Overview Snapshot A 46-year-old African American male presents for an opthalmic examination. Medical history is significant for hypertension and type II diabetes mellitus. On slit-lamp examination, there is cupping of the optic disc, with a cup-to-disc ratio > 0.6. Tonometry reveals intraocular pressure of 45 mmHg (normal is 8-21 mmHg). Peripheral field vision loss is noted on visual field exam. Introduction Optic neuropathy characterized by optic nerve damage and visual abnormalities majority of patients have increased intraocular pressure (IOP) important causative risk factor associated with increased resistance to aqueous outflow compresses retinal blood supply or retinal ganglion cells optic disc atrophy with cupping → visual loss increased cup-to-disc ratio Glaucoma can be characterized into open-angle or angle-closure Epidemiology a leading cause of blindness open-angle glaucoma is more common risk factor examples family history age race Presentation Symptoms open-angle usually asymptomatic insidious onset of peripheral vision loss angle-closure acute onset of blurry vision painful halos around lights ↓ vision (photophobia/blurry vision) Physical exam open angle no distinct physical exam findings angle closure fixed-dilated pupil corneal clouding/edema conjunctival injection/redness eyeball firm to palpation Evaluation Measure IOP with tonometry normal is 8-21 mmHg Assessment of optic disc shows enlarged cup-to-disc ratio (> 0.4) Visual field testing Pachymetry measures corneal thickness if corneas are thick, it may falsely elevate IOP on tonometry Gonioscopy gold standard for angle-closure glaucoma Differential Macular degeneration Ischemic optic neuropathy Treatment Open-angle pharmacologic increases aqueous outflow prostaglandins (becoming first-line) α-agonists cholinomimetics decreases aqueous production carbonic anhydrase inhibitors α-agonists β-blockers laser therapy trabeculoplasty surgical filtration bleb Angle-closure iridotomy topical β-blockers and α2-agonists epinephrine contraindicated!!! α1-agonism causes mydriasis oral carboanhydrase inhibitors (acetazolamide) Prognosis, Prevention, and Complications Open-angle prognosis does not substantially reverse prevention may involve lowering IOP complications blindness Angle-closure prognosis progressive vision loss that may lead to blindness if not detected early and not properly managed