Secondary glaucoma due to other eye diseases

Classification: By etiology: inflammatory glaucoma; phacogenic glaucoma; vascular glaucoma; neovascular glaucoma; phlebohypertensive glaucoma; dystrophic glaucoma; traumatic glaucoma; postoperative glaucoma; neoplastic glaucoma. By IOP level: with normal IOP; with moderately elevated IOP; with high IOP. By degree of visual field changes and optic nerve disc damage: early stage;

advanced stage; far advanced stage; terminal stage. By course (dynamics of visual functions): stabilized; non-stabilized.

METHODS, APPROACHES AND DIAGNOSTIC PROCEDURES Diagnostic criteria Complaints and history Complaints: pain in the eye with irradiation of pain to the corresponding part of the head; blurred vision, decreased visual acuity; visual field constriction; discomfort in the eye. NB! Complaints and history depend on the etiology of secondary glaucoma. The course of secondary glaucoma is sometimes asymptomatic. History: presence of another disease of the visual organ; presence of general pathology or trauma. Physical examination: none. Laboratory investigations: none. Instrumental investigations: visometry: possible decrease in visual acuity; biomicroscopy: in any secondary glaucoma there may be iris dystrophy. In phacomorphic glaucoma there may be a shallow anterior chamber, the lens is opaque with a pearlescent tint; in uveal glaucoma posterior synechiae, occlusion and adhesion of the pupil. Hyphema, newly formed vessels may be present in vascular glaucoma. In traumatic glaucoma - damage to anterior chamber structures. In phacotopic glaucoma – absence or displacement of the lens, vitreous hernia. In neoplastic glaucoma – presence of + tissue in the anterior chamber angle. ophthalmoscopy: widening and deepening of excavation on the optic nerve disc, decoloration and asymmetry of the optic nerve disc; tonometry: elevation of IOP above the tolerance level; perimetry: visual field constriction, changes in the central visual field, presence of specific scotomas in the Bjerrum zone, enlargement of the blind spot; visual field constriction occurs mainly on the nasal side (in the upper nasal sector), more advanced stages are characterized by concentric visual field constriction. In the advanced stage of the disease, visual fields are narrowed by at least 5 degrees on the inner side, in far advanced stage visual fields in at least one meridian are narrowed and do not extend beyond 15 degrees from the fixation point. It is necessary to consider perimetric indices – MD and PSD. MD – mean deviation or mean defect, an indicator of overall visual field loss. The smaller

the indicator, the more pronounced the negative dynamics. PSD – pattern standard deviation (variability of defects) – accounting for possible scatter of pattern (target) visibility indicators depending on age, refraction, media transparency. Reflects the severity of focal visual field lesions. MD > -2 dB − normal; MD = -2 − -6 dB − early glaucoma; MD = -6 − -12 dB − advanced glaucoma; MD < -12 dB − far advanced glaucoma; PSD − indicator of irregularity of the hill of vision shape; PSD < 2 − normal. gonioscopy: various degrees of anterior chamber angle opening are assessed according to the Van Beuningen scheme (0-IV degree of opening), the presence of goniosynechiae, intensity of trabecular pigmentation (according to A.P. Nesterov's classification) are noted. ophthalmoscopy: during ophthalmoscopy, qualitative and quantitative assessment of the optic disc is performed. Qualitative assessment of the optic disc: widening and deepening of optic disc excavation; exposure and shift of the vascular bundle to the nasal side; decoloration of the optic nerve disc; contour of the neuroretinal rim, its absence or tendency to break through to the edge; peripapillary choroidal atrophy in the beta-zone. Quantitative assessment of the optic disc: size (area) of the optic disc; cup-to-disc ratio (C/D); neuroretinal rim to disc ratio. morphometric analysis of the optic nerve disc: signs of glaucomatous optic neuropathy based on refined quantitative assessment of the optic disc. pachymetry: allows more accurate evaluation of eye tonometry data. Tonometry data on eyes with cornea having central thickness greater than 570 μm need correction downward. Patients with CCT less than 520 μm need correction of tonometric indicators upward. echobiometry: allows assessment of the condition of internal eye structures when refractive media are opaque (topology, size, density of membranes, lens, vitreous body, etc.); ultrasound biomicroscopy: provides detailed echo-visualization, qualitative and quantitative assessment of spatial relationships of structural elements of the anterior segment of the eye (cornea, anterior and posterior chambers of the eye, ciliary body, iris and lens), as well as surgically formed outflow pathways after antiglaucoma operations; OCT of the anterior segment: allows measurement of corneal thickness throughout its extent with maximum accuracy, depth of the anterior chamber of the eye, as well as determination of the anterior chamber angle profile and measurement of its width. Assessment of

