AD_HTT_023_030___MAR09_07 2/3/07 4:27 PM Page 23
How to treat
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GLAUCOMA
What is glaucoma?
GLAUCOMA is a progressive optic
neuropathy characterised by the
combination of both changes in the
structure of the optic nerve (disc cup-
ping) and loss of visual field (blind
spots or scotomas).
Raised intraocular pressure (IOP)
is the main cause of this damage, but
it can often occur without elevated
pressure (termed normal-tension
w w w. a u s t r a l i a n d o c t o r. c o m . a u
Complete How to Treat quizzes online (www.australiandoctor.com.au/cpd) or in every issue.
glaucoma). Although visual damage
is not reversible, it can usually be
arrested by treatment with eye drops,
laser or other surgery.
There are two main types of glau-
coma — open angle and closed
angle. By far the most common form
is primary open-angle glaucoma
(POAG), which is asymptomatic in
its early stages and is slowly pro-
inside
Definition
Detection,
diagnosis and
monitoring
Medications and
their side effects
Glaucoma surgery
The author
DR STUART L GRAHAM,
clinical lecturer, Save Sight
Institute, University of Sydney;
and consultant ophthalmologist,
Eye Associates, Sydney, NSW.
Correction
The How to Treat article
‘Chronic kidney disease’
(2 February) advised the use
gressive if not treated. POAG has an overall incidence of of gliclazide and glimepiride
The diagnosis of POAG is often about 2%, but this increases signifi- as best treatment options for
late because its detection can be elu- cantly in the latter decades to up to patients with chronic kidney
sive until the disease process is well 8%. disease and diabetes.
advanced. A substantial amount of The main risk factors for POAG are However, glimepiride should
vision can be lost before the patient age and family history. Additional sys- be avoided because of the
becomes aware of any defect. This temic associations include diabetes, risk of hypoglycaemia and
is why population studies reveal that hypertension, migraine, Raynaud’s the authors recommend
up to 50% of glaucoma in the com- syndrome and possibly sleep apnoea. treatment with gliclazide or
munity is undiagnosed. cont’d next page glipizide.
LIS BS
P
TE
D
7-DAY CONTINUOUS PAIN RELIEF 1
Before prescribing please review Approved Product Information and review State and Federal regulations. For Product
Information and PBS Information refer to primary advertisement elsewhere in this publication. Product Information is
available from Mundipharma Pty Limited. ABN 87 081 322 509 Level 26, 6 O’Connell St. SYDNEY NSW 2000.
® Norspan is a registered trademark.
1: Norspan Product Information (August 2005). MUNNOR020ADS
www.australiandoctor.com.au 9 March 2007 | Australian Doctor | 23
AD_HTT_023_030___MAR09_07 2/3/07 4:27 PM Page 24

How to treat – glaucoma

from previous page Figure 1: Acute angle-closure glaucoma.

Ocular risks include
myopia, pseudo-exfoliation
syndrome (accumulation of
small white glycoprotein
particles within the eye) and
thin central corneas.
Normal-tension glaucoma
is a subgroup of the open-
angle glaucomas. It is pre-
sumed that patients with this
condition have nerves that
are highly susceptible to
pressure, a vascular patho-
physiology or some other
form of neurodegenerative
disease. They still show a
clinical response to lowering
of IOP, so they are treated
as for POAG.
Angle-closure glaucoma is
much less common, but has
a higher incidence in Asian
people. It involves quite a
different mechanism and
presentation. The angle is
the region between the
cornea and the base of the
iris, where the drainage
channels are located (trabec-
ular meshwork).
The angle can obstruct if
the peripheral iris moves for-
ward in susceptible eyes. It
is associated with a sudden
rise in IOP, a painful red eye
with blurring and a mid-
dilated pupil. It rapidly pro-
ceeds to blindness if not
treated promptly.
Table 1: The two main types of glaucoma
Features Open angle Closed angle
Presenting None usually, central vision loss Blurring, haloes, pain – deep ache,
symptoms only in late stages, unrecognised redness, headache, vomiting
mid-peripheral field loss progresses
to tunnel vision eventually
Signs Disc cupping, visual field loss, Mid-dilated non-reacting pupil, very high
raised intraocular pressure (IOP) IOP, cloudy cornea (figure 1)
Referral Not urgent — very slow disease process Emergency — rapid visual loss can follow
Treatment Control IOP with topical therapy, Immediate IOP lowering, topical IV,
laser or surgery urgent laser treatment to open angle
Prognosis Very good if detected early and Good if prompt treatment given, but
managed well. About 10% still show many still require treatment and surgery
slow progression later
Differential Exclude optic nerve compression and Iritis, keratitis, herpes zoster,
diagnosis tumours if atypical features ophthalmicus, scleritis
Table 2: Differential diagnosis of other common causes of vision loss
Corticosteroids
Diagnosis Features
Corticosteroids — particularly when given as eyedrops, but also
Cataract Slow onset (years) of visual blurring, glare symptoms, frequent glasses
any form of systemic administration such as inhalers — can
change, monocular diplopia
induce raised IOP in susceptible people and cause a secondary
Macular degeneration Slow (or sudden if haemorrhagic) loss of central vision, distortion open-angle glaucoma. If there is a family history or the patient is
(metamorphopsia), central blur or blind spot already known to have glaucoma, the IOP should be checked if
Retinal detachment Flashes, floaters, black curtain partly obstructing view and slowly therapy is continuing beyond two weeks.
progressing from one side across field of view
Optic neuritis Rapidly increasing vision loss, pain on eye movement Congenital glaucoma
Migraine (variant episodes) Scintillating lights, expand and migrate across field in minutes, with Beware big-eyed babies with blepharospasm: watery eyes may
scotoma. If both eyes involved, cortical not be just a blocked tear duct. The high pressure expands the
Iritis Pain, perilimbal blush, poorly reacting pupil, blurring but vision loss globe and causes corneal oedema, with pain and tearing. This
not a major feature unless severe is rare, however (1:10,000 births).
The two main types of of secondary glaucomas, tary, uveitic, traumatic, con- aqueous fluid from the eye.
glaucoma are compared in which are relatively uncom- tact lens induced) that through The differential diagnoses
table 1. mon, caused by various disor- various mechanisms interfere of glaucoma are listed in
There is also a wide range ders (eg, neovascular, pigmen- with the internal drainage of table 2.

