What is the pathophysiology, diagnosis, and management of glaucoma for an ophthalmology rotation?

From the Guidelines

Glaucoma management should prioritize controlling intraocular pressure (IOP) to prevent optic nerve damage and vision loss, with treatment decisions based on individual risk factors and patient preferences, as outlined in the Primary Open-Angle Glaucoma Suspect Preferred Practice Pattern guidelines 1.

Key Points for Glaucoma Management

• Glaucoma is a group of eye conditions characterized by optic nerve damage, often due to elevated IOP, leading to progressive vision loss.
• Primary open-angle glaucoma (POAG) is the most common form, typically asymptomatic until late stages.
• Diagnosis involves measuring IOP, assessing the optic nerve head for cupping, visual field testing, and gonioscopy to evaluate the anterior chamber angle.
• Treatment aims to lower IOP through medications, laser procedures, or surgery, with the goal of controlling IOP in the target range, stabilizing optic nerve/RNFL status, and maintaining stable visual fields 1.

Treatment Options

• First-line medications include prostaglandin analogs (e.g., latanoprost 0.005%, travoprost 0.004%, bimatoprost 0.03%) once daily at night.
• Second-line options include beta-blockers (e.g., timolol 0.25-0.5% twice daily), alpha-2 agonists (e.g., brimonidine 0.1-0.2% three times daily), and carbonic anhydrase inhibitors (e.g., dorzolamide 2% three times daily).
• Laser trabeculoplasty should be considered when nonadherence, cost, convenience, side effects, or risks of medication are factors 1.

Risk Factors and Monitoring

• Assess for risk factors including age >60, family history, African or Hispanic ancestry, high myopia, thin central corneal thickness, and diabetes.
• Regular monitoring of IOP, optic nerve appearance, and visual fields is essential for managing progression, with target IOP typically 20-30% below baseline.
• The diagnosis, severity of the disease, prognosis and management plan, and likelihood of long-term therapy should be discussed with the patient, taking into account the patient's quality of life and life expectancy 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Overview of Glaucoma

• Glaucoma is the leading cause of blindness worldwide, after cataracts, and is a chronic progressive optic neuropathy characterized by damage to the optic nerve and retinal nerve fiber layer 2, 3, 4.
• It can lead to permanent loss of peripheral or central vision if left untreated or poorly managed.
• The global prevalence of glaucoma in people aged 40 to 80 years is estimated to be 3.5%, and it is projected that 111.8 million people will have glaucoma in 2040 4.

Classification and Risk Factors

• Glaucomas are usually categorized by the anatomy of the anterior chamber angle (open vs narrow/closed), rapidity of onset (acute vs chronic), and major etiology (primary vs secondary) 2.
• Risk factors for glaucoma include older age, nonwhite race, family history of glaucoma, and certain systemic medical conditions such as corticosteroids, anticholinergics, certain antidepressants, and topiramate 3.
• Intraocular pressure is the only known modifiable risk factor for glaucoma 2, 3.

Diagnosis and Monitoring

• Diagnostic testing to assess for glaucoma and to monitor for disease progression includes measurement of intraocular pressure, perimetry, and optical coherence tomography 3.
• Regular eye examinations should be performed in at-risk patients to prevent the insidious loss of vision that can develop before diagnosis 2.

Treatment Options

• Treatment of glaucoma involves lowering intraocular pressure, which can be achieved with various classes of glaucoma medications, as well as laser and incisional surgical procedures 2, 3.
• Prostaglandin analogues, such as latanoprost, are a class of ocular hypotensive drugs that have been developed for the treatment of open angle glaucoma and are considered first-line treatment by the European Glaucoma Society guidelines 5, 6.
• Latanoprost has been shown to be effective in reducing intraocular pressure and has a good safety and tolerability profile, with common ocular adverse events including conjunctival hyperemia, pigmentation of the iris, and ocular surface effects or irritation 5, 6.

Management and Prevention

• Vision loss from glaucoma can be minimized by recognizing systemic conditions and medications that increase a patient's risk of glaucoma and referring high-risk patients for a complete ophthalmologic examination 3.
• Patients with glaucoma require lifelong management, and clinicians should ensure that patients remain adherent with taking glaucoma medications and monitor for adverse events from medical or surgical interventions used to treat glaucoma 3, 4.