the magnitude of anterior chamber angle opening and functioning of drainage systems in patients with glaucoma. Indications for specialist consultations: consultation with otorhinolaryngologist and dentist regarding absence of chronic foci of infection; consultation with oncologist for neoplastic glaucoma to exclude generalization of the process; consultation with endocrinologist for vascular glaucoma; consultation with infectious disease specialist for inflammatory glaucoma. NB! In the presence of concomitant general pathology, a conclusion from the appropriate specialist regarding absence of contraindications to surgical treatment is necessary, as well as to identify etiological factors in the development of secondary glaucoma.

TREATMENT TACTICS AT THE OUTPATIENT LEVEL: Treatment principles: reduction of IOP (achievement of "target pressure"); treatment of the underlying disease that is the cause of secondary glaucoma development; improvement of ocular blood flow.

The main direction of glaucoma treatment is hypotensive therapy aimed at reducing IOP to prevent further irreversible progression of visual function impairment. Treatment begins with monotherapy using a first-choice medication. If it is ineffective, not tolerated, or contraindicated, treatment starts with another medication or switches to combination therapy. First-choice medications include non-selective beta-blockers and prostaglandin analogues. If first-choice medications are ineffective, second-line medications are added to the combination: M-cholinomimetics, carbonic anhydrase inhibitors, or alpha-agonists. The adequacy of the achieved hypotensive effect is regularly verified by monitoring visual function dynamics and the condition of the optic nerve disc. If local hypotensive therapy is ineffective, laser methods for reducing intraocular pressure or surgical treatment are employed, depending on the presence of indications.

CLINICAL PROTOCOL FOR DIAGNOSIS AND TREATMENT

pathogenetic mechanisms and clinical manifestations. [1,2]

Conditions for protocol revision: revision of the protocol 5 years after its publication and from the date of its entry into force or in the presence of new methods with evidence level. 7.5 List of references used: 1) Guidelines for the diagnosis and treatment of glaucoma in the Republic of Belarus, Minsk, 2012. 2) National guidelines on glaucoma (guide) for polyclinic physicians. Edition 1. Edited by Egorov E.A., Astakhov Yu.S., Shchuko A.G. Moscow, 2009. 3) Ophthalmoscopic characteristics of changes in the optic disc and nerve fiber layer in glaucoma (manual for physicians). A.V.Kuroedov, V.V.Gorodnichiy, V.Yu.Ogorodnikova, N.M.Solnov, Z.P.Kushim, A.S.Alexandrov, K.V.Kuznetsov, A.Yu.Makarova. Moscow, 2011. 4) Terminology and guidelines for glaucoma. European Glaucoma Society, 4th edition, 2014. 5) The Ahmed shunt versus the Baerveldt shunt for refractory glaucoma: a metaanalysis. Wang S, Gao X, Qian N. BMC Ophthalmol. 2016 Jun 8;16:83. 6) Efficacy and economic analysis of Ex-PRESS implantation versus trabeculectomy in uncontrolled glaucoma: a systematic review and Meta-analysis. Wang L, Sha F, Guo DD, Bi HS, Si JK, Du YX, Tang K. Int J Ophthalmol. 2016 Jan 18;9(1):124-31. 7) Device-modified trabeculectomy for glaucoma. Wang X, Khan R, Coleman A. Cochrane Database Syst Rev. 2015 Dec 1;(12). 8) Comparison of Ahmed glaucoma valve implantation and trabeculectomy for glaucoma: a systematic review and meta-analysis. HaiBo T, Xin K, ShiHeng L, Lin L. PLoS One. 2015 Feb 26;10(2). 9) Meta-analysis of randomized controlled trials comparing EX-PRESS implantation with trabeculectomy for open-angle glaucoma. Wang W, Zhang X. PLoS One. 2014 Jun 27;9(6).

