Elliott M. Kanner, MD, PhD, Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University College of Physicians and Surgeons, New York, NY, USA.
James C. Tsai, MD, Associate Professor and Director, Glaucoma Division, Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University College of Physicians and Surgeons, New York, NY, USA.

Glaucoma is a sight-threatening, progressive optic neuropathy whose incidence increases with age. Currently, the only proven treatment for glaucoma is the reduction of intraocular pressure (IOP). As medical treatment has become safer and diagnostic modalities have become more sensitive, it has become possible to detect and treat glaucoma earlier. This means that with more aggressive screening and treatment, a common cause of irreversible blindness can be prevented. As more patients are treated earlier, it is important not only for ophthalmologists but also for primary care physicians to be aware of the barriers to adherence and possible interactions and side effects of glaucoma medications. Parallels between glaucoma and other neurodegenerative disease are stimulating new approaches to therapy beyond IOP control, targeted directly at the prevention of axonal loss.
Key words: glaucoma, intraocular pressure, medications, neuroprotection, retinal ganglion cell.

Choice of Treatment is not Limited by Age but is Case-Specific

Robert M Schertzer, MD, FRCSC
Glaucoma & Anterior Segment Surgery
Multimedia Technology
Medical Director Visual Field and Optic Nerve Head Imaging Units
VHHSC/UBC Eye Care Centre

When pharmaceutical treatment of glaucoma proves ineffective, several surgical options remain available. In fact, some types of glaucoma may be best handled with immediate surgical intervention, even without prior medical management. Ocular surgery is any procedure that causes an alteration in the structure of the eye and can be laser (using a light) or incisional (using microsurgical blades). The type of surgical intervention indicated will depend on the mechanism of the glaucoma.

Laser surgery
There are three types of laser surgery used in treating glaucoma: trabeculoplasty, iridotomy, and cycloablation.

Trabeculoplasty, usually performed with an Argon green laser, is the application of laser energy next to the drainage channels (trabecular meshwork) around the circumference of the iris inside the eye (the coloured part of the eye.) This is used only for open-angle types of glaucoma, especially chronic ("primary") open angle glaucoma, pseudoexfoliation glaucoma, or pigmentary glaucoma.

Reviewing the Major Classes of Antiglaucoma Medication

Catherine M. Birt, MA, MD, FRCSC
Sunnybrook & Women's College
Health Science Centre,
Assistant Professor,
University of Toronto

Medical management of glaucoma is a field that has expanded dramatically over the past five or six years. Since aging is one of the major risk factors for the development of glaucoma, it is an area that is of great relevance to anyone managing geriatric patients. The purpose of this article is to review the five major classes of antiglaucoma medications, the drugs that are currently available in each class, their indications and their side effects.

Glaucoma is considered to be an optic neuropathy with characteristic optic nerve damage (with loss of the neuroretinal rim and an increased cup-to-disc ratio) and visual field changes (with arcuate field defects progressing to complete loss of peripheral vision). Intraocular pressure (IOP) is not part of the definition of the disease, as many people with statistically elevated IOP do not develop the neuropathy, and many patients with statistically normal IOP do. Intraocular pressure is considered a major risk factor for the development of glaucoma. Other risk factors include advanced age, race, positive family history, myopia, and systemic factors such as diabetes and hypertension. Glaucoma is generally divided into open versus closed angle, and each of these can be subdivided into primary and secondary subtypes.