In general, GLAUCOMA is a diverse group of eye conditions with the optic nerve impairment and loss of vision. Unless treated, the blindness is a final outcome. The disease is MULTIFACTORIAL optic neuropathy with a characteristic acquired loss of the optic nerve fibers. It has a wide range of risk factors expressed, with the increased eye pressure at the first place.
Glaucoma is mostly a chronic disease, with concealed onset, without clear symptoms, hardly recognized by the patient on time. Still this deceitful disease leaves an alarming number of blind people of different age in our country.
In this country, these patients are very often left without help, because of a great fear of the old, aggressive unsuccessful surgical methods predominantly present in our country.
It is high time to do something! Contemporary ophthalmology has conceived and demystified this phenomenon, and has offered an OFFICIAL survey about the early discovery and treatment of glaucoma, the disease that leads into darkness – blindness, if not recognized in time. The earliest stage are changes at the level of the retinal ganglion cells, before the appearance of symptoms, and it could last for a while, before the disease goes on progressively thereafter. The therapy starts immediately when the subtle changes are discovered. The choice of an adequate surgical method or a combination of methods for each patient individually is a very important precondition, and the most delicate moment during the battle against this monster.
Many years of costly studies have given the possibilities of ‘keeping the disease’ under control, using a powerful medication in the form of eye drops. However, the inability to interpret correctly the ‘normal and high’ values of the intraocular pressure (IOP) as one of the glaucoma’s major risk factors is astounding.
For an eye evidently impaired, “normal, desired “eye pressure certainly has to be lower than the standard normal levels of healthy eyes.
Like other leading glaucoma centers in EUROPE, Special Hospital SVETI VID has been treating this problem according to the contemporary new standards and attitudes for many years. In collaboration with the distinguished names of the European ophthalmology, the new more refined surgical approaches are cherished, with the unpenetrating deep sclerectomy among them with gel implants. Thus the risks of the old, aggressive, non-adapted surgical techniques have been overcome.
The first reaction of a patient after being brought face to face with the glaucoma diagnosis is disbelief. Apart from having the values of IOP twice as high as normal, the increased eye pressure, as the most common manifestation of glaucoma, does not make pain. There are specific defects in the peripheral visual field, while the central vision remains intact for a long time, and the patient does not recognize the first symptoms. When pain and evident defects in the visual field appear, the damage is irreversible, with a certain part of the optic nerve already destroyed. The aim of the therapy is to keep the disease at that stage, and the intraocular pressure under control.
We have to demystify the problem and help the patient understand his disease, for only if he does, he will accept the necessity for an early treatment. This is a lifelong disease, while the prompt and adequate therapy can enable the patient to live with a disease that is under control (like with controlled blood pressure).
The increased IOP is considered to be the most common risk factor, but not the only one. The old attitude that the glaucoma represents the increased values of intraocular pressure itself with the impairments of the optic nerve and typical glaucoma defects in the visual field is insufficient and has changed today. The increased IOP will certainly speed up the appearance of glaucoma impairments, but glaucoma is not “equal the high eye pressure.” In some cases, very fine changes have been noted in the papilla of the optic nerve in the conditions of ‘relatively’ normal or even lower IOP.
This is a so-called normal or low-tension glaucoma. It is agreed to take the IOP values between 9 and 21 mm Hg as normal. However, approximately 25 percent of people with “relatively normal“ IOP have certain glaucomatous changes.
This means that the assessment of the IOP value must be connected to a serious evaluation of many other risk factors and the presence of predisposition for the disease, and not performed separately. If the optic disk is already impaired, or there is a visual field defect, with a positive family history, the value of IOP should be kept lower than usual, at a value that would not lead to further impairments. Like in coronary disease, when we tend to have the value of blood pressure and level of serum lipid lower than in healthy people, without risk factors.
Regarding the IOP value, even when it is for example 22 mmHg, we should suspect glaucoma, until we confirm the other changes or exclude the risk.
A difference in the eye pressure in both eyes, as well as large daily oscillations of IOP, the asymmetry in the look of the papilla of both eyes, represent an alarm for a complete examination with computerized visual field and immediate therapy if the diagnosis is confirmed.
The increased intraocular pressure (“hard eye”) develops due to the imbalance between the production and outflow of aqueous humor – either an excess of aqueous production or impeded aqueous egress. Every major category of pathology is represented in one form of glaucoma or another. If the eye anatomy is “normal”, with the normal look of the anterior chamber angle and anterior chamber depth, this is so-called open angle glaucoma. If there are some changes in the anterior structure, hereditary or acquired, this is called narrow-angle or angle-closure glaucoma. In some predispositions with the aging process, the anterior chamber angle becomes narrow and this is a risk of an acute glaucoma attack, especially under dilated pupils (in darkness or with mydriaticum!). This is why it is very important to inspect the chamber angle first before the dilatation of the pupil!!!
