Clinical Concepts

Primary Open-Angle Glaucoma

Clinical Update
Jasmine W. Yumori, OD, FAAO; and Mary P. Cadogan, DrPH, RN, GNP-BC

Abstract
Glaucoma is an optic neuropathy that is
usually associated with an elevated intra-
ocular pressure. Primary open-angle glau-
coma (POAG) is the most common type of
glaucoma and is progressive and bilateral
but typically asymmetric in patients. Stud-
ies have shown that reducing intraocular
pressure reduces the risk of vision loss. In
the United States, medical intervention
by means of prescription eye drops is the
initial line of treatment. Nurses play an
important role in educating individuals,
particularly older adults, about the impor-
tance of routine eye care to earlier diag-
nose, treat, and adequately manage eye
diseases such as POAG.

Photos, available in the public domain, courtesy of the National Eye Institute, National Institutes of Health.
About the Authors
Dr. Yumori is Assistant Professor, West-
ern University of Health Sciences, College
of Optometry, Pomona, and Dr. Cadogan
is Professor, Adjunct Series, University of
California, Los Angeles, School of Nursing,
Los Angeles, California.
The authors disclose that they have no
significant financial interests in any product
or class of products discussed directly or
indirectly in this activity, including research
support. The authors express their gratitude
to Drs. Elizabeth Hoppe and Raymond
Maeda for reading/commenting on the
manuscript and to Ms. Ruth Harris for as-
sistance in confirming copyright permissions.
Address correspondence to Jasmine W.
Yumori, OD, FAAO, Assistant Professor,
Western University of Health Sciences,
College of Optometry, 309 E. 2nd Street,
Pomona, CA 91766; e-mail: jyumori@
westernu.edu. An example of normal vision (top) and vision in advanced stages of primary open-angle
Posted: March 2, 2011 glaucoma (bottom), in which patients may start to report problems with missing areas
doi:10.3928/00989134-20110210-01 in their side vision.

10 Copyright © SLACK Incorporated

 Glaucoma is not one disease but
refers to a group of diseases that
cause damage to the optic nerve,
which connects the retina to the
brain. If glaucoma is left untreated,
it can lead to vision loss and blind-
ness. Glaucoma has been reported
to affect 2.5 million Americans and
is the leading cause of visual im-
pairment among African American
and Hispanic individuals (Rodri-
guez et al., 2002; Sommer et al.,
1991). Among all Americans, glau-
coma is the second-leading cause of
irreversible vision loss.
A common method of classify-
ing subtypes of glaucoma is based
on the appearance of the irido-
corneal angle, which is the angle
formed by the iris and the cornea
(Kwon, Fingert, Kuehn, & Alward,
2009). The iridocorneal angle has
been identified as the primary Figure. The mechanism of aqueous humor production and drainage.
drainage route for the aqueous Diagram, available in the public domain, courtesy of the National Eye Institute,
humor. Glaucoma is commonly National Institutes of Health.
classified as either “open angle” or
“closed angle” and divided into pri- the etiology of POAG is constantly The range of distribution for IOP
mary and secondary types. Primary undergoing further investigation, cut-off points used to indicate el-
open-angle glaucoma (POAG) strong evidence suggests glaucoma evated IOP vary within the litera-
accounts for up to 90% of cases is caused by damage to the reti- ture, ranging from 18 to 26 mmHg
of glaucoma in the United States nal ganglion cell axons within the with a mode of 22 mmHg (Tavares,
(Distelhorst & Hughes, 2003) and lamina cribrosa of the optic nerve Medeiros, & Weinreb, 2006); the
will be the focus of this clinical head (Burgoyne, Downs, Bellezza, IOP associated with POAG is
review. The American Academy of & Hart, 2004; Gaasterland, Tan- typically defined as more than 22
Ophthalmology’s (AAO) Preferred ishima, & Kuwabara, 1978), leading mmHg. However, some patients
Practice Pattern (AAO Glaucoma to gradual vision loss. Two main may develop glaucoma with-
Panel, 2005) describes POAG as theories have emerged to explain out elevated IOP; this is termed
a chronic, generally bilateral, and the mechanism of ganglion cell normotensive glaucoma. Others
often asymmetric disease character- dysfunction: mechanical and vaso- may have elevated IOP without
ized in at least one eye by all of the genic. According to the mechani- glaucomatous optic nerve damage;
following: evidence of optic nerve cal theory, elevated IOP causes this is termed ocular hypertension
damage; characteristic visual field deformation of the lamina cribrosa (Coleman, 1999). Because IOP re-
abnormalities; adult onset; open, structure, which leads to blockage mains the leading and only modifi-
normal-appearing anterior chamber of axon transport and subsequent able risk factor for glaucoma, it is
angles; and absence of other (sec- axon damage (Quigley, 1999). Ac- important to understand the role of
ondary) causes of OAG. cording to the vasogenic theory, IOP leading to optic nerve damage.
vascular insufficiency at the optic IOP is determined by the balance
Etiology and nerve head results in hypoxia and between production and outflow of
Pathophysiology decreased nutrition to optic nerve aqueous humor in the eye (Mar-
Historically, POAG was char- axons ultimately with ganglion cell quis & Whitson, 2005). The Figure
acterized as a disease of elevated death (Osborne, Melena, Chidlow, shows the mechanism of aqueous
intraocular pressure (IOP), but & Wood, 2001). humor production and drainage.
accumulating evidence points to a Elevated IOP is frequently Aqueous humor is produced by
much more complex process. While found in individuals with POAG. the ciliary body in the posterior

