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OD PERSPECTIVE

Glaucoma Discussed

There are several types of glaucoma including open angle, narrow angle, pseudoexfoliation, steroid-induced, pigmentary, congenital, glaucomas associated with hereditary or familial diseases, inflammatory, phacogenic, traumatic, neovascular, drug-induced, glaucoma secondary to an intraocular hemorrhage, and glaucoma associated with intraocular tumors, retinal detachments, chemical burns, and iris atrophy. Other forms of glaucoma include glaucomatocyclitic crisis or Posner-Schlossman Syndrome, Fuchs heterochromic iridocyclitis, uveitic glaucoma, and herpetic keratouveitis.

Every glaucoma has one thing in common; it can cause visual field losses, vision losses, and potential blindness. Every patient who has any form of glaucoma needs to be under the care of an eye doctor. In many states, the management and care of glaucoma can be directed by an optometrist. When the glaucoma requires surgical intervention or higher levels of medical care, a glaucoma specialist/ophthalmologist may be required. Many optometrists are so busy with their practices taking care of primary care needs that they work cooperatively with an ophthalmologist. But, there are also many well qualified and well-trained optometrists who can manage and treat glaucoma patients unless surgery is indicated or when other vision complications occur.

Patients with glaucoma should be educated as to what the action, plan, consequences, and future will be once it has been diagnosed. It is considered a disease. Some patients may be in denial that there is anything wrong when they can see well and there may be no pain. The topic of having a laser procedure may create tension, anxiety, or fear. If surgical interventions are required, patients must be advised and counseled as to the medical consequences as well as the financial costs, risks, and benefits of any surgery.

Surgical options for glaucoma include iridotomy, trabeculectomy, drainage implants including valved or non-valved, and iStent implants. In a recent article in the Journal of Cataract and Refractive Surgery, July, 2015, Dr.’s Dada, Rathi, and Angmo indicated that there are positive outcomes for clear lens extraction (cataract surgery) in eyes with primary angle closure glaucoma. “Clear lens extraction led to a significant reduction in IOP, a widening of the anterior chamber angle, and a reduced need for ocular hypotensive medications in eyes with primary angle closure and persistently raised IOP after a laser peripheral iridotomy.”

There are many eye drop medications that can treat glaucoma. The decisions as to what drops and how many drops are needed would be something that a glaucoma specialist would determine. The costs of medications must be discussed because patients sometimes cannot afford these high costs which seem to be escalating. When a patient is elderly or in a nursing home, there may be a need for someone else to put drops in the eyes on a regular basis. And compliance using eye drops on a regular daily basis is something that needs to be reinforced with every patient.

According to a British Journal of Ophthalmology article at http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC1856963/
, ”glaucoma is the second leading cause of blindness worldwide disproportionately affecting women and Asians. There were 60.5 million people with open angle glaucoma (OAG) and angle closure glaucoma (ACG) in 2010, and that number will increase to 79.6 million people by 2020. 74% of these people will have OAG, women will comprise 55% of OAG, 70% of ACG, and 59% of all glaucomas in 2010. Asians will represent 47% of those people with glaucoma and 87% of those with ACG. Bilateral blindness will be present in 4.5 million people with OAG and 3.9 million people with ACG in 2010, rising to 5.9 and 5.3 million respectively. Glaucoma is 15 times more likely to cause blindness in African Americans than in Caucasians. The prevalence of glaucoma rises rapidly among Hispanics over the age of 65.”

Acute narrow angle glaucoma can occur suddenly when the iris is pushed or pulled forward. As the lens in the eye changes with age, it can contribute to a narrowing of the angle, also. If the aqueous fluid is blocked in the drainage angle of the eye, the intraocular pressure will rise and damage the optic nerve. Acute angle closure glaucoma can present with pain in one eye, redness, blurry vision, headaches, halos, dilated pupils, vision loss, nausea, and vomiting. Gonioscopy must be part of every clinical exam in order to determine the status of the angle. There may be peripheral anterior synechiae, corneal edema, and the intraocular pressure may be very high. This problem must be managed very quickly and is an ocular emergency. If the higher pressures are not reduced quickly, permanent vision loss will occur.

Every ECP must have a minimum database that provides the optimum of care and service for every patient. Extra concern for glaucoma patients exists when there is a family history of glaucoma, the presence of diabetes, high blood pressure, heart disease, visual field losses, decreased vision, high intraocular pressure, unusual or unexplainable visual problems, corticosteroid use, physical injuries or trauma to the eye. A more aggressive approach for a suspicious patient must be undertaken which may include a referral to an ophthalmologist. A patient history will provide the symptoms that a patient is experiencing as well as allow the ECP to know if there is any family history of eye problems or other medical problems. Corrected and uncorrected visual acuity measurements at distance and near will further allow the ECP to determine if there is reduced vision as well as to determine if there is myopia, hyperopia, astigmatism, or presbyopia present.

A refraction may indicate for example, that a highly farsighted patient may have narrow angles or a highly myopic patient may have open angles. The angles must be viewed under a biomicroscope and gonioscopy can allow the ECP to view the actual anatomy of the angle. Intraocular pressures must be determined for each eye by using a non-contact tonometer, a Tonopen, or a Goldmann tonometer. If there is any suspicion of eye pressures that are outside of normal, several measurements should be taken at different times of the day due to cyclic fluctuations through the day. The evaluation of intraocular pressure (IOP) is usually based on measurements done during office hours. As IOP is considered a major risk factor for glaucoma, an undetected IOP spike could be the missing link that has not been taken into account. People with thin corneas can be at an increased risk of developing glaucoma so it is important to use a pachymeter in order to determine if this is an added risk factor.

Every eye exam should include visual field testing which would include a screening or a threshold test depending upon concerns or risk factors. Any glaucoma patient should be informed that visual field testing will be done on a regular basis. These visual field tests are important in order to know if a problem exists, to monitor any changes once any treatment is started, and to be able to change the treatment strategy if significant visual changes do occur. Also, every patient should be dilated in order to determine the health of the retina, the retinal vascular system, the optic nerve, and the macula. Fundus photography and taking pictures of the optic nerve are very important. These photos can allow the ECP to monitor changes in the cup to disc ratio of the optic nerve. If a cup to disc ratio is high such as 0.5 or 0.6, this can be another risk factor for glaucoma including the fact that the vertical size of the cup must be compared to the horizontal size.

There has been improved diagnosis and management for glaucoma including the use of an OCT (Optical Coherence Tomography). An OCT is another tool that measures the thickness of the retinal nerve fiber layer. The average values of the nerve fiber layer thickness can be calculated and compared to what should be normal. OCT’s can be an expensive piece of equipment with prices ranging from $9000-$45000.

In a July, 2015 Review of Optometry article on “Treating Glaucoma in the Real World”, Dr. Murray Fingeret, a leading authority on this subject, and Aliza Becker offer these suggestions when treating a glaucoma patients’ medication adherence; “build trust with your patients, educate, educate, educate, provide written instructions, offer reminder strategies for taking medications, and make sure patients understand their insurance coverage.” These are good suggestions under any circumstances.

Jason Smith
OD, MS

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