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Key Features

  • Usually bilateral optic neuropathy characterized by optic disk cupping and progressive visual field loss, generally associated with elevated intraocular pressure

  • Primary open-angle glaucoma

    • Intraocular pressure is elevated because of abnormal drainage of aqueous

    • In general, more severe in Afro-Caribbeans and Africans, and probably in Hispanics

  • Chronic angle-closure glaucoma

    • Intraocular pressure is elevated as a result of obstruction to aqueous flow

    • More common in Asians

  • Secondary open-angle glaucoma occurs

    • In ocular disease (pigment dispersion, pseudoexfoliation, uveitis)

    • In trauma

    • With long-term corticosteroid therapy

  • Normal-tension glaucoma: intraocular pressure not elevated

  • Ocular hypertension: elevated intraocular pressure without optic disk cupping or visual field loss

Clinical Findings

  • Asymptomatic until severe visual loss has developed

  • Visual fields progressively constrict, but central vision (acuity) remains good until late

Diagnosis

  • Screening tests essential to early diagnosis

    • Measure intraocular pressures

    • Examine optic disks

    • Test visual fields

  • All persons older than 50 should undergo measurements of intraocular pressure and ophthalmoscopy every 3–5 y

  • In diabetics and those with a family history of glaucoma, annual examinations are indicated

Treatment

  • See Table 7–2

  • Most common agents to reduce intraocular pressure

    • Topical prostaglandin analogs

    • β-Adrenergic blocking agents

  • Other topical agents

    • α-Adrenergic agonists

    • Carbonic anhydrase inhibitors

  • If medical therapy is inadequate, consider surgical therapy

    • Trabeculectomy

    • Laser trabeculoplasty

    • Viscocanalostomy, deep sclerectomy with collagen implant, and Trabectome (a minimally-invasive glaucoma surgery procedure)

      • Avoid a full-thickness incision into the eye

      • Associated with fewer complications but are more difficult to perform

  • Prophylactic laser peripheral iridotomy

    • Can be performed to reduce the risk of acute and chronic angle closure glaucoma in patients with asymptomatic narrow anterior chamber angles

    • However, there are concerns about the efficacy and the risk of cataract progression and corneal decompensation

Table 7–2.Topical ophthalmic agents.

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