How is glaucoma diagnosed?

GLAUCOMA, specifically POAG, Figure 2A: A normal optic disc. The optic cup is the paler area in the centre
has classically been diagnosed by Figure 3A and 3B: Optic disc haemorrhages — a sign of progressive
and is assessed relative to overall disc size. In this case the cup-to-disc ratio glaucoma. There are two small haems on the right (A) and one on the left (B).
testing for raised IOP. However, is 0.4; a ratio >0.6 is suspicious of glaucoma. 2B: Optic disc of a patient with These can also occur in hypertension, diabetes and posterior vitreous
we now know that at least one- glaucoma. The darker fundus is due to racial background (Asian). Note the detachment. The left disc is notching superiorly, consistent with glaucoma.
third of glaucoma patients never relatively larger disc overall, with the cup extending out to the inferior rim,
have high pressure, yet they showing loss of nerve fibres. The mottled pigment crescent is a feature of
develop typical disease features (ie, myopic (short-sighted) eyes.
normal-tension glaucoma). A A
Also, many patients can have
ocular hypertension for years and
never develop the disease. There-
fore screening for the disease
cannot rely on raised IOP alone. It
is essential to examine the optic
nerve to see if damage (loss of
nerve fibres) is present.
Clinically the first changes usu-
ally occur at the optic disc and it
remains vital that the clinician look
for the characteristic sign of optic
disc cupping. Every doctor should
learn to view the optic disc with
an ophthalmoscope, and anyone B B
with a large cup, or an asymmetry
between the optic discs of the two
eyes, should be referred for investi-
gation.
Classically, the cup-to-disc ratio
has been used to detect disease, and
a cup greater than 60% of the disc
area (C:D ratio >0.6) is very suspi-
cious of glaucoma (figure 2).
Unfortunately, evaluation of the
C:D ratio is very subjective and suf-
fers from a large amount of inter-
and intra-observer variability. Even
more importantly, the size of the
C:D ratio is directly related to the
size of the optic disc. Large optic document the status of the nerve orrhage is also an important sign inferior arcuate defects join up, the
discs have physiologically large and to look for subtle future (see figure 3). patient is left with tunnel vision.
cups and small discs have physio- changes that might suggest pro- The other means of detection is to This still remains the gold standard
logically small cups. gression of the disease. look for visual field loss. Glaucoma for diagnosis despite its limitations,
A final call based on appearance It is safer to refer someone if they blind spots (scotomas) tends to be which are discussed below. How-
alone can sometimes be difficult have a large cup, particularly if arc shaped, or ‘arcuate’, which cor- ever, there are also several newer
even for a trained glaucoma sub- there is a family history of glau- responds to the distribution of the methods of detecting and monitor-
specialist. Therefore, in such cases coma, even if this will involve some damaged nerve fibres. ing the disease that have recently
optic disc photographs are used to false positives. An optic disc haem- Ultimately when superior and been developed.

