LECTURE No. 25. Primary glaucoma

Glaucoma is a chronic eye disease that manifests itself as a constant or periodic increase in intraocular pressure, a special form of optic nerve atrophy, and significant changes in the visual field.

Etiopathogenesis and classification. There are primary, secondary and congenital glaucoma. The development of primary glaucoma is influenced by both local and general factors. Local factors include changes in the drainage system and microvessels of the eye, general hereditary predisposition, neuroendocrine and hemodynamic disorders. Before an increase in intraocular pressure, trophic changes occur in the drainage system of the eye, which causes a violation of the circulation of aqueous humor and an increase in ophthalmotonus.

Classifying primary glaucoma, it is necessary to take into account the form and stage of the disease, the level of intraocular pressure and the dynamics of visual functions. The state of the iridocorneal angle of the anterior chamber and the site of violation of the main resistance to the outflow of aqueous humor determines the form of glaucoma. There are open-angle and closed-angle forms of glaucoma.

With open-angle glaucoma, dystrophic changes in the trabecular tissue and intratrabecular canals of varying severity, as well as blockade of the Schlemm's canal, occur. Types of open-angle glaucoma include pigmentary, pseudoexfoliative and low intraocular pressure glaucoma. In pigmentary open-angle glaucoma, the pigment completely covers the trabecular zone, which leads to a violation of the outflow of aqueous humor and an increase in intraocular pressure. Pseudoexfoliative glaucoma leads to the deposition of pseudoexfoliation on the posterior surface of the cornea, iris, ciliary body, and in the iris-corneal angle of the anterior chamber. Pseudoexfoliative glaucoma often coexists with cataracts. Glaucoma with low intraocular pressure is characterized by typical symptoms of primary glaucoma: visual field changes and partial atrophy of the optic nerve with glaucomatous excavation of the optic disc. With damage to the optic nerve is often associated with its low tolerance to ophthalmotonus, as well as severe sclerosis of the vessels that feed the optic nerve. Often there is a combination of glaucoma with low intraocular pressure and persistent vegetative-vascular dystonia, proceeding according to the hypotensive type.

Angle-closure glaucoma is characterized by blockade of the iris angle of the anterior chamber by the root of the iris, as well as the development of goniosynechia. Glaucoma occurs with pupillary block, shortening of the iris angle of the anterior chamber, flat iris, and vitreocrystalline block. In mixed form of glaucoma, the signs of open-angle and closed-angle glaucoma are combined.

There are four stages of the disease: initial, advanced, advanced and terminal, and at the same time an acute attack of angle-closure glaucoma. The designation of each stage is carried out by a Roman numeral for a brief record of the diagnosis. The staging of glaucoma is determined by the state of the visual field and the optic disc. The initial stage is characterized by the absence of marginal disc excavation and changes in the peripheral boundaries of the visual field. The advanced and advanced stage of glaucoma is characterized by the presence of marginal excavation, narrowing of the peripheral boundaries of the visual field, and the appearance of central and paracentral scotomas. At the advanced stage of the disease, the visual fields are narrowed by at least 5° from the inside, at a far advanced stage, the field of vision is narrowed at least in one meridian and does not go beyond 15° from the fixation point. According to the state of ophthalmotonus, normal, moderately elevated and high intraocular pressure are distinguished.

clinical picture. Open-angle glaucoma usually occurs after the age of forty. The onset of the disease is often asymptomatic. 1520% of patients complain about the appearance of iridescent circles around the light source, periodic blurred vision. Often there is an early, age-inappropriate weakening of accommodation. There are minor changes in the anterior part of the eye. Sometimes there is an expansion of the ciliary arteries and episcleral veins. The depth of the anterior chamber in the case of open-angle glaucoma is usually not changed. Characteristic is the early appearance of changes in the iris in the form of segmental atrophy of the ciliary zone or diffuse atrophy of the pupillary zone with destruction of its pigment border.

The clinical picture of open-angle glaucoma is characterized by the development of glaucomatous atrophy of the optic nerve in the form of marginal excavation. In this case, a whitish or yellowish ring (halo) may appear near the optic nerve head.

In gonioscopic examination, the iris angle of the anterior chamber is always open, and is usually quite wide and only in rare cases somewhat narrowed. Corneoscleral trabeculae are sclerotic. There is exogenous pigmentation of the iris angle of the anterior chamber. With open-angle glaucoma, there is a slow and gradual increase in intraocular pressure as resistance to the outflow of aqueous humor increases. There are the following average figures for the ease of outflow, which correspond to the stages of development of open-angle glaucoma: in the initial stage 0,14, in advanced and advanced 0,08, in the terminal 0,04 mm3 / min per 1 mm Hg. Art. The deterioration of visual functions may be a consequence of the growing phenomena of glaucomatous atrophy of the optic nerve head. Early changes in the visual field are characterized by the expansion of the blind spot and the appearance of small scotomas in the paracentral region, later turning into Bjerrum's arc scotoma.

