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Glaucoma and Systemic Diseases

As editors of Glaucoma Now and together with our publishing team we are happy to present our issue for 2020 with the main topic: Glaucoma and Systemic Diseases. In this issue, well known experts (M. Bruce Shields, Karin Pillunat, Paul Healey and Denis Wakefield) share their wealth of knowledge and experience to stimulate us.

Inside This Issue
Special Focus: The Glaucomatous Process: An Historical Perspective
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Author: M. Bruce Shields, M.D.
Marvin L. Sears Professor Emeritus, Department of Ophthalmology and Visual Science, Yale University School of Medicine, USA


Core Concepts

  • The definition of glaucoma has evolved since ancient times to the present understanding of a group of characteristic optic neuropathies.
  • Manifest glaucoma has the two basic stages of optic nerve damage and progressive loss of visual field.
  • The glaucomatous process includes three pre-manifest stages (initial event, early ocular tissue alteration and pre-neuropathy event) and the two manifest stages. 
  • All glaucomas have the five stages of the glaucomatous process, which is important to recognize in order to know how closely to follow each patient and when and how to treat.
  • Since all forms of glaucoma share the five stages of the glaucomatous process, it may be that primary and secondary divisions should be reconsidered in future classifications of the glaucomas.
What’s New: Glaucoma in patients with high blood pressure and arteriosclerosis
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Author: Karin R. Pillunat, MD, PhD; Lutz E. Pillunat, MD, PhD
Department of Ophthalmology, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany


Core Concepts

  • Chronic systemic diseases, such as arterial hypertension (aHTN), vascular dysregulation, cardiac arrhythmia and dyslipidemia may be modifiable risk factors for primary open-angle glaucoma (POAG).
  • Despite conflicting findings, most of the population-based glaucoma studies do describe an association be-tween aHTN and POAG.
  • Arterial HTN is a common comorbidity in patients with POAG.
  • Sleep-time systemic hypotension is associated with progression of the disease and needs to be sought and avoided.
  • Blood pressure fluctuations and intraocular pressure (IOP) fluctuations cause fluctuations in ocular perfusion pressures, which in turn cause blood flow instability and oxidative stress at the optic nerve head (ONH) com-pounded by  the deficient autoregulation capacity associated with POAG.
  • Primary vascular dysregulation (PVD) is often associated with low blood pressure and vasospastic symptoms. Most of the symptoms result from an impaired autoregulation of blood sup-ply. The condition is associated with a higher risk of normal pressure glaucoma (NPG).
  • Atrial fibrillation (AF) has been shown to increase the risk of developing NPG.
  • Hypercholesterolemia might be asso-ciated with POAG. Long-term statin use seems to be associated with a reduced incidence of POAG.
Clinical Issues: Glaucoma and Diabetes
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Author: Paul R. Healey BMedSc, MBBS(Hons) MMed, PhD, FRANZCO Clinical Associate Professor, Sydney University
Glaucoma Service, Westmead & Sydney Eye Hospitals


Core Concepts

  • Glaucoma and Diabetes have a complex relationship:
  • Primary open angle glaucoma is more common in people with diabetes.
  • Elevated glucose levels are partially neuroprotective for ischaemic and glaucomatous ganglion cells.
  • Diabetic vascular disease may cause ocular ischemia, and even secondary angle closure through neovascularisation of the iridocorneal angle.
  • Intravitreal injections for diabetic retin-opathy or maculopathy can cause acute (usually transient) and chronic (often sustained) elevations in intraocular pressure (IOP) which can place glaucomatous stress on the optic nerve.
  • Long acting intravitreal steroids such as off-label triamcinolone as well as fluocinolone or dexamethasone implants can increase IOP through the steroid response.
Practical Tips: Glaucoma and systemic disease
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Author: Denis Wakefield MD, DSc, FRACP, FRCPA
Professor of Medicine, University of NSW and Director Sutherland Centre of Immunology, Sydney, Australia.


Core Concepts

  • Glaucoma may be associated with common systemic diseases
  • Spondylo-arthritis in adults and  JIA (Juvenile Idiopathic Arthritis) in children are associated with inflammatory eye disease and glaucoma.
  • Acute and chronic ocular infections are associated with glaucoma.
  • Sleep apnoea is associated with hypertension and raised IOP.
  • Drugs, particularly corticosteroids, may precipitate glaucoma.