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Editors

AnjaTuulonen

Glaucoma

Essentials

  • A general practitioner should primarily be able to recognize the symptoms of an acute glaucoma attack, master the diagnostics and the principles of acute care.
  • The diagnostics and follow-up of open-angle glaucoma require the equipment and special skills of an ophthalmologist.

Acute angle-closure glaucoma

  • It is vital that the diagnosis and treatment of acute glaucoma are not delayed.
  • Consequently, it is advisable always to consult without hesitation by phone an ophthalmologist on call at the nearest hospital with an ophthalmology unit in order to ensure appropriate treatment and referral without delays.

Symptoms

  • Headache and eye pain
  • Often nausea and vomiting
  • Redness of the eye
  • Occasionally rainbow halo around lights (cause: corneal oedema)
  • Visual impairment

Findings

  • Measuring of the intraocular pressure is the primary diagnostic procedure: usually over 50-80 mmHg.
  • Impaired visual acuity
  • Conjunctival erythema
  • Middle-sized, non-responding pupil
  • Greyish colour of the cornea
  • The eyeball feels hard on palpation through the lid.

Initial treatment

  1. Lower the intraocular pressure with 500 mg of acetazolamide (i.v., p.o. or i.m.).
    • Intravenous administration is fastest and most effective.
    • A vomiting patient cannot take tablets.
    • Intramuscular injection may be painful.
    • Allergy to sulphonamides is a contraindication.
  2. After acetazolamide pilocarpine can be dropped on the eyes, in total 2-3 drops, at 10-15-minute intervals.
  3. Timolol drops can also be used if the patient does not have
    • asthma
    • bradycardia or
    • II-III-degree AV block.
  4. Refer the patient immediately to an ophthalmological unit where medication to lower intraocular pressure is continued and laser peripheral iridotomy is performed.

Open-angle glaucoma Medical Treatment of Glaucoma and Intraocular Hypertension, Laser Trabeculoplasty for Open Angle Glaucoma

  • In most patients primary open-angle glaucoma is a slowly progressing disease in which changes may take years to be noticed.
  • Open-angle glaucoma is a progressive neuropathy of the optic nerve leading to typical structural and functional defects of the optic disk, the nerve fibre layer and visual field.
  • Glaucoma requires life-long follow-up.

Findings

  • Visual acuity and intraocular pressure
    • Normal central visual acuity and statistically normal intraocular pressure (10-21 mmHg) do not exclude open-angle glaucoma.
    • The risk of glaucoma defects increases when intraocular pressure rises (particularly when it exceeds 30 mmHg).
    • Often the intraocular pressure may be elevated to 21-30 mmHg but the optic disk remains normal and visual field defects do not appear (so-called ocular hypertension).
  • Typical fundoscopic finding
    • The optic disk is asymmetric between the right and the left eye (picture ).
    • The central cup may be enlarged or drop-like in shape (picture ) or paler than in the other eye.
  • Finger confrontation perimetry
    • Finger confrontation perimetry only reveals visual field defects caused by advanced glaucoma.
  • The diagnosis is confirmed in specialized care.

Risk groups

  • The possibility of glaucoma should be remembered especially in risk group patients (table T1), and they should be referred to an ophthalmologist for further examinations when feasible.

Risk factors for glaucoma. Source: Finnish Current Care Guideline 2014.

Risk factors1) The size of the risk
AgeDoubled every 10 years
Intraocular pressure
  • 22-29 mmHg
  • >30-35 mmHg
  • 10-13-fold
  • 40-fold
Exfoliation combined with increased intraocular pressure5-10-fold
A haemorrhage in the optic nerve head12-fold
Diabetes2-3-fold
Myopia2-6-fold
Family history3-fold
Lowered perfusion pressure together with advanced age3-fold
1) In addition,black ethnic background has also been found to be a risk factor.
Adverse effects of glaucoma drugs
  • Topically used glaucoma drugs may also cause systemic adverse effects (the list below does not contain all rare effects).
    • Alpha antagonists (apraclonidine, brimonidine)
      • Drying of the mucosa of the mouth and nose, taste disturbances, slowing of the heart rate and hypotension, fatigue
    • Non-selective beta-blockers (timolol)
      • Bradycardia, hypotension, aggravation of asthma, dizziness, nausea, depression, sleep disturbances
      • Non-selective beta-blockers should not be prescribed to patients with asthma, slow heart rate, low blood pressure, untreated cardiac insufficiency or Il-III-degree AV block.
    • Selective beta-blockers (betaxolol)
      • Systemic adverse effects are the same as those of non-selective agents, but rarer.
    • Systemic carbonic anhydrase inhibitors (acetazolamide)
      • Fatigue, dizziness, GI tract disturbances, metabolic acidosis, depression, tingling of the extremities, hypersensitivity reactions, hypokalaemia, renal stones
    • Topical carbonic anhydrase (dorzolamide, brinzolamide)
      • Disturbances of taste, drying of the mouth. Other adverse effects of sulphonamides and carbonic anhydrase inhibitors are also possible.
    • Prostaglandin derivatives (latanoprost, travoprost, bimatoprost, tafluprost)
      • No common systemic adverse effects have been observed
    • Parasympathomimetics (pilocarpine)
      • Headache in the beginning of the treatment, but other systemic effects are rare.
  • It is worthwhile to ask the patient about the use of eye drops in addition to asking about other medicines, as some patients do not remember to mention them.
  • Drugs used for other diseases may raise intraocular pressure (e.g. glucocorticoids, parasympatholytics).

Evidence Summaries ⬆