Elsevier

The Lancet

Volume 377, Issue 9774, 16–22 April 2011, Pages 1367-1377
The Lancet

Seminar
Glaucoma

https://doi.org/10.1016/S0140-6736(10)61423-7Get rights and content

Summary

Most medical practitioners have regular contact with adults who have one of the two forms of glaucoma: open-angle glaucoma or angle-closure glaucoma. Data from population-based surveys indicate that one in 40 adults older than 40 years has glaucoma with loss of visual function, which equates to 60 million people worldwide being affected and 8·4 million being bilaterally blind. Even in developed countries, half of glaucoma cases are undiagnosed. Glaucoma is mostly asymptomatic until late in the disease when visual problems arise. Vision loss from glaucoma cannot be recovered, and improved case-detection methods for glaucoma are needed. Glaucoma is commonly treated with daily eye-drop drugs, but adherence to treatment is often unsatisfactory. As a usually asymptomatic and chronic disease, glaucoma has similar treatment challenges to chronic systemic diseases. Similarities to the pathogenesis of common CNS diseases mean that common neuroprotective strategies might exist. Successful gene therapy, which has been used for other eye diseases might be possible for the treatment of glaucoma in the future.

Section snippets

Clinical definitions

In 2002, an international consensus panel published definitions of open-angle glaucoma and angle-closure glaucoma that are now widely accepted.1, 2 For both disorders, glaucoma is now recognised to be an optic neuropathy and is thought to be present only when at least one eye has both typical structural and functional defects (optic disc damage and visual field loss). This combination of damage has to be sufficiently characteristic to indicate the death of a substantial number of retinal

Clinical features and risk factors

Open-angle glaucoma is distinguished from other optic neuropathies by slow progression over months to years.11 The clinical appearance of this form of glaucoma is distinguishable from ischaemic optic neuropathy12 or chiasmal tumour-induced neuropathy by the excavation or abnormal structural deepening of optic-disc connective tissue. Of retinal neurons, glaucoma affects only retinal ganglion cells13, 14—a loss that occurs selectively more rapidly in axons that pass through the upper and lower

Clinical features, risk factors, and pathogenesis

Although angle-closure glaucoma is often related to an acute, painful crisis associated with blurred vision, more than 75% of patients do not have an acute attack,80 instead they have an asymptomatic course with progressive loss of the visual field similar to that in patients with open-angle glaucoma. Worldwide, a third of patients with primary glaucoma have angle-closure glaucoma.1 The proportionate vision loss in angle-closure glaucoma might be as much as twice as great as open-angle

Other forms of glaucoma

Glaucoma is uncommon in children, with an estimated prevalence in the USA of fewer than three per 100 000 for all forms of glaucoma in those younger than 20 years.100 Many of these cases are primary childhood-onset glaucoma, which presents during the first year of life with symptoms of tearing and photophobia and signs of enlarged and cloudy corneas. There is substantial heritability, and three genetic loci have been identified for childhood glaucoma, with one gene clearly associated with the

Conclusions

Both open-angle and angle-closure glaucoma are commonly present in older people and, with the ageing of world populations, the number with both forms of glaucoma will substantially increase in the next decade.1 The diagnosis of glaucoma of each type requires a detailed eye examination, with tests of both structure and function of the eye. New developments in diagnostic testing might soon make this process more efficient. Therapy that lowers intraocular pressure slows the progress of open-angle

Search strategy and selection criteria

I searched the PubMed and Google Scholar databases up to August, 2010, and the International Glaucoma Review Abstracts (2005 to 2010), with the following search terms: “glaucoma”, “angle closure”, “open angle”, “pathogenesis”, “diagnosis”, “treatment”, “laser”, “surgery”, “genetics”, “childhood”, “secondary”, and “neovascular”, both alone and in combinations. I mostly selected publications from the past 5 years, but did not exclude important older publications. I also searched the reference

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