Primary glaucoma

In 1952, at the All-Union Congress on Glaucoma, the classification proposed by Professor B. L. Polyak was adopted.

The classification reflects the main clinical forms of glaucoma, the dynamics of the process - the state of the eye function and the degree of compensation of intraocular pressure.

• Forms: congestive and simple glaucoma.
• Stages: initial, developed, advanced, almost absolute and absolute.
• By degree of compensation: compensated, subcompensated, uncompensated, decompensated.

[ 1 ], [ 2 ], [ 3 ], [ 4 ]

Congestive glaucoma

Congestive glaucoma is the most common form of glaucoma. It is characterized by a number of characteristic changes in the anterior segment of the eye. Most often, glaucoma is characterized by a long-term chronic course. Very rarely, the disease begins acutely, as the first attack in a previously healthy eye. Glaucoma usually affects both eyes, but the process begins first in one. The interval between the diseases of both eyes is usually small: several months, a year, two. But there are often cases when glaucoma in the second eye is detected many years (10-15) after it was detected in the first eye.

The congestive form of glaucoma is characterized by the appearance of early subjective signs, which facilitates early diagnosis of the disease. In the initial stage, patients complain of blurred vision, the appearance of rainbow circles, discomfort, sometimes slight pain in the eye area, changes in refraction - the appearance of myopia. Often these symptoms appear after emotional stress, mental and physical overload. The cause of these complaints is a short-term increase in intraocular pressure, causing transient, unstable changes in the anterior segment of the eye.

In the initial stages of congestive glaucoma there are no organic changes in the organ of vision. Periods of increase in intraocular pressure are short-term, therefore, when examining patients, visual acuity and visual field are unchanged, and there are no changes in the optic nerve. The initial period lasts from several days to a year.

Over time, the increase in intraocular pressure reoccurs more frequently, periods of increased intraocular pressure become longer, and glaucoma progresses to the stage of pronounced congestive glaucoma. At this stage, persistent objective changes appear in the anterior segment of the eye, and visual impairment is detected.

In the advanced stage of congestive glaucoma the following are observed:

1. congestive hyperemia of the anterior ciliary vessels. These vessels are visible on the sclera near the limbus and are a continuation of the muscular arteries and veins;
2. corneal dullness;
3. decreased sensitivity of the cornea. Decreased sensitivity of the cornea occurs as a result of compression of the sensory endings, and later - as a result of deep trophic disorders in them;
4. decrease in the depth of the anterior chamber as a result of an increase in the volume of the vitreous body;
5. the pupil is slightly dilated, sometimes has the shape of a vertically elongated oval, sluggishly reacts to light. This depends on the compression of the ciliary nerves and the onset of atrophy of the iris, an increase in the tone of the sympathetic nervous system;
6. ophthalmoscopy reveals optic nerve atrophy, disc excavation, kinking and displacement of blood vessels;
7. At the same time, the functions of the eye are impaired: central vision is reduced, the field of vision narrows (first from the inside, then along the rest of the periphery), the blind spot is usually enlarged and merges with the defect in the field of vision.

With a sharp narrowing of the visual field not only from the nasal side, but also from other sides, and a decrease in visual acuity, one can think of advanced glaucoma.

As a result of the continuing atrophy of the optic fibers, almost absolute glaucoma may occur, when the patient is only able to detect hand movement or light.

[ 5 ], [ 6 ], [ 7 ], [ 8 ], [ 9 ], [ 10 ]

Absolute glaucoma

Absolute glaucoma is the sad end of the disease, when vision is completely lost (zero).

The transition of glaucoma from one stage to another occurs gradually or quickly depending on the degree of compensation of the process in a given patient. To achieve a state of glaucoma compensation means to stop the development of glaucoma. With compensated (non-progressive) glaucoma, visual functions are preserved. To do this, it is necessary to create the right conditions for treatment and regimen (work and life) for the patient from the very beginning of the disease (at the stage of initial glaucoma). To compensate glaucoma, it is necessary, first of all, to ensure the normalization of intraocular pressure.

Depending on the degree of compensation of the glaucomatous process, a distinction is made between:

1. compensated glaucoma, in which intraocular pressure is normalized thanks to treatment and visual functions do not decline;
2. subcompensated, in which intraocular pressure fluctuates between 23 and 35 mm Hg;
3. uncompensated, in which intraocular pressure exceeds 35 mm Hg;
4. decompensated glaucoma, or its acute period, in which all the phenomena characteristic of initial glaucoma are present, but expressed in a mild form and occurring suddenly.

Comparative features of glaucoma and iritis

Glaucoma attack Attack of iritis 1. Intraocular pressure is increased 1. Intraocular pressure is usually normal and only sometimes slightly lowered or slightly higher 2. The cornea is swollen, cloudy, and punctured. 2. The cornea is normal 3. There is dilation of the venous vessels on the eyeball 3. Significant ciliary injection 4. The pupil is wider than on the healthy side 4. The pupil, if not dilated by atropine, is narrower than on the other side 5. Corneal sensitivity is reduced 5. Corneal sensitivity is normal 6. The front camera is small 6. Anterior chamber of normal depth 7. Pain radiates to the forehead, jaw, and back of the head 7. Pain in the eye itself 8. Complaints of rainbow-colored circles before the eye 8. There are no rainbow circles

These symptoms are mainly related to congestive glaucoma.

