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Definition
- Progressive, bilateral optic neuropathy with open anterior chamber angle, characterised by typical nerve fibre loss and elevated intraocular pressure (>21mmHg) not caused by other local or systemic pathology
Risk Factors
- Higher IOP (per definition >21mmHg), older age, African descent (6x increased risk), first-degree relatives with POAG (6x increased risk), diabetes mellitus, myopia, arterial hypertension, migraine, thin central corneal thickness
Baseline Examination
- Medical history
- Medications, diseases (especially respiratory and cardiovascular), family history, ocular trauma, refractive surgery, allergies
- Complete ophthalmologic examination including:
- Exclusion of secondary causes (PEX, pigment dispersion, etc.)
- Intraocular pressure (IOP): preferably using Goldmann applanation tonometry, possibly additional methods
- Gonioscopy: Is the angle open?
- Assessment of the optic disc (cup-disc-ratio, DDLS Stage, ISNT rule, disc hemorrhages, nerve fibre layer, peripapillary atrophy, disc size)
- Pachymetry: Corneal thickness
- OCT of retinal nerve fibre layer (RNFL) and ganglion cell layer (GCL)
- Visual Field (usually Octopus G2)
- Consider MRI head or lab tests if non-glaucomatous optic nerve damage is suspected
Follow-up
- When starting therapy: Follow-up check after 4-6 weeks
- Visual field examination 3 times a year during the first two years after diagnosis (baseline, after 3 months, then another 4 times during the first 2 years)
- EGS Guidelines 5th Edition Assessment and Follow-up Intervals
Initiation of Antihypertensive Therapy
- see Topical Glaucoma Therapy
- Initially monotherapy.
- Often a prostaglandin analogue (e.g., Lumigan or Saflutan) or beta-blocker (e.g., Timoptic or Timisol).
- Interval until follow-up check after starting therapy usually 4-8 weeks.
- If satisfactory IOP: further check after 3-6 months.
- If no IOP reduction: switch to another monotherapy, possibly SLT.
- If inadequate IOP reduction: additional agent.
- Maximum topical therapy: quadruple therapy e.g., Simbrinza 2x daily + Duotrav 1x daily
- For children:
- 1. Timo-Comod (Timolol, CI: Asthma) 0.5% once daily (not twice) or Azopt (Brinzolamide) twice daily.
- 2. Cosopt S twice daily.
- 3. DuoTrav once daily.
- Note: Alphagan is contraindicated in children!
- EGS Guidelines 5th Edition Therapeutical Algorithm in Glaucoma Topical Therapy
Treatment
- Medical therapy: Usually initial therapy
- see above
- Laser Trabeculoplasty: Can also be initial therapy or secondary if there’s insufficient pressure reduction from medication
- Laser application to the trabecular meshwork to improve aqueous humor outflow
- Therapeutic effect varies greatly and is often temporary but can last months to years
- SLT = Selective laser trabeculoplasty (Nd:YAG laser)
- ALT = Argon laser trabeculoplasty (obsolete)
- Surgical Therapy:
- Trabeculectomy: Standard glaucoma surgery
- Shunt techniques: Ahmed Tube, Baerveldt Tube
- MIGS (Minimally Invasive Glaucoma Surgery)
Sources
- EyeWiki Primary Open-Angle Glaucoma
- European Glaucoma Society Terminology and Guidelines for Glaucoma, 5th Edition,
- Licensed under a Creative Commons License Attribution-NonCommercial 4.0 International CC BY-NC 4.0 DEED
- The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Kalla Gervasio MD, Travis Peck MD et al; Lippincott Williams&Wilkins; 8th Edition (2021)
- Kanski’s Clinical Ophthalmology: A Systematic Approach; John E Salmon MD; Elsevier; 9th Edition (2019)