The diagnosis of glaucoma is usually made clinically and requires a comprehensive eye examination, including slit lamp, applanation tonometry, gonioscopy and dilated stereoscopic evaluation of the optic disc and retina. Automated perimetry is obtained if glaucoma is suspected. This establishes the presence of functional damage and provides a baseline for follow-up. Imaging techniques are not essential for the diagnosis but may have a role to play in the follow-up. We recommend a comprehensive eye examination for every clinic patient with the objective of detecting all potentially sight-threatening diseases, including glaucoma.

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Glaucoma is a neurodegenerative disease characterized by loss of retinal ganglion cells and their axons. Recent evidence suggests that intraocular pressure (IOP) is only one of the many risk factors for this disease. Current treatment options for this disease have been limited to the reduction of IOP; however, it is clear now that the disease progression continues in many patients despite effective lowering of IOP. In the search for newer modalities in treating this disease, much data have emerged from experimental research the world over, suggesting various pathological processes involved in this disease and newer possible strategies to treat it. This review article looks into the current understanding of the pathophysiology of glaucoma, the importance of neuroprotection, the various possible pharmacological approaches for neuroprotection and evidence of current available medications.

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The purpose of the review is to provide an update on the role of imaging devices in the diagnosis and follow-up of glaucoma with an emphasis on techniques for detecting glaucomatous progression and the newer spectral domain optical coherence tomography instruments. Imaging instruments provide objective quantitative measures of the optic disc and the retinal nerve fiber layer and are increasingly utilized in clinical practice. This review will summarize the recent enhancements in confocal scanning laser ophthalmoscopy, scanning laser polarimetry, and optical coherence tomography with an emphasis on how to utilize these techniques to manage glaucoma patients and highlight the strengths and limitations of each technology. In addition, this review will briefly describe the sophisticated data analysis strategies that are now available to detect glaucomatous change overtime.

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Congenital glaucoma is a global problem and poses a diagnostic and therapeutic challenge to the ophthalmologist. A detailed evaluation under general anesthesia is advisable to establish the diagnosis and plan for management. Medical therapy has a limited role and surgery remains the primary therapeutic modality. While goniotomy or trabeculotomy ab externo is valuable in the management of congenital glaucoma, primary combined trabeculotomy-trabeculectomy offers the best hope of success in advanced cases. Trabeculectomy with antifibrotic agent and glaucoma drainage devices has a role in the management of refractory cases, and cyclodestructive procedures should be reserved for patients where these procedures have failed. Early diagnosis, prompt therapeutic intervention and proper refractive correction are keys to success. Management of residual vision and visual rehabilitation should be an integral part of the management of children with low vision and lifelong follow-up is a must.

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Surgical option for glaucoma is considered when other modalities are not working out to keep the intraocular pressure under control. Since the surgical procedures for glaucoma disrupt the integrity of the globe, they are known to produce various complications. Some of those complications can be vision-threatening. To minimize the morbidity, it is very important that one should know how to prevent them, recognize them and treat them. The objective of this article is to provide insight into some of those complications that will help the ophthalmologists in treating glaucoma patients in their clinical practice.

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Primary angle closure glaucoma (PACG) is a major form of glaucoma in large populous countries in East and South Asia. The high visual morbidity from PACG is related to the destructive nature of the asymptomatic form of the disease. Early detection of anatomically narrow angles is important and the subsequent prevention of visual loss from PACG depends on an accurate assessment of the anterior chamber angle (ACA). This review paper discusses the advantages and limitations of newer ACA imaging technologies, namely ultrasound biomicroscopy, Scheimpflug photography, anterior segment optical coherence tomography and EyeCam, highlighting the current clinical evidence comparing these devices with each other and with clinical dynamic indentation gonioscopy, the current reference standard.

