Glaucoma is an eye disorder characterized by high intraocular pressure (IOP) and optic nerve damage. It may have a gradual or acute onset.

There are two major forms of glaucoma:
- Primary open-angle glaucoma (POAG)—develops without symptoms until vision loss occurs from irreversible increased IOP and nerve damage
- Angle-closure glaucoma (also known as narrow angle glaucoma, acute glaucoma, and pupillary block)—can be primary (due to anatomic predisposition) or secondary (due to another process, such as membrane growth over the angle or a mass in the posterior eyeball segment pushing the angle closed); acute angle-closure glaucoma develops quickly and requires immediate treatment

Pathophysiology

POAG

The angle of the anterior chamber is open but trabecular meshwork is partially blocked.
IOP usually increases, possibly due to increased production of aqueous humor or decreased outflow, leading to cupping and atrophy of the optic disk and loss of optic nerve fibers with eventual atrophy of the optic nerve.

Angle-Closure Glaucoma

The outflow of aqueous humor through the trabecular meshwork is blocked because of a complete or partial closure of the angle of the anterior chamber.
Pressure builds up behind the iris, causing the peripheral iris to bow forward and cover all or part of the anterior chamber angle.
Blockage leads to increased IOP and damage to the trabecular network and optic nerve.
Aqueous egress through the pupil is limited.

Causes

POAG

Exact cause is unknown; possibly hereditary
One theory identifies possible accumulation of mucopolysaccharides in the trabecular meshwork as the underlying mechanism

Angle-Closure Glaucoma

Predisposing ocular anatomy or a secondary process

Risk Factors

Elevated IOP
History of another eye condition or trauma
Hypertension
Age older than 40
Family history
Long-term corticosteroid use
Asian or Inuit heredity

POAG

Increased IOP
Positive family history
Myopia
Diabetes
Cardiovascular disease, hypertension
Prolonged use of topical, periocular, inhaled, or systemic corticosteroids
Central corneal thickness
Age older than 40 years

Angle-Closure Glaucoma

Small cornea
Hyperopia
Advanced age
Medications, such as anticholinergics, antihistamines, and antidepressants
Asian ethnicity
Family history
Female sex
Stressful situation

Incidence

Glaucoma is the second leading cause of blindness worldwide.
POAG is the most common form of glaucoma and the leading cause of blindness attributed to glaucoma.
More females develop angle-closure glaucoma.
POAG affects approximately 1% of Americans; it occurs primarily in people older than age 40.

Complications

Varying degrees of vision loss
Total blindness

Assessment

History

POAG

Typically asymptomatic
Possible lack of awareness of vision changes

Angle-Closure Glaucoma

With acute angle-closure glaucoma, rapid onset symptoms likely
Possibly mild or no symptoms (gradual changes in peripheral vision with chronic form)
Periocular pain
Blurred vision
Redness in eye
Lacrimation
Frontal headache
Nausea and vomiting
Halos around lights

Physical Findings

POAG

Fluctuating or increased IOP
Cup-to-disk ratio greater than 0.5
Paracentral scotomas
Visual field deficits; central field loss occurring late in the disease

Angle-Closure Glaucoma

Elevated IOP
Lid edema
Conjunctival hyperemia
Fixed mid-dilated pupil
Corneal edema
Reduced central visual acuity
Halos around lights and blurry vision

Diagnostic Test Results

Diagnostic Procedures

Tonometry measurement shows increased IOP.
Slit-lamp examination shows effects of glaucoma on the anterior eye structures.
Gonioscopy shows the angle of the eye's anterior chamber (the gold standard for diagnosing angle-closure glaucoma).
Ophthalmoscopy aids visualization of the fundus.
Perimetry or visual field tests show the extent of peripheral vision loss.
Fundus photography shows optic disk changes.
Pachymetry is done to measure corneal thickness.

Optic disk changes

Cupping of the optic disk is characteristic of primary open-angle glaucoma.

Treatment

	WARNING!
	Acute angle-closure glaucoma is considered an emergency because of its rapid onset. If left untreated, it can lead to blindness in less than 1 week.

General

Reduction of IOP
Venous thromboembolism prophylaxis while the resident is hospitalized or on complete bed rest

Activity

Bed rest (with acute angle-closure glaucoma)

Medications

IV fluids

POAG

Ocular hypotensive agents to decrease aqueous production, such as beta-adrenergic antagonists (timolol maleate, levobunolol hydrochloride, carteolol hydrochloride, betaxolol hydrochloride); parasympathomimetics (miotics), such as pilocarpine hydrochloride (ophthalmic); carbonic anhydrase inhibitors, such as oral acetaZOLAMIDE, topical brinzolamide–brimonidine tartrate; adrenergic agonists, such as brimonidine tartrate, to suppress aqueous inflow
Prostaglandin analogues, such as latanoprost, bimatoprost, or travoprost, to increase aqueous outflow
Hyperosmotic agents, such as IV mannitol or oral glycerin

