CLINICAL: Glaucoma

It’s About Time

Early diagnosis, with appropriate treatment, leads to better prognosis

The early diagnosis and relative intervention of glaucoma, as with many other medical conditions, is the key to the best patient outcomes. With this in mind, here’s a review of what optometrists should look for during annual comprehensive exams, the guiding principles regarding treatment and appropriate follow-up.


Glaucoma’s earliest stages look like early vertical neuroretinal rim thinning, with correlating subtle retinal nerve fiber layer (RNFL) defects and/or associated transient glaucomatous disc hemorrhages.

Diffuse RNFL loss with correlating OCT RNFL thinning.
Image courtesy of Dr. Lifferth


When considering the personalized type and intensity of treatment, optometrists need to remember the following two guiding principles:

  1. “The rate of disease progression is of fundamental importance in considerations of treatment for glaucoma patients,” according to 7th Consensus Meeting: Medical Treatment of Glaucoma. “Treatment is indicated for patients whose rates of progression will most likely result in [decreased] vision-related quality of life over the projected remaining years of life.”
  2. “The effects of treatment, the patient’s quality of life and the patient’s life expectancy are to be considered in the decision-making process about therapy, reports the American Academy of Ophthalmology Preferred Practice Pattern Glaucoma Panel. “The diagnosis, severity of the disease, prognosis and management plan and likelihood of long-term therapy should be discussed with the patient. . . [Let’s] remember that the goal of treatment is to maintain the IOP in a range at which visual field loss is unlikely to significantly reduce a patient’s health-related quality of life over his or her lifetime.”

Note the inferior temporal retinal nerve fiber layer wedge defect OD.
Image courtesy of Dr. Lifferth


Initially, and ideally, schedule patients for additional testing within a few weeks if they have:

  • High and/or asymmetrical IOPs.
  • Narrow angles, pigmentary dispersion or pseudoexfoliation.
  • Inferior temporal and/or superior temporal neuroretinal rim thinning, retinal nerve fiber layer defects and/or glaucomatous disc hemorrhages.
  • Abnormal structural and/or functional glaucoma testing.

Those patients with an earlier diagnosis and appropriate treatment have the best prognosis in retaining functional vision throughout their lifetimes. Optometrists, as the primary eye care providers, are in the best positions to identify glaucoma early. OM