Clinic: Glaucoma Workup

Question 1

Provide a suggested sequence for a Glaucoma workup (8)

Answer 1

(VA) –> SL–> IOP –> Gonio –> pachymetry –> VF (dilation as doing) –> OCT –> Fundus lens –> Repeat IOP

NB: subject to change based on supervisor/patient. It’s variable. Could also include red cap perhaps?

Question 2

Do you always have to do refraction on a glaucoma patient? Why/why not?

Answer 2

No. If we do refraction, we might not fit everything in. You need to prioritize based on patient’s needs/wants

Question 3

How long after diagnosing glaucoma does the patient typically see an ophthalmologist? Does this vary?

Answer 3

4 months. But it’s up to the patient. Some patients are happy to just keep seeing the optom

Question 4

How should you evaluate the RNFL in fundus examination for glaucoma? (3)

Answer 4

Look for:
superior + inferior dropout (loss of ISNT
Slit or wedge defects + assoc. notches in NRR
BDB presence/distribution (check with red free filter if needed)

Question 5

List 7 reasons for glaucoma suspicion on fundus examination

Answer 5

Vertical notching
Loss of ISNT
increase in CD size over time
Deepening of cup 
CD asymmetry of > 0.2
Drance Haemorrhages
Baring of circumlinear vessels

Question 6

What Visual field test options are there for glaucoma (3)

Answer 6

Humphrey 30-2 SITA standard
Humphrey 24-2 SITA standard
Medmond Fast Threshold

Question 7

How should the patient be set up for visual field testing?

Answer 7

with near correction + px properly positioned and watched

Question 8

What is the most important aspect to measure for OCT in a glaucoma patient?

Answer 8

Change over time

Question 9

What OCT test should you perform on a glaucoma patient?

Answer 9

Mac Vertical (= Glaucoma TSNIT) (whereas mac horizontal is a more general scan and can be used for other conditions like AMD)

Question 10

How many IOP measurements should you make, at minimum, when measuring IOP?

Answer 10

2 measurements per eye

Question 11

What IOP value should we consider very seriously even in the absence of other findings?

Answer 11

Any IOP of 26mmHg or over

Question 12

What CCT values are considered a risk factor for glaucoma?

Answer 12

<555 microns

Question 13

When should you perform gonio on a glaucoma patient?

Answer 13

1st review and regularly thereafter. Measure deepest angle in all 4 quadrants + level of pigmentation if present.

Question 14

How often do we generally review glaucoma patients?

Answer 14

Typically 6 or 12 monthly, depending on risk. Sometimes we’ll have 1 month reviews (e.g. if wanting to monitor the use of new drops)

Question 15

What differential should we ensure we aren’t missing when assessing glaucoma?

Answer 15

Neurological problems

Question 16

What should you consider in history for a glaucoma assessment? (3)

Answer 16

FOH: which relative, age of onset, type/duration, tx, effect on vision
Other Risk Factors: age>50yo, race (african), CV disease, DM, Migraines, Sleep apnoea, Myopia, Smoking
Relevant Meds: b-blockers, steroids, etc, any side effects of glaucoma meds such as breathing, sore eyes, cardiovascular