Further development of the glaucomatous process characterizes the detection of defects in the peripheral visual field. The narrowing of the visual field occurs mainly on the nasal side (in the upper nasal sector). The late stages of the disease are characterized by concentric narrowing of the visual field and a decrease in visual acuity.

Primary open-angle glaucoma is typical for middle-aged and elderly people. Changes occurring in the body are characteristic of this age group. A number of negative factors such as low blood pressure, the presence of cervical osteochondrosis, sclerotic changes in extracranial vessels affect the course and prognosis of primary open-angle glaucoma. All these factors lead to a deterioration in the blood supply to the brain and eyes. This leads to a disruption of normal metabolism in the tissues of the eye and optic nerve, a decrease in visual functions.

Local factors negatively affecting the course and prognosis of open-angle glaucoma include a decrease in the resistance of the optic nerve head to compression, deterioration in tonographic parameters, unstable intraocular pressure (above 28 mm Hg with tonometry with a load of 10 g), an increasing ratio of excavation diameters and optic disc.

Angle-closure glaucoma accounts for 20% of primary glaucoma cases. It usually progresses over the age of forty. It most often manifests itself in individuals with hypermetropia, since the anatomical features of eyes with such refraction (small anterior chamber and large lens) are predisposed to its development. The course of angle-closure glaucoma is characterized by periods of exacerbations and remissions. There are two main factors influencing the mechanism of increasing intraocular pressure: the advancement of the iris lens diaphragm (or the formation of an iris fold at its root during pupil dilation) and a functional pupillary block. In this case, the iris takes on a bulging configuration (bombing) and causes blockade of the anterior chamber angle. The course of the disease occurs in waves: with increases in intraocular pressure (attacks) and interictal periods.

An acute attack of angle-closure glaucoma is provoked by emotional arousal, pupil dilation, copious fluid intake, overeating, cooling, body position that causes venous congestion in the eye area (with prolonged head tilt down, neck compression, etc.), drinking in a significant amount. Patients have pain in the eye, radiating along the trigeminal nerve to the forehead and temples, blurred vision, the appearance of iridescent circles when looking at a light source. Characterized by a slow pulse, nausea, and sometimes vomiting. The listed symptoms are observed either simultaneously, or each separately. An acute attack of glaucoma is always characterized by a decrease in visual acuity. There is an expansion of the anterior episcleral vessels (congestive injection), clouding of the cornea as a result of edema of its epithelium and stroma, a shallow anterior chamber, pupil dilation with a sharply reduced reaction to light. Sometimes the moisture of the anterior chamber becomes cloudy due to an increase in the protein content in it. The iris is hyperemic, its tissue is swollen. Opacities are often noted in the lens in the form of white spots located subcapsularly (disseminated subcapsular Vogt cataract). Corneal edema makes it difficult to examine the fundus. If it is possible to reduce the swelling of the cornea, then it becomes clear that the optic disc is swollen, and the retinal veins are dilated.

In an acute attack of glaucoma, intraocular pressure is maximal, the iris angle of the anterior chamber is completely closed. There is a rapid increase in ophthalmotonus and a decrease in pressure in the Schlemm's canal. The root of the iris is often pressed against the corneoscleral zone with such force that it compresses the vessels of the iris. This causes an acute local circulatory disorder and focal necrosis of the iris, and then there are zones of its atrophy and deformation of the pupil. All this is a consequence of the development of aseptic inflammation, the appearance of posterior synechia and spraying of iris pigment epithelium cells, goniosynechia and subcapsular cataracts. This can adversely affect the optic nerve.

Subacute attack of angle-closure glaucoma is milder. In this case, the angle of the anterior chamber of the eye does not close all the way or is not tight enough, which determines the clinical picture of the disease. Mild cases are characterized by blurred vision and the appearance of iridescent circles when looking at a light source. There is an expansion of the superficial vessels of the eyeball, slight swelling of the cornea, a slight dilation of the pupil. When gonioscopy marked blockade of the angle of the anterior chamber of the eye, especially below. Characterized by an increase in intraocular pressure up to 40 mm Hg. Art., a significant decrease in the coefficient of ease of outflow. With an increase in intraocular pressure up to 60 mm Hg. Art. symptoms are more pronounced: pain in the eye and superciliary arch and all of the above signs appear. The result of a subacute attack, in contrast to an acute one, is characterized by the absence of deformation and displacement of the pupil, segmental atrophy and gross goniosinechia.

