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LEARNING OBJECTIVES:

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After completing this case study, the reader should be able to:

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  • Identify the importance of regular eye examinations and the early diagnosis of glaucoma.

  • List the risk factors for developing open-angle glaucoma.

  • Select and recommend agents from different pharmacologic classes when indicated and provide the rationale for drug selection, including combination products to increase adherence.

  • Recommend conventional glaucoma therapy as well as other options in glaucoma management when indicated.

  • Formulate basic ophthalmologic monitoring parameters used in glaucoma therapy.

  • Counsel patients on medication regimens and proper ophthalmic administration technique.

  • Discuss potential adverse drug reactions with patients to increase therapy adherence.

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PATIENT PRESENTATION

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Chief Complaint

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“My vision is closing down and I am having difficulty seeing cars at intersections while driving.”

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HPI

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Macy Connor is a 75-year-old woman who presents for follow-up of advanced POAG. She reports adherence with latanoprost nightly and timolol/brimonidine (Combigan) 2 times daily in the right eye and dorzolamide 3 times daily in the left eye. She feels that her vision in the left eye is beginning to blur, and she is having more difficulty seeing objects in the top part of her vision. She finds that she has to move her head more to see objects in her periphery. She denies eye pain, flashes or floaters. She is feeling more tired recently and just does not have the energy to do the things she used to do.

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Mrs Connor was first diagnosed with POAG 20 years ago during a routine eye exam to update her eyeglass prescription. She had no visual disturbances at that time, and her best corrected vision was 20/20 OU. She was started on pilocarpine 1% 3 times daily in both eyes and developed brow ache and blurred vision. This was discontinued and she was started on timolol 0.5% twice daily in both eyes. Her highest IOP prior to treatment was 28 mm Hg, which improved to 22 mm Hg on timolol. Her eye pressure gradually increased requiring the addition of brimonidine 3 times daily and latanoprost nightly in both eyes. She underwent cataract surgery 2 years ago and experienced an IOP spike to 55 mm Hg and was given acetazolamide 250 mg PO 4 times daily for 5 days after surgery until her pressure improved back to baseline. She underwent trabeculectomy with mitomycin C on the left eye last year; dorzolamide 3 times daily was added when the IOP again began to increase.

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PMH

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  • Hypertension, well controlled on lisinopril for 6 years

  • Kidney stones (occurred while taking acetazolamide)

  • Migraine headaches; well controlled on sumatriptan with 1–2 migraines per year

  • Depression; controlled with exercise and counseling only. Has never taken medications for depression

  • Myopia; corrected with glasses

  • Astigmatism; corrected with glasses

  • Pseudophakia; cataract surgery three years ago

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FH

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