Glaucoma

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Description

Open-angle glaucoma

• Description
• Medicine treatment
• Referral

Acute-angle closure glaucoma

• Description
• Medicine treatment
• Referral

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H40.0-6/H40.8-9

DESCRIPTION

• Glaucoma is characterised by damage to the optic nerve with associated visual field loss, for which raised intra-ocular pressure (IOP) is a primary risk factor.
• Glaucoma is classified as open-angle or angle-closure. 
• Glaucoma may occur as a primary condition or secondary to other ocular conditions. 
• The condition is usually bilateral, but may be unilateral or asymmetrical (especially with secondary causes).

OPEN-ANGLE GLAUCOMA

H40.1

DESCRIPTION

• Mostly asymptomatic.
• History of gradual loss of vision in the affected eye or loss of visual field.
• Often suspected after seeing cupping of optic disc on routine fundoscopy or finding elevated intra-ocular pressure on screening.

MEDICINE TREATMENT

Refer to an ophthalmology unit for diagnosis and initiation of treatment.

First line

ß-blocker monotherapy:

• Non-selective ß-blocker, e.g.:
  • Timolol 0.25%, ophthalmic drops, instil 1 drop 12 hourly.

LoE:IIb^vii

OR

• Selective ß-blocker:
  • Betaxolol 0.25–0.5%, ophthalmic drops, instil 1 drop 12 hourly.

LoE:IVb, LoE:IIb^viii

Second line

• Prostaglandin analogue monotherapy, e.g.:
  • Latanoprost 0.005%, ophthalmic drops, instil 1 drop daily.
    • Use as first line if patient has contra-indication to ß-blocker.
    • Use in place of ß-blocker if patient has intolerable side effects with ß blocker or if there is no significant reduction in IOP with ß-blocker.

OR

• Prostaglandin analogue in combination with non-selective ß-blocker if there is insufficient reduction in IOP with ß-blocker monotherapy, e.g.
  • Bimatoprost 0.03% + Timolol 0.5%

LoE:Ib^ix

OR

• Prostaglandin analogue in combination with selective ß-blocker if there a contraindication to a non-selective ß-blocker e.g.
  • Latanoprost 0,005% with betaxolol 0.25-0.5%

Third line

Intolerance to prostaglandin analogue, or poor response: 

• Alpha-agonist, e.g.:

LoE:IIIb^x

• Brimonidine 0.15–0.2%, ophthalmic drops, instil 1 drop 12 hourly.
  • Use as second line if patient is allergic to prostaglandin analogue.
  • Use in place of prostaglandin analogue if there is no significant further reduction in IOP when adding prostaglandin analogue to ß-blocker.
  • Use in combination with ß-blocker and prostaglandin analogue if the patient still has progression of disease or target IOP is not reached.

Failure to respond:

• Alternatives in consultation with a specialist:
• Parasympathomimetic agent:
  • Pilocarpine 1%, ophthalmic drops, instil 1 drop 6 hourly.

LoE:IVb

In severe cases, as a temporary measure before ocular surgery, in consultation with a specialist:

• Carbonic anhydrase inhibitor:
  • Acetazolamide, oral, 250 mg 6 hourly.

LoE:IIIb^xi

REFERRAL

All to an ophthalmology unit.

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ACUTE ANGLE-CLOSURE GLAUCOMA

H40.2

DESCRIPTION

• Usually presents acutely with sudden onset of severe eye pain and redness, associated with nausea, vomiting and hemicranial headache.
• Loss of vision in the affected eye.
• Coloured haloes or bright rings around lights.
• Hazy-looking cornea.
• Fixed, semi-dilated pupil.
• Shallow anterior chamber.
• Severely elevated intra-ocular pressure. When measured with finger palpation, the affected eye feels hard, compared to the other eye.
• If intraocular pressure rises more slowly, the patients may be asymptomatic with gradual loss of vision.

MEDICINE TREATMENT

Institute initial therapy and then refer IMMEDIATELY to an ophthalmology unit.

Try to achieve immediate reduction in IOP:

• Acetazolamide, oral, 500 mg immediately as a single dose.
  • Followed by 250 mg 6 hourly.
  • AND
  • Timolol 0.25–0.5%, ophthalmic drops, instil 1 drop 12 hourly.
• Also treat patient for associated pain and nausea. See sections See Perioperative analgesics and Treatment of PONV.

Where those measures fail, for short-term use only: 

• Mannitol, IV, 1.5–2 g/kg as a 20% solution over 30–60 minutes.

OR

• Glycerol, oral, 1 g/kg of 50% solution as a single dose immediately.

REFERRAL

All to an ophthalmology unit.

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 1.0_30 September 2024

Chapter 18 Eye Disorders_18.3 Glaucoma