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Glaucoma: symptoms, diagnosis, further insights

What is Glaucoma and what does it entail?

Glaucoma is a group of diseases in which there is an increase in intraocular pressure, damaging the optic nerve, causing irreversible damage to it and consequently to the visual field, which can lead, in severe cases, to blindness. In this group of diseases, we find forms that are profoundly different from each other, with the most common being open-angle glaucoma (chronic simple glaucoma): a debilitating, complex, and insidious disease, sometimes difficult for the ophthalmologist to approach.

In Italy, more than 550,000 people are affected by glaucoma, a disease responsible for 4,500 new cases of blindness each year in our country (1 new case of blindness every 2 hours). The frequency increases with age, from around 2% around the age of 40 to over 10% after the age of 70.

Primary and secondary  prevention

Speaking about primary prevention when it comes to glaucoma is not easy. Primary prevention refers to behavior or actions conducted directly on the environment to prevent the onset of the disease. The reason is soon said: glaucoma itself is not preventable, but in the majority of cases, the progression of damage and blindness are preventable. Since the disease is asymptomatic until the late stages, when a significant and irreversible functional impairment has already appeared, an early diagnosis is indispensable to promptly initiate therapy that stops the progression of damage.

The importance of early diagnosys

Open-angle glaucoma, or as previously mentioned, chronic simple glaucoma, is a insidious condition because the damage is not perceived by the patient until the late stages, when there has already been a significant and irreversible loss of visual capacity. For this reason, early diagnosis is indispensable, which can only be achieved through regular check-ups, essential for relatives of glaucomatous individuals and which must be intensified as age progresses.

For this reason, it is essential to undergo regular eye examinations, at least every 4 years up to the age of 40, then every two years, increasing the frequency in subjects at risk. Only in this way is it possible to detect even slight alterations that may suggest the onset of glaucoma.

Target pressure

By analogy with arterial hypertension, many believe there is a limit value for intraocular pressure: this is not true at all. In reality, the maximum tolerated value of intraocular pressure varies from person to person and can change over the course of life. The ideal pressure for each individual patient is also called the “target pressure.”

Hence the need for the examination not to be limited to just measuring intraocular pressure but also to include a direct examination of the optic disc (part of the fundoscopic examination), and if necessary, appropriate investigations should be carried out (visual field examination and OCT of the nerve fibers).

Risk factors for the development of glaucomatous diseas

  • Family history
  • High intraocular pressure Age (risk increases with age)
  • Race (higher frequency and severity in patients of color)
  • Corneal thickness (low corneal thickness is a risk factor)
  • Vascular diseases, arterial hypertension, diabetes mellitus
  • Use of specific medications (corticosteroids, psychotropic drugs)

Terapy and treatments

At present, the only effective therapeutic option to prevent or impede the progression of damage is to reduce intraocular pressure: fortunately, most forms are mild enough to be treated with eye drops or laser applications.

Eye drops: the first-choice treatment

Eye drops generally constitute the first-choice treatment (unless laser treatment is possible) and include 4 groups of drugs:

  • Beta-blockers,
  • Prostaglandin analogues,
  • Carbonic anhydrase inhibitors,
  • Sympathomimetics.

These can also be used in combination to enhance their hypotensive effect. The choice of a specific eye drop is made based on effectiveness, tolerability, and any contraindications. It is crucial that the therapy is administered regularly. However, it is estimated that about 50% of glaucoma patients do not correctly adhere to the therapy (due to difficulties in instillation, discomfort, or because there is no perceived immediate benefit in undergoing the therapy).

The Laser

Laser treatment is a para-surgical procedure involving the application of laser pulses to the trabecular meshwork to improve its permeability and facilitate the drainage of aqueous humor from inside the eye. It is particularly indicated in the early stages of glaucoma as an alternative to eye drops, and it is a treatment feasible only in patients with specific eye characteristics. The hypotensive effect typically lasts from several months to a few years, but the treatment can be repeated if there is a new increase in intraocular pressure.

The Surgery

Surgery is considered the last resort due to the possibility of complications or failures in reducing pressure, which can occur even when the procedure is performed correctly. In recent years, there have been significant advancements aimed at improving the effectiveness and safety of traditional operations and introducing minimally invasive surgical techniques.

These techniques can be performed on an outpatient basis and, if necessary, simultaneously with cataract surgery. Unfortunately, they do not have the same efficacy as traditional techniques in lowering intraocular pressure. For this reason, they are reserved for cases of glaucoma that are not highly advanced, where a modest reduction in intraocular pressure is sufficient. It can be safely stated that generally, the more effective a surgery is in lowering intraocular pressure, the higher the risks of complications associated with it.

How is the type of surgical intervention chosen?

Each type of surgical intervention is characterized by a mean postoperative pressure (obtained from the average postoperative pressures in a large group of patients), which is the pressure we can expect after that type of surgery. The choice is therefore determined by the pressure value we want to achieve in a particular patient (target pressure): obviously, the intervention is chosen in which the results are compatible with the desired level of pressure, and, all other things being equal, the least risky one is chosen. Therefore, the intervention that predicts a postoperative pressure lower than the target pressure with the lowest risk will be chosen.

Can Glaucoma surgeries be performed at Minihospital “Sandro Pertini”?

The MiniHospital “Sandro Pertini” has an ophthalmology laboratory equipped with state-of-the-art instruments for performing any diagnostic investigation and intervention related to ophthalmology.

The technological equipment available at our facility and the expertise of Professor Marco Nardi make the MiniHospital an excellent facility in this field and the best choice to address the aforementioned vision-related issues. This excellence adds to the other equally important areas of outpatient specialist medicine, surgery, diagnostic imaging, and rehabilitation medicine.

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