24 | Australian Doctor | 9 March 2007 www.australiandoctor.com.au

AD_HTT_023_030___MAR09_07 2/3/07 4:27 PM Page 25
Detecting and monitoring glaucoma
Standard ophthalmic tests
IOP measurement (tonometry)
THIS is done by direct con-
tact against the cornea after
application of local anaes-
thetic, for example, with a
Goldman tonometer, or with
an air-jet non-contact ton-
ometer.
The latter can produce
some falsely high readings on
occasions, but has enabled
optometrists to do mass
screening examinations of the
public and refer when a
patient has raised pressure.
It is now known that the
corneal thickness can affect
the IOP reading, so this is
now also measured with ultra-
sound (pachymetry) to allow
for any necessary adjustments
to be made.
Gonioscopy
This involves close examina-
tion of the angle region using
a special contact lens contain-
ing internal mirrors, to deter-
mine whether the patient is at
risk of angle closure. If the
angle is narrow, a laser irido-
tomy is performed which
helps open the angle configu-
ration and prevent a sudden
attack of closure.
Optic disc photographs
These are used to document
the status of the nerve and to
look for subtle changes in the
future that might suggest pro-
gression of the disease. Stereo
photos can provide 3D assess-
ment of the disc structure.
Visual field testing (perimetry)
In white-on-white automated
perimetry the patient is asked
to detect small white-light tar-
gets projected into their
peripheral field of view on a
dim white background. The
intensity of the spots is varied
until they are not detected, to
establish the threshold level
for each of the 54 points that
extend out to 24° of eccen-
tricity or more.
It is limited by the fact that
a large proportion (up to
50%) of the nerve fibres can
be lost before an initial defect
is seen and that patients find it
difficult — even stressful —
to perform. The results are
also variable, with a recog-
nised phenomenon of a learn-
ing effect: it may take up to
three tests before a meaningful
result is produced.
New methods available for
detecting glaucoma
The newer methods are specif-
ically designed to detect
change at earlier stages of the
disease or to be less subjective.
Psychophysical tests have been
developed that target smaller
subpopulations of ganglion
cells.
Optic disc and nerve fibre
imaging techniques using
scanning laser ophthalmo-
scopes or optical coherence
tomography can provide
objective measures of struc-
tural change.
Figure 4: Standard subjective automated visual field testing and objective visual field testing with Figure 7: Optic cup seen in cross-section, imaged with optical
multifocal visual evoked potential (mVEP), both showing scotoma (blind spot), compared with a coherence tomography (OCT).
normal data base.
SUBJECTIVE VISUAL FIELD – WHITE ON WHITE
100%) for detecting moder-
OBJECTIVE VISUAL FIELD – MULTIFOCAL VEP ate to severe losses in glau-
VEP traces Amplitude deviation coma, making it suitable for
visual field screening, but it is
Temporal Nasal
area area less suited to monitoring
established defects.
The development of the
new FDT matrix, with a
32˚ 32˚ greater number of smaller tar-
gets, improves the ability of
FDT to determine the spatial
extent of visual field defects,
276 nV P value (%) although its sensitivity is
279 ms ≥5.0 <5.0 <2.0 <1.0 lower.
Short-wave automated
Figure 5: Optic disc imaged with scanning laser ophthalmoscope. Still within normal limits (green perimetry or blue/yellow
ticks) but the red area on the pixel plot (B) suggests focal change compared with baseline. perimetry
Short-wave automated
A B perimetry (SWAP) is similar
to standard automated
perimetry except that it uses
a blue-light stimulus pro-
jected onto a bright-yellow
background. This isolates
the blue cone pathway by
saturating the red and green
cones and simultaneously
suppressing rod activity.
Previous investigations have
established that SWAP is a
more sensitive indicator of
early damage and progression
of field loss than standard
Air-jet non- automated perimetry. Clini-
Figure 6: Optic disc imaged with scanning laser polarimeter.
cally it is recommended par-
contact Nerve fibres polarise light: yellow = thicker fibres, blue =
thinner fibres. ticularly for younger patients
tonometry can with early disease or high-risk
produce some Right Nerve Fibre Thickness Map suspects.
falsely high Objective perimetry —
readings on multifocal visual evoked
occasions, but potential
has enabled Because of the variability of
subjective techniques, an
optometrists to objective measure of the visual
do mass field is valuable (figure 4). The
screening multifocal visual evoked
examinations of potential (mVEP) technique
involves simultaneously
the public. recording visual evoked
potential responses from each
of 58 segments of the visual
field out to 24°, compared
with conventional VEP which
records only a mass signal
dominated by the central field.
The visual stimulus is a
checkerboard pattern of
These tests are usually only and bright bars at a very high pseudo-randomly reversing
available at specialist’s prac- frequency. This produces the checks at each of the 58 sites.
tices or major eye clinics. All appearance of twice as many The patient is required to look
the tests described below are bars than are physically pre- at a central fixation point.
useful adjuncts to the clinician sent. Subjects respond to test Four electrodes are placed
but cannot be solely relied on patterns at multiple sites over the occipital region to
for diagnosis. within the field of view. record responses from the
The advantages of the FDT visual striate cortex.
New visual field techniques are that it is a compact, trans- The mVEP technique is
Frequency-doubling technology portable test, with tolerance ideal for patients with unreli-
(FDT) to refractive errors and rapid able standard perimetry. Clin-
FDT works by flickering a test times. It has good sensi- ical studies have shown high
coarse pattern of vertical dark tivity and specificity (96- sensitivity (95%) for detecting
www.australiandoctor.com.au 9 March 2007 | Australian Doctor |
scotomas in glaucoma. It may
also be very useful in detecting
and monitoring optic neuritis,
and possibly predicting
patients at higher risk of mul-
tiple sclerosis.
The advantages of the
method are that it removes
subject indecision, and
patients find it easier to per-
form. Limitations are that it
is more technician dependent,
and visual acuity is still impor-
tant (patients need to focus on
the centre).
New structural tests
Imaging of the optic disc and
retinal nerve fibre layer
The following new technolo-
gies document the structure of
the optic nerve head and pro-
vide a basis for future com-
parisons to detect change over
time.
Heidelberg retinal tomogra-
phy (figure 5). This is a scan-
ning laser ophthalmoscope
that rapidly projects a laser
grid across the disc (1-2 sec-
onds) and records with multi-
ple layers of focal depth. It
then generates a 3D image of
the optic disc surface and sur-
rounding retina.
The scanning laser polarime-
ter (figure 6). This instrument
provides quantitative assess-
ment of the retinal nerve-fibre
layer, using a polarised laser.
