Glaucoma Management

Clinical Presentation and Risk Factors

The American Academy of Ophthalmology notes that glaucoma is a progressive optic neuropathy characterized by retinal ganglion cell loss, optic nerve damage, and visual field defects, with elevated intraocular pressure (IOP) being the most important modifiable risk factor 1
Elevated IOP is the most important modifiable risk factor, and older age, African or Latino/Hispanic ethnicity, and family history of glaucoma are also key risk factors 1, 2
A thin central cornea (<555 μm) is associated with a 36% risk of glaucoma progression, compared to 2% risk with a central corneal thickness (CCT) >588 μm 3, 4
Diabetes mellitus increases the risk of glaucoma by 48% when combined with hypertension, and myopia, particularly axial myopia, is also a risk factor 5, 6
Low ocular perfusion pressure and systemic hypertension are also critical concerns, and may increase the risk of glaucoma 1, 5, 6

The primary goal of glaucoma treatment is to lower IOP to a target level that prevents further optic nerve damage and preserves quality of life, with medical therapy as first-line treatment 3, 1
The initial target IOP reduction should be at least 20% from baseline, and the target IOP should be adjusted downward if optic nerve deterioration occurs despite treatment 3, 4, 1
Prostaglandin analogues are effective first-line agents for IOP reduction, and beta-adrenergic antagonists are effective alternatives or adjuncts when prostaglandin analogues are insufficient or contraindicated 3, 1

Long-term monitoring for disease progression is mandatory, regardless of treatment status, and should include gonioscopy, central corneal thickness measurement, IOP measurement, optic nerve imaging, and visual field testing 3, 4, 1, 2
High-risk patients should be monitored every 6-12 months, and any documented progression should prompt an increase in target IOP reduction and intensified monitoring 7

Patients with diabetes require more aggressive IOP targets due to compounded risk, and may be associated with elevated IOP through altered corneal biomechanics 5, 6
Systemic hypertension is a critical concern, and low diastolic perfusion pressure in treated hypertensive patients increases glaucoma risk, requiring coordination with primary care to avoid excessive blood pressure lowering that compromises optic nerve perfusion 5, 6