10) Summary of Glaucoma Diagnostic Testing Accuracy: An Evidence-Based MetaAnalysis. Ahmed S, Khan Z, Si F, Mao A, Pan I, Yazdi F, Tsertsvadze A, Hutnik C, Moher D, Tingey D, Trope GE, Damji KF, Tarride JE, Goeree R, Hodge W. J Clin Med Res. 2016 Sep;8(9):641-9. doi: 10.14740/jocmr2643w. Epub 2016 Jul 30. Erratum in: J Clin Med Res. 2017 Mar;9(3):231. 11) Optic nerve head and fibre layer imaging for diagnosing glaucoma. Michelessi M, Lucenteforte E, Oddone F, Brazzelli M, Parravano M, Franchi S, Ng SM, Virgili G. Cochrane Database Syst Rev. 2015 Nov 30;(11). 12) Efficacy of Additional Glaucoma Drainage Device Insertion in Refractory Glaucoma: Case Series with a Systematic Literature Review and Meta-Analysis. Lee NY, Hwang HB, Oh SH, Park CK. SeminOphthalmol. 2015;30(5-6). 13) Intraocular pressure-lowering effects of commonly used fixed-combination drugs with timolol: a systematic review and meta-analysis. Cheng JW, Cheng SW, Gao LD, Lu GC, Wei RL. PLoS One. 2012;7(9). 14) Fluorouracil in initial trabeculectomy. A prospective, randomized, multicenter study. Goldenfeld M, Krupin T, Ruderman JM, Wong PC, Rosenberg LF, Ritch R, Liebmann JM, Gieser DK. Ophthalmology. 1994 Jun;101. 15) Trabeculectomy with intraoperative mitomycin C versus 5-fluorouracil. Prospective randomized clinical trial. Singh K, Mehta K, Shaikh NM, Tsai JC, Moster MR, Budenz DL, Greenfield DS, Chen PP, Cohen JS, Baerveldt GS, Shaikh S. Ophthalmology. 2000 Dec;107(12):2305-9. 16) The Effects of Bevacizumab in Augmenting Trabeculectomy for Glaucoma: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Liu X, Du L, Li N.Medicine (Baltimore). 2016 Apr;95(15). 17) Anti-VEGF agents with or without antimetabolites in trabeculectomy for glaucoma: a meta-analysis. Xiong Q, Li Z, Li Z, Zhu Y, Abdulhalim S, Wang P, Cai X. PLoS One. 2014 Feb 11;9(2).

Secondary glaucoma Appendix 1

COMPLAINTS

Approved by the Joint Commission on Quality of Medical Services of the Ministry of Health

of the Republic of Kazakhstan on September 15, 2017

Protocol No. 27

SECONDARY GLAUCOMA DUE TO OTHER EYE DISEASES

INTRODUCTORY PART

ICD-10 Code(s):

Code Name

H40.5

Secondary glaucoma due to other eye diseases

H40.8

Other glaucoma

H40.9

Glaucoma, unspecified

Date of protocol development/revision: 2013 (revised 2017).

Abbreviations used in the protocol: IOP – intraocular pressure ONH – optic nerve head ACG – angle-closure glaucoma OAG – open-angle glaucoma AAG – acute angle-closure glaucoma attack NTG – normal (low) tension glaucoma ACA – anterior chamber angle NRR – neuroretinal rim CCT – central corneal thickness CRA – central retinal artery SPCA – short posterior ciliary arteries

Protocol users: general practitioners, ophthalmologists.

Patient category: adults.

Evidence level scale: A High-quality meta-analysis, systematic review of RCTs or large RCT with very low probability (++) of systematic error, the results of which can be applied to the

corresponding population. B High-quality (++) systematic review of cohort or

case-control studies or High-quality (++) cohort or case-control studies with very low risk of systematic error or RCT with low (+) risk of systematic error, the results of which can be applied to the corresponding population. C Cohort or case-control study or controlled study without randomization with low risk of systematic error (+). The results of which can be applied to the corresponding population or RCT with very low or low risk of systematic error (++ or +), the results of which cannot be directly applied to the corresponding population. D Case series description or uncontrolled study or expert opinion. GPP Good Practice Point.