It does not measure optic disc
dimensions or cup size — only
thickness of the retinal nerve-
fibre layer.
Optical coherence tomogra-
phy (figure 7). This is a non-
invasive, non-contact imaging
technique using back-scatter-
ered light that provides cross-
sectional images of the retina
for evaluating both retinal dis-
eases and glaucoma. It is par-
ticularly good for assessing the
macular region in macular
degeneration.
These techniques are easy to
use and have good patient
acceptance. Their main limita-
tion is that, when comparing a
patient’s optic nerve to those
of the general population,
there is such great variability
among normals that we
cannot always be certain that
strangely shaped optic discs or
thin nerves are not just normal
variants. Serial scans over time
are more valuable.
25
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How to treat – glaucoma
Medications and their main side effects (table 3)
THE five main groups of ther-
apeutic agents used to treat
glaucoma are beta blockers,
prostaglandin derivatives,
alpha 2 -adrenergic agents,
miotics and carbonic anhy-
drase inhibitors. All attempt
to lower IOP, some by reduc-
ing aqueous production,
others by increasing the escape
of aqueous from the eye.
When drugs are used, the
incidence and severity of sys-
temic side effects can be
reduced by the patient per-
forming digital punctal occlu-
sion with the index finger for
1-2 minutes after drop instil-
lation. This manoeuvre
reduces the amount of the
medication passing down the
nasolacrimal duct to the nasal
mucosa, where drugs are
readily absorbed.
Beta blockers
Timolol 0.25% or 0.5%
(Timoptol, Timoptol XE,
Timoptic, Tenopt, Nyogel
0.1% ) is a non-selective beta
blocker that lowers IOP by
reducing aqueous secretion.
Side effects include bradycar-
dia, bronchospasm and sys-
temic hypotension.
Timolol should not be used
in patients with heart block
and can cause unrecognised
reduced exercise tolerance in
the elderly. Other side effects
include fatigue, disorientation,
confusion and depression,
headache, nightmares, impo-
tence and masking of hypogly-
caemia in patients with dia-
betes. Nyogel is a gel-based
preparation, allowing a lower
concentration to be used. Levo-
bunolol (0.25%) (Betagan) is
also non-selective and has a
similar profile to Timolol.
Betaxolol (0.25%, 0.5%)
(Betoptic) is a selective beta1-
adrenergic blocking agent,
which is nearly as effective as
timolol in lowering IOP and
has the advantage of having
little effect on the cardiopul-
monary system. It is therefore
safer to use than timolol in
patients with pulmonary dis-
ease (but still not totally safe) .
Despite side effects, beta
blockers remain in widespread
use, and timolol is in all four
combination products released
to date (see later).
Prostaglandin derivatives
Latanoprost 0.005% (Xala-
tan) is a synthetic prostag-
landin derived from prostag-
landin F2α. It has an
impressive IOP-lowering effect
by increasing outflow through
the uveo-scleral pathway
rather than the trabecular
meshwork. It only requires
once-daily dosage.
It seems to be relatively free
of systemic side effects but can
irreversibly change the colour
of green-brown, yellow-
brown and hazel irises to dark
brown in some patients. It
also enhances eyelash growth.
Patients often experience
red eyes after starting therapy,
but in many cases this dimin-
28 | Australian Doctor | 9 March 2007
Table 3: Medications used in glaucoma, and their main side effects accommodative status of the coma is topical. The chosen
lens (induced myopia), which drug should be used in its
Class Generic/trade names Side effects leads to the common side lowest concentration, as
Beta blockers Timolol (0.25%, 0.5%) Bronchoconstriction, bradycardia, effects, including diminished infrequently as possible, to
(Nyogel 0.1%, Tenopt, Timoptol, fatigue, headache, confusion, night vision, permanent achieve the desired effect.
Timoptol XE, Timoptic), depression, nightmares, impotence, miosis with prolonged use, In most cases the initial
Levobunolol 0.25% (Betagan), effects on lipids, masking of reduced visual acuity, and a medical therapy is with a
Betaxolol 0.25%, 0.5% (Betoptic) hypoglycaemia generalised constriction of prostaglandin derivative or
the visual field. a beta blocker. If this is inef-
Prostaglandin Latanoprost 0.005% (Xalatan), Iris colour change to brown,
Frontal headache is a fre- fective another class of drug
derivatives Travoprost 0.004% (Travatan), eyelash growth, periorbital pigment,
quent symptom at the start can be tried, or added to the
Bimatoprost 0.03% (Lumigan) hyperaemia, HSV keratitis reactivation
of therapy but usually therapy. Pilocarpine is now
Alpha2 agonists Aproclonidine 0.5% (Iopidine), Local allergy, fatigue, dry mouth, regresses after a few weeks. usually reserved for older
Brimonidine 0.2%, (Alphagan) blurring Retinal tears and detach- patients who are uncon-
Miotics Pilocarpine 0.5-6% Miosis, headache, blurring, reduced ment are very rare compli- trolled with other medica-
night vision cations related to ciliary tions or cannot take them
Carbonic muscle contraction. because of side effects.
anhydrase inhibitors Systemic side effects are Because of the risk of side
uncommon but include effects, systemic Diamox is
Topical Dorzolamide 2 % (Trusopt), Local irritation, metallic taste
bradycardia, increased considered mainly for emer-
Brinzolamide 1% (Azopt)
sweating, diarrhoea, saliva- gency or short-term treat-
Oral Acetazolamide 250mg (Diamox) Parasthesiae, malaise, fatigue, tion and anxiety, due to ment, or in those in whom
depression, hypokalaemia, metabolic parasympathetic stimulation. surgery is undesirable or
acidosis, gastrointestinal Miotics are cheap and being deferred.
disturbances, kidney stones effective pressure-lowering In general any vascular
drugs but are now used much risk factors such as diabetes,
ishes over time. Reactivation carbonic anhydrase inhibitor less frequently because of hypertension, cholesterol or
Points to note when
of HSV keratitis has been now used in the treatment of their side effect profile. carotid artery disease should
using beta blockers
reported and, rarely, macular glaucoma is acetazolamide also be addressed. The
■ Use caution with timolol oedema in patients with pre- (Diamox) 250mg. Acetazo- Combinations patient should be encour-
and topical beta blockers. vious complicated surgery. lamide can also be adminis- Combination products use dif- aged to stop smoking and to
If the patient is already Travoprost 0.004% (Tra- tered IV in acute attacks. ferent classes of medication take regular exercise. If
taking them systemically vatan) is a similar synthetic Unfortunately, the useful- combined with timolol, which underlying cardiovascular
they should be avoided. prostaglandin. Bimatoprost ness of the drug in long-term saves the patient time and disease is present, low-dose
■ Beta blockers may be the 0.03% (Lumigan) is an alter- therapy is limited by side expense and improves compli- aspirin theoretically may
cause of unexplained native prostamide derivative. effects. Paraesthesiae of the ance. It also reduces the total help the ocular circulation.
