Primary Open-Angle Glaucoma

History

• Time of diagnosis, prior work-up, therapy, intolerances, allergies
• Family history
• Systemic history: sleep apnea, cold hands/feet, tinnitus, migraine, Raynaud's syndrome, fluid intake, low blood pressure, myocardial infarction
  • Medications: antihypertensives, sulfonamides, topiramate, antidepressants

Differential Diagnosis

• Ocular hypertension ("not yet" glaucoma)
  • Definition: IOP > 21 mmHg on two or more days, normal anatomy/gonioscopy/optic disc cupping/visual field/RNFL
  • Therapy: > 24 mmHg
  • Management: IOP follow-up at 2-4 weeks, then every 3 months; after 1 year without progressive glaucomatous defects, follow-up every 6 months
• Secondary open-angle glaucoma see XXX

Diagnostics

• Subjective visual acuity
• Applanation tonometry
• Slit lamp
  • Conjunctiva: injected
  • Cornea: KP, pigment dispersion
  • Anterior chamber: cells, Tyndall, shallow anterior chamber
  • Iris/pupil: PEX, transillumination, reduced motility, synechiae, rubeosis iridis
  • Lens: cataract, thick lens, glaukomflecken, PEX
• Fundus in miosis
  • Optic disc: cupping (cup-disc ratio), notch, color, rim (ISNT rule), disc margin hemorrhages
  • Macula
  • Retina: vascular architecture, hemorrhages
• Gonioscopy: angle (Shaffer), dysgenesis
• Visual field (Octopus G2): scotomas, relative defects
• OCT M P and photos
  • M: ganglion cell layer (GCL)
  • P: RNFL (correct tracking if needed), progression
• Pachymetry (Scheimpflug imaging, Pentacam)
  • with thin corneas, IOP is falsely measured too low, and with thick corneas, falsely too high
• Diurnal pressure curve if applicable

Work-up if optic neuropathy is suspected

• MRI of the head if applicable
• Ultrasound of the carotid arteries if applicable
• Screening for sleep apnea syndrome if applicable
• Blood tests if applicable
  • e.g. vitamin B12, folic acid, complete blood count, ESR/CRP, Treponema pallidum serology, Borrelia serology, ACE, plasminogen electrophoresis, and autoantibodies

Therapy

Primarily, lowering pressure to a defined target range

• Target pressure: 30%-50% below the pressure level that leads to progression of visual field or RNFL on OCT

Topical Pressure-Lowering Therapy

• 1. Prostaglandin analogues
• Alpha-

Systemic

• Acetazolamide

Laser Procedures

• SLT (selective laser trabeculoplasty)
• LPI (laser peripheral iridotomy): narrow-angle situation

Surgical

• Cataract surgery in patients > 50 years (pressure reduction approx. 5-6 mmHg)
• MIGS (pressure reduction approx. 2-3 mmHg)
• Deep sclerectomy
• Trabeculectomy
• Drainage implants (referral to tertiary center)