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Clinical Review ABC of Eyes

Glaucoma—1: Diagnosis

BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7431.97 (Published 09 January 2004) Cite this as: BMJ 2004;328:97

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  1. P T Khaw,
  2. A R Elkington

    Introduction

    The glaucomas are a range of disorders with a characteristic type of optic nerve damage. The glaucomas are the second commonest cause of blindness in the world, and the commonest cause of irreversible blindness. The most effective way of preventing this damage is to lower the intraocular pressure.

    Normally, the ciliary body secretes aqueous, which flows into the posterior chamber and through the pupil into the anterior chamber. It leaves the eye through the trabecular meshwork, flowing into Schlemm's canal and into episcleral veins. The flow and drainage can be obstructed in several ways.


    Embedded Image

    Normal aqueous drainage and possible sites of obstruction

    Symptoms and signs

    Raised intraocular pressure

    The intraocular pressure is determined by the balance between aqueous production inside the eye and aqueous drainage out of the eye through the trabecular meshwork. Each normal eye makes about 2 μl of aqueous a minute—that is, about 70 l during the course of a lifetime. Normal intraocular pressure is 10-21 mm Hg, but it can drop as low as 0 mm Hg in hypotony and can exceed 70 mm Hg in some glaucomas.

    The rate at which raised intraocular pressure causes optic nerve damage depends on many factors, including the pressure and whether glaucomatous damage is early or advanced. In general, pressures of 20-30 mm Hg usually cause damage over several years, but pressures of 40-50 mm Hg can cause rapid visual loss and also precipitate retinovascular occlusion.

    Haloes around lights and cloudy cornea

    The cornea is kept transparent by the continuous removal of fluid by the endothelial cells. When the pressure rises quickly (acute closed angle glaucoma), the cornea becomes waterlogged, causing a fall in visual acuity and creating haloes around lights (like looking at a light through frosted glass).

    Pain

    If the rise in pressure is slow, pain is not a feature of glaucoma until the pressure is extremely high. Pain is …

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