dyspnoea, cough, fatigue, Both have a similar mode of fingers and toes are a uni- exposure to preservatives, and If the patient is taking sys-
depression, dizziness. action, efficacy and side effects versal side effect. There can the washout effects of instilling temic antihypertensive med-
to those of latanoprost. The be malaise, fatigue, depres- drops sequentially. ications, care should be
■ Systemic absorption of
prostaglandin derivatives are sion, loss of weight and Available combinations are: taken that they are not drop-
beta blockers (and other
now the most commonly decreased libido. This is ■ Cosopt (Trusopt plus ping their blood pressure too
drops) can be reduced by
prescribed agents for new often associated with sys- Timolol). low at night (‘dippers’), as
digital occlusion over the
patients. temic metabolic acidosis. ■ Xalacom (Xalatan plus nocturnal hypotension has
nasolacrimal sac after
Other side effects consist of Timolol). been shown to be linked to
installation.
Alpha2-adrenergic agents gastric irritation, abdominal ■ Combigan (Alphagan plus progression. The link with
These selectively stimulate the cramps, diarrhoea and Timolol). sleep apnoea is still con-
alpha2 receptors in the ciliary nausea. Kidney stone forma- ■ DuoTrav (Travatan plus tentious, but could be con-
epithelium to reduce the for- tion is another rare complica- Timolol). sidered.
mation of aqueous. The two tion, related to decreased uri- Rarely, calcium channel
drugs available are apracloni- nary citrate excretion. Drug interactions and blockers such as nifedipine
dine 0.5% (Iopidine) and bri- Because the carbonic anhy- systemic medications may possibly be of benefit in
monidine 0.2% (Alphagan). drase inhibitors belong to the The main risk is that of com- certain cases when an under-
They are both very useful sulfonamide family of drugs, bining systemic beta blockers lying vasospastic process is
for short-term pressure con- they may cause the Stevens- with topical preparations, suspected, but should be
trol, particularly after laser Johnson syndrome and blood increasing the risk of side used with caution.
therapy to prevent pressure dyscrasias. effects, especially now there
spikes. In longer-term treat- Dorzolamide (Trusopt) 2% are several combination Follow-up evaluation
ment, aproclonidine tends to is a carbonic anhydrase products containing timolol. After initiation of therapy
lose some efficacy over time inhibitor that can be used in Oral Diamox can cause the patient is seen at 2-4-
and has a fairly high incidence drop form (usually three severe hypokalaemia and weekly intervals until the
of local allergy. times daily). It is not as potent metabolic acidosis, so caution IOP is controlled, and then
Brimonidine is more alpha2 as the oral form but carries is required when there is at 3-6-monthly intervals.
What about marijuana?
specific and therefore has less minimal chance of systemic polypharmacy in the elderly. Unfortunately the actual safe
■ Yes it can lower IOP, but
potential for the alpha1-related side effects. It is less effective Some diuretics and topiramate level of IOP is still unknown,
the dose/effects are
side effects. It is similar to tim- than timolol at lowering IOP. (Topamax) have rarely been although in most cases fur-
variable. Cannabinoid
olol in lowering pressure and Its side effects include a reported to cause a secondary ther damage is unlikely if the
derivative agents are
has a dual mode of action, metallic taste in the mouth, angle closure due to uveal IOP has been reduced to the
being trialled in topical
both decreasing aqueous local stinging and burning. It effusions. SSRI antidepressants lower ‘teens’.
form.
inflow and increasing may exacerbate corneal prob- have in a few isolated cases An optic nerve head show-
■ No other herbal or
uveoscleral outflow. lems. Brinzolamide (Azopt) caused IOP rises. ing minimal damage can tol-
alternative agents have
Its side effects mainly relate 1% performs similarly to Many products contain erate a higher IOP than one
been conclusively shown
to local allergy, the incidence Trusopt but has an advantage warnings for use in glaucoma with gross cupping and
to be beneficial in
of which is around 15%, but of less stinging on installation. (eg, anticholinergics, tricyclic advanced visual field loss.
glaucoma. Gingko may
feelings of fatigue and lethargy antidepressants). This almost Only stability of the visual
help ocular perfusion.
can also occur. Visual blur- Miotics — pilocarpine always refers to patients with fields and optic disc struc-
Coleus potentially could
ring occurs occasionally, and (1%, 2%, 3% and 4%) and narrow angles, who are at risk ture are proof that the IOP is
lower IOP but it is difficult
dry mouth is common. carbachol 3% of angle closure, and is not a indeed at a safe level for the
to get enough delivered
Dipivefrin 0.1% (Propine) Miotics are the oldest treat- factor in POAG patients. individual.
to where it is needed to
is a drug that is converted into ment group for glaucoma and If patients with narrow Myopic (short-sighted)
the ciliary body.
adrenaline after absorption work by stimulating cholin- angles have had a prophylac- eyes seem to deteriorate
Acupuncture is not an
into the eye. Side effects relate ergic receptors. This produces tic laser iridotomy, it then faster and at lower pressures.
effective treatment for
to alpha1 activity and include contraction of the ciliary becomes safe to prescribe Underlying vascular disease
glaucoma.
conjunctival hyperaemia and muscle, which in turn pulls these drugs. If unsure, check may also predispose to
occasional headache and blur- on the trabecular meshwork with the ophthalmologist as damage at relatively lower
ring. It is now rarely used. and enhances outflow of to the type of glaucoma. pressures. The results of all
aqueous. large clinical trials suggest
Carbonic anhydrase Unfortunately cholinergic Principles of medical the lower the pressure the
inhibitors stimulation also contracts the therapy better the chances of stabil-
The only orally administered pupil (miosis) and changes the The initial therapy of glau- ising the disease.
www.australiandoctor.com.au
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Glaucoma surgery
Laser therapy
THERE are several possible
applications for the use of
lasers. The most commonly
used laser, the argon laser,
is used for a procedure
known as an argon laser tra-
beculoplasty. Multiple
microscopic burns are made
in the trabecular meshwork
to enhance the escape of
fluid into the normal
drainage system.
The procedure is suitable
for open-angle glaucoma but
is not suitable for angle-clo-
sure glaucoma or secondary
glaucomas when the mesh-
work is damaged or ob-
structed, such as traumatic
angle recession, neovascular
(rubeotic), uveitic or angle
closure.
A newer form of laser
procedure termed selective
laser trabeculoplasty has
recently been developed. It
is designed to target the
wavelength of pigment and
to release brief pulses of
energy in the trabecular cells,
without causing collateral
burns or damage.
It is therefore theoretically
much safer, and clinical trials
show that it provides at least