Diagnostic algorithm (Appendix 1).

Differential diagnosis and justification for additional

investigations NB! Differential diagnosis is conducted between phacomorphic, phacolytic glaucoma and acute angle-closure glaucoma attack.

Diagnosis Justification for Examinations Exclusion criteria differential diagnosis

diagnosis

Phacomorphic Significant Visual acuity Absence of glaucoma elevation of light perception intraocular vision pressure Anterior chamber Shallow Pronounced congestive injection of the eyeball Aqueous humor Clear Pain Lens White-gray color with pearlescent tint Phacolytic glaucoma Significant elevation of intraocular pressure

Pronounced congestive injection of the eyeball Pain Echography data Visual acuity

Anterior chamber Aqueous humor Lens Data Lens size increased Absence of light perception vision

Medium depth Opalescent

Milky color

Lens size echography Acute angle-closure glaucoma attack Significant elevation of intraocular pressure

Pronounced congestive injection of the eyeball Pain Visual acuity

Anterior chamber Aqueous humor Lens Echography data

normal or decreased Decreased, rainbow halos when looking at light Shallow Clear

May have varying degrees of opacities

Lens size does not change

Non-pharmacological treatment: Regimen: IV; Diet No. 15.

Pharmacological treatment: At the outpatient level, pharmacological treatment includes local hypotensive therapy drugs, as well as drugs for pharmacological

support of surgical treatment (anti-inflammatory, antibacterial, carbonic anhydrase inhibitors, antiseptics, antimetabolites).

List of essential medicines (with 100% probability

of use);

Drug group

Non-selective beta-blockers Prostaglandin analogues

Glucocorticoids for local/systemic

use

Antimicrobial drug of the

fluoroquinolone group for local use in

ophthalmology M-anticholinergic

International nonproprietary

name of drug

Timolol maleate eye drops Latanoprost eye drops Travoprost eye drops Tafluprost eye drops Dexamethasone* eye drops

Levofloxacin eye drops

Tropicamide eye drops

Method of administration

instillations into the conjunctival sac 2 drops 2 times daily instillations into the conjunctival sac 1 drop once daily instillations into the conjunctival sac 1 drop once daily instillations into the conjunctival sac 1 drop once daily instillations into the conjunctival sac 2 drops 6 times daily after surgery and then according to a tapering regimen instillations into the conjunctival sac 2 drops 5 times daily duration of use depending on severity of condition

instillations into the conjunctival sac 1 drop

Evidence

level A A A A B

B

C Glucocorticoids for Dexamethasone Subconjunctival B systemic use eye drops Parabulbar Local anesthetic Proxymetacaine Instillations into the conjunctival B agent eye drops sac immediately before surgical intervention and during surgery Carbonic anhydrase Acetazolamide Orally 1-2 capsules per day B inhibitors List of additional medicines (less than 100% probability of use) Drug group International Method of administration Evidence nonproprietary level name of drug Selective beta-blockers Betaxolol instillations into the conjunctival B sac 2 drops 2 times daily Carbonic anhydrase Dorzolamide instillations into the conjunctival B inhibitors sac 2 drops 2 times daily Carbonic anhydrase Brinzolamide instillations into the conjunctival B inhibitors sac 2 drops 2 times daily Alpha-adrenergic Brimonidin instillations into the conjunctival B agonist (Alpha-agonists) sac 2 drops 2 times daily M-cholinomimetic Pilocarpine instillations into the conjunctival sac, 2 drops 2 times a day

