Appropriate management of glaucoma depends on the clinician’s ability to diagnose the specific form of the disease in a given patient, to determine the severity of the condition, to predict the likelihood of progression, and to detect progression when it occurs. Clinical evaluation of the glaucoma patient or suspect begins with taking a thorough history of the current condition, including symptoms, onset, duration, and severity. Also important are the past ocular history and a general medical history, including the patient’s medications and allergies.
The following points are relevant in the assessment of all glaucoma patients. However, the clinician will tailor the evaluation to the individual patient by inquiring about other factors, as appropriate.
Age. Although glaucoma can occur in any age group, the most common forms are more prevalent in older individuals.
Race and ethnicity. Individuals of African descent or Hispanic ethnicity are at increased risk for primary open-angle glaucoma, while persons of Asian descent are at increased risk for angle-closure glaucoma. In individuals from Scandinavian countries, pseudoexfoliation syndrome accounts for a high proportion of glaucoma cases.
Family history of glaucoma. If there is a family history of glaucoma, the disease severity and outcomes experienced by other family members, including vision loss and blindness, should be obtained during initial evaluation.
Although the most common forms of glaucoma are usually asymptomatic until relatively late stages, some conditions, such as acute angle closure, are generally accompanied by pain, redness, and decreased vision. Patients with anatomically narrow angles and intermittent angle closure may report a history of having headaches and seeing halos, especially colored halos, around lights. Patients with pigment dispersion syndrome may sometimes report blurred vision, pain, or halos around lights after exercise; these symptoms may be related to active pigment dispersion and acute intraocular pressure (IOP) elevation.
Certain aspects of the patient’s ocular history may be pertinent to glaucoma, including:
Refractive error. High myopia is a risk factor for primary open-angle glaucoma, while hyperopia is a risk factor for angle closure.
Trauma. Ocular trauma can be associated with angle recession and traumatic glaucoma. Of note, it is common for patients with traumatic glaucoma to report a history of ocular trauma that occurred decades before the development of IOP elevation.
Ocular surgery. A history of complicated cataract surgery, corneal transplant, or vitrectomy may all be associated with increased risk for glaucoma. Although refractive surgery is generally not associated with an increased risk of glaucoma, keratorefractive procedures such as laser in situ keratomileusis (LASIK) or photorefractive keratotomy may result in thin corneas and artificially low IOP measurement on Goldmann applanation tonometry.
A patient’s systemic conditions can affect both the diagnosis of glaucoma and the choice of medications to treat it. Systemic diseases of particular relevance include asthma, chronic obstructive pulmonary disease (COPD), migraine headache, vasospasm, sleep apnea, diabetes, cardiovascular disease, and thyroid disease. For example, β-blockers may be contraindicated in patients with asthma or COPD; therefore, a history of these conditions should be actively sought in all patients with glaucoma or suspected glaucoma for whom treatment with topical β-blockers is being considered.
A history of migraine or vasospasm (eg, Raynaud disease) may be more prevalent in patients with glaucoma occurring at relatively low IOP. Though controversial, sleep apnea has also been described as a risk factor for glaucoma. Patients with autoimmune thyroid disorders and thyroid eye disease may have elevated episcleral venous pressure. In addition, a history of systemic arterial hypertension and therapy is relevant; treatment-related hypotension may increase the risk of progression.
Use of topical, inhaled, or systemic corticosteroids can be a risk factor for increased IOP. It is also important to inquire what, if any, ocular hypotensive medications the patient has previously used and reactions or allergies to them. If a patient is already taking systemic β-blockers for other conditions, topical β-blockers will have diminished IOP-lowering efficacy. The clinician should also inquire about a history of reaction or allergy to sulfonamide medications, including the type and severity of the reaction; patients with a known allergy to a sulfonamide agent may have a higher risk of a subsequent reaction to carbonic anhydrase inhibitors, although cross-reactivity between sulfonamide antibiotics and nonantibiotics may be as low as 10%. Certain systemic medications, such as topiramate, may be associated with increased risk for angle-closure glaucoma (see Chapter 10). In addition, the systemic use of drugs that have anticholinergic activity may increase the risk of angle-closure disease in persons with anatomically narrow anterior chamber angles.
Review of records
A review of pertinent records, particularly those documenting past IOP levels, status of the optic nerve, and visual field, is useful in guiding current glaucoma management. Information on maximum recorded IOP levels is important in setting IOP goals for treatment. Records of optic nerve status and visual fields can be crucial in establishing whether changes have occurred over time, both for patients suspected of disease and for those with established glaucoma. In cases of suspected glaucoma, documentation of optic disc progression over time may establish the diagnosis even in the absence of visual field loss. In patients with previously diagnosed disease, records showing progressive optic nerve damage or visual field loss are indicative of uncontrolled disease. If the disease is not adequately controlled while the patient is on topical ocular hypotensive therapy, the clinician should actively seek to obtain a history of adherence to treatment.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.