[ 11 ], [ 12 ], [ 13 ], [ 14 ], [ 15 ], [ 16 ], [ 17 ]

Simple glaucoma

Simple glaucoma is much less common than congestive glaucoma: 4-5% of cases compared to congestive glaucoma. It occurs without objective changes in the anterior segment of the eye. The disease begins unnoticed, so that patients very often do not suspect that one of their eyes is affected, and discover this by accident.

The appearance of the eyes in simple glaucoma is normal: irritation is completely absent, occasionally one can notice slightly dilated veins and a slightly dilated pupil that weakly reacts to light. The main symptom of glaucoma - increased intraocular pressure - in simple glaucoma may be only weakly expressed.

Often, during the first examination, the intraocular pressure turns out to be normal, and only by repeated and systematic measurement at different hours over several days can some increase and instability of this pressure be established. At the same time, it turns out that in the evening the pressure is significantly lower than in the morning (a difference of 5 mm Hg will speak in favor of glaucoma).

With simple glaucoma, as with congestive glaucoma, the field of vision gradually decreases and visual acuity falls. Since the pupil glows grayish and therefore does not seem completely clear, an inexperienced doctor who does not have ophthalmoscopy techniques may mistake simple glaucoma for senile cataract. In essence, simple and congestive glaucoma are the same disease, and these forms can transform into each other: congestive glaucoma transforms into simple and vice versa.

Simple glaucoma, unlike congestive glaucoma, is characterized by a smooth, slow course, increases in intraocular pressure are low, sharp fluctuations in intraocular pressure are rare. But the disease progresses steadily.

The main symptoms of simple glaucoma are increased pressure, development of optic nerve atrophy with excavation of its disk, narrowing of the visual field and decreased visual acuity. The absence of early subjective sensations leads to the fact that patients seek medical attention only when visual functions are reduced, i.e., when irreversible changes have already occurred. Often, vision in one eye is completely lost or sharply reduced. Late visits to the doctor by the patient correspondingly worsen the prognosis of simple glaucoma. With late recognition and irregular treatment of glaucoma, blindness occurs.

Absolute glaucoma is the outcome of all clinical forms of glaucoma that proceed unfavorably and end in blindness. Under the influence of constantly acting increased ophthalmotonus, circulatory and metabolic disorders in the eye tissues, sharp atrophic changes occur, the function completely fades away, the eye is hard as a stone. Sometimes severe pain begins. Absolute glaucoma becomes absolute painful glaucoma. In the eye with absolute glaucoma, dystrophic processes are noted, the cornea is often affected in the form of dystrophic keratitis, corneal ulcers, etc. Dystrophic ulcers can become infected, a purulent corneal ulcer develops, often ending in a corneal perforation. When the cornea is punctured in an eye with high intraocular pressure, an expulsive hemorrhage may swell - a rupture of the long posterior ciliary arteries under the choroid. In this case, all or part of the membranes of the eyeball are pushed out of the eyeball under the pressure of blood.

In 1975, at the All-Union Congress of Ophthalmologists on the pathophysiological mechanisms of hypertension, the following forms were identified:

1. closed-angle glaucoma, in which the increase in intraocular pressure is caused by a blockade of the anterior chamber angle, intraocular structures (iris, lens, vitreous body) or goniosynechiae;
2. open-angle glaucoma caused by damage to the drainage system of the eye;
3. mixed glaucoma, in which both mechanisms of increasing intraocular pressure are combined. There is also non-glaucoma ophthalmic hypertension, caused by an imbalance between the production and outflow of aqueous humor of the eye.

When formulating a diagnosis, the stages of glaucoma are designated.

• Stage I (initial) - the peripheral field of vision is normal, but there are defects in the central field of vision. The fundus is without visible changes, but a small excavation of the optic disc may already be noted, not reaching its edge.
• (Stage I (advanced) - the peripheral field of vision is narrowed on the nasal side by more than 10°, excavation of the optic nerve disc is moderately expressed and reaches the edge in some areas.
• Stage III (advanced) - the peripheral field of vision is narrowed on the nasal side to 15°, deep marginal excavation of the optic nerve head.
• Stage IV (terminal) - there is no object vision or light perception is preserved with incorrect projection of light, total excavation and atrophy of the optic nerve.

The state of intraocular pressure. The following gradations are used to indicate it:

• A - normal pressure (does not exceed 21 mm Hg);
• B - moderately elevated blood pressure (from 22 to 32 mm Hg);
• C - high blood pressure (more than 32 mm Hg).

Dynamics of the glaucoma process:

1. stabilized glaucoma - with long-term observation (at least three months), the condition of the visual field and optic nerve head remains stable;
2. Unstabilized glaucoma - the narrowing of the visual field and excavation of the optic disc increase. Primary open-angle glaucoma. Primary acute-angle glaucoma also occurs in young people, but it is more typical for mature and elderly people and is the most common form of glaucoma. The disease is observed equally often in both men and women. Primary open-angle glaucoma is considered a genetic disease, in most cases, polygenic transmission of the disease is noted.