Updated: 8/23/2020

Glaucoma

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Topic
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Questions
8
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Evidence
4
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Topic
Overview
 
 
Snapshot
  • A 46-year-old African American male presents for an opthalmic examination. Medical history is significant for hypertension and type II diabetes mellitus. On slit-lamp examination, there is cupping of the optic disc, with a cup-to-disc ratio > 0.6. Tonometry reveals intraocular pressure of 45 mmHg (normal is 8-21 mmHg). Peripheral field vision loss is noted on visual field exam.
Introduction
  • Optic neuropathy characterized by optic nerve damage and visual abnormalities
    • majority of patients have increased intraocular pressure (IOP)
      • important causative risk factor
      • associated with increased resistance to aqueous outflow
      • compresses retinal blood supply or retinal ganglion cells
        • optic disc atrophy with cupping → visual loss
          • increased cup-to-disc ratio
  • Glaucoma can be characterized into
    • open-angle or angle-closure 
  • Epidemiology
    • a leading cause of blindness
    • open-angle glaucoma is more common
    • risk factor examples
      • family history
      • age
      • race
Presentation
  • Symptoms 
    • open-angle 
      • usually asymptomatic 
      • insidious onset of peripheral vision loss
    • angle-closure 
      • acute onset of blurry vision 
      • painful
      • halos around lights
      • ↓ vision (photophobia/blurry vision)
  • Physical exam
    • open angle
      • no distinct physical exam findings
    • angle closure 
      • fixed-dilated pupil
      • corneal clouding/edema
      • conjunctival injection/redness
      • eyeball firm to palpation
Evaluation
  • Measure IOP with tonometry
    • normal is 8-21 mmHg
  • Assessment of optic disc shows enlarged cup-to-disc ratio (> 0.4)
  • Visual field testing
  • Pachymetry
    • measures corneal thickness
      • if corneas are thick, it may falsely elevate IOP on tonometry
  • Gonioscopy 
    • gold standard for angle-closure glaucoma
Differential
  • Macular degeneration
  • Ischemic optic neuropathy
Treatment
  • Open-angle 
    • pharmacologic
      • increases aqueous outflow
        • prostaglandins (becoming first-line)
        • α-agonists
        • cholinomimetics
      • decreases aqueous production
        • carbonic anhydrase inhibitors
        • α-agonists
        • β-blockers
    • laser therapy
      • trabeculoplasty
    • surgical
      • filtration bleb
  • Angle-closure
    • iridotomy 
      • definitive treatment, but not used for initial management
    • topical β-blockers and α2-agonists
      • epinephrine contraindicated!!!
        • α1-agonism causes mydriasis
    • oral carboanhydrase inhibitors (acetazolamide) 
      • IV if patient has nausea/vomiting 
Prognosis, Prevention, and Complications
  • Open-angle
    • prognosis
      • does not substantially reverse
      prevention
      • may involve lowering IOP
      complications
      • blindness
  • Angle-closure
    • prognosis
      • progressive vision loss that may lead to blindness
        • if not detected early and not properly managed

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Questions (8)
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(M2.OP.17.4765) A 52-year-old female presents to the emergency room with severe right eye pain and vision loss. The symptoms started a couple hours ago while she was out to a late dinner. She denies ever feeling these symptoms before. In addition to the pain and blurry vision, she reports excessive tearing. She denies discharge from her eye. The patient’s past medical history is significant for hypertension and rheumatoid arthritis. Her medications include hydrochlorothiazide and sulfasalazine. She has a 40 pack-year smoking history. She works as a pre-school teacher at a local school. Figure A shows physical examination findings of both eyes. The right pupil is less reactive to light in comparison to the left pupil. Figure B shows a fundoscopic exam of the right eye. Fundoscopy of the left eye is unremarkable. Which of the following is the most accurate test to diagnose the patient’s condition?

QID: 109035
FIGURES:
1

Culture and gram stain

0%

(0/36)

2

Fluoroscein stain

3%

(1/36)

3

HLA-B27 test

0%

(0/36)

4

Gonioscopy

56%

(20/36)

5

Tonometry

42%

(15/36)

M 6 D

Select Answer to see Preferred Response

(M2.OP.16.4690) A 56 year old female comes to the ED complaining of moderate right eye pain, headache, and acute onset of blurry vision, which she describes as colored halos around lights. She was watching a movie at home with her husband about an hour ago when the pain began. On physical exam of her right eye, her pupil is mid-dilated and unresponsive to light. Her right eyeball is firm to pressure. Intraocular pressure (IOP) measured with tonometer is elevated at 36mmHg. Which of the following is the most appropriate emergency treatment?

QID: 107584
1

Timolol ophthalmic solution

50%

(5/10)

2

Epinephrine ophthalmic solution

10%

(1/10)

3

Laser peripheral iridotomy

30%

(3/10)

4

Anti-cholinergic ophthalmic solution

10%

(1/10)

5

NSAID ophthalmic solution

0%

(0/10)

M 7 E

Select Answer to see Preferred Response

(M2.OP.15.35) A 60-year-old female presents to the emergency department with severe pain and vision loss in her left eye. She states that the pain and vision loss seemed to start when she was driving through a dark tunnel. She has never experienced symptoms like this before and has no prior history of ophthalmologic problems. Her left eye is demonstrated in Figure A, is poorly responsive to light, and feels hard to the touch. What is the most likely cause of this patient's presentation?

QID: 105035
FIGURES:
1

Open angle glaucoma

6%

(2/32)

2

Closed angle glaucoma

88%

(28/32)

3

Cataract

0%

(0/32)

4

Central retinal artery occlusion

0%

(0/32)

5

Central retinal vein occlusion

3%

(1/32)

M 6 B

Select Answer to see Preferred Response

(M3.OP.14.57) A 59-year-old woman presents with sudden onset ocular pain. She reports she was visiting the planetarium when the pain started, and she is now seeing halos around lights. She has vomited several times from the pain. Her temperature is 97.6°F (36.4°C), blood pressure is 154/91 mmHg, pulse is 89/min, respirations are 16/min, and oxygen saturation is 98% on room air. Physical examination is notable for the finding in Figure A. Which of the following is the definitive treatment for this patient?

QID: 106380
FIGURES:
1

Iridotomy

14%

(2/14)

2

Methylprednisolone

0%

(0/14)

3

Pilocarpine drops

7%

(1/14)

4

Retinal reattachment

71%

(10/14)

5

Timolol drops

7%

(1/14)

M 11 E

Select Answer to see Preferred Response

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Evidence (4)
EXPERT COMMENTS (12)
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