non-selective beta-adrenoblockers + prostaglandin analogues

Timolol maleate + travoprost*

instillations into the conjunctival sac, 1 drop once a day

Level B

Timolol maleate + latanoprost*

instillations into the conjunctival sac, 1 drop once a day

Level B Timolol maleate + tafluprost*

instillations into the conjunctival sac, 1 drop once a day

Level B

non-selective beta-adrenoblockers + carbonic anhydrase inhibitors

Timolol maleate + brinzolamide

instillations into the conjunctival sac, 2 drops 2 times a day

Level B

Timolol maleate + dorzolamide*

instillations into the conjunctival sac, 2 drops 2 times a day

Level B tear film protector

Sodium hyaluronate*

Instillations into the conjunctival sac, 2 drops 4 times a day

Level B

Nonsteroidal anti-inflammatory drug for topical use in ophthalmology

Bromfenac eye drops

Instillations into the conjunctival sac, 1 drop 2 times a day for 14 days

Level C

Antimicrobial drug of the fluoroquinolone group for topical use in ophthalmology

Moxifloxacin eye drops

Instillations into the conjunctival sac, 2 drops 5 times a day for 14 days

Level B

Antimicrobial drug of the fluoroquinolone group for topical use in ophthalmology

Ofloxacin eye drops

instillations into the conjunctival sac, 2 drops 5 times a day

duration of use depending on severity of condition

Level B

agent for topical use in ophthalmology

Proxymetacaine eye drops

Instillations into the conjunctival sac

Level B

• use of the drug after registration in the Republic of Kazakhstan

Surgical intervention

In secondary glaucoma, when local hypotensive therapy is ineffective, laser intervention is proposed: laser trabeculoplasty; laser gonioplasty, synechiolysis; laser iridotomy; cyclophotocoagulation.

In secondary glaucoma, when local hypotensive therapy is ineffective, and when local hypotensive therapy and laser intervention are ineffective, surgical treatment is proposed:

non-penetrating deep sclerectomy;

trabeculectomy.

Further management:

first month – biomicroscopy once a week; first 3 months – tonometry once a month.

observation by an ophthalmologist at least once every 3 months;

IOP control once a month;

gonioscopy – once a year;

perimetry control 2 times a year;

ophthalmoscopy 2 times a year.

Preventive measures:

healthy lifestyle;

treatment of the underlying disease – the etiological factor in the development of secondary glaucoma.

Indicators of treatment effectiveness:

compensation of intraocular pressure – control tonometry; stabilization of visual field – control perimetry; stabilization of glaucomatous excavation of the optic disc – control ophthalmoscopy and optic nerve tomography.

TREATMENT TACTICS AT THE INPATIENT LEVEL:

day hospital: laser and surgical treatment. 24-hour hospital: surgical + surgical treatment for concomitant pathology.

At the inpatient level, in secondary glaucoma, when local hypotensive therapy is ineffective, laser or surgical intervention is proposed.

patient observation card, patient routing: none.

non-drug treatment:

regimen: IV; diet No. 15.

drug treatment:

Inpatient treatment includes local hypotensive therapy drugs, as well as drugs for pharmacological support of surgical treatment (anti-inflammatory, antibacterial, carbonic anhydrase inhibitors, antiseptics, antimetabolites).

List of essential medicines (with 100% probability of use);

Drug group

International nonproprietary name

Method of administration

Level of evidence

non-selective beta-adrenoblockers

Timolol maleate eye drops

instillations into the conjunctival sac, 2 drops 2 times a day

Level A

Prostaglandin analogues

Latanoprost eye drops

instillations into the conjunctival sac, 1 drop once a day

Level A Travoprost eye drops

instillations into the conjunctival sac, 1 drop once a day

Level A Tafluprost eye drops

instillations into the conjunctival sac, 1 drop once a day

Level A

Antimicrobial drug of the fluoroquinolone group for topical use in ophthalmology

Moxifloxacin eye drops

instillations into the conjunctival sac, 2 drops 3 times a day

continue treatment for 2-3 days

if condition improves after infection; if there is no improvement within 5 days.

adults: 2 drops 3 times a day

continue treatment for 2-3 days

if condition improves after infection; if there is no improvement within 5 days

used for prevention of surgical wound infection, 2 drops 5 times a day postoperatively for 14 days

Level A

Glucocorticoids for topical use in ophthalmology

Dexamethasone eye drops

instillations into the conjunctival sac, 2 drops 6 times a day after surgery and then according to a tapering regimen

Level B

Antimicrobial drug of the fluoroquinolone group for topical use in ophthalmology

Levofloxacin eye drops

instillations into the conjunctival sac, 2 drops 5 times a day

duration of use depending on severity of condition

Level A

M-anticholinergic

Tropicamide eye drops

instillations into the conjunctival sac

Level C Glucocorticoids for systemic and local use

Dexamethasone

Subconjunctival

Parabulbar

Level B

Local anesthetic agent

Proxymetacaine eye drops

Instillations into the conjunctival sac immediately before surgery and during surgery

