Glaucoma
Glaucoma is a group of eye diseases that can lead to damage of the optic nerve. The optic nerve transmits visual information from the eye to the brain. Glaucoma may cause vision loss if left untreated. It has been called the "silent thief of sight" because the loss of vision usually occurs slowly over a long period of time. A major risk factor for glaucoma is increased pressure within the eye, known as intraocular pressure. It is associated with old age, a family history of glaucoma, and certain medical conditions or the use of some medications. The word glaucoma comes from the Ancient Greek word γλαυκός, meaning 'gleaming, blue-green, gray'.
Of the different types of glaucoma, the most common are called open-angle glaucoma and closed-angle glaucoma. Inside the eye, a liquid called aqueous humor, which is produced by the ciliary body, helps to maintain shape and provides nutrients. The aqueous humor normally drains through the trabecular meshwork. In open-angle glaucoma, the drainage is impeded, causing the build up of aqueous to accumulate in the anterior chamber causing the pressure inside the eye to increase. This elevated pressure can reduce vascular perfusion in the vitreous chamber and can damage the optic nerve and peripheral glial tissues. In closed-angle glaucoma, the drainage of the eye becomes suddenly blocked, leading to a rapid increase in intraocular pressure. This may lead to intense eye pain, blurred vision, and nausea. Closed-angle glaucoma is an emergency requiring immediate attention.
If treated early, the progression of glaucoma may be slowed or even stopped. Regular eye examinations, especially if the person is over 40 or has a family history of glaucoma, are essential for early detection. Treatment typically includes prescription of eye drops, medication, laser treatment or surgery. The goal of these treatments is to decrease eye pressure.
Glaucoma is a leading cause of blindness in African Americans, Hispanic Americans, and Asians. Its incidence rises with age, to more than eight percent of Americans over the age of eighty, and closed-angle glaucoma is more common in women.
Epidemiology
In 2013 for the population aged 40-80 years, the global prevalence of glaucoma was estimated at 3.54%, thus affecting 64.3 million worldwide. The same year, 2.97 million people in North America had open-angle glaucoma. By 2040, the prevalence of all types of glaucoma was projected to increase to 111.82 million worldwide and to 4.72 million in North America.Globally, glaucoma is the second-leading cause of blindness, while cataracts are a more common cause. In the United States, glaucoma is a leading cause of blindness for African Americans, who have higher rates of primary open-angle glaucoma, and Hispanic Americans. Bilateral vision loss can negatively affect mobility and interfere with driving.
A meta-analysis published in 2009 found that people with primary open-angle glaucoma do not have increased mortality rates or increased risk of cardiovascular death.
A 2024 JAMA Ophthalmology article reports that in 2022, an estimated 4.22 million people in the U.S. had glaucoma, with 1.49 million experiencing vision impairment due to the condition, according to a meta-analysis. The study found that Black adults were about twice as likely to be affected by glaucoma as White adults. Glaucoma prevalence was 1.62% among individuals aged 18 and older and 2.56% among those aged 40 and older, while vision-affecting glaucoma occurred in 0.57% and 0.91% of these age groups, respectively.
Signs and symptoms
Open-angle glaucoma usually presents with no symptoms early in the course of the disease, but it may gradually progress to involve difficulties with vision. It usually involves deficits in the peripheral vision followed by central vision loss as the disease progresses, but less commonly it may present as central vision loss or patchy areas of vision loss. On an eye examination, optic nerve changes are seen indicating damage to the optic nerve head.Acute angle-closure glaucoma, a medical emergency due to the risk of impending permanent vision loss, is characterized by sudden ocular pain, seeing halos around lights, red eye, very high intraocular pressure, nausea and vomiting, and suddenly decreased vision. Acute angle-closure glaucoma may further present with corneal edema, engorged conjunctival vessels, and a fixed and dilated pupil on examination.
Opaque specks may occur in the lens in glaucoma, known as glaukomflecken. The word is German, meaning "glaucoma-specks".
Risk factors
Glaucoma can affect anyone. Some people have a higher risk or susceptibility to develop glaucoma due to certain risk factors, including increasing age, high intraocular pressure, a family history of glaucoma, and use of steroid medications.Ocular hypertension
is an important risk factor for glaucoma, but only about 10–70% of people, depending on ethnic group, with primary open-angle glaucoma actually have elevated ocular pressure. Ocular hypertension—an intraocular pressure above the traditional threshold of or even above —is not necessarily a pathological condition, but it increases the risk of developing glaucoma.A study with 1636 persons aged 40–80 who had an intraocular pressure above 24mmHg in at least one eye, but no indications of eye damages, showed that after five years, 9.5% of the untreated participants and 4.4% of the treated participants had developed glaucomatous symptoms, meaning that only about one in 10 untreated people with elevated intraocular pressure will develop glaucomatous symptoms over that period. Given these results, the clinical decision to treat everyone with elevated intraocular pressure with glaucoma therapy as a preventative measure is a matter of debate. As of 2018, most ophthalmologists favored treatment of those with additional risk factors.
