how to take history of a glaucoma patient?

1. Dr. Ahmed Usman Khalid
PGR-3 Ophthalmology
History Taking In Glaucoma

2. History
 ‘ History taking – most neglected aspect of
glaucoma management.
 Due to
1. most cases are asymptomatic
2. IOP > 21mmHg is not synonymous with
glaucoma
3. Inability to appreciate pitfalls in IOP
measurement
4. Inability to appreciate other diseases which may
mimic glaucoma.

3. What to ask?
 Demography
 Symptoms
 Alarming signs
 Past ocular history
 Systemic history
 Drug history
 Trauma history
 Family history
 Socioeconomic history
 Activities
 Emotions
 Dietary history

4. Demography
 Age – positive risk factor
 Gender – ACG in females , PXG & PG in males
 Race – Highest incidence of POAG in blacks,
intermediate in whites and south Asia, lowest in
northern Asia

6. Symptoms
 Most cases are asymptomatic- hence the
‘treacherous’ disease
1. Blurred vision with colored haloes ( colored vs.
noncolored)
2. Pain
3. Myopic shift
4. Subjective visual field defects
5. Subjective loss of visual aquity

7. 6. Loss of color vision
7. Patient’s own sense of pressure in the eye.
8. Blackouts

8. Alarming signs
 Early onset of presbyopia
 Frequent change of glasses
 Difficulty in night driving
 Color vision impairment – blue yellow
 Blurred vision in early morning or afternoon

9. Past ocular history
 Myopia – 2-3 folds increased POAG prevalence
 60% of eyes progressing from OHT to POAG were
myopic¹
 Beijing eye study – subjects with >-6 DS myopia
significantly higher frequency of glaucoma than -0.5D to -
3DS, or emmetropia²
¹Arch Ophthalmol 1982;100:1464
²Opthalmology 2007;114:216

10.  Previous glaucoma treatment
 For secondary glaucoma:
1. Uveitis
2. Refractive , RD or cataract surgery
3. Trauma

11. Systemic diseases
 Blood pressure ( Los Angeles Latino Eye Study)
 Thyroid disease.
 Diabetes ( metformin – protective against
glaucoma? )
 Asthma or respiratory allergies
 Cardiovascular diseases
 Renal disease.
 Migraine and Reynaud's phenomenon
 Neurological queries ( headaches, weakness )
 Recent MI – unexpected disc and field
progression

12. Systemic medications
 Anti-histamines, anti-spasmodics, medications for
parkinsonism – dangerous for patients with glaucoma
 Steroids – topical, systemic, nasal spray, ointment (
dose, duration, strength)
 Systemic beta-blockers – low-tension glaucoma
 SSRIs – significantly reduced risk of POAG
 Anticoagulants - for surgical planning

13. Drug-drug interaction

14. Past history of trauma
 Angle recession glaucoma typically occurs years
to decades after the trauma.
 Loss of consciousness & massive blood loss –
nonprogressive form of low-tension glaucoma

15. Family history
 Positive family history – true warning signal to the
clinician
 First degree relative – 10 times higher risk¹
 Sibling of glaucoma patient is at more risk than
either parent or child¹.
¹Arch Ophthalmol. 1994;112(1):69-73

17. Socioeconomic history
 One of the costly disease
 Cost of medications throughout the life is a major
burden

18. Activities
 No evidence that patients with glaucoma should
alter their daily life activity.
 Pigmentary glaucoma.
 Exercise may actually lower IOP in POAG
patients.
 Sleep time < 3 hours or > 10 hours per night –
more likely for visual field defects

19. Emotions
 No known relationship.
 In apprehensive patients, tranquilizers seem to
cause modest IOP lowering.
 In patients with narrow angles, emotions can
precipitate an attack of angle-closure glaucoma.

20. Food & drink
 Large volumes of water taken rapidly do cause a
transient rise in IOP in many glaucomatous eyes.
 Argemone oil – suspected to cause reversible
epidemic glaucoma
 IOP is nearly always temporarily lowered by
alcoholic drinks
 Caffeine – slight transient rise in IOP

21. Summary
 Detailed glaucoma history is essential to
1. Detect the population at risk
2. Prevent the side effects of Tx
3. Diagnose and treat glaucoma at an early stage

22. Take home message
 Clinicians have an obligation to take the time to
talk to all patients with glaucoma and listening to
their concerns with particular attention
 It is humbling how many second opinions are
requested by patients with glaucoma, in truth only
to find a clinician who will take the time to talk to
them.