Journal of Gerontological Nursing • Vol. 37, No. 3, 2011 11

chamber, the area behind the iris
and in front of the lens. Aqueous
humor circulates from the posterior
chamber through the pupil into the
anterior chamber and exits the eye
primarily through the trabecular
meshwork and canal of Schlemm
where it enters the venous system
(Marquis & Whitson, 2005). Some
aqueous humor also leaves the eye
through the secondary uveoscleral
drainage pathway (Kwon et al.,
2009). While short-term variations
are associated with factors such as
diurnal variation and posture, treat-
ment for glaucoma is focused on
decreasing production or increas-
ing outflow of aqueous humor to
decrease IOP and thus minimize
damage to the optic nerve.
Generalized Risk Factors
Generalized risk factors for
POAG include a positive patient
history of systemic hypertension
(Memarzadeh, Ying-Lai, Azen, &
Varma, 2008; Yanagi et al., 2010),
elevated body mass index (BMI)
(Memarzadeh et al., 2008; Shiose &
Kawase, 1986), diabetes (Yanagi et
al., 2010), and smoking (Grzybows-
ki, 2008; Zanon-Moreno, Garcia-
Medina, Zanon-Viguer, Moreno-
Nadal, & Pinazo-Duran, 2009).
While many of these variables
may be correlated, studies such as
the Los Angeles Latino Eye Study
have shown that these are indepen-
dently associated with elevated IOP
(Memarzadeh et al., 2008). Based
on these risk factors, altered ocular
blood flow and oxidative stress are
suspected to be a major factor in
the development and progression
of POAG. Increased age (Miyazaki,
Segawa, & Urakawa, 1987); male
gender (Kahn & Milton, 1980); Af-
rican American, Hispanic, and/or
Native American heritages (Kuzin,
Varma, Reddy, Torres, & Azen,
2010); and a family history of
glaucoma (Wang et al., 2010) have
also been shown to be possible risk
factors for POAG. A slow increase
in IOP has been shown with age;
12
it is suspected that as one ages,
there may be a decreased outflow
of aqueous humor (Miyazaki et al.,
1987). This may also be seen due
to concomitant increases in blood
pressure and BMI associated with
age (Kim & Varma, 2010).
CLINICAL EVALUATION
Because POAG is slowly
progressive, patients are typically
asymptomatic until later stages
of the disease (Lee et al., 1998).
Furthermore, visual field loss is
not commonly appreciated because
individual visual fields of each eye
overlap when both eyes are open.
In advanced stages of the disease,
patients may start to report prob-
lems with missing areas in their side
vision. Vision loss from glaucoma
is irreversible. Routine comprehen-
sive dilated eye examinations by an
optometrist or ophthalmologist are
necessary to allow for early diagno-
sis and prompt treatment of POAG
and other eye diseases to optimally
preserve vision. Recommendations
for comprehensive eye evaluations
can be found in the online docu-
ment Comprehensive Adult Medi-
cal Eye Evaluation (AAO, Hoskins
Center for Quality Eye Care,
2010). During a comprehensive eye
examination, eye health and visual
function are carefully evaluated.
While visual acuity may be affected
in patients with more advanced
glaucoma, the diagnosis of POAG
mainly focuses on evaluation of
optic nerve head appearance, IOP
readings, pachymetry or corneal
thickness measurements, visual
field performance, and anterior
chamber angle appearance.
Disease MANAGEMENT
The standard method of treating
POAG is by stabilizing fluctuations
in and consistently lowering IOP
while minimizing adverse effects of
therapy to optimize patients’ health
and quality of life. Medical inter-
vention by means of prescription
eye drops is the first line of treat-
ment (Vetrugno et al., 2008). The
main categories of medications used
to treat POAG are prostaglandin
analogs, ophthalmic beta blockers,
ophthalmic adrenergic agonists,
ophthalmic or oral carbonic anhy-
drase inhibitors, and ophthalmic
cholinergic agonists. Information
on these classes of medications is
summarized in Table 1. Laser and
incisional surgical procedures have
also been shown to be effective in
reducing IOP and decreasing the
glaucomatous progression (Parrish,
Feuer, Schiffman, Lichter, & Musch,
2009). Although studies have shown
no statistically significant differ-
ence in the change of visual field
defects between medical and surgical
intervention (Lichter et al., 2001)
and that both methods delay and/or
decrease progression of vision loss
(Kass et al., 2002; Leske et al., 2007),
medical intervention is typically the
first line of treatment since surgery
is associated with more eye discom-
fort, an increased risk of cataract,
and a slight reduction in distance
vision at 5 years (Burr, Azuara-
Blanco, & Avenell, 2005). Short-
term variations in IOPs are also seen
diurnally and with postural changes;
a maximum IOP value is usually
detected in the morning and the
lowest value in the early afternoon
(Saccà et al., 1998). A recent study
also determined that sleeping with
the head erect at 30 degrees lowers
IOP compared with a supine posi-
tion (Buys et al., 2010).
Strategies to Optimize
Chronic Care
Patients are examined follow-
ing initiation of therapy to evalu-
ate efficacy. Once IOP readings
have been adequately reduced,
reevaluation is typically in 3- to
6-month intervals, with dilated
examinations completed annually.
Adjustments in therapy may be
implemented if IOP readings are
not at target, if there is progres-
sive optic nerve damage, or if there
is difficulty with the prescribed
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 Table 1
Glaucoma medication classes
Mechanism of Common Dosing Cap
Drug Class Action Common Medications Schedulea Possible Side Effects Color
Prostaglandin Enhances Latanoprost (Xalatan®), 1 drop before Increased lash pigmenta- Teal
analogs uveoscleral bimatoprost (Lumigan®), bedtime tion, hypertrichosis, in-
outflow travoprost (Travatan®) creased iris and periocular
skin pigmentation
Ophthalmic Decreases aque- Timolol (Timoptic®), be- 1 drop two times Bradycardia, broncho- Blue or
beta blockers ous formation taxolol (Betoptic®), levobu- per day spasm, hypotension, de- yellow
nolol (Betagan®), carteolol pression, decreased libido
(Ocupress®), metipranolol
(Optipranolol®)
Ophthalmic Decreases aque- Brimonidine (Alphagan P®), 1 drop three times Dry mouth, dry nose, Purple
adrenergic ous formation, apraclonidine (Iopidine®) per day tachyphylaxis, lethargy,
agonists may enhance headache, allergic reac-
uveoscleral tions
outflow
Ophthalmic or Decreases aque- Dorzolamide (Trusopt®), 1 drop three times Lethargy, depression, Orange
oral carbonic ous formation brinzolamide (Azopt®), oral per day aplastic anemia; contrain-
anhydrase acetazolamide (Diamox®) dicated in patients allergic
inhibitors to sulfa
Ophthalmic Increases Pilocarpine (Isopto Car- 1 drop three times Headache, miosis, sweat- Green
cholinergic trabecular pine®, Pilocar®, and others), per day ing, salivation, bradycardia
agonists outflow, may carbachol (Isopto Car-
enhance bachol®), echothiophate
uveoscleral (Phospholine Iodide®)
outflow