Level B

Carbonic anhydrase inhibitors

Acetazolamide

Orally, 1 tablet

Level B

Antimicrobial drug of the fluoroquinolone group for topical use in ophthalmology

Ciprofloxacin eye drops

Instillations into the conjunctival sac, 2 drops 5 times a day for 14 days

Level A

Antimicrobial drug of the aminoglycoside group for topical use in ophthalmology

Tobramycin eye drops

Instillations into the conjunctival sac, 2 drops 5 times a day for 14 days

Level A

aminoglycoside group days for topical application in ophthalmology Local anesthetic agent oxybuproсaine + Instillations into the conjunctival A procainamide sac immediately before surgical intervention and during surgery Nonsteroidal nepafenac Instillations into the conjunctival C anti-inflammatory +bromfenac + sac 2 drops 1-2 times a day agents diclofenac

days

sodium List of additional medications (less than 100% probability of use)

Drug group

Selective beta-adrenoblockers

Carbonic anhydrase inhibitors

Carbonic anhydrase inhibitors

Alpha-adrenomimetic (Alpha-agonists)

M-cholinomimetic

Non-selective beta-adrenoblockers+prostaglandin analogues

Non-selective beta-adrenoblockers

International nonproprietary name of medication

Betaxolol eye drops

Dorzolamide eye drops

Brinzolamide eye drops

Brimonidine eye drops

Pilocarpine eye drops

Timolol maleate+travoprost eye drops

Timolol maleate+lata

Method of administration instillations into conjunctival cavity

drops 2 times a day

drop 1 time a day

instillations into Level of evidence

B

B

B

B

B

B

B +prostaglandin analogues noprost conjunctival cavity eye drops

Non-selective beta-adrenoblockers Timolol maleate+taf instillations into B +prostaglandin analogues luprost conjunctival cavity

Non-selective beta-adrenoblockers Timolol maleate+bri instillations into B + nzolamide conjunctival cavity carbonic anhydrase

inhibitors Non-selective beta-adrenoblockers Timolol maleate+dor instillations into B + zolamide conjunctival cavity carbonic anhydrase eye drops

inhibitors Non-selective beta-adrenoblockers Timolol maleate+ instillations into B + Pilocarpine conjunctival cavity 2 M-cholinomimetics eye drops drops 2 times a day Tear film Sodium hyaluronate Instillations into C protector eye drops conjunctival cavity 2 drops 3-5 times a day 14 -

days days

Nonsteroidal Bromfenac eye Instillations into C anti-inflammatory drops conjunctival cavity drug for topical

drops 3-4 times a day 14 days

application in ophthalmology Antimicrobial Moxifloxacin Instillations into B fluoroquinolone eye drops conjunctival cavity drug for topical

drops 5 times a day, 14 days

application in ophthalmology Antimicrobial Ofloxacin eye instillations into conjunctival B fluoroquinolone drops cavity 2 drops 5 times a day drug for topical duration of use depending on application in severity of condition ophthalmology Agent for topical Proxymetacaine Instillations into B application in eye drops conjunctival cavity ophthalmology Angiogenesis Aflibercept Intravitreal or A inhibitors

intracameral injection

Administered 2 mg 1-2 days before surgical treatment for glaucoma.

Angiogenesis ranibizumab Intravitreal or A inhibitors Alpha-adrenomimetics phenylephrine

Subconjunctival injection

C Should be reserved for treatment of postoperative

complications - shallow

anterior chamber syndrome or ciliochoroidal detachment

Surgical intervention: laser trabeculoplasty; laser gonioplasty with synechiolysis; laser iridotomy; cyclophotocoagulation; non-penetrating deep sclerectomy; trabeculectomy; trabeculectomy+ implantation of glaucoma drainage devices; cataract extraction; cataract extraction combined with hypotensive surgery; cataract extraction combined with hypotensive surgery with implantation of glaucoma drainage devices.

