John C. Morrison, M.D.	Irvin P. Pollack, M.D.
Professor of Ophthalmology	Professor of Ophthalmology
Oregon Health and Science University	The Johns Hopkins University
And	And
Director of the Glaucoma Service	Emeritus
The Fred P. Thompson Glaucoma Clinic	Ophthalmologist-In-Chief and
and Casey Eye Institute	Director Krieger Eye Institute
Portland, Oregon	Sinai Hospital of Baltimore
	Baltimore Maryland

Thieme

New York • Stuttgart

Consulting Editor: Esther Gumpert

Editorial Assistant: Owen Zurhellen

Director, Production and Manufacturing: Anne Vinnicombe

Production Editor: Becky Dille

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Library of Congress Cataloging-in-Publication Data

Glaucoma : a clinical guide / [edited by] John C. Morrison, Irvin P. Pollack p. ; cm.

Includes bibliograpical references.

ISBN 0-86577-915-5 (TMP : alk. paper) -- ISBN 3131246715 (GTV : alk. paper) 1. Glaucoma. I. Morrison, John C., 1951 - II. Pollack, Irvin P.

[DNLM: 1. Glaucoma. WW 290 G54935 2003] RE871 .G5437 2003

617.7'41--dc21

2002075001

Copyright © 2003 by Thieme Medical Publishers, Inc. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution. This applies in particular to Photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage.

Important note: Medical knowledge is ever-changing. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may be required. The authors and editors of the material herein have consulted sources believed to be reliable in their efforts to provide information that is complete and in accord with the standards accepted at the time of publication. However, in the view of the possibility of human error by the authors, editors, or publisher, of the work herein, or changes in medical knowledge, neither the authors, editors, or publisher, nor any other party who has been involved in the preparation of this work, warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from use of such information. Readers are encouraged to confirm the information contained herein with other sources. For example, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this publication is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs.

Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

Printed in Hong Kong 5 4 3 2 1

TMP ISBN 0-86577-915-5

GTV ISBN 3 13 124671 5

To our wives, Lynne and Marlene And to our families

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .		xi
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .		xv
Section I. Epidemiology and Genetics of Glaucoma
1.	Epidemiology of Glaucoma—Anne L. Coleman, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	2
2.	Glaucoma Genetics—Mary K. Wirtz, Ph.D. and John R. Samples, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . .	12

Section II. Determinants of Intraocular Pressure

3.Anatomy and Physiology of Aqueous Humor Formation—John C. Morrison, M.D.,

	Thomas F. Freddo, O.D., Ph.D., and Carol B. Toris, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	24
4.	Anatomy and Physiology of Aqueous Humor Outflow—John C. Morrison, M.D.
	and Ted S. Acott, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	34
5.	Gonioscopy—Julia Whiteside-Michel, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	42
6.	Intraocular Pressure and Tonometry—Henry Jampel, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	57
7.	Aqueous Humor Dynamics—Carol B. Toris, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	70
Section III. The Optic Nerve
8.	Anatomy and Physiology of the Optic Nerve—James E. Morgan, M.D., and John C. Morrison, M.D. . . . . .	80

9.Clinical Evaluation of the Optic Nerve Head—Mamdouh Nakla, M.D.

	and Joseph Caprioli, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	90
10.	Glaucomatous Optic Neuropathy—Mamdouh Nakla, M.D., Joseph Caprioli, M.D.
	and James A. Morgan, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	94
11.	Quantitative Imaging of the Optic Disc—Balwantray C. Chauhan, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . .	106
12.	Evaluating the Nerve Fiber Layer—Pait Teesalu, M.D., Ph.D.,
	and P. Juhani Airaksinen, M.D., Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	114
13.	Perimetry—Chris Johnson, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	125
Section IV. The Glaucomas
14.	Classification of Glaucoma—John C. Morrison, M.D., and Irvin P. Pollack, M.D. . . . . . . . . . . . . . . . . . .	150
15.	Primary Open-Angle Glaucoma—Monica Y. Allen, M.D., and Eve J. Higginbotham, M.D. . . . . . . . . . .	153
16.	Angle-Closure Glaucoma—Irvin P. Pollack, M.D. and Jacob Wilensky, M.D. . . . . . . . . . . . . . . . . . . . . . .	163
17.	Childhood Glaucoma—John R. Samples, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	181
18.	Steroid-Induced Glaucoma—Abbot F. Clark, Ph.D. and John C. Morrison, M.D. . . . . . . . . . . . . . . . . . .	197
19.	Pigment Dispersion Syndrome and Pigmentary Glaucoma—Donald A. Abrams, M.D. . . . . . . . . . . . . .	207
20.	Pseudoexfoliation Syndrome and Glaucoma—Douglas H. Johnson, M.D. . . . . . . . . . . . . . . . . . . . . . . . .	215
21.	Neovascular Glaucoma—John C. Morrison, M.D. and Michael L. Klein, M.D. . . . . . . . . . . . . . . . . . . . . .	226
22.	Iridocorneal Endothelial Syndrome—Annapurna Singh, M.D. ,
	and Jody R. Piltz-Seymour, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	237
23.	Elevated Episcleral Venous Pressure and Glaucoma—Michael Passo, M.D. . . . . . . . . . . . . . . . . . . . . . . .	243
24.	Ocular Trauma, Hemorrhage, and Glaucoma—Scott Elliot LaBorwit, M.D. . . . . . . . . . . . . . . . . . . . . . . .	250
25.	Lens–Induced Glaucoma-F. Jane Durcan, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	261

