Dr. Lin is Staff Physician, Michael E. DeBakey Veterans Affairs Medical Center, and Assistant Professor of Ophthalmology, Baylor
College of Medicine, Houston, Texas.
Dr. Orengo-Nania is Eye Care Line Executive, Michael E. DeBakey Veterans Affairs Medical Center, and Professor of Ophthalmology, Baylor College
of Medicine.
Dr. Braun is Staff Physician, Michael E. DeBakey Veterans Affairs Medical Center, and Assistant Professor of Medicine and Medical Ethics,
Baylor College of Medicine.
Disclosure: The authors state that they have no conflicting interests to disclose.Abstract
Chronic open-angle glaucoma is a leading cause of blindness and visual impairment in older adults. Optic nerve damage and
the associated peripheral and subsequent central vision loss are irreversible, but early diagnosis and treatment will give
patients the best chance to maintain functional vision and quality of life. Primary care physicians can assist with the diagnosis
of glaucoma by making appropriate referrals for routine ophthalmic examinations, especially in patients with risk factors
for glaucoma. Medication adherence and persistence may also be enhanced by discussing strategies to improve medication use
and efficacy in the primary care setting. Recognition of adverse reactions from glaucoma medications and surgeries will allow
proper management of these potentially serious conditions. Patients with advanced visual deficits can still benefit from treatment
as well as low-vision and supportive care and should be referred for an ophthalmic evaluation. With an understanding of comprehensive
glaucoma management, primary care physicians play an invaluable role in assisting their patients with effective and timely
therapy that will result in improved outcomes.
Lin AP, Orengo-Nania S, Braun UK. Management of chronic open-angle glaucoma in the aging US population. Geriatrics. 2009;64(7):20-28.
Key words: glaucoma, intraocular pressure, optic nerve, prostaglandin analogue, selective alpha-2 agonist, carbonic anhydrase
inhibitor, trabeculectomy, tube shunt, low vision, blindness
Drugs discussed: apraclonidine, betaxolol, bimatoprost, brimonidine, brimonidine/timolol, brinzolamide, dorzolamide, dorzolamide/timolol,
latanoprost, levobunolol, timolol, travoprost
Figure 1
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Untreated glaucoma results in an irreversible loss of vision, and it is a leading cause of blindness worldwide and in the
United States.1-3 Open-angle glaucoma affects an estimated 2.2 million Americans and with the aging population, the prevalence of glaucoma
is projected to increase by 50% to about 3.4 million by 2020.3 In the United States, glaucoma is 1 of 3 leading causes of blindness (best corrected central vision of ≤20/200 or peripheral
vision of <20 degrees) and visual impairment (best correct central vision <20/40, the legal unlimited driving vision requirement
in most states). In 2004, approximately 1 million Americans were blind and 2.4 million were visually impaired.4 Age, race (African American and Hispanic ethnicity), family history, diabetes mellitus, eye trauma, and long-term steroid
use are some risk factors associated with increased risk of developing glaucoma and its progression.2-4 Given the chronic progressive natural history of the disease, advanced glaucomatous visual loss tends to occur disproportionately
in the elderly and can severely impair functional abilities and quality of life. Activities that require contrast sensitivity,
such as dark adaptation, and functional peripheral vision, such as navigation and mobility, are particularly affected in patients
with advanced glaucoma.5,6
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