To whom should a patient with a family history of glaucoma be referred for evaluation and management?

Referral for Patients with Family History of Glaucoma

Patients with a family history of glaucoma should be referred to an eye care professional (ophthalmologist or optometrist) for comprehensive ophthalmologic examination including optic nerve assessment, visual field testing, and intraocular pressure measurement. 1, 2

Who Qualifies for Screening

Family history of glaucoma is recognized as a major risk factor that qualifies patients for Medicare-covered glaucoma screening, regardless of age. 2 This reflects the substantial increase in glaucoma risk when family history is present, particularly when combined with other risk factors. 2

Specific Populations Requiring Referral

The following patients with family history warrant referral to eye care professionals:

• All patients with a positive family history of glaucoma should undergo comprehensive eye examination 1, 2
• African Americans aged 50 years or older with family history face particularly elevated risk (approximately 3 times higher age-adjusted prevalence compared to whites) and require urgent attention 2
• Hispanics aged 65 years or older with family history (4.7% prevalence in those older than 40 years) 2
• Patients with diabetes mellitus and concurrent family history 1

Critical Information to Document Before Referral

When referring patients with family history, obtain and communicate the following details to the eye care professional:

• Severity and outcome of glaucoma in affected family members, including any history of visual loss from glaucoma 1
• Patient's race/ethnicity (African American, Hispanic, Asian descent) 1
• Age of the patient 1
• Systemic conditions: diabetes, asthma/COPD, migraine headache, Raynaud's syndrome, cardiovascular disease 1
• Current medications, particularly corticosteroids (topical, oral, injected, or inhaled), anticholinergics, certain antidepressants, and topiramate 1, 3
• Ocular history: refractive error (especially hyperopia), trauma, prior ocular surgery (including LASIK, SMILE, or photorefractive keratectomy) 1

What the Eye Care Professional Will Evaluate

The comprehensive glaucoma evaluation includes:

• Visual acuity measurement at distance and near 1
• Pupil examination for reactivity and relative afferent pupillary defect 1
• Intraocular pressure (IOP) measurement 1, 2
• Gonioscopy to assess anterior chamber angle 1
• Central corneal thickness (CCT) determination 1
• Optic nerve head (ONH) and retinal nerve fiber layer (RNFL) examination 1
• Visual field assessment using automated perimetry 1
• Fundus examination 1

Common Pitfalls to Avoid

• Do not assume normal IOP rules out glaucoma: Half of patients with glaucoma have normal intraocular pressure (<22 mmHg), so diagnosis requires structural assessment of the optic nerve and visual field testing, not just pressure measurement 4, 5
• Do not delay referral: Most patients with primary open-angle glaucoma are asymptomatic in early and moderate stages, and functional symptoms only appear with significant visual field loss 4
• Do not dismiss transient symptoms: Patients reporting intermittent blurred vision, halos around lights, eye pain, headache, or eye redness may have intermittent angle closure and face 50% risk of acute attack within 5 years if untreated 1, 6

Treatment Expectations After Diagnosis

Treatment is initiated only when definitive glaucoma is diagnosed, not based solely on family history or elevated IOP. 2 Medical treatment reduces visual field progression with an odds ratio of 0.62 (95% CI 0.47-0.81) compared to placebo, and combined medical and/or surgical treatment reduces progression with a hazard ratio of 0.56 (95% CI 0.39-0.81). 2