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Automated perimetry has become the mainstream for assessment of functional glaucomatous loss and progressive damage. Recent improvements with the Swedish interactive thresholding algorithm (SITA) strategy and the guided progression analysis (GPA) have further settled standard achromatic perimetry (SAP) as the preferred method for diagnosis and follow-up of functional loss. Although SAP is still considered the gold standard, function-specific perimetry may offer advantages for early diagnosis. Frequency doubling technology (FDT) and short-wavelength automated perimetry (SWAP) have been shown to be helpful, especially when SAP is normal and there is a suspicion of glaucoma. Studies using rarebit perimetry have also shown promising results. Studies have observed that each test identifies a different subset of eyes, and combining the tests may improve sensitivity. Nevertheless, the more sophisticated analyses do not reduce the importance of a correct interpretation of the test results.

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Glaucomas comprise a group of hereditary optic neuropathies characterized by progressive and irreversible visual field loss and damage to the optic nerve head. It is a complex disease with multiple molecular mechanisms underlying its pathogenesis. Genetic heterogeneity is the hallmark of all glaucomas and multiple chromosomal loci have been linked to the disease, but only a few genes have been characterized, viz. myocilin (MYOC), optineurin (OPTN), WDR36 and neurotrophin-4 (NTF4) in primary open angle glaucoma (POAG) and CYP1B1 and LTBP2 in congenital and developmental glaucomas. Case-control-based association studies on candidate genes involved in different stages of glaucoma pathophysiology have indicated a very limited involvement. The complex mechanisms leading to glaucoma pathogenesis indicate that it could be attributed to multiple genes with varying magnitudes of effect. In this review, we provide an appraisal of the various efforts in unraveling the molecular mystery in glaucoma and also some future directions based on the available scientific knowledge and technological developments.

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Primary angle closure glaucoma (PACG) is equally prevalent in Indian in Asian population as the primary open angle glaucoma. Eighty-six percent of people with PACG are in Asia, with approximately 48.0% in China, 23.9% in India and 14.1% in southeast Asia. To understand PACG, it is mandatory to understand its classification and type of presentation with the underlying pathophysiology. The treatment options are medical, laser and/or surgical. The present article provides an overview of PACG.

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Surgical intervention is mandatory in the case of documentation of the progression of glaucomatous optic neuropathy despite the administration of maximal tolerated medical therapy, and in cases where compliance is poor. Minimal complications, good long-term intraocular pressure (IOP) control, and precisely titrated target IOPs resulting in avoidance of visual impairment are the primary goals of surgical intervention. This article is an attempt to provide a broad overview of the therapeutic options available to the glaucoma surgeon. The available surgical modalities have undergone modifications and refinements over time, with a view to improve patient outcomes and visual recovery, yet are fraught with intra- and postoperative complications. The risk and benefits of each of the available surgical options must be critically evaluated and customized to fit the needs of the particular patient. There is insufficient evidence at present to establish the superiority of any of these surgeries over the other.

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Aim: To provide a synopsis of primary angle closure disease in India, and Indian studies on the same. Results: Primary angle closure glaucoma forms almost half of all adult primary glaucomas seen in a hospital setting in India. Anatomically, corneal diameters and anterior chamber depths were least in acute and chronic PACG eyes as compared to subacute eyes and controls. Besides relative pupillary block, a Valsalva maneuver during activities of daily living may be responsible for intermittent angle closure and raised IOP in predisposed eyes. Iridotomy alone, controlled the intraocular pressure in 66.7% of subacute eyes and 12.9% of the acute. Medical therapy was additionally required for 35.5% of the acute eyes, 12.1% of the subacute and 30.0% of the chronic cases. There was a greater mean and peak IOP reduction, achieved with 0.005% latanoprost once daily, 8.2 ± 2.0 mm Hg, compared with 0.5% timolol twice daily, 6.1 ± 1.7 mm Hg2. A progression of PACS to PAC was seen in 22%, PAC to PAC OHT in 38.7% and PAC OHT to PACG in 30.7% over 5 years. Conclusions: Primary angle closure disease is common in India, and can be managed well with iridotomy, followed by an appropriate control of IOP.

