Case 066: Primary Open-Angle Glaucoma

PATIENT PRESENTATION

Chief Complaint

“I cannot see out of the corner of my eyes anymore”

History of Present Illness

Robert George is a 67-year-old male who presented to the Emergency Department at his local community hospital complaining of vision loss. He has been losing his peripheral vision over the last couple of years and is now at the point where he would like to be evaluated to determine any potential pharmacotherapy that could improve his vision.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. What are the goals of therapy in the management of this patient’s glaucoma?

   Hint: See Treatment in PPP

2. What are the most appropriate potential first-line pharmacotherapeutic options for this patient at this time?

   Hint: See Table 62-5, Figure 62-3, and Treatment in PPP

3. What adverse effects should be monitored for with each potential first-line pharmacotherapeutic option in this patient?

   Hint: See Treatment in PPP

4. If this patient had instead presented with closed anterior angles on ophthalmic examination and significant ocular pain, what recommendations would you have made?

   Hint: See Treatment in PPP

5. How should you counsel this patient regarding appropriate ophthalmic medication administration technique?

   Hint: See Outcome Evaluation in PPP

FOLLOW-UP

Two weeks after discharge with newly prescribed pharmacotherapy for his primary open-angle glaucoma, Mr. George is re-admitted to the hospital with a COPD exacerbation. Which medications often prescribed for a COPD exacerbation could directly impact his primary open-angle glaucoma?

Hint: See Special Considerations: Drug-Induced Glaucomas and Outcome Evaluation in PPP

CASE SUMMARY

Global Perspective

The estimated global prevalence of primary open-angle glaucoma (POAG) is 2.2-2.4%. However, there are significant ethnic differences in prevalence noted across the globe, with the African continent (and in particular, the Igbo tribe of Nigeria) having the highest reported prevalence (4.0%). Furthermore, experts are predicting a 131% increase in the number of patients on the African continent with POAG by the year 2040. Of particular note, black patients have smaller trabecular meshwork height and thinner central corneal thickness, develop POAG earlier, and appear to have more aggressive disease than Caucasian or Asian patients.

Key References