Primary open angle glaucoma

Question 1

Risk factors for glaucoma

Answer 1

age
genetics
first degree relatives
Afro Caribbean
myopia
hypertension
diabetes mellitus
corticosteroids

Question 2

Typical presentation

Answer 2

Insidious and may be picked up on routine optometry appointment

peripheral visual field loss ‘tunnel vision’
decreased visual acuity

Question 3

Fundoscopy findings

Answer 3

1. Optic disc cupping => increased cup-to-disc ratio
2. Optic disc pallor
3. Bayonetting of vessels - vessels have breaks as they disappear into the deep cup and re-appear at the base
4. Cup notching (usually inferior where vessels enter disc)
5. Disc haemorrhages

Question 4

Investigations for suspected glaucoma

Answer 4

automated perimetry to assess visual field

slit lamp to assess optic nerve and fundus for a baseline

tonometry to measure IOP

central corneal thickness measurement

gonioscopy to assess peripheral anterior chamber configuration and depth

Question 5

aim of glaucoma treatment

Answer 5

Lower IOP

Question 6

If patients have an IOP >24mmHg what treatment can be offered according to NICE guidelines?

Answer 6

360° selective laser trabeculoplasty (SLT)

Laser to trabecular meshwork to improve aqueous drainage

Question 7

What eye drops are commonly used to treat glaucoma?

Answer 7

1st Line:
- prostaglandin analogue (PGA) e.g. Latanoprost

2nd Line:
- beta-blocker (timolol)
- carbonic anhydrase inhibitor (acetazolamide, dorzolamide)
- sympathomimetic eye drops (brimonidine)

Question 8

In refractory glaucoma, what surgery may be used to treat the disease?

Answer 8

trabeculectomy

Question 9

What eye drops used to treat glaucoma increase uveoscleral outflow?

Answer 9

Prostaglandin analogues (Latanoprost)

Miotics (Pilocarpine - muscarinic agonist)

Question 10

What eye drops used to treat glaucoma ONLY reduce aqueous production?

Answer 10

Beta Blockers (Timolol)
Carbonic anhydrase inhibitors (acetazolamide, Dorzolamide)

Question 11

Which class of eye drop both reduces aqueous production and increases outflow?

Answer 11

Sympathomimetics
(brimonidine, an alpha2-adrenoceptor agonist)

Question 12

What class of eye drop can cause brown pigmentation of the iris and increased eyelash length?

Answer 12

Prostaglandin analogues (Latanoprost)

Question 13

What class of eye drop should be avoided in asthmatics and patients with heart block?

Answer 13

Beta Blockers (Timolol)

Question 14

What class of eye drop should be avoided if taking MAOI or tricyclic antidepressants?

Adverse effects also include hyperaemia

Answer 14

Sympathomimetics
e.g. Brimonidide

Question 15

Systemic absorption of which eye drop class can cause sulphonamide-like reactions?

Answer 15

Carbonic Anhydrase inhibitors (Acetazolamide, Dorzolamide)

Question 16

Adverse effects of this class of eye drop include a constricted pupil, headache and blurred vision

Answer 16

Miotics - Pilocarpine (muscarinic agonist)