Acute glaucoma, unlike its older brother (chronic simple glaucoma) is a glaucoma that is silent for most of the time, that is, most of the time the patient has no symptoms of any kind; this means that glaucoma occurs in patients who are mostly asymptomatic for what concerns the pressure of the eye and all the other ocular pathologies, therefore it occurs in a patient who has nothing, this is one of the characteristics. Prevention is very important and the ophthalmologist recognizes this.
Acute glaucoma is an important event, it is one of the few eye urgencies that exist, together with retinal detachment, thrombosis and some other vascular pathology as well as traumatic, and which occur suddenly after a stress, after an instillation of drops to dilate the pupil, after anesthesia or a situation in which the patient’s adrenergic tone is particularly high.
The pupil dilates and the iris crowds the iridocorneal angle: what does it mean? It means that the eye with acute glaucoma is very small, it has no space; the space inside the eye is reduced and the dynamics of the pupil, with the movement of the iris, is spoiled by this reduction of space and can cause crowding of the corner, which is filled by the iris tissue and the liquid can no longer get out of the eye. Not being able to get out of the eye any more, there is an acute rise in pressure and it has very high values: let’s say that from a normal pressure of 16 mm of mercury you can get to an acute glaucoma attack even at 50-60 mm of mercury.
The eye with 60 mm of internal pressure mercury is hard as a golf ball, sore red, the pupil is half dilated and does not react and the patient begins to have important symptoms such as nausea, vomiting, headache, photophobia and restlessness (because of course he cannot sit still); this leads him to the eye emergency room where a diagnosis of acute glaucoma is made and what was needed to be done much earlier in a protected outpatient setting is done: acute glaucoma therapy. Acute glaucoma therapy consists of making a hole inside the iris and this hole can be made with the YAG laser or surgically (so the patient must be taken to the operating room).
Of course, this preventive hole in the iris should be done in conditions of a quiet eye, with normal pressure, with a non-inflamed eye and with a calm patient; this is to say that all this should be done first, instead sometimes we find ourselves having to do it in an eye emergency room when the situation has gotten out of hand. In this case, there was therefore a problem of prevention: the patient who went to the ophthalmologist was not diagnosed with a state of anatomical predisposition to have the attack of acute glaucoma.
Acute glaucoma occurs only in the case of a particular anatomical predisposition: when the front of the eye is particularly small; this occurs especially in farsightedness and in patients with a swollen lens due to cataracts. So the farsighted patient, perhaps 60, 70, 80 years old with a major cataract is certainly at risk of having an acute glaucoma attack.
In an ophthalmology clinic it is necessary to make the appropriate diagnostics and then see the state of the eye under the slit lamp (i.e. with a microscope); the ophthalmologist must suspect the possibility of reduced satiety and then, if necessary, perform appropriate tests.
The appropriate exams are gonioscopy, that is, the study of the iridocorneal angle done in a traditional way or done, even better, with modern methods, which are the corneal topographer equipped with a camera or the corneal topographer equipped with OCT. With these methods, a precise diagnosis can be made and an iconography can be given to the patient as proof of what you are saying, then the photo of the eye is shown with the reduced space, the narrow angle and the iris crowding the corner and closing it.
The patient, with these tests, may decide to do or not to do a prophylactic laser treatment. The message is: the eye examination must be carried out in depth and, if necessary, undergo a topographical examination that highlights the state of the iridocorneal angle. At this point, if the iridocorneal angle is at risk (therefore it is narrow), it is necessary to undergo iridectomy with a laser; the other more radical solution is to remove the lens and once the patient is operated on for cataract, the risk goes to 0, because the plastic lens is much smaller than the human lens.
So if a patient with a risk of acute glaucoma attack has cataracts and the cataract must be removed in a short time it is not necessary to do the iridectomy, because if the patient is operated on for cataracts the week after, you can put eye drops to narrow the pupil while waiting for the surgery and therefore there is no risk.
Glaucoma is a slowly progressive disease characterized by the rise of pressure inside the eye, a measure that is commonly carried out during eye examination.
The increase in pressure, which is commonly measured in the arm by a family doctor, is perceptible to the patient only when it has caused a serious and now irreversible loss of vision.
If diagnosed early, it can be cured in most cases with simple eye drops, or even with the application of a particular technique, called pneumotrabeculoplasty, that is capable of normalizing the pressure, freeing one from the bondage of using eye drops.
If not diagnosed in time, glaucoma advances causing a reduction in the amplitude of the visual field and progresses slowly over the years up to the so-called “telescope field of vision”, the last stage before blindness. This is the importance of early diagnosis so as to undergo the appropriate preventive checks at the right time.
Glaucoma is an increasingly frequent pathology that affects people after a certain age (say from mature age to presenile age, to senile age) and is still an important cause of blindness in our advanced world.
Glaucoma is being fought in various ways but basically lowering the eye pressure and this can be done by reducing the production of the liquid or by increasing the outflow of the aqueous humor of the eye. All therapies usually use this method, eye drops mostly to increase the outflow and reduce production. On the corner, traditional lasers favor the outflow of the aqueous humor, even in surgery.
There is a new method which is that of the 810 nanometer micropulsed laser, therefore the wavelength is that of the infrared. Thanks to the fact that it is micropulsed, this laser allows a cyclo-photoablation of the ciliary body and practically creates a shock on the part of the eye dedicated to the production of the aqueous humor. There is no destruction of the ciliary body as was the case with lasers but with the micropulsed there is only a reduction in the production of the aqueous humor.
Thanks to the micropulsation of the impulse, we can go to act on open angle glaucomas, on glaucomas that are simply refractory to therapy, without precluding any treatment in the future.
We are talking about a new, repeatable treatment that is done with the eye closed, therefore not in a sterile environment. It can be done on an outpatient basis, causes average pain that can last a maximum of 24 hours and has the ability to reduce the pressure by about 30%, for at least 18 months, according to the studies we have available today. It is very promising and opens new frontiers to the treatment of simple chronic glaucoma.
The big news is that the impulses are micropulsed, therefore they do not have a photo-destructive, only reducing the amount of activity of the ciliary body, without destroying them.
The ciliary processes are the basis of the life’s metabolism of the eye. It cannot be played with. They are destroyed only in extreme cases, while with the micropulsed laser we can go to simply reduce its activity in a repeatable, non-invasive, very low risk kind of treatment.