equivalent efficacy if not better
results than traditional laser.
It is presumed new cells repop-
ulate the meshwork after the
procedure. The procedure can
potentially be repeated, unlike
argon laser trabeculoplasty,
which it has replaced in my
clinical practice.
A second type of treat-
ment is the peripheral laser
iridotomy, which uses the
laser to create a channel
through the iris. Either argon
laser or Nd YAG laser can
be used for this. The purpose
of the channel is to prevent
or treat angle-closure glau-
coma.
Aqueous collecting in the
posterior chamber can pass
directly through the irido-
tomy to the anterior cham-
ber, allowing the peripheral
iris to move backwards,
minimising pupil block.
Pupil block occurs when
the margin of the pupil sits
snugly back against the
convex anterior lens surface
and slows the flow of aque-
ous through to the anterior
chamber. This causes the
peripheral iris to bulge for-
ward and obstruct the mesh-
work by direct contact.
If the angle-closure attack
is already established, a
peripheral laser iridotomy is
an effective emergency treat-
ment that saves the patient
from conventional surgery.
It usually does not serve to
lower the pressure on its
own in open-angle glau-
coma.
Occasionally it is neces-
sary to perform both periph-
eral laser iridotomy and
argon or selective laser tra-
beculoplasty if a patient is at
risk of both forms of glau-
coma, but they are usually
done at separate sessions.
Laser therapy is performed
on site at either the special-
ists’ rooms or the hospital
clinic. It is done as a day
procedure and the patient
can walk out afterwards.
The procedures are virtually
painless, so they do not
require any anaesthetic other
than topical for placing a
special contact lens.
Apart from some initial
blurring for a few hours,
vision quickly returns to
normal. Each treatment only
takes a few minutes to per-
form.
When does laser treatment
become necessary?
In POAG, laser trabeculo-
plasty is usually used as a
second-line treatment when
eye drops have either not
provided sufficient effect on
their own, or are not well
tolerated because of side
effects.
Laser can also be used as a
first-line treatment if the
ophthalmologist and patient
prefer this approach. Occa-
sionally the laser treatment
lowers the IOP enough to
allow the patient to reduce
the number of eye drops
being used.
Argon or selective laser
trabeculoplasty can lower
IOP by up to one-third in
most patients (about 70%
will show a response).
However, the magnitude of
the reduction achieved
varies greatly between indi-
viduals and is impossible to
predict.
The duration of effect
ranges from months to many
years (up to 10 years). Most
studies claim that about
75% of patients will achieve
a lowering of pressure, with
the remainder unchanged.
Peripheral iridotomies usu-
ally remain open for life, and
only occasionally close spon-
taneously.
Filtration surgery
In general, filtration surgery
should be considered in
cases of uncontrolled glau-
coma despite maximally tol-
erated medical therapy and
laser therapy. The aim of
glaucoma filtration surgery
is to create a new route of
escape for the aqueous fluid,
from the anterior chamber
directly to the subconjuncti-
val space. From there the
fluid will be reabsorbed via
the episcleral venous system
and returned to the blood-
stream.
Trabeculectomy
This is the most common
surgical procedure per-
formed for glaucoma. It can
be done in isolation or
together with cataract
extraction and lens implant
(a combined procedure). A
two-thirds-thickness scleral
trapdoor is dissected, and a
deep block of sclera is
excised to enter the anterior
chamber.
A peripheral iridectomy is
performed. The scleral flap
is repositioned and resutured
with 10/0 nylon. The con-
junctiva is closed over the
top, but aqueous filters
through the trapdoor and
this lifts the conjunctiva up
into a bubble or ‘bleb’ at the
site of filtration, from where
it is reabsorbed by conjunc-
tival vessels.
Some serious complica-
tions can occur at the time
of surgery (such as expulsive
haemorrhage) or later,
including changes in refrac-
tion, hyphema, shallow ante-
rior chamber or hypotony,
wound leaks, endophthalmi-
tis, cataract (late, around 30-
50%), conjunctival scarring
and bleb failure.
The success rate of filtra-
tion surgery in glaucoma is
about 80-90%. Success is
defined as lowering the pres-
sure into the normal range
(<20mmHg). The results are
less favourable in young
patients, black patients, eyes
with uveitis or neovascular
glaucoma and in people with
any previous ocular surgery.
In high-risk groups such
as these, success rates are as
low as 50% for routine tra-
beculectomy, unless anti-
scarring agents are used.
During the last two
decades, anti-metabolites
have been commonly used in
conjunction with glaucoma
filtration surgery to reduce
scarring. Postoperative 5-flu-
orouracil (5-FU) has been
used since the mid-1980s. It
was found to increase the
success of filtration surgery
in high-risk eyes.
More recently, mitomycin-
C and 5-FU are being used
intra-operatively during glau-
coma filtration surgery, and
have demonstrated increased
surgical success rates.
Implant tubes (Molteno,
Baerveldt and Ahmed)
Tube implants consist of a
domed plate attached to a
tube that allows free flow to
the implant from the anterior
chamber. In this way the fis-
tula is maintained and a reli-
able, more posteriorly located
bleb is formed. Molteno
implants are used in cases for Further reading
which previous surgery has Mitchell P, et al. Prevalence
been unsuccessful, or when of open-angle glaucoma in
standard surgery is not likely Australia: the Blue
to be effective. Mountains Eye Study.
Ophthalmology 1996;
When to refer 103:1661-69.
All patients with POAG and Kass MA, et al. The Ocular
a family history of glaucoma Hypertension Treatment
should have a baseline check Study. Archives of
by age 40, and earlier if Ophthalmology 2002;
there are several family 120:701-13.
members involved, or the Graham SL. Are vascular
age of onset was relatively factors involved in
young. They should then glaucomatous damage?
have a routine check every Australian and New
four years. Zealand Journal of
If there are additional risk Ophthalmology 1999;
factors such as myopia, 27:354-56.
hypertension, diabetes, Ray- Graham SL, et al. Clinical
naud’s syndrome, migraine application of the multifocal
or known ocular risk factors VEP in glaucoma. Archives
(such as pseudo-exfoliation), of Ophthalmology 2005;
the frequency of checks 123:729-39.
should be increased appro- Fraser C, et al. Multifocal
priately, for example, every VEP latency analysis —
1-2 years. predicting progression to
Any patient with angle- multiple sclerosis. Archives
closure glaucoma and a of Neurology 2006; 63:847-
painful red eye needs imme- 50.
diate referral, particularly if
the pupil is reacting poorly. Online resources
Intermittent angle-closure ■Glaucoma Australia is a
attacks can produce episodes very active patient-support
of pain and blurring (with group with online patient
or without haloes), without information, regular
redness, so beware of this on newsletters and
history. educational meetings for
patients:
www.glaucoma.org.au

