GLAUCOMA MANAGEMENT

Overview
 It is a group of diseases characterized by progressive optic neuropathy
and visual field loss
 It is a major blinding disease worldwide and the leading cause of
irreversible blindness
 Classified based of etiology, age of onset, mechanism, chronicity, and
more
 Usually bilateral, but may be unilateral or asymmetrical (usually
secondary)
Risk factor

 Primary risk factor is elevated IOP (> 21 mm Hg), “normal IOP” doesn‘t
rule out glaucoma
 Others risks are advanced age, positive family history, race, refractive
error, eye surgery or injury, steroid use, inflammation, refractive error.

 Primary open angle and Pseudo-exfoliative glaucoma are the commonest

types in Ethiopia
Chronic Glaucoma: Clinical features
Symptoms
 Mostly asymptomatic (“sight thief”)
 History of gradual loss of vision in the affected eye or loss of visual

field
Signs
 Cupping of optic disc on fundoscopy and /or elevated IOP
 RAPD (useful to detect an eye with advanced glaucoma)
 Digital palpation to compare both eyes
Investigations and diagnosis:

 Tonometry measures intraocular pressure (IOP)

 Visual field test (confrontation, FDT, standard perimetry)
 Ophthalmoscopy fundus examination
Treatment: Goal

 Early detection, control IOP and preserve vision

 Maintain the IOP to the safe level that does not cause damage
 Halt progressive optic nerve head damage and visual field loss
 Decrease the medication side effects
Non-pharmacological treatment

 Surgery – Trabeculectomy, Tube-shunt implant

 Laser treatment
 Pharmacological treatment
Chronic open angle glaucoma
 Beta adrenergic antagonist

 Timolol 0.25% or 0.5% eye drops, instill 1 drop BID OR

 Betaxolol 0.5% eye drops, instill 1 drop BID

 Prostaglandin analogues:

 Latanoprost 0.005% eye drops, instill 1 drop daily if target IOP not reached
 NB. Currently prostaglandin analogue eye drops are the first line, if available
 Also, can be used alone in cases of intolerance and contraindications to

betablockers
 Alternative: Travoprost 0.004%
Cont’d
Adrenergic Agonists
 Brimonidine 2% eye drops, instill 1 drop BID  Apraclonidine eye drop,

instill BID or TID

 NB. Use as second line if patient has allergic reaction to prostaglandin

analogue, in place of prostaglandin analogue and/or in combination with

ß-blocker. Avoid use in children less than 2 years.
 Combination drugs can be used if the patient has poor response.

 Combinations should be from different therapeutic classes.

Para sympathomimetic:

 Pilocarpine, 2 and 4%, eye drops, instill 1 drop QID, drug of choice in
pigmentary glaucoma
 NB. Avoid use in young patient (except in pigmentary Glaucoma),
uveitic glaucoma, and primary open angle glaucoma (POAG) with high
myopia
 Carbonic anhydrase inhibitors:
 Acetazolamide 125 to 250mg, BID to QID or Methazolamide 50 to 100mg,
BID to TID
 Dorzolamide 2% eye drop 1 drop BID or TID or Brinzolamide 1% eye drop, 1
drop BID to TID
 NB: The oral preparations only used in cases of very high IOP used for short
period, due to side effects
 Referral: Refer all cases of glaucoma and/or glaucoma suspect to an
ophthalmologist