Glaucoma is an umbrella term, which covers a group of diseases with a characteristic pattern of optic nerve damage that if left untreated, or treated inadequately or inconsistently, can lead to irreversible vision loss. The initial glaucoma evaluation includes all components of a comprehensive adult medical evaluation, focusing on those elements that specifically pertain to the diagnosis and management of glaucoma, which may require more than one visit. Accurate history taking and high-quality diagnostic testing are integral to informed decision making for the clinician.
The following structured guideline for a glaucoma workup is broken into two parts. The first part is the initial intake of a patient who is new to the practice and is being referred for evaluation, who may or may not have already been diagnosed with glaucoma and has been on treatment, or is suspected to be at higher risk for glaucoma by the referring physician and treatment has not been initiated. The second part is for established glaucoma patients currently on treatment or glaucoma suspect patients returning for follow up.
A note about the workup
The components of the workup often depend on subspecialty and doctors, as each clinician has their own preference for which of these components they include in their assessment. So, it is imperative you consult with your clinician on their preferences on what to perform and what to include in your specific workup.
For the sake of brevity and efficiency in performing the
glaucoma workup, this article does not include:
• History that would be reconciled during patient’s general workup, as we assume the referring doctor provided this information in the patient record when the patient was referred.
• History and testing that would be reconciled during every patient visit (confrontation fields, information on patient’s medications, allergies, surgeries, etc.).
Part 1: New patient glaucoma workup
• Research chart notes from previous providers, including:
A. Diagnosis, or suspected diagnosis
B. Highest pressure recorded (Tmax)
C. Visual field results
D. Optical coherence tomography (OCT) trends
E. Medications
F. Visual complaints
G. Previous eye surgeries
H. Medications that have been tried in the past and why they are no longer using them
• History directly from patient. Ask the patient about:
A. Visual complaints
1. Change in peripheral vision
2. Contrast changes
3. Physical complaints
4. Pain or pressure sensation, or feeling that the eye is bigger than it should
5. Functional status
6. Ask, Is your vision preventing you from participating in any of your regular activities, such as driving or reading?
B. Medications that could impact glaucoma
1. Steroids (including topical, oral, and injection). Although medication use and allergies are reconciled at each patient visit, pay careful attention to steroids, as steroid-induced glaucoma is a serious condition manageable by early detection.
C. Surgeries. Although a history of surgeries is reconciled at each patient visit, pay attention to eye-related procedures, as these may affect intraocular pressure.
1. Ocular
a. Glaucoma
- Minimally invasive glaucoma surgery (MIGS)
- Trabeculectomy
- Tube shunt
b. Lasers
- ALT, SLT, LPI, YAG
c. Refractive
- LASIK, RK, PRK
- Cataract (complicated vs. routine)
d. Other (pterygium excision, oculoplastic, retina, transplants, etc.). Pregnancy
D. Pregnancy
E. Lifestyle
1. History of competitive swimming (episodic holding breath, pressure from goggles)
2. History of playing instruments (episodic holding of breath, possible Valsalva)
3. Yoga participation
F. Systemic history
1. Although systemic history is available in the patient history, pay attention to sleep apnea, with or without CPAP or BiPAP use, as these have been shown to increase IOP.
G. Family history of glaucoma
1. Severity
2. Outcome (history of visual loss from glaucoma)
3. Known treatments
H. Race/ethnicity
• Diagnostic tests to conduct:
A. Visual field
1. Automated per protocol (requires an order from the clinician)
B. OCT disc and macula per protocol (requires an order from the clinician, and may include documentation of one or more of the following)
1. Overall retinal nerve fiber layer (RNFL)
average
2. Any wedge or sectoral defects present
3. Ganglion cell analysis
C. Pachymetry (requires an order from the clinician)
D. Slit lamp examination The slit lamp examination is often left to the clinician to document in the chart, but recognizing these findings is helpful for the technician in regard to understanding how reliable testing may be, what type of glaucoma a patient may have (pigmentary, open angle vs. closed angle), whether the patient is compliant with their medication, or if they are tolerating their medication. Consult your physician regarding their preferences in recognizing and charting these findings as is appropriate. Regardless, all techs should be looking at angles whenever dilating.
1. External, lids, and adnexa (signs of possible allergic reaction to medication or orbitopathy)
a. Lid thickening
b. Ptosis
c. Telangiectasias along lid margin
2. Anterior chamber
a. Angles (if angles appear narrow consult your clinician for further instruction)
b. Endothelial pigment dispersion (Krukenberg’s spindle)
c. Iris
- Nevi near the angles
- Presence of an iridotomy or iridectomy
- Whether a tube is touching the iris
- Transillumination defects of the iris
d. Lens
- Status of lens (natural versus pseudophakic vs. aphakic)
- Pigment on surface of lens
3. Corneal surface
a. Epithelial disruption
b. Bullous keratopathy
c. Edema
Part 2: Established patient glaucoma workup
• History from the patient (as above) in relation to the last time they were seen. Include:
A. Vision complaints
B. Functional complaints
C. Physical complaints
D. How they are tolerating the medication (if applicable)
E. How compliant they are with the medication (if applicable)
F. New changes to their overall health history since last visit
1. Surgeries
2. Changes in medications
3. New diagnoses
• Diagnostic test to conduct:
A. Best-corrected visual acuity
B. Pupil assessment
1. Anisocoria
2. Reactivity to light
3. Afferent pupillary defect
C. Applanation tonometry
1. Prior to dilation (must be approved by the clinician)
D. Visual field
1. Confrontational fields
2. Automated per protocol (requires an order from the clinician)
E. OCT Disc and macula per protocol (requires an order from the clinician)
1. Document overall RNFL average
2. Any wedge defects present
3. Ganglion cell analysis
F. Dilation per protocol
G. Slit lamp evaluation as above
A systematic approach
While a glaucoma workup may seem like a daunting task, find a systematic approach to gathering information and find the flow that helps you streamline this process. In addition to streamlining the workup, always explain to the patient when each test is being performed, and consult with your clinician for their preferences. OP
Lynn Girdlestone, COA, OSA, OSC, is the practice manager at Swedberg Eye Care, Edmonds, WA, and Vision Director for the Seattle/King County Clinic.
