Dr. Yousaf JamalGlaucoma Fellow

Alshifa Trust Eye Hospital, Rawalpindi

• History taking… “ The most neglected part”

• Good Hx can avoid• Misdiagnosis

• Potential adverse effects of glaucoma Tx

• Good Hx helps• Targeting the population at risk

• Greeks recognized a group of disorders in 400 BC• ‘Glaucosis’ ….. Bluish green hue of the eye

• However cataract was also included

• Arabian writings in 10th century associated it with elevated IOP

• In 19th century, glaucoma was recognized as a distinct group

• Shields textbook of Glaucoma, 6th ed

• Patients bio data… age/gender/race

• Symptoms

• Alarming signs

• Past ocular Hx

• Systemic Hx

• Drug Hx

• Addictions

• Family Hx

• Socioeconomic Hx

• Age… increasing age

• Gender… females in ACG

• Race… • POAG highest in blacks, intermediate in whites & south Asia,

lowest in northern Asia

• Increasing age related to increased prevalence of glaucoma

• Rule of thumb of prevalence…• Doubles for each decade over 40 (RR=2/decade)

• Ten fold higher in > 80yrs compared to 40-49 yrs.

Age-Group Prevalence of POAG, %

White Black Hispanic IndianUnited States

Baltimore Baltimore Arizona Tamil Nadu

40-49 y 0.6 0.9 1.2 0.5 0.3

50-59 y 1.5 0.4 4.1 0.6 1.6

60-69 y 2.7 0.9 5.5 1.7 1.8

70-79 y 5.1 2.9 9.2 5.7 2.9

>80 y 7.3 22 11.3 12.6

• POAG… usually asymptomatic

• Blurred vision with haloes

• Decreased contrast sensitivity

• Visual field loss

• Eye pain

• Early onset presbyopia

• Unable to read 6/6 in either eye during visits

• Frequent change of glasses

• Difficulty in night driving

• Color vision impairment… blue-yellow

• Early morning or afternoon blurred vision

• Myopia… 2-3 folds increased POAG prevalence 1

• Previous glaucoma Tx

• For secondary glaucoma• Uveitis

• Ocular surgery

• Refractive, RD, cataract

• Trauma

1. Mitchell P, Hourihan F, Sandbach J, et al. The relationship between glaucoma and myopia: the Blue Mountains Eye Study. Ophthalmology. 1999; 106(10):2010-2015.

• Diabetes • Probable risk factor

• POAG prevalence appears to be 2-folds than normal 1

• Blood pressure• Most meaningful is ‘diastolic ocular perfusion pressure’

• DOPP < 55 mmHg have RR of 3.2 in POAG incidence 2

• Hypertension relation to glaucoma is confusing

1. Klein BE, Klein R, Jensen SC. Open-angle glaucoma and older-onset diabetes. The Beaver Dam Eye Study. Ophthalmology. 1994;101(7):1173-1177.

2. Leske MC, Wu SY, Nemesure B, et al. Incident open-angle glaucoma and blood pressure. Arch Ophthalmol. 2002;120(7):954-959

• Hypoxia • IHD, TIA, CVA

• Anemia

• Blood loss

• Vasospasm (Migraine & Raynaud’s Phenomenon)

• Sleep apnea

• Asthma/COPD…for Tx POV also

• Thyroid disorders• Graves disease… raised episcleral pressure 1

• Some also suggest… hypothyroidism 2

• Cushing syndrome 3

• Pituitary dysfunctions 4

• Testosterone may raise IOP

• Estrogen & progesterone may lower IOP

1. Karadimas P, Bouzas EA, Topouzis F, et al. Hypothyroidism and glaucoma. A study of 100 hypothyroid patients. Am J Ophthalmol. 2001;131(1): 126-128.

2. Krupin T, Jacobs LS, Podos SM, et al. Thyroid function and the intraocular pressure response to topical corticosteroids. Am J Ophthalmol. 1977; 83(5):643-646

3. Haas JS, Nootens RH. Glaucoma secondary to benign adrenal adenoma. Am J Ophthalmol. 1974;78(3):497-500.

4. Abdel-Aziz M, Labib MA. The relationship of the intraocular pressure and the hormonal disturbance. II. The pituitary gland. Bull Ophthalmol Soc Egypt. 1969;62(66):61-72.

• Current & previous topical medications

• Steroids use

• Beta blockers for HTN

• Anticoagulants… for surgical planning

• Drugs that raise IOP… • Corticosteroids

• Anticholinergics & antihistamines

• Sulfonamides…rare

• Caffeine… slight transient rise

• Ketamine & muscle relaxants

• Smoking • Raise IOP immediately

• Vasoconstriction & elevated episcleral pressure

• Alcohol• Neuronal damage in long-term

• First degree relative…ten times higher risk

• Sibling of glaucoma pt. is at more risk than either parent or child

• Tielsch JM, Katz J, Sommer A, et al. Family history and risk of primary open angle glaucoma. The Baltimore Eye Survey. Arch Ophthalmol. 1994; 112(1):69-73

• One of the costly disease

• Cost of medications for life long is difficult in our setup

• Maintain healthy weight

• Keep BP & other medical conditions in control

• Don’t smoke

• Limit caffeine to moderate levels

• Exercise daily

• Glaucoma has multiple risk factors

• Good history can help to…• Detect population at risk

• Avoid over/under treatment of pts.

• Primary eye care doctors should be educated to ask their pts. about family Hx

• Glaucoma pts. should be told to alert their first degree relatives and prompt screening

• And all this is possible if we emphasize on good Hx

THANK YOU ALL