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Cholinergic agents such as pilocarpine appear to increase outflow by physically opening the meshwork pores secondary to ciliary muscle contraction cholesterol foods to help lower discount 20mg pravachol visa. Prostaglandins are thought to result in remodeling of extracellular matrix in the meshwork, thereby increasing outflow. The uveoscleral outflow of aqueous humor is increased by prostaglandin analogs and - and 2-adrenergic agonists. Either type can be a primary inherited disorder, congenital, or secondary to disease, trauma, or drugs and can lead to serious complications. Both primary and secondary glaucomas may be caused by a combination of open-angle and closed-angle mechanisms (Table 94-1). The risk of developing glaucoma increases with older age, family history of glaucoma, lower ocular perfusion pressure, lower blood pressure, thinner central cornea, optic disk hemorrhage, larger cup-to-disk ratio, and specific visual fields findings. More direct measurements of therapeutic outcome, such as optic disk examination and visual field evaluation, also must be used as monitors of disease progression. It consists of approximately 1 million retinal ganglion nerve cell axons, blood vessels, and supporting connective tissue structures (lamina cribrosa). A normal physiologic cup does not extend beyond the optic nerve rim and has a varying diameter of less than one-third to one-half that of the disk (cup-to-disk ratio: 0. These disk changes result from optic nerve axonal degeneration and remodeling of the supporting structures. A loss of retinal nerve fiber layer might be visualized in glaucoma patients with detectable visual field loss. This pattern of changes is consistent with visual field losses and loss of visual sensitivity seen in glaucoma. Newer methods of assessing damage to the retinal nerve fiber layer and optic disk have been described. These methods offer the ability to assess the damage to the optic nerve quantitatively. Determination of the visual field allows assessment of optic nerve damage and is an important monitoring parameter in treatment. However, visual field changes typically lag behind optic disk changes, and a loss of 25% to 35% of retinal ganglion cells is usually required before detectable visual field defects are noted. The peripheral visual field is measured using a visual field instrument called a perimeter. Other indicators, such as color vision changes and contrast sensitivity, may allow earlier and more sensitive detection of glaucomatous changes. Genetic studies have more clearly defined the underlying molecular events responsible for the Mendelian forms of the disease. However, the chromosome locations identified may play some factor in the more complex forms. The future of genetic studies in glaucoma will include discovery of new glaucoma genes, determination of clinical phenotypes associated with these genes and mutations, understanding how environmental factors interact, and developing a database that can be used for further testing. Genome-wide association studies have identified new loci that are associated with clinically relevant optic disk parameters, including the optic disk area and vertical cup-disk ratio.

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