For eye pressures, a value of above atmospheric pressure is often used, with higher pressures leading to a greater risk. However, some may have high eye pressure for years and never develop damage. Conversely, optic nerve damage may occur with normal pressure, known as normal-tension glaucoma. In case of above-normal intraocular pressure, the mechanism of open-angle glaucoma is believed to be the impeded exit of aqueous humor through the trabecular meshwork, while in closed-angle glaucoma, the iris blocks the trabecular meshwork. Diagnosis is achieved by performing an eye examination. Often, the optic nerve shows an abnormal amount of cupping.
Family history and genetics
Positive family history is a risk factor for glaucoma. The relative risk of having primary open-angle glaucoma is increased about two- to four-fold for people who have a sibling with glaucoma. Glaucoma, particularly primary open-angle glaucoma, is associated with mutations in several genes, including MYOC, ASB10, WDR36, NTF4, TBK1, and RPGRIP1. Many of these genes are involved in critical cellular processes that are implicated in the development and progression of glaucoma, including regulation of intraocular pressure, retinal ganglion cell health, and optic nerve function. Normal-tension glaucoma, which comprises 30-90% of primary open-angle glaucoma, is also associated with genetic mutations.Additionally, some rare genetic conditions increase the risk of glaucoma, such as Axenfeld-Rieger syndrome and primary congenital glaucoma, which is associated with mutations in CYP1B1 or LTBP2. They are inherited in an autosomal recessive fashion. Axenfeld-Rieger syndrome is inherited in an autosomal dominant fashion and is associated with PITX2 or FOXC1.
Ethnicity
The total prevalence of glaucoma is about the same in North America and Asia, but the prevalence of angle-closure glaucoma is four times higher in Asia than in North America.In the United States, glaucoma is more common in African Americans, Latinos, and Asian-Americans.
Other
Other factors can cause glaucoma, known as "secondary glaucoma", including prolonged use of steroids ; conditions that severely restrict blood flow to the eye, such as severe diabetic retinopathy and central retinal vein occlusion ; ocular trauma ; plateau iris; and inflammation of the middle layer of the pigmented vascular eye structure, known as uveitic glaucoma.Pathophysiology
The main effect of glaucoma is damage to the optic nerve. Eventually, this damage leads to vision loss, which can deteriorate with time. The underlying cause of open-angle glaucoma remains unclear. Several theories exist on its exact etiology. Intraocular pressure is a function of the production of liquid aqueous humor by the ciliary processes of the eye, and its drainage through the trabecular meshwork. Aqueous humor flows from the ciliary processes into the posterior chamber, bounded posteriorly by the lens and the zonules of Zinn, and anteriorly by the iris. It then flows through the pupil of the iris into the anterior chamber, bounded posteriorly by the iris and anteriorly by the cornea.From here, the trabecular meshwork drains aqueous humor via the scleral venous sinus into scleral plexuses and general blood circulation.
In open/wide-angle glaucoma, flow is reduced through the trabecular meshwork due to the degeneration and obstruction of the trabecular meshwork, whose original function is to absorb the aqueous humor. Loss of aqueous humor absorption leads to increased resistance and thus a chronic, painless buildup of pressure in the eye.
In primary angle-closure glaucoma, the iridocorneal angle is narrowed or completely closed, obstructing the flow of aqueous humor to the trabecular meshwork for drainage. This is usually due to the forward displacement of the iris against the cornea, resulting in angle closure. This accumulation of aqueous humor causes an acute increase in pressure and damage to the optic nerve.
The pathophysiology of glaucoma is not well understood. Several theories exist regarding the mechanism of the damage to the optic nerve in glaucoma. The biomechanical theory hypothesizes that the retinal ganglion-cell axons are particularly susceptible to mechanical damage from increases in the intraocular pressure as they pass through pores at the lamina cribrosa. Thus, increases in intraocular pressure would cause nerve damage as seen in glaucoma. The vascular theory hypothesizes that a decreased blood supply to the retinal ganglion cells leads to nerve damage. This decrease in blood supply may be due to increasing intraocular pressures, and may also be due to systemic hypotension, vasospasm, or atherosclerosis. This is supported by evidence that those with low blood pressure, particularly low diastolic blood pressure, are at an increased risk of glaucoma.
The primary neurodegeneration theory hypothesizes that a primary neurodegenerative process may be responsible for degeneration at the optic nerve head in glaucoma. This would be consistent with a possible mechanism of normal tension glaucoma and is supported by evidence showing a correlation of glaucoma with Alzheimer's dementia and other causes of cognitive decline.
Both experimental and clinical studies implicate that oxidative stress plays a role in the pathogenesis of open-angle glaucoma as well as in Alzheimer's disease.
Degeneration of axons of the retinal ganglion cells is a hallmark of glaucoma. The inconsistent relationship of glaucomatous optic neuropathy with increased intraocular pressure has provoked hypotheses and studies on anatomic structure, eye development, nerve compression trauma, optic nerve blood flow, excitatory neurotransmitter, trophic factor, retinal ganglion cell or axon degeneration, glial support cell, immune system, aging mechanisms of neuron loss, and severing of the nerve fibers at the scleral edge.