	CONTENTS	• vii
26.	Ocular Inflammation and Glaucoma—John C. Morrison, M.D.,
	and James T. Rosenbaum, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	274
27.	Retinal Disorders and Glaucoma—Albert O. Edwards, M.D., Ph.D., and Yuri Ishihara, M.D. . . . . . . . . .	291
28.	Glaucoma After Anterior Segment Surgery—Martin B. Wax, M.D.,
	and James Umlas, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	305
29.	Intraocular Tumors and Glaucoma—Christopher D. Pelzek, M.D.,
	and Andrew P. Schachat, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	321
30.	Systemic Diseases and Glaucoma—Andreas Katsuya Lauer, M.D., and John C. Morrison, M.D. . . . . .	334
Section V. Medical Therapy of Glaucoma
31.	Principles of Ocular Medications—Reay H. Brown, M.D., and Gary D. Novack, Ph.D. . . . . . . . . . . . . . .	354
32.	Adrenergic Agonists—Janet B. Serle, M.D., and Anthony C. Castelbuono, M.D. . . . . . . . . . . . . . . . . . . .	363
33.	Adrenergic Antagonists—Paul Rafuse, M.D., Ph. D., F.R.C.S.C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	374
34.	Cholinergic Agents—Robert J. Derick, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	383
35.	Prostaglandin Analogs—David Lawlor, M.D., Carol B. Toris, Ph.D., and Carl B. Camras, M.D. . . . . . . .	391
36.	Carbonic Anhydrase Inhibitors—Ivan Goldberg, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	399
37.	Hyperosmotic Agents—Janet B. Serle, M.D., John Danias, M.D., Ph.D.,
	and Donna J. Gagliuso, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	406
38.	Neuroprotection—Elaine C. Johnson, Sc.D., and John C. Morrison, M.D. . . . . . . . . . . . . . . . . . . . . . . . . .	412
Section VI. Laser Therapy of Glaucoma
39.	Basics of Lasers—Douglas E. Gaasterland, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	426
40.	Laser Trabeculoplasty—Alan L. Robin, M.D., and Miray Hamparian, M.D. . . . . . . . . . . . . . . . . . . . . . . .	430
41.	Laser Iridotomy—Alan L. Robin, M.D., and Babak Eliassi-Rad, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . .	439
42.	Cyclodestruction—Irvin P. Pollack, M.D., and John S. Pollack, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	446
Section VII. Surgical Therapy of Glaucoma
43.	Filtration Surgery—Allan E. Kolker, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	458
44.	Cataract Surgery and Glaucoma—Kuldev Singh, M.D., Rommel Bautista, M.D.,
	and Weldon W. Haw, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	471
45.	Aqueous Shunts—Paul A. Sidoti, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	481
46.	Ocular Hypotony—Mary G. Lynch, M.D., and Reay H. Brown, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . .	498
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .		509

Foreword 1

Rapid advances in knowledge about glaucomatous diseases make it more difficult for textbooks to keep up-to- date. The increasing degree of sub-specialization and developments in technology, basic research, pharmacology, and surgery, further add to the problems encountered by efforts made to produce a timely, coherent, and inclusive glaucoma textbook by one or two authors. Multi-authored texts, on the one hand, often sacrifice uniformity of style and content and can introduce variations in quality as well as unnecessary duplication. On the other hand, they can provide the most timely expertise and stimulating controversial points of view. Most important, the juxtaposition of research and practice in such books requires the authors and the readers to attempt to bridge the gap between the laboratory and the clinical problems. Such two-way interactions are necessary if progress is to be made in “translational research.” This can increase our understanding of the pathogenesis of the glaucomas, improve methods of diagnosis and treatment, and ultimately their prevention.

