Glaucoma

Question 1

What are warning signs/risk factors for acute angle closure (which may lead to galucoma)?

Answer 1

Hx of:
- Previous episodes of blurred vision, headaches, eye pain associated with nausea + seeing halos around lights (these are due to intermittent angle closure typically occurring in the evening and are relieved by sleeping)

• Precipitating factor e.g. watching TV in a dark room, adopting a semi-prone position e.g. for reading, use of adrenergic or antimuscarinic drug

Question 2

What are some typical symptoms of acute angle closure?

Answer 2

Acute painful red eye - severe + headache + N+V

Impaired acuity

Halos around lights (from a hazy oedematous cornea)

Semi-dilated and fixed pupil - classically in a vertical oval shape

A tender, hard eye; intraoccular pressure (as measured by an optometrist) is very high

Sub-acute symptoms are similar but less severe and may resolve on lying supine, on closing the eyes or after sleep

Question 3

What do you do if you suspect acute angle closure?

Answer 3

Admit immediately for specialist ophthalmology assessment and treatment

If cannot admit immediately, - lie person flat with face up and not supported by pillows as may relieve some pressure on the angle

If drugs are available:

• Pilocarpine eye drops - one drop of 2% in blue eyes and 4% in brown - will constrict the pupil and allow better drainage of aqueous humour
• Timolol eye drops - BBlocker used to reduce the production of aqueous humour
• Acetazolemide 500mg PO to reduce aqueous humour production
• Analgesia PRN
• Anti-emetic PRN

Question 4

What is the longer term management of acute angle closure?

Answer 4

To reduce intraoccular pressure and allow aqueous humour to flow freely from posterior to anterior chamber of the eye

Will need laser iridotomy - hole in the iris so doesnt have to drain via pupil

Also treat the unaffected eye preventatively

Question 5

How do you manage ocular hypertension and suspected/confirmed open angle glaucoma?

Answer 5

Not all need treatment - regular F/U with ophthalmologist in some

Topical prostaglandin or prostamide

Topical Betablocker

Monitor for correct eye dropper technique, adherence and side effects

Laser or surgical correction e.g. selective laser trabeculoplasty (SLT) (selectively destroys melanin pigment - opening spaces in trabecular meshwork for drainage)