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Glaucoma is now considered an abnormal physiology in the optic nerve head that interacts with the level of intraocular pressure (IOP), with the degree and rate of damage depending on the IOP and presumably the degree of abnormal physiology. Diagnosis of normal-tension glaucoma (NTG), defined as glaucoma without a clearly abnormal IOP, depends on recognizing symptoms and signs associated with optic nerve vulnerability, in addition to absence of other explanations for disc abnormality and visual field loss. Among the findings are a halo or crescent of absence of retinal pigment epithelium around the disc, bilateral pre-chiasmal visual field defects, splinter hemorrhages at the disc margin, vascular dysregulation (low blood pressure, cold hands and feet, migraine headache with aura, and the like), or a family history of glaucoma. Possibly relevant, is a history of hemodynamic crisis, arterial obstructive disease, or sleep apnea. Neurological evaluation with imaging is needed only for atypical cases or ones that progress unexpectedly. Management follows the same principle of other chronic glaucomas, to lower the IOP by a substantial amount, enough to prevent disabling visual loss. However, many NTG cases are non-progressive. Therefore, it may often be wisein mild cases to determine whether the case is progressive and the rate of progression before deciding on how aggressivene to be with therapy. Efforts at neuroprotection and improvement in blood flow have not yet been shown effective.

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Evidence-based medicine is an evolving new paradigm. With the advent of numerous new diagnostic techniques and therapeutic interventions, one needs to critically evaluate and validate them by appropriate methods before adopting them into day-to-day patient care. The concepts involved in the evaluation of diagnostic tests and therapy are discussed. For delivering the highest level of clinical care, evidence alone is not sufficient. Integrating individual clinical experience and patients' perspectives with the best available external evidence is essential.

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Purpose: To present an overview of the recent observations and research that shed light on the understanding of open and closed angle glaucoma. Methods: Literature review. Results: Glaucoma is a major eye problem afflicting millions of people worldwide. As the population increases, the number of people with glaucoma also increases, with glaucoma becoming an increasing public health concern. This paper presents the natural history of open angle and angle closure glaucoma. We examine the glaucomatous progression in terms of changes in optic disk morphology and visual fi elds as well as the risk factors for progression. Conclusions: This present review highlights the magnitude of glaucoma globally and the need for a greater understanding of this disease and its natural progression.

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Glaucoma is a serious sight-threatening disorder aptly named the Silent thief of sight. India, being the second most populous country in the world, has about 20% of the world glaucoma population. The complex geographical and socioeconomic architecture and the economic extremes have a profound effect on its health system. The present times are abundant with fresh developments in the field of glaucoma. Though newer modalities are present in India, they are not ample and are unequally distributed. Adherence and persistence with medical therapy is an issue owing to a multitude of factors. In such a setting, most of the ophthalmologists find themselves performing glaucoma surgeries quite often. In the present era, there are a number of new surgeries to choose from, especially procedures which are nonpenetrating and blebless. Faced with a spectrum of surgeries from shunts to canal surgeries and trabecular bypass devices, the surgeon is often in a dilemma. Still, trabeculectomy remains the gold standard with an increasing trend toward glaucoma drainage devices. The new procedures and devices are worth exploring but await long-term results, good training of surgeons and cost effectiveness.

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Glaucoma is one of the leading causes of blindness worldwide. Various randomized controlled clinical trials have shown that lowering intraocular pressure (IOP) does reduce progression of primary open-angle glaucoma. However, there is lots of interest in nonpharmacological options that includes lifestyle adjustment and alternative and complementary therapy (ACT). At least 5% glaucoma population uses ACT. Various lifestyle activities like exercise and alcohol can reduce IOP by 1 to 2 mm Hg but would have small effect on glaucoma. The psychological stress can increase IOP. Hypothetically and few studies do show neuroprotective effect (or effect on ocular blood flow) of alcohol, Gingko biloba, bilberry, but the current evidence is weak for its routine use. We must also remember the side effects of 'medications' (e.g., marijuana, alcohol) before promoting as remedy for glaucoma. In current armamentarium of glaucoma management, ACT cannot substitute the conventional treatment available to lower IOP.

