00:01
So, as promised,
there are different forms of glaucoma
there's a closed-angle glaucoma
and open-angle glaucoma and
a normal-pressure glaucoma.
00:12
Let's look first at
closed-angle glaucoma.
00:14
This one is the easiest
for me to visualize
in my mind's eye about
what's going on here.
00:20
So, up above is going
to be our cornea,
we're going to have the
anterior chamber above the iris,
we see the iris there.
00:28
And the iris is actually,
there should be an opening
that allows that green
arrow to flow the fluid
between the iris and the
lens and out through the pupil
into the anterior chamber
where it can access the
trabecular meshwork.
00:43
And where it can flow out
through the canal of schlemm.
00:47
And what's going on here is that
for various reasons, the lenses
a budding onto the iris.
00:55
And now we can't get
that flow out of there.
00:57
So it makes sense,
it's called a closed-angle
because we cannot flow fluid
out, okay.
01:07
The aqueous humor
outflow is blocked
from the posterior chamber
where it's being generated.
01:12
Remember the posterior
chamber is that little bit
behind the iris in
front of the lens
and we can't get it out
to the anterior chamber.
01:22
Why can this happen?
So we can have a very
shallow anterior chamber.
01:27
Okay, if it just the
configuration of the cornea,
the lens and
everything else that
space gets squished.
01:35
The lens size can be big,
you can have a much larger
lens or distortion of lens
that presses it up
against the iris.
01:43
You can have it displaced.
01:45
So instead of being kind
of posteriorly situated,
it can be, float
forward, if you will,
and have a more
anterior location
and therefore a but
on top of the iris.
01:58
And you can have a very narrow
entrance to the anterior chamber angle.
02:03
So it just because of the way
that the anatomy is assembled.
02:08
Secondary causes.
02:09
So if you get
inflammation of the uvea,
okay, so of the iris
or of the ciliary body,
then that clearly
will cause some edema.
02:18
And that edema can
expand those tissues
where they previously
would have flow.
02:24
Now there are edematous
and they abut one another.
02:26
So uveitis will do that.
02:28
Trauma can clearly do
this by causing damage,
causing hemorrhage, causing a
variety of other things that will
also affect the general
anatomy of that angle.
02:38
Steroids also
influence blood flow,
they also influence
the anatomical kind of
colocation of these
various structures.
02:49
And then retinopathies,
things that are actually impact
the retina more posteriorly can
have an impact on the geometry
that's going on here.
03:00
So basically,
in closed-angle glaucoma,
it's a problem of geometry.
03:05
We're not able to
get the normal flow
from the ciliary body out
from the posterior chamber
into the pupil and out through the canal
of schlemm and the trabecular meshwork.
03:18
Okay,
it's basically the geometry.
03:22
And although it's very
easy to understand,
it's not the most common
cause of glaucoma.
03:28
So closed or narrow angle glaucoma
is only 20% of all glaucomas.
03:33
It tends to be more severe
than open-angle glaucoma.
03:36
And this is kind of
understandable because
we've basically
have blocked flow
and we're continuing to crank out
lots and lots of aqueous fluid.
03:45
It is associated with increased
age, so just the vagaries of aging,
we will have some changes in
the geometry of the anterior
and posterior chambers of the eye with
all those various structures there.
03:56
Overall, due to the higher prevalence of open-angle glaucoma,
glaucoma is more common in the African American ethnicity
than it is in the Caucasian or Asian ethnicities.
04:09
However, closed-angle glaucoma is more common in patients of Asian and Inuit descent.
04:15
And they're very much
can be a family history.
04:17
So if you think about it,
you know, all these structures
have a genetic basis
for how they're organized
and how they're put together,
how they're assembled and how
they lay relative to one another.
04:27
And if dad had a slight
change in geometry,
it's very possible that you might
have a slight change in geometry.
04:33
So family history
is very common.
