What is the approach to managing glaucoma care?

Management of Glaucoma Care

The cornerstone of glaucoma management is aggressive IOP reduction to a target level individualized by disease severity, with a goal of at least 25% reduction from baseline, combined with systematic monitoring of optic nerve structure and visual function to prevent irreversible blindness. 1, 2

Initial Diagnostic Workup

Every patient requires comprehensive baseline documentation before initiating treatment:

• IOP measurement with multiple readings at different times of day to capture diurnal variation 2
• Gonioscopy to confirm open angles and exclude secondary causes—this is mandatory and must be documented 1
• Central corneal thickness (CCT) measurement, as thin corneas (<555 μm) significantly increase risk of progression 1
• Optic nerve head examination with stereoscopic disc photography to document baseline structural damage 2
• RNFL and macular ganglion cell complex imaging using optical coherence tomography (OCT) 2
• Standard automated perimetry (SAP) using 24-2 or 30-2 protocols to establish baseline visual field status 2, 3

Disease Severity Classification

Classification determines treatment intensity and follow-up frequency 1:

• Mild glaucoma: Definite optic disc/RNFL/macular abnormalities with normal visual fields on SAP 1
• Moderate glaucoma: Structural abnormalities plus visual field defects in one hemifield not within 5 degrees of fixation 1
• Severe glaucoma: Structural abnormalities plus visual field defects in both hemifields and/or loss within 5 degrees of fixation in at least one hemifield 1

Target IOP Determination

Set target IOP based on disease severity, baseline IOP, and risk factors—aim for at least 25% reduction from pretreatment levels. 2

For high-risk patients (baseline IOP ≥26 mmHg with CCT ≤555 μm), untreated progression risk reaches 36% versus only 2% for low-risk patients (IOP <24 mmHg with CCT >588 μm) 1. This dramatic difference mandates aggressive initial treatment in high-risk individuals.

Treatment Algorithm

First-Line Medical Therapy

Initiate treatment with either a topical prostaglandin analog or a nonselective beta-blocker. 4, 5

• Prostaglandin analogs are increasingly preferred as first-line agents due to superior efficacy and once-daily dosing 6
• Beta-blockers (timolol 0.5% twice daily) remain a valid first-line option, particularly when prostaglandins are contraindicated 7, 4

Second-Line Adjunctive Therapy

When monotherapy fails to achieve target IOP:

• Topical carbonic anhydrase inhibitors (dorzolamide or brinzolamide) provide additional 15-20% IOP reduction 7
• Alpha-2 agonists (brimonidide) for further aqueous suppression 7, 4

Third-Line Options

• Parasympathomimetic agents (pilocarpine) are reserved for refractory cases due to side effect profile 4

Laser and Surgical Interventions

Consider laser trabeculoplasty or selective laser trabeculoplasty when medication adherence, cost, convenience, side effects, or inadequate IOP control become limiting factors. 1

• Laser trabeculoplasty increases aqueous outflow through the trabecular meshwork 6
• Incisional surgery (trabeculectomy, drainage tube implantation) is reserved for patients failing medical and laser therapy 4, 6
• Minimally invasive glaucoma surgeries (MIGS) offer improved safety profiles with modest efficacy reductions compared to traditional surgery 8

Monitoring Protocol

Treated or High-Risk Patients

Follow every 3-6 months until stable, then extend intervals cautiously. 2

Each visit must include:

• Visual acuity measurement 2
• Slit-lamp biomicroscopy 2
• IOP measurement 2
• Periodic ONH and RNFL evaluation 2

Untreated Low-Risk Glaucoma Suspects

Follow every 12-24 months with full structural and functional assessment. 2

Critical Management Principles

Adjustment for Progression

If structural or functional deterioration occurs despite treatment, immediately lower target IOP further and intensify therapy. 1

Both structural imaging and visual field testing are essential, as some patients show visual field loss without corresponding optic nerve progression 1. Never rely on a single modality.

Patient Education and Adherence

Discuss diagnosis, risk factors, prognosis, treatment options, and likelihood of lifelong therapy with patients and family members at every decision point. 1

Non-adherence is a major cause of treatment failure. Address barriers including cost, side effects, and dosing complexity 5, 6.

Special Populations and Risk Factors

High-Risk Groups Requiring Aggressive Management

• African Americans: Threefold higher prevalence than non-Hispanic whites, leading cause of blindness in this population 1
• Hispanics/Latinos: Comparable prevalence rates to African Americans 1
• Asian Americans: Higher prevalence than non-Hispanic whites 1
• Patients with family history: Significantly elevated risk requiring earlier and more frequent screening 1

Modifiable and Non-Modifiable Risk Factors

IOP is the only modifiable risk factor—all treatment targets this parameter. 1

Other significant risk factors include:

• Older age 1
• Thin central cornea 1
• Low ocular perfusion pressure 1
• Type 2 diabetes mellitus 1
• Myopia 1
• Disc hemorrhage 1
• Large cup-to-disc ratio 1

Quality of Life Considerations

Minimize treatment side effects while maintaining IOP control to preserve quality of life and visual function. 1

Glaucoma significantly impacts daily activities including reading, walking, and driving, with performance deteriorating as severity worsens 2. Patients face increased fall risk and motor vehicle collision rates 2. Balance aggressive treatment against treatment burden, as direct medical costs approach $3 billion annually in the US 2.

Common Pitfalls to Avoid

• Never diagnose glaucoma based solely on elevated IOP—many patients with ocular hypertension never develop glaucoma, while normal-tension glaucoma occurs with IOP <22 mmHg 3, 9
• Never skip gonioscopy—failure to identify angle closure or secondary causes leads to inappropriate treatment 1
• Never rely on structural imaging alone—integrate clinical examination, imaging, and visual field testing, as devices have false-positive rates and normative database limitations 1
• Never delay treatment in high-risk patients—those with IOP ≥26 mmHg and thin corneas have 36% progression risk over 5 years 1
• Never use prostaglandin analogs in lens-induced glaucoma preoperatively—they increase inflammation 7