Diagnostics. Early diagnosis of primary glaucoma is extremely important. It is based on the patient's complaints, the history of the disease, the clinical picture, the results of the study of the functions of the eye, especially the central region of the visual field, the state of intraocular pressure and tonography data.

Tonometry is the main method for determining intraocular pressure. The pressure is measured in the supine position of the patient with a tonometer with a load of 10 g, while the tonometric pressure is determined, which normally should not exceed 27 mm Hg. Art. Intraocular pressure in the right and left eyes normally differ by about 5 mm Hg. Art. Daily tonometry is considered very important for the diagnosis of glaucoma. Measurement of intraocular pressure is usually made at 68 o'clock in the morning and at 68 o'clock in the evening, it is desirable to measure it in the middle of the day. Determination of daily changes in ophthalmotonus occurs in a hospital or in a glaucoma dispensary: ​​morning measurement of intraocular pressure is carried out in a patient still in bed. The normal study duration is 710 days, with a minimum of 34 days. There is a calculation of the average morning and evening indicators of the level of intraocular pressure and the amplitude of the ophthalmotonus. The optimal range of ophthalmotonus fluctuations during the day should not be higher than 5 mm Hg. Art. The difference in fluctuations exceeding 5 mm Hg. Art., is the reason for suspicion of glaucoma. Of great importance is the absolute value of the rise in ophthalmotonus (more than 27 mm Hg). If they occur repeatedly, then this is a reliable sign of glaucoma.

Elastotonometry is a method for determining ophthalmotonus in the case of measuring intraocular pressure with tonometers of various masses. With elastotonometry, it is necessary to use a set of Maklakov tonometers weighing 5, 7,5, 10 and 15 g, with the help of which, in ascending order of their mass, intraocular pressure is measured 4 times. The readings of tonometers of different masses are plotted on a graph: the mass of tonometers in grams is plotted on the abscissa axis, and the values ​​of tonometric intraocular pressure are plotted on the ordinate axis. The grounds for suspicion of glaucoma are the high onset of the elastocurve (intraocular pressure more than 21 mm Hg with tonometry with a load of 5 g), a shortened or elongated type of elastocurve (span less than 7 and more than 12 mm Hg). More accurate data on the hydrodynamics of the eye are obtained using electronic tonographs.

Tonography is a method for studying the dynamics of aqueous humor with graphic recording of intraocular pressure. The method essentially consists in prolonged tonometry with further calculation of the main indicators of the hydrodynamics of the eye, the coefficient of ease of outflow and the minute volume of aqueous humor. Electronic tonographs help to conduct tonographic studies. The nature of the state of the outflow tracts of aqueous humor from the eye as a whole is determined by the coefficient of ease of outflow. In addition, it can be used to calculate the minute volume of aqueous humor.

A guaranteed confirmation of the diagnosis is a combination of the results of tonography, daily tonometry and perimetry of the central part of the visual field. The diagnosis of glaucoma is not in doubt if the outflow easiness coefficient is less than 0,15, and the diurnal curve is pathological, in addition, scotomas are noted in the central part of the visual field.

Glaucoma is suspected in the following cases: intraocular pressure equal to 27 mm Hg. Art. and higher; complaints characteristic of glaucoma; shallow anterior chamber; blanching of the optic disc (or part of it) or the beginning development of glaucomatous excavation; asymmetry in the condition of the two eyes (differences in the level of intraocular pressure, the depth of the anterior chamber, the condition of the optic discs); the presence of small paracentral relative and absolute scotomas in the field of view. If during the first measurement of intraocular pressure according to Maklakov (with a load of 10 g), the tonometric pressure is equal to 27 mm Hg. Art. and above, it is necessary to repeat the measurement after 2030-XNUMX minutes (strictly observing the rules of tonometry) to make sure that there is an increased intraocular pressure, eliminating the measurement error. Differential diagnosis of glaucoma is carried out with ophthalmohypertension.

Treatment. Currently, there are three main areas of drug treatment of glaucoma: ophthalmohypotensive therapy (local and general) in order to normalize intraocular pressure; therapy that improves the blood supply to the inner membranes of the eye and the intraocular part of the optic nerve; therapy aimed at normalizing metabolism in the tissues of the eye in order to influence the degenerative processes characteristic of glaucoma.