I have had the opportunity to review all chapters of

Glaucoma: Science and Practice and found them to be up- to-date, stimulating and remarkably coherent. This is in no small part due to the excellent editorial work by Morrison and Pollock. They are to be congratulated for the organization of subjects and the selection of experts for each chapter, as well as the editing of the final product. This single volume should prove most useful to the student, resident or fellow who want to acquire authoritative information about all aspects of the disease. It also will appeal to the clinician and basic scientist, as well as stimulating the all-important potential clinician-scientist. It presents them with the current status of our knowledge, as well as confronting them with the outstanding problems presented by the glaucoma patient.

Bernard Becker, M.D.

St. Louis, Missouri

Foreword 2

Of the professorial aphorisms swirling amid those vulnerable first years of a new career, one indelibly seared my mind with a daunting, yet lasting, revelation: “You will be known by the people you train.” Even now, as I sit in an audience, strange emotions stir whenever one of my former students ascends the podium. From their roots in the ancient world, physicians have always been called on both to heal and to teach, the latter, perhaps, the more sacred of duties. Healing helps one at a time, but the passing of the knowledge reaches millions for generations to come.

Teachers of medicine can feel no greater joy than when their own students embark on a project of sharing their knowledge, as one of my first glaucoma postgraduate fellows, Dr. John Morrison, with Dr. Irvin Pollack, has undertaken with this volume. To do so exhaustively, in a complete book of the science and practice of glaucoma, compounds the pleasure for the mentor. Drs Pollack and Morrison, editors of Glaucoma: Science and Practice, have assembled a remarkable group of expert authors, in many instances choosing among the most promising of their own students and colleagues, but always bringing the most valued experience and expertise to the page.

We live in a new Information Age, but some complain that random bytes so choke the wind as to defy interpretation. As never before, students, clinicians, and

the public struggle to separate scientific truth from smoky anecdotes generated from personal aggrandizement, academic survival, or aggressive marketing. Against the headwind of such data streams, students and clinicians yearn for information smelted in the crucible of credible scientific analysis. How appropriate, then, when a book on glaucoma opens with a discussion of epidemiology, that arcane key to interpretation of the data onslaught. The book devotes its first quarter to the science underlying the study of glaucoma. These clinician–scientist editors know that the understanding of the scientific basis for tests performed, diagnoses made and treatments available must underpin logical and successful glaucoma practice.

The book divides itself naturally into three segments, the scientific basis of glaucoma, the clinical entities of glaucoma and the therapy of glaucoma. The reader has available current information ranging from the very beginning of research on aqueous humor dynamics to the latest on the glaucoma genome. Here the novitiate can grasp the basis of glaucoma thought, how and where the aqueous flows, why and how the optic nerve becomes susceptible to damage, and how the intraocular pressure and optic nerve are measured. The chapters each stand alone as complete reviews of their individual subjects but

hang together in contiguity and continuity. For the purist, the text is all here, referenced both currently and historically. At the same time, for the more harried reader, side bars depict clinical Pearls, and Pitfalls. Highlighted Controversial Topics serve notice when not all the cognoscente agree and spice the glaucoma fascination.

The second section addresses classification and various entities of clinical glaucoma as we now recognize them. Morrison and Pollack review the evolution of classification schemes over time from the anatomical differences apparent decades ago through the more subtle clinical differences recorded recently, and can only anticipate further modification in future decades. Even as we cherish our nineteenth century books, we willingly make allowances for nuances of classification in the context of contemporary knowledge. We expect further transition as genotypic differentiation becomes possible. In the meantime, the text provides an accurate and worthy guide through the morass of clinical entities of glaucoma.

As conceptual change in glaucoma inches forward with each addition to the scientific literature, modes of therapy, described in the third section, leap forward in incremental bounds with fanfare of new drug strategies or technical innovations. Thirty years ago, the options for

FOREWORD • ix

glaucoma therapy were few and generally unpleasant. Now, the choice of drugs is vast with many options within each new category, their nuances often more reflective of marketing and fashion than science. Laser surgery has found its way into a broad spectrum of modalities and incisional surgery offers a host of varieties. Considering the dramatic changes in therapy over the past two decades, perhaps these sections on treatment are most vulnerable to obsolesce within any book. To compensate, the editors have selected authors who bring the latest modalities, the basis from which they have sprung, and the directions toward which they point.

In the final analysis, physicians can derive comfort from books on the shelf, those from both the past and the present. For the practicing lifetime, they become ready and friendly consultants. When our time is finished, our books remain as icons of what we read, what we knew, what we valued and who we were. Glaucoma: Science and Practice will sit proudly among my books, as a manifestation of my investment in my student and an outstanding glaucoma reference in its own right.

E. Michael Van Buskirk, M.D.

Portland, Oregon

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Contents

Foreword 1

Foreword 2