Putting it all together
Don’t get bogged down in the details and focus on what is important. Most importantly - how is the patient doing? Glaucoma tends to be asymptomatic until it’s too late. We often prescribe symptomatic treatments for an asymptomatic condition. Don’t lose sight (pun intended) of what we are here for - to help the patient live a quality life, specifically by preserving and optimizing visual function while minimizing adverse effects. Also remember, people are living longer - 60 is the new 30!
Next ask yourself what is the diagnosis, is there progression, and do you recommend a change in treatment and follow up interval? If it helps, here’s a choose your own adventure script:
This is a __ year old __ (M/F) with __ (severity/type) glaucoma OD and __ (severity/type) OS and surgical history of __ OD and __ OS here for __ week/month follow up with __ (purpose of visit). Patient __(does not have any acute concerns, is most concerned about __).
Overall, I think the patient is (stable, at increased risk for progression, or concerning for progression) because __.
My recommendation is to (continue treatment, gather more information, or modify treatment with medication/laser/surgery) and have the patient return in __ weeks/months with __ (any testing or surgery).
Here’s an example:
63 yo M with severe POAG OD with hx of trab 3 years ago, moderate POAG OS with hx of phaco/istent 1 year ago, here for 3 month f/u with VF testing. Patient feels vision is stable, but is most concerned about his dry eye symptoms.
Overall, I think the right eye is stable and the left eye is at increased risk for progression because IOP is above target at 17 on latanoprost, and VF shows superior arcuate defect, possibly worse.
My recommendation is to modify treatment OS by adding timolol and having patient return in 4-6 weeks for IOP check. I will also encourage PFAT use.
The Glaucoma Visit
Working backwards, with the goal in mind - what parts of the exam are important to pay attention to? In addition to the obvious things (how the patient is doing, vision, pressure) here are some key elements not to overlook during a glaucoma evaluation:
History
Highest IOP (Tmax) if known
Ocular history, surgeries, laser
Current medications, medication intolerances (asthma/COPD, heart block)
Risk factors: Family history, blunt ocular trauma, steroid use, migraines/vasospasm, nocturnal hypotension
Exam
APD - patients with asymmetric visual field loss likely have an APD. Document accurately!
CVF - a good confrontation visual field can pick up mild to moderate peripheral field loss
Refraction - very hyperopic or myopic? astigmatism from prior filtering surgery?
IOP by applanation - always check this yourself. An accurate reading is important, and sometimes the tonopen or iCare can be inaccurate.
Gonio - all new patients, and at least annually for phakic patients following up. More frequently if at risk for primary angle closure.
Central corneal thickness / pachymetry - all new patients, just once is enough. The purpose is risk stratification - thinner corneas may be associated with a higher risk for glaucoma progression, and tend to have IOPs underestimated by applanation (not a linear relationship and any correction factors are estimates, but important to keep in mind)
Corneal hysteresis - measures the “shock absorbency” of the cornea. The average corneal hysteresis in normal eyes is higher (9.6 to 10.7 mmHg) compared to mean values in POAG (8 to 10 mmHg).
SLE
Lids/lashes - PGA effects (trichiasis, periorbital fat atrophy, darkening), brimonidine allergy (erythema, scaling of skin), blepharitis (treat prior to surgery)
Conj - medication toxicity (follicles, injection); mobility and thickness (pre-op eval), presence of scarring, bleb morphology (focal or diffuse, elevation, ischemic or vascularized, seidel if IOP low), coverage of tube
Sclera/episclera - dilated vessels may indicated elevated episcleral venous pressure (Sturge-Weber, AV fistulae, TED), sentinel vessels (intraocular mass), oculodermal menalocytosis (risk for melanoma and glaucoma), scleritis
Cornea - epithelial erosions, microcystic edema (acute IOP rise), endopigment (Krukenberg spindle - pigment dispersion), Haab striae (congenital), exfoliative material (PXF), KP (uveitic), irregular vesicular lesions (PPMD), beaten-bronze appearance (ICE), posterior embryotoxon (Axenfeld-Rieger)
AC - depth (Van Herick method to estimate, but don’t skip gonioscopy; if shallow, grade 1 = peripheral IK touch, grade II = mid-peripheral IK touch - specify central depth in multiples of corneal thickness, grade III = lens-K touch), cells (WBC, RBC, pigment, fibrin), symmetry between eyes, tube position
Iris - examine undilated; transillumination defects (peripupillary or mid), neovascularization, pseudoexfoliation, heterochromia, ectropion uveae, correctopia, nevi, atrophy, signs of trauma, iris color (blue eyes may resist using a PGA)
Lens - cataract grade and any phacomorphic appearance (anterior vaulting), pseudoexfoliation, donesis, glaucomflecken
DFE
Vitreous - inflammatory cells, hemorrhage, ghost cells
Nerve - symmetry, vertical elongation, focal thinning or notch, disc heme, color (there are many other features to consider - see optic disc assessment
Macula - don’t overlook other etiologies for vision loss, as glaucoma patients tend to share risk factors for retina problems. evaluate for edema, ERM, AMD, etc
Vessels - tortuosity, vein occlusions
Periphery - choroidal detachment (serous, hemorrhagic, or mixed), retinal detachment, masses
Testing
HVF - Obtain 2 tests a few months apart as a baseline, then follow up with 1-2 tests per year, with more frequent tests if there is concern for progression. Usually need 2 tests demonstrating a defect to be certain there is progression, as test-test variation is common. The first test is often a freebie with learning artifact; don’t lose hope! Many patients do better with practice. Have a low threshold to get 10-2 HVF (or a 24-2C, if patient is reliable test taker) especially for patients who describe noticing vision changes, have a defect near fixation on 24-2, or have a clean 24-2 but have other findings concerning for glaucoma (remember only 4 points of the 24-2 overlap with the 10-2). Note that alternating a 10-2 with 24-2 runs the risk of delaying detection of progression unless tests are done more frequently. Head-mounted visual fields can be helpful especially for patients with poor mobility or difficulty positioning in the HVF machine.
OCT - Obtain both RNFL and GCC (ganglion cell complex) if available. The GCC can be useful both in early disease (catches loss before RNFL thinning) and late disease (can measure ganglion cell thickness even when RNFL has thinned to the “floor”).
Optic disc photos - A picture is worth a thousand words. Disc photos can catch disc hemorrhages much better than our own eyes. A baseline photo is key, and photos may be repeated on a case by case basis - atypical nerves that are difficult to follow using OCT (myopic, extremely small or large nerves, large areas of circumferential peripapillary atrophy) may be better assessed using photos.
