Key concepts

Practitioners can play an important role in eye care by assessing patients for risk factors and referring to an ophthalmologist for appropriate screening and evaluation.

Acute primary angle-closure glaucoma (PACG) is a medical emergency and requires laser or surgical intervention.

Patients with primary open-angle glaucoma (POAG) typically have a slow, insidious loss of vision. This is contrasted by the course of acute PACG, which can lead to rapid vision loss that develops over hours to days.

Û1 The goals of therapy are to prevent further loss of visual function; minimize adverse effects of therapy and its impact on the patient's vision, preserve general health and quality of life; control intraocular pressure (IOP) to reduce or prevent further optic nerve damage; and educate and involve the patient in the management of their disease.

O Current therapy is directed at altering the flow and production of aqueous humor, which is the major determinant of IOP.

® Because POAG is a chronic, often asymptomatic condition, the decision of when and how to treat patients is difficult because the treatment modalities are often expensive and have potential adverse effects or complications. Therefore the clinician should evaluate the potential effectiveness, toxicity, and the likelihood of patient adherence for each therapeutic modality.

An initial target IOP should be set at 20% lower than the patient's baseline IOP. The target IOP can be set lower (30-50% of baseline IOP) for patients who already have severe disease or have normal-tension glaucoma (NTG).

It is important to review the patient's medication history for potential drug-drug and drug-glaucoma interactions, adherence, presence of systemic and ocular adverse drug reactions, and ability to use ophthalmic preparations.


Glaucoma refers to a spectrum of ophthalmic disorders characterized by neuropathy of the optic nerve and loss of retinal ganglion cells, which leads to permanent deterioration of the visual field and potentially total vision loss. Glaucoma can be classified as primary and secondary. Primary glaucoma refers to glaucoma that cannot be attributed to a pre-existing ocular or systemic disease while, secondary glaucoma refers to glaucoma that can be attributed to preexisting ocular or systemic disease. Examples of primary glaucoma include open angle, closed angle, and congenital. Examples of secondary glaucoma include pigmentary glaucoma, neovascular glaucoma, traumatic glaucoma, and pseudoexfoliative glaucoma.

Primary open-angle glaucoma (POAG) is characterized by normal anterior-chamber angles, glaucomatous changes of the optic disc, and peripheral visual field loss. Patients with elevated intraocular pressure (IOP), without glaucomatous changes, are

considered to have ocular hypertension. ' Patients with ocular hypertension that have normal appearing anterior-chamber angles and an eye exam suspicious of early glaucomatous damage are classified as POAG suspects. Primary angle-closure glaucoma (PACG) is the obstruction of the anterior angle by the iris causing moderate to high elevations in IOP. POAG and PACG represent the most common types of glaucoma and therefore will be the focus of this chapter.

Table 61-1 Recommended Frequency of Comprehensive Adult Medical Eye Evaluation

Age (Years)

With Risk Factors for Glaucoma

No Known Risk Factors

65 or above

6-12 months

1-2 years


1-2 years

1 -3 years


1 -3 years

2-4 years

Under 40

2-4 years

5-10 years

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