The selection of local antihypertensive drugs for the treatment of patients with primary glaucoma is carried out taking into account the following circumstances. Intraocular pressure usually decreases after a single instillation. This is the basis for conducting a drug test before the systematic administration of the drug. With subsequent instillations, the hypotensive effect is regularly repeated. Nevertheless, the manifestation of the antihypertensive effect of the drug does not occur immediately, at first it may be mild and intensify in subsequent days of treatment. The hypotensive effect in the case of prolonged use decreases until complete resistance to this drug. With long-term treatment of a patient with glaucoma, this is the reason for the expedient replacement of one drug with another. Often there is resistance to the drug from the very beginning (this drug does not help reduce intraocular pressure, therefore, its administration is impractical). In some cases, after the instillation of the drug, an increase in intraocular pressure occurs (a paradoxical effect). In this case, the appointment of this tool is contraindicated.

In the case of developing a drug treatment regimen for a patient with glaucoma, an observation period is established (at least two to three weeks), after which it is necessary to use the drug. In the future, the effectiveness of treatment is monitored once every 1 months.

Treatment of patients with primary glaucoma usually begins with the administration of instillations of solutions of cholinomimetic drugs, most often a 1% solution of pilocarpine hydrochloride 23 times a day. Pilocarpine helps improve the outflow of aqueous humor from the eye, which is a consequence of lowering intraocular pressure. If normalization of intraocular pressure is not observed after treatment with a 1% solution of pilocarpine hydrochloride, instillation of a 2% solution of pilocarpine 3 times a day is prescribed. If three-time instillations are insufficient, long-acting solutions of pilocarpine are used. These drugs are used 3 times a day. In the ophthalmic medicinal film, pilocarpine hydrochloride is also prescribed 12 times a day and 2% pilocarpine ointment at night.

Other cholinomimetic agents (13% solutions of carbacholine or 25% solutions of aceclidine) are used much less frequently. If cholinomimetic drugs are insufficiently effective, one of the miotic agents with anticholinesterase action (prozerin, phosphakol, armin, tosmilen) is additionally prescribed. The frequency of instillation of these drugs is no more than twice a day. Their action is also aimed at improving the outflow of aqueous humor from the eye.

For patients with open-angle glaucoma with low or normal blood pressure, with insufficient effectiveness of pilocarpine hydrochloride, instillations are added

1 2% solutions of adrenaline hydrotartrate, dipivalyl epinephrine, isoptoepinal, or adrenopilocarpine is prescribed

2 3 times a day. The decrease in the production of aqueous humor and partly the improvement in its outflow are explained by the hypotensive effect of adrenaline. When treating patients with open-angle glaucoma, along with pilocarpine, it is necessary to use 3% and 5% solutions of fethanol. Adrenaline differs from fethanol in that the latter has a longer and milder effect on blood vessels, therefore it is indicated for patients with glaucoma combined with the initial stage of hypertension. The hypotensive effect of fethanol is mainly due to a decrease in the secretion of aqueous humor.

It is possible to use instillations of a 0,5% solution of clonidine (hemitone). The hypotensive effect of clonidine leads to inhibition of aqueous humor secretion, as well as improvement of its outflow. The effectiveness of treatment is monitored 23 times a month.

They are also used in the form of eye drops/adrenergic blocking agents (1% anaprilin, 1% propranolol, 0,250,5% optimol). The decrease in the secretion of aqueous humor is explained by the hypotensive effect of these drugs. They do not change the size of the pupil and do not affect blood pressure.

In the case of insufficient effectiveness of local antihypertensive therapy for open-angle glaucoma, it is supplemented with a short-term appointment of antihypertensive drugs of general action: carbonic anhydrase inhibitors (diamox, diacarb), osmotic (glycerol) and neuroleptic drugs (chlorpromazine). Carbonic anhydrase inhibitors reduce the production of intraocular fluid, which leads to a decrease in intraocular pressure. These drugs are especially effective in hypersecretory glaucoma. Diakarb is administered orally at a dose of 0,1250,25 g from 1 to 3 times a day. After three days of taking diakarba, it is recommended to take a break for 12 days. The appointment of glycerol and chlorpromazine occurs once with acute increases in intraocular pressure.

It is necessary to decide on the surgical treatment of open-angle glaucoma individually, taking into account the form of glaucoma, the level of intraocular pressure, the coefficient of ease of outflow, the state of the angle of the anterior chamber, the field of view and the general status of the patient. The main indications for surgery are a persistent and significant increase in intraocular pressure, despite the use of various antihypertensive drugs; progressive deterioration of the visual field; negative dynamics of clinical data (the state of the iris, the angle of the anterior chamber, the optic nerve), i.e., the unstabilized nature of the course of the glaucomatous process.