04:36
Okay, that's closed-angle
glaucoma, and if they say
that's the one that's easiest
for me to kind of understand.
04:42
Let's look at
open-angle glaucoma.
04:43
In open-angle glaucoma in fact,
the flow looks to be just fine.
04:49
The geometry is normal.
04:52
We have the ciliary body that's
cranking out aqueous fluid.
04:56
It's able to get out between
the iris and the lens.
05:00
It's able to get out through the
pupil, it's able to
move through into the
trabecular meshwork
Oh my goodness,
everything looks fine.
05:08
So it's not, you know,
it's not the geometry anymore.
05:12
So what else is going on here?
Well, in fact it's the green
box says at the bottom,
you can have that trabecular
meshwork, the canal of schlemm
where the fluid is
supposed to be going out,
it can be blocked.
05:23
So basically now,
this is a drainage problem.
05:26
This is not a geometry problem.
05:28
But there is now junk
clogging the sewer drain,
the canal, a schlemm, the trabecular
meshwork, allowing fluid out
that can be blocked
from white cells
or just inflammation in general.
05:41
So an uveitis,
inflammation of the ciliary body
and the iris or the choroid
can actually cause now edema
or increased white cells that
can sit in the sewer grate
and prevent the fluid
from getting out.
05:55
If you have a vitreous hemorrhage,
if you have a hemorrhage of any kind,
red cells can get in there
and kind of clog up the works.
06:01
And if you have a retinal detachment
or you have a retinopathy,
those elements can
also float around
and end up blocking the outflow.
06:10
So this is a clogged sewer drain
is another way to think
about open-angle glaucoma.
06:17
So there can be a couple
different primary causes.
06:21
So it's not just that there's
clogging, you can actually have
a little over
aggressive, a little,
you know,
a little too enthusiastic
production of the aqueous
humor by the ciliary body
and there's more production than
can be successfully drained.
06:37
Okay, that kind of makes sense or
you can have decreased drainage.
06:40
Either one of those will
lead now to increased fluid
pressure within that anterior
chamber which eventually then
translocates and has
effects on the optic nerve.
06:51
Secondary causes, so we can have
as we talked about previously,
blockage of the trabecular meshwork,
clogging of the sewer drain
with white cells from an uveitis,
red cells from a vitreous hemorrhage
or retinal detachment elements.
07:04
Okay, good.
07:07
This is the most common cause of
glaucoma, open-angle glaucoma.
07:12
Like other forms of glaucoma,
it is associated
with increasing age.
07:16
So if you have more junk,
and more junk over time
that may block your
fluid going out.
07:23
As I said before,
glaucoma overall is more frequently
seen in African American ethnicity.
07:32
But open-angle glaucoma
is no exception.
07:35
And there may well
be a family history.
07:36
So again, if mom has a chronic
overproduction of aqueous fluid,
then you may have an
overproduction of aqueous fluid
because of the same
genetic variation.
07:50
And then there's normal
pressure glaucoma.
07:53
This one is basically
has all the same features
of primary open-angle glaucoma,
the entity we just described,
fluid is flowing appropriately,
everything's open, nothing's closed,
and nothing is
particularly blocked.
08:11
But you can still have optic
nerve atrophy in the setting.
08:17
And the point about this
is that it is probably
still an effect of pressure.
08:25
But the pressures that we
measure in the anterior chamber
are within the normal limits.
08:31
So we haven't exceeded
about that 21 mm Hg.
08:37
Why is this happening then since
the pressure is not elevated?
Well, in fact, there's probably more than
just increased anterior chamber pressures
that will be drivers for optic
nerve atrophy and glaucoma.
08:49
And you can have subtle
changes in vasculature
that may compromise blood
flow to the optic nerve
and that may be a cause.
08:57
So...
08:59
if you're thinking about
normal pressure glaucoma,
it's the same as open-angle glaucoma
in terms of the general anatomy,
but the pressures are
within the normal limits.