Further management NB! Antibacterial and anti-inflammatory therapy for prevention of postoperative inflammatory complications. For prevention of excessive scarring in the area of newly created outflow pathways, use of corticosteroid drugs (dexamethasone 2 mg 0.5 ml) and antimetabolites in the form of subconjunctival injections. Further management: for 1 month after surgery instillation of anti-inflammatory and antibacterial drugs; intraocular pressure monitoring once a month; perimetry monitoring twice a year; ophthalmoscopy twice a year.

Indicators of treatment effectiveness and safety of diagnostic and treatment methods: absence of postoperative complications; compensation of intraocular pressure.

ORGANIZATIONAL ASPECTS OF THE PROTOCOL: 7.1 List of protocol developers with qualification data: 1) Aldasheva Neilya Akhmetovna – Doctor of Medical Sciences, Deputy Chairman of the Board of JSC "Kazakh Scientific Research Institute of Eye Diseases". 2) Ageleuova Akmaral Kusainovna – physician of the highest category, JSC "Republican Diagnostic Center". 3) Abysheva Laura Dorbethanovna – physician of the first category JSC "Kazakh Scientific Research Institute of Eye Diseases" instructor of the postgraduate education department. 4) Sangilbaeva Zhamilya Ospanovna – physician of the second category, resident physician of the day hospital JSC "Kazakh Scientific Research Institute of Eye Diseases".

5) Asylbekova Assel Serikovna – Candidate of Medical Sciences, highest category physician, JSC "Kazakh Scientific Research Institute of Eye Diseases", Head of the Functional Diagnostics Department. 6) Tokymbaeva Zhenisgul Nurmankyzы – first category physician, JSC "Kazakh Scientific Research Institute of Eye Diseases", Astana branch. 7) Smagulova Gaziza Azhmagiевna – Candidate of Medical Sciences, Associate Professor, Head of the Department of Propaedeutics of Internal Diseases and Clinical Pharmacology, RSE on REM "West Kazakhstan State Medical University named after M. Ospanov" – clinical pharmacologist.

Indication of absence of conflict of interest: none.

Reviewers: Utelbaeva Zauresh Tursynovna – Doctor of Medical Sciences, Department of Ophthalmology, RSE on REM "Kazakh National Medical University named after S.D. Asfendiyarov".

PHYSICAL EXAMINATIONS

LABORATORY INVESTIGATIONS

INSTRUMENTAL INVESTIGATIONS

Eye pain 2. Pain irradiation to the corresponding

part of the head 3. Blurred vision, decreased visual acuity 4. Visual field constriction 5. No complaints Blood pressure level

(relevant for diagnosing diencephalic glaucoma) Laboratory investigations:

• signs of inflammation in uveal glaucoma
• Visometry: decreased visual acuity

Biomicroscopy: in any secondary glaucoma there may be iris dystrophy. In phacomorphic glaucoma there may be a shallow anterior chamber, the lens is opaque with a pearlescent tint; in uveal glaucoma - posterior synechiae, pupillary occlusion and adhesion. Hyphema, newly formed vessels may be present in vascular glaucoma. In traumatic glaucoma - damage to anterior chamber structures. In phacotopic - absence or displacement of the lens, vitreous hernia. In neoplastic - presence of + tissue in the anterior chamber angle

Ophthalmoscopy: widening and deepening of excavation on the optic nerve disc, discoloration and asymmetry of the optic nerve disc

Tonometry: IOP elevation above the tolerable level Perimetry: constriction of visual field boundaries, changes in the central visual field

Gonioscopy: varying degrees of anterior chamber angle opening, presence of goniosynechiae, foreign body, + tissue, hyphema

Morphometric analysis of the optic nerve disc: signs of glaucomatous optic neuropathy

INDICATIONS FOR HOSPITALIZATION WITH INDICATION OF TYPE OF HOSPITALIZATION: 4.1 Indications for planned hospitalization in an inpatient facility with round-the-clock stay (regional eye hospitals, ophthalmology departments of multidisciplinary city or regional hospitals): absence of intraocular pressure compensation for surgical treatment; progression of the glaucomatous process (visual field constriction, increase in glaucomatous excavation of the optic nerve disc). 4.2. Indications for emergency hospitalization: increased intraocular pressure with intumescent cataract; increased intraocular pressure with hypermature cataract; increased intraocular pressure against the background of exacerbation of uveal process; lens luxation into the anterior chamber in phacotopic glaucoma.