Glaucoma Week Series- episode 10 (Glaucoma Management)

Optom
Managing Glaucoma tends to be a long term thing. The first thing that should always come to mind when  faced with Glaucoma prospect is to differentiate between the types of Glaucoma, because the various types require quite a different approach in management. The next question is to start treating versus monitoring! Is it necessary to commence treatment if the symptoms are not there while there is a strong cause of suspicion, like a cupped disk without pressure or a high pressure without a cupping etcThe clinician is faced with the option of either comencement of treatment or close monitoring the patient, but I often start a low grade management @ the slight suspicion of Glaucoma! Such as educating the patient very well about the syndrome & in some cases prescribing gutt: Timolol meleate 0.5 percent i bds. The patient should be returning to the clinic monthly for a close follow up which includes checking intra ocular pressure, measuring the size of the disk (is there any excavation? Has the cup gone beyond 0.5 threshold? etc).If patients comes in with an already established Glaucoma, treatment with drugs comences immediatly! I monitor patient's visual acuity, do refraction, use ophthalmoscope to rule out a secondary cause or any other eye disease while establishing glaucomaas the cause of the impairment (most often a very poor vision in one eye that keeps degenerating and tends towards the other eye or recently changed glasses that no longer effective or even diminishing vision towards evening could be the reason of visit!)I then check patient's I.O.P with schiotz tonometer ( its out-dated though, but desperate times always call for desperate measures!). I always puntuate my tests with patient's education, this is one of the most important pearl in managing Open Angle Glaucoma especially in the rural communities. We send patients to the city to do central visual field tests with either the Humphrey analyser, the Octopus visual field analyser or any automated visual field analyser periodically, which is often attached in the patient's report for analysis and education! We have tried severally to inroduce co-management with Ophthalmologists in the city but seem to leave the patient vulnerable.It should be known that various medications are used in the management of Glaucoma, but I always pay attention to the cost burden on the patients! This is to avoid creating a psycholgical backlash which often times discourages the patient & hence mounts this person's handicap!After establishing that systemically, the patient is not @ risk of any pulmonary disease I give him/her a starting therapy of gutt: Timolol 0.5 percent bds x 1/12. (a beta blocker). I add postalglandin analog like, Latanoprost or travatan or xalatan 1 noct. x 1/12 in the course of management. Recently Alphagan (Brimodimine, an Alpha agonist) has attracted my interest while I no longer use miotics like Pilocarpine as it has been widely reported to have very serious side effects like retinal deterchments etc Alphagan could be combined with either a beta blocker or a postalglandin analog to promote efficacy of management. Note, a beta blocker reduces aqueous production, an alpha blocker promotes outflow and has been hypotesised to contain neuro-protectors to maintain the integrity of neuro-retinas which often suffers in Glaucoma process. On the other hand, a postalglandin analog promotes uveo-scleral flow (this contributes 10 percent of outflow). Acetozolamide (diuretics), Slow K (reduces the clearance of potasium in the body) are adjunts in managing Glaucoma. In some cases, the use of surgery is advised especially in the closed angle type of glaucoma! We shall discuss this mode of treatment/management in subsequent blog! Happy Good Friday! Be responsible for your eyes!To be continued...Dr Ezebuiroh Okwudiri Victor.