In recent years, laser methods have been used to treat primary glaucoma. In the case of open-angle glaucoma, the use of laser goniopuncture and trabeculospasis with argon or ruby ​​lasers is effective.

The most effective in the drug treatment of angle-closure glaucoma are miotic drugs, mainly cholinomimetic drugs (pilocarpine, carbacholine, aceclidine). It is also possible to prescribe a 0,250,5% solution of timolol. Strong anticholinesterase miotics (armin, phosphacol, tosmilen), promoting a sharp constriction of the pupil, can cause pupillary block, so they are usually not prescribed for closed-angle glaucoma. In this form of glaucoma, adrenomimetic drugs (adrenaline, fethanol, clonidine) are also contraindicated due to their mydriatic properties and the possibility of blocking the iridocorneal angle of the anterior chamber. General agents for reducing intraocular pressure include diacarb and glycerol used orally.

With insufficient drug therapy, surgical and laser treatment is also used. Laser treatment consists of laser iridectomy and iridoplasty.

Treatment of an acute attack of glaucoma. An acute attack of glaucoma requires urgent specialized care, the main purpose of which is to reduce intraocular pressure and thus normalize impaired blood circulation in the eye, restore metabolism in the tissues of the eye and the optic nerve.

On an outpatient basis, treatment begins with instillations of a 1% (preferably 2%) solution of pilocarpine hydrochloride every 15 minutes for 1 hour, then every 30 minutes for the next 2 hours and then every hour. Instead of pilocarpine, a 1,53% solution of carbocholine can be administered. A 0,5% solution of Optimol is also instilled. Simultaneously with miotics, 0,5 g of diacarb or glycerol (50% glycerol solution) is prescribed orally at the rate of 11,5 g of glycerol per 1 kg of body weight. The decrease in intraocular pressure after taking glycerin begins after about 30 minutes, and after

1 1,5 hours its maximum reduction is achieved. Upon completion of emergency measures, the patient is sent to inpatient treatment. In the hospital, if the effect of previous treatment is insufficient after 23 hours and in the absence of arterial hypotension, the administration of chlorpromazine, which produces a pronounced sedative effect, is indicated. The drug reduces blood and intraocular pressure. The decrease in intraocular pressure under the influence of chlorpromazine is due to a decrease in the production of aqueous humor. Aminazine is administered as part of a lytic mixture containing a 2,5% solution of aminazine (1 ml), a 1% solution of diphenhydramine (2 ml) and a 2% solution of promedol (1 ml). Solutions of these medications are collected into one syringe, after which they are administered intramuscularly. After administration of the lytic mixture, patients must remain in bed for 34 hours in a horizontal position to prevent orthostatic collapse. In cases of severe corneal edema, eye baths with a 2040-810% glucose solution are indicated. If the described drug treatment does not stop an acute attack of glaucoma within XNUMX hours, anti-glaucoma surgery is performed.

General drug treatment for primary glaucoma includes the prescription of drugs that improve metabolic processes in the retina and optic nerve. Vasodilators and drugs that affect tissue metabolic processes are means that stabilize visual functions in patients with glaucoma with normal intraocular pressure. Of these drugs, the most widely used internally are nicotinic acid (0,05 g 23 times a day for two to three weeks), nikoshpan (1 tablet 23 times a day for two to three weeks), noshpa (0,04 g 23 times a day), nigexin (0,25 g 34 times a day for the first 23 weeks and 2 times a day for another two weeks), aminalon (0,5 g 3 times a day for a month or more), Cavinton (0,005 g 23 times a day), Complamin (0,15 g 23 times a day), Trental (0,1 g 23 times a day), Riboxin (0,2 g 23 times a day), glio6, or pyridoxylate (0,1 g 23 times a day), biogenic stimulants (PhiBS subcutaneously, 0,5 ml, 1520 injections per course), 1% solution of sodium salt of ATP (1 ml intramuscularly daily, 3 injections per course), 0,25% solution of cytochrome C (4 ml intramuscularly every other day, 1015 injections per course), B vitamins.

A combination of drugs is advisable. To stabilize visual functions, patients with glaucoma are prescribed a medicinal complex, including Eleutherococcus (30 drops 3 times a day for a month), cytochrome C (0,25% solution, 4 ml intramuscularly every other day, 1015 injections per course) and ascorbic acid (orally 0 g 1 times a day for a month). The specified drug treatment for patients with glaucoma is carried out in courses lasting 3 month 1 times a year, taking into account the need to normalize intraocular pressure.

Author: Shilnikov L.V.

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