innovation in glaucoma treatment. The laser, a device that produces a high-energy beam of light, is used to make about 100 small burns in the drainage meshwork at the edge of the iris. Scientists think that the scars from these burns help stretch open the holes in the meshwork, making it easier for fluid to filter out. Laser surgery can be done in an ophthalmologist's office in a relatively short time. Usually, people who have this surgery must continue taking some glaucoma medication afterwards, although they may be able to lower the dosage and still keep intraocular pressure under control. However, the pressure-lowering effect of the laser treatment may wear off eventually, and for this reason patients sometimes have a second or third treatment session.

WHAT IS MEDICAL SCIENCE DOING ABOUT OPEN-ANGLE GLAUCOMA?

In the United States, most research on glaucoma is supported by the National Eye Institute (NEI). It is part of the National Institutes of Health, a component of the U.S. Department of Health and Human Services. The NEI is supporting a wide range of studies to learn more about the causes of glaucoma and improve its detection and treatment.

One major study now underway will further evaluate argon laser surgery for open-angle glaucoma. This nationwide study, called the Glaucoma Laser Trial, is for people whose glaucoma was recently diagnosed. Its goal is to learn whether early laser treatment offers any advantages over treatment with medications alone. Another goal is to learn what disadvantages or risks may be associated with the new laser treatment. Findings from this research will help doctors determine the best approach to preserving the vision of people with open-angle glaucoma.

Clinical research on glaucoma drugs is aimed at improving their effectiveness, safety, and ease of use, and reducing their unpleasant side effects. Some scientists are searching for new - and better - drugs, while others are experimenting with new ways of delivering drugs to the eye.

Researchers are also studying different types of lasers, as well as ultrasonic devices, for treating open-angle glaucoma that does not respond to drugs or conventional surgery. In one study they are trying to find a way to improve the effectiveness of conventional glaucoma surgery. In addition, investigators are developing new diagnostic devices to improve the early detection of glaucoma, so that doctors will be better able to determine which patients need therapy.

Eye researchers are also trying to find out why black Americans appear to be particularly susceptible to open-angle glaucoma. In fact, some studies have suggested that the risk of glaucoma-induced blindness is several times higher for blacks than for whites. Scientists are attempting to identify the factors that might account for this difference. Their research is expected to yield important information that will lead to better ways of protecting black people from glaucoma.

Information that will help to improve glaucoma treatment is also expected to emerge from basic research on the eye. Such work includes studies of the changes that occur in the eye as it ages and the factors controlling production and drainage of aqueous humor.

WHAT IS GLAUCOMA SCREENING?

Many civic groups, hospitals, and community health centers in the United States offer glaucoma screening in an effort to identify people who are at high risk for glaucoma but don't know it. In screening programs, a health worker tests both eyes for increased pressure, using a tonometer. Tonometers may worry some people because part of the instrument touches the eye, but eyedrops can be used to numb the eye and the procedure is quick and painless. Some programs use non-contact tonometers which do not touch the eye, but instead measure the resistance to a puff of air blown at the eyeball.

The person who is found to have high intraocular pressure in a screening test is generally urged to make arrangements for a more thorough eye examination soon. This is because screening by tonometry can detect elevated intraocular pressure, but cannot reveal whether this condition has affected the optic nerve or side vision. To check for those key signs and thus learn whether glaucoma is present, doctors must examine the optic nerve and the field of vision. Intraocular pressure will be checked again to determine whether it is still elevated or whether it has dropped back to normal since the screening test. At the end of a complete eye examination, some people will learn that they have glaucoma and need treatment. Others will get the welcome news that they don't have the disease.

It is important to remember, however, that "passing" a screening test for glaucoma does not necessarily mean that you have no eye problems. Some cases of glaucoma are missed by screening, and other eye diseases may go undetected as well. So people who appear problem-free on the screening test should continue to have regular, thorough eye examinations to safeguard their visual health.

WHAT IS OCULAR HYPERTENSION?

Occasionally, eye examinations reveal that the pressure within one or both eyes is above normal, but the optic nerve and visual field are all right. This condition is called Ocular Hypertension. A person who has it is at risk for developing glaucoma; the higher the pressure, the greater the risk. Of ocular hypertension is diagnosed, the eye care specialist will be able to advise whether it is better to begin treatment to lower the intraocular pressure right away, or whether it is preferable to wait, have regular eye check-ups, and consider treatment only if definite signs of open-angle glaucoma appear.

WHAT ARE THE OTHER FORMS OF GLAUCOMA?

.In Low-Tension Glaucoma, optic nerve damage and restricted side vision occur unexpectedly in a person with normal intraocular pressure. The treatments used for this condition are the ones described in the section headed "How is Open-Angle Glaucoma Controlled?"

.In some people, an anatomical peculiarity of the eye, often inherited, makes the angle between the iris and cornea unusually narrow and easily closed off. This narrow angle can retard fluid drainage, causing numerous episodes of high pressure - a condition called Chronic Narrow-Angle Glaucoma. If the narrow angle closes suddenly and completely, fluid backs up fast and eye pressure goes up rapidly. This event, called Acute Narrow-Angle Glaucoma or Angle-Closure Glaucoma, is a medical emergency. It causes severe pain and nausea as well as redness of the eye and blurred vision. Unless the patient has treatment to improve the flow of fluid, the eye can become blind in as little as one or two days. Generally, surgery is needed to restore outflow of aqueous and prevent further angle-closure attacks. Lasers have been very helpful as an alternative to conventional surgery for treating narrow-angle glaucoma.

.Some infants are born with defects in the angle of the eye that slow the normal drainage of aqueous. This relatively rare Congenital Glaucoma is easily recognized in affected infants, who have cloudy eyes, are sensitive to light, and tear excessively. Surgery is usually indicated and can prevent loss of vision if it is done soon enough.

.Glaucoma can also develop as a complication of other medical conditions. These Secondary Glaucomas are sometimes associated with eye surgery or with advanced cataracts, eye injuries, some kinds of eye tumors, or uveitis (eye inflammations). A severe form of glaucoma, called neovascular glaucoma, is linked to diabetes. Also, corticosteroid drugs - used to treat eye inflammations and a variety of other diseases - can trigger glaucoma in a few people.

HOW CAN PEOPLE LEARN MORE ABOUT GLAUCOMA?

If you are in one of the groups at special risk for glaucoma, as described in the first section of this pamphlet, you should ask your doctor about this disease. He or she can test your eyes for high intraocular pressure or refer you to an eye specialist for glaucoma tests. If you are older than age 40, you should have your eyes checked for glaucoma every two to three years.

For more information on glaucoma, check your public library, or a medical library if you live near a hospital or medical school. Also, you may wish to contact these organizations:

American Academy of Ophthamology 655 Beach Street P.O. Box 7424 San Francisco, California 94120-7424 (415) 561-8500

American Optometric Association 243 Lindbergh Boulevard St. Louis, Missouri 63141 (314) 991-4100

American Foundation for the Blind 15 West 16th Street New York, New York 10011 (212) 620-2000

National Society to Prevent Blindness 500 East Remington Road Schaumburg, Illinois 60173 (312) 843-2020

This brochure was prepared by the National Eye Institute, NIH, Building 31, Room 6A32, Bethesda, MD 20892. The telephone number is: (301) 496-5248.

NIH Publication No. 89-651

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