a
Varies based on medication concentration and other variables.

medical regimen (either based on
contraindications, intolerance, or
non-optimal adherence).
Because POAG is a chronic
condition, optimal and ongo-
ing management is essential for
preservation of vision. Like other
chronic illnesses with few or no
symptoms, it may be challeng-
ing for those with glaucoma to
continue treatment and follow
up at the recommended inter-
vals. Two measures are used most
frequently to understand patterns
of medication use among individu-
als with glaucoma. Adherence is
a measure of the degree to which
an individual follows the pre-
scribed treatment regimen during
a defined time period, and persis-
tence is a measure of the time to
discontinuation of the prescribed
medications (Schwartz & Quigley,
2008). The Glaucoma Adherence
and Persistency Study, the larg-
est study to date among glaucoma
patients, used administrative data
from 13,956 patients receiving an
initial glaucoma medication who
were followed for at least 1 year
after receiving the initial pre-
scription (Friedman et al., 2008).
Of those with data available for
evaluation at the end of the year,
59% were using their medica-
tion but only 10% had used their
medication continuously. Other
studies have examined the reasons
for low adherence and persis-
tence among those being treated
for glaucoma. For example, Tsai,
McClure, Ramos, Schlundt, and
Pichert (2003) described multiple
factors associated with low adher-
ence. These include cost of medi-
cation, complexity of regimen, side
effects, knowledge/skill, memory,
motivation/health beliefs regard-
ing benefit and efficacy, comorbid-
ities and need for multiple other
medications, dissatisfaction with
provider, inadequate communica-
tion by provider about need for
continued treatment, living alone,
major life events, travel, competing
activities, and change in routine.
Other factors found to be associ-
ated with lower adherence and
persistence are lower health lit-
eracy (Kharod, Johnson, Nesti, &
Rhee, 2006), depression (Jayawant,
Bhosle, Anderson, & Balkrishnan,
2007), dependence on others for
administering eye drops (Sleath
et al., 2006), and hospitalization
(Yousuf & Jones, 2010).

