Beth Hertz

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	Primary care physicians (PCPs) are in a qualified position to assist in the diagnosis of glaucoma. With an understanding of comprehensive glaucoma management, physicians can direct their patients to therapy that will improve their outcomes.

	Through patients’ routine visits, primary care physicians can make referrals for ophthalmic examinations, especially in patients who present with the risk factors for glaucoma. A major problem in treating glaucoma patients is medication adherence and PCPs can discuss strategies to improve medication use and efficacy.

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	Recognition of adverse reactions from glaucoma medications and surgeries will allow proper management of these potentially serious conditions. Here is a basic overview of glaucoma and what primary care physicians can assist their patients.

	• Did you know that about 3 million Americans have glaucoma but only half know it?

	• Glaucoma is a leading cause of blindness for people over 60 years of age.

	• Early diagnosis and treatment can stop glaucoma from robbing your patients of their sight!

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	Many patients do not schedule regular eye examinations. This mean that primary care physicians are uniquely positioned to be the first line of defense in spotting suspected cases of glaucoma early on and encouraging their patients to see an eye care professional.

	Often, glaucoma pressure builds up slowly and patients do not experience any symptoms, which is why it is important for everyone to have regular eye examinations with an ophthalmologist or optometrist. Encourage your patients to do this!

	However, sometimes there are symptoms, including:

	-Seeing rainbow-colored circles around lights;

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	Glaucoma can affect anyone but here is who is most at risk for it:

	• Age: Being over 40 years old, with an even greater risk over age 60;

	• Race: Being of African, Asian, or Hispanic descent;

	• Having other problems: High myopia, thin central cornea, long-term steroid use, past serious eye injury, diabetes, or high blood pressure all increase risk

	There are several types of glaucoma. They include:

: This is the most common form of glaucoma. It occurs when the trabecular meshwork stops draining fluid out of the eye, which allows intraocular pressure (IOP) to rise. This can damage the optic nerve. As this happens, people may see “blank spots” in their vision.

: Patients with an IOP that seems to be within a normal range can still lose when their optic nerve is damaged.

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Angle-closure glaucoma (also called “narrow-angle glaucoma”):

 When a patient’s iris is very close to the drainage angle in the eye, it can block the outflow, leading to a sudden increase in IOP. Symptoms include severe eye pain, headache, blurred vision, nausea, and seeing halos around lights. This is an emergency, warranting an immediate referral to an ophthalmologist, to avoid irreversible blindness.

: This is when glaucoma develops as a result of another eye problem, such as an injury or an ocular tumor.

 Congenital glaucoma, uveitic glaucoma, exfoliative glaucoma, and neovascular glaucoma.

	Medications are the first line of treatment for glaucoma. However, they have many side effects that patients will often mention to their PCP. These problems can lead to a high rates of patient noncompliance with therapy, particularly since most patients are unable to discern any immediate benefit from their medication.

	Side effects that you may see in your patients being treated with glaucoma medications include:

	            • Stinging or itching in the eyes;

	            • Red eyes or red skin around the eyes;

	            • Changes in pulse;

	            • Blurred vision;

	            • Unusual eyelash growth;

	            • Changes in eye color;

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	Encourage your patients to talk to their ophthalmologist about any concerns they have with their medications, instead of just stopping taking them. The ophthalmologist may recommend they switch to another class of glaucoma medication. There are many options.

	One way to help patients who are experiencing systemic problems with their glaucoma medicine is to encourage them to cover their punctum with a finger while administering their drops and for a few minutes afterward. This significantly reduces the amount of medicine entering the rest of the body without reducing how much reaches the eye.

	Surgery may be needed for patients who do not achieve adequate results with medication. While an ophthalmologist is the best person to determine which procedure is right for each patient, here is an overview of the options:

 This involves creation of an alternative pathway to allow fluid to flow out of the eye. The conjunctiva is lifted and a partial thickness flap of sclera is dissected. Then, the tissue blocking the aqueous outflow is removed. This is the most common glaucoma surgery performed today. PCPs should be alert to the possibly of ocular infections afterward as well as conjunctivitis.

 A laser is applied to the filtration area on the inside of the cornea to decrease outflow resistance, thereby lowering IOP. This may not be effective long term but can yield good results, and reduce the dependence of medication, for several years. Be alert to a return of glaucoma symptoms over time.

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 A permanent plastic tube is implanted into the anterior chamber to allow the aqueous fluid to exit.

 Instead of seeking to improve aqueous outflow, this procedure aims to reduce aqueous production by ablating the ciliary body with cryotherapy or laser surgery.

. The latest advancement in glaucoma surgery is MIGS, or micro-invasive glaucoma surgery. These surgical devices are used to reduce IOP by increasing the outflow of aqueous humor. MIGS procedures offer minimally invasive approach, where the surgeon uses small cuts or micro-incisions through the cornea, thus limiting trauma to surrounding scleral and conjunctival tissues. The procedures also minimize tissue scarring, allowing traditional glaucoma procedures to be performed in the future if required.

	Glaucoma is a leading cause of blindness, a problem which is made even more serious by the fact that many patients do not notice any symptoms until it is too late to prevent permanent blindness.

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	PCPs can help their patients by being alert to the symptoms and encouraging all patients to have regular dilated eye examinations that include IOP measurements, gonioscopy, pachymetry, and perimetry testing. This is particularly important in patients who are over 60, who have a family history of glaucoma, or who are of African, Asian, or Hispanic descent.

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