What is your diagnosis?
A 75-year-old woman presents to her primary care provider complaining of gradual vision loss.
The diagnosis is...
The image is consistent with a diagnosis of primary open-angle glaucoma (POAG):
- POAG is an idiopathic condition characterized by normal anterior chamber angle, elevated intraocular pressure (IOP), and optic nerve damage.
- Signs of POAG include optic disc cupping secondary to retinal ganglion cell loss.
- Patients may have asymptomatic, constricted visual fields and vision loss in advanced disease.
- Risk factors include elevated IOP, older age, family history, low central corneal thickness, myopia, and African ancestry.
What is the role of the primary care or emergency medicine physician?
- Refer glaucoma suspects (ie, cup-disc ratio >0.5 or IOP >21 mm Hg) nonurgently to ophthalmology.
- Consider glaucoma screening for high-risk patients such as African Americans, Hispanics, people with diabetes, and those with a family history of glaucoma. Screening is not recommended for asymptomatic adults.
- Suggest that patients at age 40 get a baseline ocular examination by an ophthalmologist.
What is the role of the ophthalmologist?
The ophthalmologist will evaluate the cup-disc ratio (normal, <0.5) for signs of optic nerve damage, use Goldmann applanation tonometry to measure IOP (normal, ≤21 mm Hg), and use gonioscopy to evaluate the anterior chamber angle.
Normal cup-disc ratio on fundus examination.
Goldmann applanation tonometry.
Normal anterior chamber angle.
What is the treatment?
The goal of therapy is to lower IOP via reduced aqueous humor production or increased outflow. Treatment options include the following:
- topical: alpha agonists (eg, brimonidine), beta-blockers (eg, timolol), miotics (eg, pilocarpine), carbonic anhydrase inhibitors (eg, dorzolamide), and prostaglandins (eg, latanoprost)
- systemic: carbonic anhydrase inhibitors (eg, acetazolamide)
- surgical: laser trabeculoplasty, trabeculectomy, glaucoma drainage devices, minimally invasive glaucoma surgery, and cyclodestructive procedures
Learn more: Ophthalmology resources for medical students