Author’s case study ■ Eye Associates (patient

Slowly progressing ocular
hypertension in an older
woman
hypertension, and her manage-
ment plan was annual observa-
tion. She remained stable with
information on common
eye disorders):
Corneal thickness revealed www.eyeassociates.com.
thin corneas, at R 478µm and L au
480µm. True IOP was therefore ■ Save Sight Institute

A 58-YEAR-old woman pre- an IOP range of 18-24mmHg several points higher than sus- (services and research):
sented in 1986 with a family his- for the next 10 years. pected, and pressure not as well www.eye.usyd.edu.au
tory of glaucoma in her mother. Her left optic disc then started controlled as thought. ■ Royal Australian and

She had IOPs of R 22mmHg
and L 26mmHg. She had
normal-appearing optic discs,
with cup-to-disc ratios of 0.5 in
both, and normal visual fields.
There were no other systemic or
ocular risk factors.
She was diagnosed with ocular
to thin at the superior pole. She
started treatment with timolol,
and IOP was maintained in the
17-20mmHg range (inside the
normal limits of 10-20mmHg).
However, her visual field defect
progressed and further notching
of the optic disc was detected.
Latanoprost was added to her New Zealand College of
treatment to achieve lower target Ophthalmology:
pressure in her left eye, aiming www.ranzco.edu
for <14mmHg. A subsequent
disc haemorrhage in the right Proprietary statement
eye suggested that glaucoma was Dr Graham is a consultant
active in this eye also and so for ObjectiVision Pty Ltd.
needed tighter control.

www.australiandoctor.com.au 9 March 2007 | Australian Doctor | 29

AD_HTT_023_030___MAR09_07 2/3/07 4:28 PM Page 30

How to treat – glaucoma

GP’s contribution
pilocarpine drops. Unfortu- ing to bradycardia and can requires corneal thickness
nately, she did not improve also cause depression. measurement and visual field
and she also had nausea and values.
worsening confusion. General questions for the
When her ophthalmologist author What pressures are consid-
returned to work, her ocular The RACGP does not rec- ered unacceptably high, so
pressures were 16mmHg in ommend routine screening that patients should be seen
DR PHILIP LYE both eyes. Several months for glaucoma using tonome- as soon as possible by an
later her pressures were still try or visual field tests. How- ophthalmologist?
Sutherland, NSW
in the high teens, and he ever, GPs play an essential There is no definite cut-
stopped all the above eye role in identifying patients at off, but certainly IOPs
Case study drops and changed her to higher risk for glaucoma and >30mmHg should be treated
JEAN, an 80-year-old Aus- dorzolamide-timolol drops referring them to an oph- as relatively urgent, as there
tralian woman, has had (Cosopt). thalmologist for testing. is an increased risk of a vas-
glaucoma for many years. Unfortunately, Jean still Patients with increased risk cular occlusion in this sce-
Over the last few years she has intermittent headaches include those aged over 60 nario.
had been treated with and pains behind her eyes. or with a family history of
betaxolol (Betoptic, Beto- Her ocular pressures are in glaucoma, or with high I would like a very simple
quin) and brimonidine the mid-teens, her blood myopia >8 diopters, diabetes section on how to read a
(Alphagan, Enidin). I saw pressure is now just under or history of long-term RNFL report and perimetry
her when her usual GP was control and her pulse rate is steroid use. Would it be rea- report. Copies of these are
on holidays. about 50bpm. could be exacerbated are titrating dosage of glau- sonable to recommend a now routinely sent to me by
She complained of She is also taking ramipril, because she is also using sys- coma medications? glaucoma check at the 45- the ophthalmologist and I
headaches, pain behind her irbesartan, metoprolol and temic metoprolol. Cosopt If the pressures are not 49 year check up if patients have no idea what I am
eyes, fatigue and worsening hydrochlorothiazide for her still contains a beta blocker, dangerously high or the have the above risk factors? reading! Is there a simple
anxiety. Her blood pressure hypertension. For anxiety and pilocarpine can cause optic disc not badly dam- Yes. explanation available?
was 200/90mmHg and I and depression she takes headaches by ciliary muscle aged, we usually wait 3-6 Unfortunately there is no
increased her antihyperten- oxazepam and doxepin. contraction. weeks to check, depending Have formulas been devel- simple approach, as all the
sive medications. You should consider using on the class of drug being oped to calculate risk of tests use different printouts
I was not able to refer Questions for the author one of the prostaglandin used. Prostaglandins can glaucoma by factoring in and statistical analyses. Peri-
Jean to her usual ophthal- Could Jean’s glaucoma treat- derivatives (if not already take six weeks to reach these risk factors? metric and imaging tests all
mologist and requested the ment account for some of tried) dorzolamide or brin- stable effects. The Ocular Hypertension use a probability plot com-
local optometrist measure her symptoms? If so, what zolamide; otherwise laser Treatment Study findings pared with normative values,
her IOP, which showed other medications should we treatment would be the next Could she be having adverse (see Further reading) have so any point at the p<0.01
readings of 22-23mmHg in try? choice. drug interactions? been used to produce a risk level is highly significant,
both eyes. She was also Beta blockers and bri- Yes, definitely, with the calculator for ocular hyper- (but not diagnostic or spe-
noted to be developing a monidine can both cause How often should her ocular other agents she is taking. tension that can be used by cific for glaucoma). Interpret
right cataract, so I added headaches and fatigue. This pressures be checked if we Timolol could be contribut- ophthalmologists, but this with caution!

