importance of history in glaucoma
TRANSCRIPT
• 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
• 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