High hyperopia with a shallow anterior chamber is a predisposition for glaucoma, as well.
Glaucoma as a secondary appearance (‘consequently’) develops in inflammatory processes in the eye (uveitis), post –traumatic, because of adhesions in the chamber angle. It could also be a complication of the ‘maturing’ cataract, when a swollen lens pushes the iris forward and narrows the anterior chamber and the chamber angle, or blocks the communication of the fluid from the posterior part into the anterior part by blocking the pupil’s area. A long waiting for the operation of a mature cataract is a threat for the lens disintegration with a uveitis inflammatory reaction as a complication, or for the angle closure and an acute attack of glaucoma.
These are the dangers of the outdated comprehension of “waiting for the cataract to mature for the operation” which was abandoned in 1970s. A prevention of this is an early cataract surgery – phacoemulsification (ultrasound operation).
Early changes in glaucoma develop at the level of the retinal ganglion cells, before any clear clinical sign of disorder. The nourishment of the tissue is basically impaired due to perfusion disturbances in the very delicate sensitive ganglion cell and optic nerve (axons) tissue. Its sensitivity is higher in the increased IOP or daily oscillations in the IOP of more than 6 mm Hg. Perfusion disturbances present in general diseases: carotid artery occlusion, low blood pressure, diabetes mellitus, certainly have a great impact on changes in the optic nerve axons, and so does any local predisposition, such as high myopia.
These risk factors can make the impairment worse, but that does not mean that everyone with some circulatory disturbances has to develop glaucoma.
The genetics determines the sensitivity of the delicate tissues to the risk factor exposure.
The disease could be expressed in early childhood, solitary or combined with some other congenital disorder, such as cataract or aniridia. It is important to look for glaucomatous appearance after the discovery of congenital cataract, and even if not expressed at the same time, to be aware of a possible delayed onset.
The aim of the therapy is to protect the optic nerve and keep the eye pressure at a reasonable value. The first step comprises eye drops, but in the case of an imminent threat of a glaucoma attack in angle-closure glaucoma, the laser is applied. If the maximum therapy does not stop the progression of glaucomatous changing in the optic disc and visual field, surgery is the method of choice.
Loosing time or coming to wrong decisions cannot save the optic nerve. Surgery on a blind eye is an ethical problem, because it is absurd. Doctors who are not familiar with this problem should immediately direct the patients to the right place. An uncritical assessment of the intraocular pressure values and unrecognized first signs of disorder lead to a catastrophic outcome. Maximum therapy means all available resources for controlling the disease by medication, having in mind the age of the patient. In younger patients (30-40 years of age) with the apparent deterioration after two different medications, one should seriously consider the surgery. These people are facing many years of the battle against glaucoma and the application of these medicaments for many years certainly is not harmless. Though powerful, these medications have side effects, and in some cases they are contraindicated, as well. After many years of using drops, the tissue loses the characteristics of its “nature biology“, which reduces the effects of the late surgery.
The aim of the surgical procedure is to provide a balance between the production and outflow of the aqueous humor. The decision when to operate and which method or a combination of methods to use depends on many factors: the type of glaucoma, duration of the disease, degree of damages, value of IOP. These factors determine the value of the desired IOP level, and of course the type of surgery.
Concerning all the delicacy of this disorder, the decision about surgery should be made by top experts who are familiar with all the details, and all the advantages and disadvantages of the available surgical options, and who have mastered these surgical techniques.
Uncritical performing persistently the same, aggressive and non-adapted surgical technique surely contributes to the increase in the number of blind people in Serbia. This ‘imprint’ surgery is catastrophic for the patients and inapplicable any more in contemporary ophthalmology.
Basic diagnostics, a complete evaluation of disease, adequate assessment of IOP values, understanding the early typical changes in the look of the papilla, choosing the right time for starting the treatment, are highly beneficial for good disease management, if taken seriously.
With a better organization and thinking, this should not have to be an unsolvable problem at the level of the primary and secondary health care, and at the same time this is going to be of immense significance in the fight against blindness caused by glaucoma.
We have introduced such attitudes and the contemporary approach to the treatment of glaucoma in Serbia and established the Glaucoma Centre, headed by the European expert Prof S. Pitrova. This disease has been successfully kept under control owing to the today’s treatment options and surgical procedures.
IOP – intraocular pressure
PNO, optic nerve papilla, optic disk – head of the optic nerve
Perfusion – tissue blood supply
IOP – intraokularni, očni pritisak
Papila vidnog živca, PNO, optik disk – početak, glava očnog živca
Perfuzija – snabdevanje tkiva krvlju