Journal of Gerontological Nursing • Vol. 37, No. 3, 2011 13

 Table 2
Strategies to Improve Glaucoma Assessment and Management
Nurses’ Role
Be familiar with current clinical practice guidelines for
diagnosis of glaucoma and recommended intervals for
comprehensive eye examinations
Identify and educate patients about risk factors for glau- • Encourage reduction of modifiable risk factors through smoking ces-
coma (i.e., age, race/ethnicity, family history, diabetes, sation, education, and adherence to dietary and exercise guidelines.
obesity, smoking)
Review each patient’s medical history for a diagnosis of
glaucoma and note (a) duration of diagnosis, (b) treat-
ment prescribed, and (c) adherence to treatment
Evaluate self-management ability of individuals with
known glaucoma and provide education and referrals
as needed
Strategies to Improve Care
Ask about last comprehensive eye examination:
• Were the eyes dilated?
• Was eye pressure measured?
• Has the next appointment been scheduled?
• Relate nonmodifiable risk factors to increased need for comprehen-
sive eye care and frequency of examination.
• Evaluate for the presence of any symptoms or visual limitations
• Screen for possible medication side effects
• Assess ability to instill eye drops
• Identify any barriers to treatment adherence
• Encourage sleeping with head propped at 30° angle
• Evaluate impact of glaucoma on quality of life
• Ensure ability to read medication labels and medical forms
• Encourage use of large print and extra-bright lighting if needed
• Refer for rehabilitation of visual impairments.

Quality of Life
Receiving a diagnosis of POAG
may influence patients’ quality of
life (QOL). Results of recent studies
have found that disabilities related
to POAG extend beyond clinically
measurable vision deficits. Findings
from the Barbados Eye Studies doc-
ument lower perceived functional
status and well-being among those
diagnosed with POAG compared
with those without the diagnosis
(Wu, Hennis, Nemesure, & Leske,
2008). In particular, participants
with POAG reported lower QOL
for distance activities (e.g., driv-
ing), social functioning, and mental
health. One study reported lower
scores for Mexican Americans with
POAG in all QOL subscales except
general health and noted that most
declines were in subscales associated
with driving (Mangione et al., 2001).
Others describe that POAG patients
report of a loss of confidence in
themselves, especially when outside
the home (Coleman, 1999). Cole-
man (1999) noted that this lack of
confidence may be associated with
the loss of peripheral vision, depth
perception, and contrast sensitiv-
ity that occur with POAG. These
POAG-associated visual impair-
ments may increase risk for falls and
motor vehicle accidents (Glynn et
al., 1991; Owsley, McGwin, & Ball,
1998).
SUMMARY and Implications
for Nurses
POAG is an important condi-
tion among older adults for several
reasons. It is a common cause of
irreversible vision loss among all
older adults but particularly among
African American and Hispanic
older adults. Because it is asymp-
tomatic, significant optic nerve
damage and visual loss can occur
unless early diagnosis and interven-
tion occur. Once thought of as only
a disease related to increased IOP,
ongoing research points to a much
more complex disorder. Newer
technologies allow earlier and more
accurate diagnosis of POAG, but
reduction of IOP remains the only
target for clinical intervention.
Longer-acting topical medications
have improved treatment options,
but adherence and persistence with
treatment remains a challenge for
both patients and clinicians. Nurses
have an important role in recogniz-
ing individuals at risk, stressing the
importance of regular comprehen-
sive eye evaluations, identifying
barriers to treatment, responding to
psychosocial impacts of POAG, and
providing appropriate referrals and
resources for individuals with visual
limitations. Table 2 provides specific
recommendations for improving
care of POAG among older adults.
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