Practical Ophthalmology for GPs: Glaucoma Mr Kuang Hu MA MB BChir PhD (Cantab) FRCOphth Consultant Ophthalmic Surgeon 9 October 2014

What is glaucoma? Management of glaucoma Differential diagnosis of acute glaucoma Referral pathways Glaucoma

Blinding 2 nd biggest cause of blindness worldwide Functional deficit, handicap, disability Common Affects more than 1 in 100 of 40+ years old 10% of Croydon patients have it, or are at risk What is Glaucoma?

People don’t notice until it’s too late Visual loss is painless and progressive Exception is acute glaucoma What is Glaucoma?

What is Glaucoma? Group of diseases with common features: Eye pressure is too high Damage to the optic nerve Damage to vision Treatment is to lower eye pressure

What is Glaucoma? Spectrum of damage to vision Mild:minimal visual loss no handicap or disability Severe:tunnel vision trips, can’t drive End stage: ‘blind’ can’t read, can’t see TV

Acuterapid rise in pressure Chronicgradual rise in pressure Two types of glaucoma

History History Hours Hours Severe pain Severe pain Nausea Nausea Examination Examination Severe blurring Severe blurring Normal lids Normal lids Red conjunctiva Red conjunctiva Hazy Cornea Hazy Cornea Rock hard eye Rock hard eye Acute glaucoma Refer immediately

Chronic glaucoma Painless Gradual loss of vision White eye Previous diagnosis Already on drops

Management of Glaucoma Identify Identify Acute glaucoma: 1 case every 3-10 years Acute glaucoma: 1 case every 3-10 years Definite chronic glaucoma Definite chronic glaucoma Possible chronic glaucoma – ‘suspects’ Possible chronic glaucoma – ‘suspects’ High risk of chronic glaucoma – raised pressure High risk of chronic glaucoma – raised pressure

Management of Glaucoma Identify Identify Pressure measurement Pressure measurement Pachymetry Pachymetry Gonioscopy Gonioscopy Visual field test Visual field test Slit-lamp stereoscopic examination of optic disc Slit-lamp stereoscopic examination of optic disc Imaging of optic disc Imaging of optic disc

Treat Treat Lower eye pressure Lower eye pressure Prevent further damage to optic nerve Prevent further damage to optic nerve Prevent progression of visual loss Prevent progression of visual loss Prevent disability and handicap Prevent disability and handicapMedicationsLaserSurgery Management of Glaucoma

Management of Glaucoma Medication Eye drops (5 classes) Oral, intravenous Laser Selective laser trabeculoplasty YAG laser iridotomy Argon laser iridoplasty Diode laser cycloablation Surgery Minimally-invasive, eg Trabectome (NICE) Lens extraction Trabeculectomy with cytotoxic antiscarring agents Aqueous shunt ‘tube’ surgery (several types)

Management of Glaucoma Two basic types

Management of Glaucoma Two basic types Chronic Gradual rise in pressure Painless White eye Gradual visual loss Treatment with drops

Management of Glaucoma Two basic types Chronic Gradual rise in pressure Painless White eye Gradual visual loss Treatment with drops Please prescribe drops

Management of Glaucoma Two basic types ChronicAcute Gradual rise in pressure Sudden rise in pressure Painless Acutely painful White eye Red eye Gradual visual loss Rapid visual loss Treatment with drops Drops, IV drugs, laser Please prescribe drops

Management of Glaucoma Two basic types ChronicAcute Gradual rise in pressure Sudden rise in pressure Painless Acutely painful White eye Red eye Gradual visual loss Rapid visual loss Treatment with drops Drops, IV drugs, laser Please prescribe drops Recognize and refer as EMERGENCY

Management of Glaucoma Two basic types ChronicAcute Gradual rise in pressure Sudden rise in pressure Painless Acutely painful White eye Red eye Gradual visual loss Rapid visual loss Treatment with drops Drops, IV drugs, laser Please prescribe drops Recognize and refer as EMERGENCY

Management of Glaucoma Two basic types ChronicAcute Gradual rise in pressure Sudden rise in pressure Painless Acutely painful White eye Red eye Gradual visual loss Rapid visual loss Treatment with drops Drops, IV drugs, laser Please prescribe drops Recognize and refer as EMERGENCY

Management of Glaucoma Two basic types ChronicAcute Gradual rise in pressure Sudden rise in pressure Painless Acutely painful White eye Red eye Gradual visual loss Rapid visual loss Treatment with drops Drops, IV drugs, laser Please prescribe drops Recognize and refer as EMERGENCY

Acute Glaucoma?

Differential Diagnosis of Acute Glaucoma Infective conjunctivitis Subconjunctival haemorrhage Iritis Acute glaucoma Endophthalmitis Orbital cellulitis

1-minute ophthalmic assessment History Acute or chronic Severity of pain Other symptoms, past ophthalmic history Examination Acuity Lids Conjunctiva Cornea If possible: Pupils, pressure

History History Spontaneous Spontaneous Mild pain Mild pain Mild blurring Mild blurring Examination Examination Looks like blood Looks like blood 1-minute ophthalmic assessment Subconjunctival haem Conservative: BP, INR Refer if not resolving

History History Days Days Mild pain Mild pain Sticky discharge Sticky discharge Examination Examination Mild blurring Mild blurring Mild swelling lids Mild swelling lids Red conjunctiva Red conjunctiva Clear cornea Clear cornea Normal pupils Normal pupils 1-minute ophthalmic assessment Conjunctivitis Chloramphenicol eye drops QDS for 1 week

History History Days or weeks Days or weeks Moderate pain Moderate pain Photophobia Photophobia Examination Examination Moderate blurring Moderate blurring Normal lids Normal lids Red conjunctiva Red conjunctiva Clear cornea Clear cornea Unreactive pupil Unreactive pupil 1-minute ophthalmic assessment Iritis Refer within 24 hours

History History Hours Hours Severe pain Severe pain Nausea Nausea Examination Examination Severe blurring Severe blurring Normal lids Normal lids Red conjunctiva Red conjunctiva Hazy cornea Hazy cornea Rock hard eye Rock hard eye 1-minute ophthalmic assessment Acute glaucoma Refer immediately

History History Hours Hours Severe pain Severe pain Recent surgery Recent surgery Examination Examination Severe blurring Severe blurring Normal lids Normal lids Red conjunctiva Red conjunctiva Normal Cornea Normal Cornea Hypopyon Hypopyon 1-minute ophthalmic assessment Endophthalmitis Refer immediately

History History Severe pain Severe pain Loss of vision Loss of vision Double vision Double vision Examination Examination Loss of vision Loss of vision Unreactive pupil Unreactive pupil Reduced motility Reduced motility Proptosis Proptosis 1-minute ophthalmic assessment Orbital cellulitis Refer immediately

Differential diagnosis of Acute Glaucoma Use the 1-minute ophthalmic assessment DiagnosisManagement Subconjunctival haemConservative ConjunctivitisChloramphenicol IritisRefer within 24 hrs Acute glaucomaRefer immediately EndophthalmitisRefer immediately Orbital cellulitisRefer immediately

Referral pathways Urgent = Telephone Routine = Referral letter

Summary Glaucoma is a sight-threatening disease Acute glaucoma is rare, but has common mimics Chronic glaucoma is common Identifying chronic glaucoma requires many tests Treatment is by lowering eye pressure Moorfields is here to help

Practical Ophthalmology for GPs: Glaucoma Mr Kuang Hu MA MB BChir PhD (Cantab) FRCOphth Consultant Ophthalmic Surgeon 9 October 2014