Advanced glaucoma is often easy to identify. However, our aim as ophthalmologists is to prevent a patient from reaching this state. Identifying glaucoma early can have long-lasting impacts on your patient’s quality of life. Here are five tips to help you be the best glaucoma detective you can be.
- Identify the cause. Although primary open-angle glaucoma is a common diagnosis, it is technically a diagnosis of exclusion. By considering all of the other possibilities, you will give your patient the best chance at preserving vision. Have a running list in your mind of the major classifications of glaucoma – everything from narrow angle, pigmentary dispersion, pseudoexfoliation, phacomorphic, phacolytic, neovascular, traumatic, steroid-related, etc. There is quite a variety within the glaucoma diagnosis. As a bonus, this will help you code in ICD-10!
- Conduct gonioscopy and repeat as necessary. Use the dimmest light possible and have the patient look straight ahead. Inspect the angle and look for angle characteristics using one of the angle-grading criteria, such as Spaeth or Shaffer system. Also look for a Sampolesi line, heavy pigmentation, angle recession, neovascularization of the angle. Repeat gonioscopy will often yield additional clues as you follow this patient over the years. Be sure to also document this in your chart. Your notes can help when determining if the patient may be a good candidate for laser treatment.
- Do a careful slit lamp examination. This will help find multiple other characteristics of secondary glaucoma. Look for anterior chamber inflammation, iris transillumination defects either at the pupillary margin or mid-periphery, pupillary ruff material, lens capsule pigment, a Krukenberg spindle, phacodenesis and radial iris sphincter tears.
- Once you have a diagnosis, consider the treatments. Pseudoexfoliation glaucoma responds very well to SLT. However, treating pigmentary dispersion glaucoma with SLT requires careful IOP monitoring after treatment. Narrow-angle glaucoma can be helped with a peripheral iridotomy, but you’ll need repeat gonioscopy afterwards to ensure the angle anatomy has opened. Otherwise, lens extraction may be required.
- Don’t forget OCT. This technology is a great addition to the glaucoma detective’s arsenal. Much of early glaucoma does not result in visual field loss. However, early structural changes can be evaluated with OCT. You can then counsel patients on their risk factors earlier in their course. Patients with ocular hypertension and very early glaucoma but normal visual fields can be candidates for biannual visual fields, alternating with OCT of the nerve fiber layer.
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About the author: Roma Patel, MD, MBA, is the chief of ophthalmology at the Sacramento VA Hospital and assistant professor at the University of California Davis Eye Center. She completed her glaucoma fellowship at Duke Eye Center and enjoys the many challenges and long-term relationships with her glaucoma patients. She is also a member of the Academy’s YO Committee.