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In the last decade, there have been reports on the prevalence of glaucoma from the Vellore Eye Survey, Andhra Pradesh Eye Diseases Survey, Aravind Comprehensive Eye Survey, Chennai Glaucoma Study and West Bengal Glaucoma Study. Population-based studies provide important information regarding the prevalence and risk factors for glaucoma. They also highlight regional differences in the prevalence of various types of glaucoma. It is possible to gather important insights regarding the number of persons affected with glaucoma and the proportion with undiagnosed disease. We reviewed the different population-based studies from India and compare their findings. The lacunae in ophthalmic care that can be inferred from these studies are identified and possible reasons and solutions are discussed. We also discuss the clinical relevance of the various findings, and how it reflects on clinical practice in the country. Since India has a significantly high disease burden, we examine the possibility of population-based screening for disease in the Indian context.

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Complicated glaucomas present considerable diagnostic and management challenges. Response to treatment can be unpredictable or reduced compared with other glaucomas. However, target intraocular pressure and preservation of vision may be achieved with selected medical, laser and surgical treatment. The evidence for such treatment is expanding and consequently affords clinicians a better understanding of established and novel techniques. Herein we review the mechanisms involved in the development of complicated glaucoma and the current evidence supporting its management.

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Glaucoma care is more an art than science. The introduction of several new classes of glaucoma medications and the completion of many large randomized clinical trials have not changed this fact. While we now have better choices when initiating glaucoma therapy relative to our predecessors, the principles of glaucoma therapy have not changed much during this period. Debates continue regarding the utility of concepts such as "the monocular therapeutic trial," "target intraocular pressure (IOP)," and "maximal medical therapy." Our tools for detecting and following glaucomatous disease have improved but are not precise enough for us to prospectively predict which patients will do better or worse than others. Much attention has been given to disease stage, rate of progression, and compliance with medications but regular patient follow-up, an area that has received little attention, may be among the most important predictors of patient outcomes.

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Lasers have been used in the treatment of primary open angle glaucoma (POAG) over the years, with the hope that they would eventually replace medical and surgical therapy. Laser trabeculoplasty (LT) is an application of argon, diode, or selective laser energy to the surface of the trabecular meshwork to increase the aqueous outflow. The mechanisms by which intraocular pressure (IOP) is lowered could be mechanical, biologic, or by division of adjacent cells. It is commonly used as an adjunct to medical therapy, but is contraindicated if the angle is obstructed, e.g., peripheral anterior synechia (PAS) or developmental glaucomas. About 75% of individuals will show a significant fall in IOP after argon laser trabeculoplasty (ALT), and the response is similar with selective laser trabeculoplasty (SLT). The effects of LT are not always long lasting, with about 10% of individuals showing a rise in IOP with every passing year. Laser thermal sclerostomy, ab interno or externo, is an alternative to other full-thickness filtration procedures. Longer wavelengths in the infrared range have water-absorptive characteristics that facilitate perforation of the sclera. These lasers can be used to avoid intraocular instrumentation and minimize conjunctival trauma.

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Glaucoma is a preventable cause of blindness if timely effective and successful treatment is provided. Patient adherence to the medication is a constant challenge that is now recognized as an essential component to treatment. Several studies have demonstrated that patients are more likely to be adherent to their medication if they understand the disease and the rationale for treatment and if their treatment regimen is simplified. Additionally, using eye drops has its own set of challenges that must be recognized and addressed at the clinical level. Although numerous socioeconomic factors are associated with poor adherence, these factors must be addressed at the societal level. Maximizing patient adherence to medication has the potential to reduce the number of surgical interventions required to treat glaucoma, prevent unnecessary vision loss, and save the overall healthcare system money in the long run.

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As all developed countries are struggling with health care costs growing too large and too fast, the current performance and overburden of glaucoma services demand a reappraisal of current management strategies. The performance of the glaucoma care in western countries offers several opportunities to improve the simultaneous under- and over-diagnosis and treatment. Since available resources are finite, they should be targeted to produce the best eye health. There is an obvious need for prioritization of all interventions, including improving case finding. The limited evidence to date indicates that we do not have enough evidence to decide whether systematic population screening could be cost-effective in the developed world. This article gives an overview of the methods of economic evaluation and the evidence on cost-effectiveness of systematic screening for glaucoma in the developed world, need for future research and challenges related to evaluation of increasing economic literature as well as need to change behaviors on the basis of evidence.

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