INSTRUCTIONS
How to Treat Quiz Complete this quiz to earn 2 CPD points and/or 1 PDP point by marking the correct answer(s) with
an X on this form. Fill in your contact details and return to us by fax or free post.
FAX BACK FREE POST ONLINE
Photocopy form How to Treat quiz www.australiandoctor.com.au/cpd/
Glaucoma — 9 March 2007 and fax to Reply Paid 60416 for immediate feedback
(02) 9422 2844 Chatswood DC NSW 2067

1. Which TWO statements about primary about every five years ❏ d) About one-third of patients using you give Jim?
open-angle glaucoma (POAG) are correct? ❏ c) If she develops POAG, early and brimonidine will develop local allergy side ❏ a) A peripheral laser iridotomy would be the
❏ a) Long-sighted people are at greater risk of continued treatment can prevent progression effects most suitable procedure for Jim
this condition in 90% of cases ❏ b) He has about a 70% chance of
❏ b) Family history and age are the most ❏ d) Having hypertension increases her risk of 6. Thomas has been started on timolol drops. improvement in his IOP with argon or
significant risk factors POAG Which THREE side effects should you warn selective laser trabeculoplasty
❏ c) Visual losses can be restored by treatment him about? ❏ c) Having laser treatment will allow Jim
❏ d) Incidence in older people is up to 8% 4. Janice is referred to an ophthalmologist ❏ a) Impotence to be free of using eye drops
for assessment. Which TWO statements ❏ b) Fatigue ❏ d) He will probably only need a topical
2. Which TWO features are characteristic of about the diagnosis of POAG are correct? ❏ c) Dry mouth anaesthetic if he has laser surgery
POAG? ❏ a) An IOP >20mmHg is considered abnormal ❏ d) Nightmares
❏ a) Loss of visual field ❏ b) For exclusion of glaucoma patients need 9. Which TWO statements about
❏ b) Universal elevation of intraocular pressure fundoscopy as well as IOP measurement 7. Jim, 79, is using several different eye drops angle-closure glaucoma are correct?
(IOP) ❏ c) On field testing, blind spots are usually for his POAG — trusopt-timolol combined ❏ a) The angle is the region between the iris and
❏ c) Optic disc cupping circular in shape drops (Cosopt), bimatoprost and pilocarpine. the lens
❏ d) Rapid progression if untreated ❏ d) Gonioscopy is used to measure IOP He complains of reduced night vision, a ❏ b) It is more common in Caucasian people
metallic taste in his mouth, headache and ❏ c) It usually presents with a painful red eye
3. Janice, 48, presents for a repeat 5. Thomas, 67, has just been diagnosed with tiredness. Which THREE associations of with a mid-dilated pupil that does not react
prescription for her antihypertensive POAG and his ophthalmologist wishes to medications and side effects are correct? to light
medication. She wears glasses for distant start him on medical therapy. When choosing ❏ a) Trusopt-timolol and metallic taste ❏ d) Patients may report seeing haloes and
vision and has had no problems with her therapy which TWO statements about ❏ b) Pilocarpine and reduced night vision have a headache and vomiting
vision. She has not seen her optometrist for medication side effects are correct? ❏ c) Bimatoprost and headache
many years. Janice mentions that her mother ❏ a) Timolol should not be used if Thomas has a ❏ d) Trusopt-timolol and fatigue 10. Which TWO medications can cause
uses eye drops for POAG. What information history of asthma secondary glaucoma?
would you discuss with Janice (choose TWO)? ❏ b) A disadvantage of latanoprost is the need 8. Jim is tired of constantly using eye drops ❏ a) Corticosteroid eye drops
❏ a) As Janice has no visual symptoms she is to use it three times daily and putting up with side effects. He asks ❏ b) Beta blockers
unlikely to have glaucoma ❏ c) Reactivation of HSV keratitis is a potential about the possibility of surgery to treat his ❏ c) SSRI antidepressants
❏ b) She should be screened for glaucoma problem with latanoprost glaucoma. Which TWO pieces of advice do ❏ d) Salbutamol

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Quiz: Dr Marcela Cox
Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The mark required to obtain points is 80%. Please note that some questions have more than one correct answer. Your CPD activity will be updated on your RACGP records every January, April, July and October.

NEXT WEEK The next How to Treat looks at community-acquired pneumonia. The author is Professor Nigel Stocks, professor and head, discipline of general practice; director, primary health care research
evaluation and development program; director, Australian sentinel practices research network, school of population health and clinical practice; and assistant dean (student), medical school faculty of health
sciences, University of Adelaide, Australia.

30 | Australian Doctor | 9 March 2007 www.australiandoctor.com.au