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Disc cupping and field loss progress at a variable rate, leading to profound field loss constriction and ultimately blindness.
Management aims to lower the intra-ocular pressure sufficiently to arrest progressive visual field loss.
- even though increased IOP is not the only cause of glaucomatous neuropathy, it is one of the few risk factors which can be modified (1)
- normal and damaging levels of intra-ocular pressure cannot be easily quantified but must be assessed at each examination by comparison to visual fields, intra-ocular pressure and disc appearance previously.
Medical and surgical treatments are available. The aim is to increase the efficiency of drainage or reduce the production of aqueous.
There is evidence that suggests previous multiple medical therapy increases
the risk of failure of surgical treatment. It is for this reason there is an
increasing trend to recommend surgery as a primary treatment, or after failure
to control intraocular pressure with a single topical agent (for example, if
the pressure remains above 21 mmHg) (1).
NICE suggest that (2):
- take into account any cognitive and physical impairments when making decisions
about management and treatment
- check that there are no relevant comorbidities or potential drug interactions
before offering pharmacological treatment
- offer a generic prostaglandin analogue (PGA) to people with IOP of 24
mmHg or more (OHT) if they are at risk of visual impairment within their
- suspected glaucoma
- do not offer treatment to people with suspected COAG and IOP less than
24 mmHg. Advise people to continue regular visits to their primary eye
care professional, at clinically appropriate intervals
- offer a generic PGA to people with suspected COAG and IOP of 24 mmHg
or more, in line with the recommendations on treatment for people with
Management undertaken by ophthalmologists includes (3):
- prostaglandin analogues – as first choice
- beta blockers – as second choice
- other useful drugs like carbonic anhydrase inhibitors or alpha agonists can be used
- in refractory cases – oral carbonic anhydrase inhibitors may be necessary
- surgery – laser trabeculoplasty, trabeculotomy may be required (3)
Last reviewed 01/2018