Glaucoma Symptoms and Management in Older Adults with Family History
Symptoms of Glaucoma
Primary open-angle glaucoma (POAG), the most common form, is typically asymptomatic in early stages, which is why up to 75% of cases remain undiagnosed. 1, 2
Early-Stage POAG (Most Common)
- No symptoms in the majority of patients—this is the critical pitfall that leads to delayed diagnosis 3, 4
- Gradual peripheral vision loss that patients typically do not notice until advanced stages 2
- Central vision remains intact until late disease 4
Acute Angle-Closure Glaucoma (Medical Emergency)
- Sudden severe eye pain and headache 5
- Blurred vision with halos around lights (due to corneal edema) 5
- Eye redness 5
- Mid-dilated, non-reactive pupil 5
- Nausea and vomiting 5
- This requires immediate ophthalmologic referral to prevent permanent vision loss within hours 5
Risk Assessment for Your Patient
Family history increases glaucoma risk 1.92 to 9.2-fold depending on the number of affected relatives, making this patient high-risk and qualifying them for Medicare-covered screening. 6
Additional Risk Factors to Assess
- Age over 65 years (prevalence increases from 2.7% at age 43-49 to 7.7% at age 75-79) 1
- African American ethnicity (3-fold higher risk) 6
- Hispanic ethnicity (4.7% prevalence over age 40) 6
- Type 2 diabetes mellitus 1
- Myopia 1
- Hypothyroidism 1
- Low blood pressure or cardiovascular disease 1, 7
Screening and Diagnosis Recommendations
This patient should be referred to an ophthalmologist for comprehensive evaluation including tonometry, optical coherence tomography, gonioscopy, and visual field testing—not screened in primary care. 1, 6
Why Primary Care Screening is Inadequate
- Hand-held tonometers and ophthalmoscopes lack acceptable diagnostic accuracy 1
- Approximately 50% of POAG patients have intraocular pressure (IOP) below 22 mmHg at single screening, missing half of cases 1
- Diagnosis requires monitoring over years to document progressive changes 7
Comprehensive Ophthalmologic Evaluation Should Include
- IOP measurement via tonometry (normal is ≤21 mmHg, but not diagnostic alone) 1, 4
- Optic nerve head examination looking for cup-to-disc ratio ≥0.3 7
- Optical coherence tomography (OCT) to detect retinal nerve fiber layer thinning 1, 7
- Visual field testing (perimetry) to identify characteristic peripheral defects 1, 4
- Gonioscopy to differentiate open-angle from angle-closure glaucoma 1
- Central corneal thickness measurement (thinner corneas increase risk) 1
Risk Calculator Utilization
Use the validated OHTS risk calculator (available at https://ohts.wustl.edu/risk/) incorporating age, cup-to-disc ratio, pattern standard deviation, central corneal thickness, and IOP to estimate 5-year risk of developing glaucoma. 1
Treatment Approach
Treatment should only be initiated when definitive glaucoma is diagnosed with documented optic nerve damage or visual field loss—not based solely on family history or elevated IOP. 6
First-Line Treatment Options
Topical prostaglandin analogs or beta-blockers are first-line medical therapy, with selective laser trabeculoplasty as an alternative primary treatment. 1, 3
Medical Therapy
- Prostaglandin analogs (most commonly used first-line) 3, 8
- Beta-blockers (timolol) 9, 3
- Contraindicated in patients with asthma, COPD, sinus bradycardia, or heart block 9
- Alpha-2 agonists (second-line adjunctive therapy) 3, 8
- Topical carbonic anhydrase inhibitors (second-line adjunctive therapy) 3, 8
- Oral carbonic anhydrase inhibitors (acetazolamide) for acute situations 10
Laser Therapy
- Selective laser trabeculoplasty should be considered when medication adherence, cost, convenience, or side effects are concerns 1
Treatment Goals
The target IOP should be set at 20% below the mean of several baseline measurements, with the ultimate goal of preventing visual field loss that would affect quality of life. 1
- Target pressure must be individualized and may require adjustment during follow-up 1
- Medical treatment reduces visual field progression with odds ratio 0.62 compared to no treatment 6
- Combined medical/surgical treatment reduces progression with hazard ratio 0.56 6
Surgical Options (When Medical Therapy Fails)
Critical Management Pitfalls
Common Errors to Avoid
- Do not rely on IOP alone for diagnosis—50% of POAG patients have normal IOP 1, 4
- Do not use timolol in patients with respiratory disease or cardiac conduction abnormalities 9
- Do not treat elevated IOP without documented optic nerve or visual field damage (this is ocular hypertension, not glaucoma) 1
- Do not assume family history alone warrants treatment—it only increases screening priority 6
Medication Adherence Barriers
- Emphasize that glaucoma medications prevent blindness despite lack of symptoms 2
- Address cost concerns (Medicare covers screening for high-risk patients including those with family history) 1, 6
- Monitor for medication side effects that reduce adherence 1
Prognosis Considerations
Without treatment, POAG progresses to significant visual impairment, but with proper IOP-lowering therapy, progression can be delayed or prevented in most patients. 3, 8