Angle-Closure Glaucoma

Systemic carbonic anhydrase inhibitors, such as IV acetaZOLAMIDE
Ophthalmic carbonic anhydrase inhibitors such as brinzolamide–brimonidine tartrate, dorzolamide hydrochloride
Topical beta-adrenergic blockers, such as timolol maleate and betaxolol hydrochloride
Ophthalmic prostaglandins such as travoprost, latanoprost, or bimatoprost
Topical miotics such as pilocarpine hydrochloride (ophthalmic)
Oral hyperosmotic agents such as mannitol

	WARNING!
	Occasionally, systemic absorption of a beta-adrenergic blocker from eyedrops is enough to cause bradycardia, hypotension, heart block, bronchospasm, impotence, or depression.

Surgery

Immediate laser or surgical iridectomy (for acute angle-closure glaucoma)
Argon laser trabeculoplasty
Trabeculectomy
Shunt surgery

Nursing Considerations for Long-Term Care

	LTC Tips
	Older adult residents in long-term care commonly have altered drug distribution and drug metabolism due to higher body fat, decreased muscle mass, possible hepatic disease, and decreased drug excretion; these conditions can be caused by compromised kidney function. Additionally, older adult residents are at greater risk of adverse drug interactions due to polypharmacy.

Nursing Interventions

Assess the resident's and family's awareness and understanding of the condition.
Assess the resident's anxiety and comfort level.
Encourage the resident to express feelings and level of comfort.
Teach the resident and family about the disease, the treatment regimen and options, signs and symptoms to report (such as pain, anxiety, and visual changes), and the importance of adhering to the treatment regimen.
Teach the resident and family about ophthalmic medications, dosages, route, times of administration, correct administration technique, and possible adverse reactions.
Teach the resident strategies to cope with any changes in visual acuity.
Teach the resident strategies to become actively involved in the treatment regimen, and encourage involvement in self-care activities according to ability level.
Administer ophthalmic medications, as ordered; monitor and report any adverse medication reactions to the resident's practitioner.
Monitor the resident's environment for potential safety hazards and initiate interventions to prevent falls and injuries (such as keeping pathways clear, providing adequate lighting, keeping frequently used items within easy reach, and preventing clutter).
Avoid room changes and/or rearranging of the room whenever possible.
Facilitate eye examinations, as needed.
Provide and encourage the resident's participation in activities and interests.
Refer the resident and family to counseling and social services, as needed.
Ensure that adaptive equipment is available for activities of daily living and leisure activities requiring visual acuity.
Ensure the appropriateness of visual appliances.

Monitoring

Vital signs
Comfort and anxiety level
Resident's ability to perform self-care and activities safely
Visual changes (eye pain, rainbows or halo effects around lights, blurred or cloudy vision)
Frequency, duration, and severity of visual symptoms
Resident's knowledge of the disease process
Resident's knowledge of and adherence to the treatment regimen
Resident's motivation and willingness to participate in the treatment regimen, self-care, and activities
Social isolation

Associated Long-Term Care Nursing Procedures

Ambulation, progressive, long-term care
Assessment differences in an older adult, long-term care
Care of the resident with visual impairment, long-term care
Care plan preparation, long-term care
Change in status, identifying and communicating, long-term care
Difficult behavior management, long-term care
Documentation, long-term care
Eye care
Eyedrop administration
Eye ointment application
Fall management, long-term care
Fall prevention, long-term care
Health history interview and physical assessment, long-term care
Oral drug administration
Pain assessment, long-term care
Pain management

Resident Teaching

General

Include the resident's family or caregiver in your teaching, when appropriate. Provide information according to their individual communication and learning needs. Be sure to cover:

disorder, diagnostic testing, and treatment, including the need for immediate treatment of acute angle-closure glaucoma
need for meticulous adherence to the prescribed drug therapy
all procedures and treatments, especially surgery
technique for proper eyedrop administration
that most residents recover lost vision with adequate treatment for acute angle-closure glaucoma
that lost vision associated with POAG can't be restored but that treatment can minimize further loss
importance of adhering to therapy, including use of eyedrops and schedule of use
modification of the resident's environment for safety and how vision will be altered postoperatively or while the eye is patched
signs and symptoms that require immediate medical attention, such as sudden vision changes, eye pain, and headache
importance of glaucoma screening for early detection and prevention
need for lifelong monitoring for POAG
importance of follow-up evaluations for vision testing, IOP measurement, and visual field testing, as appropriate.

Discharge Planning

Participate as part of a multidisciplinary team to coordinate discharge planning efforts. The team may include a bedside nurse, social worker, case manager, primary care practitioner, and eye surgeon.
Assess the resident's and family's understanding of the diagnosis, treatment, prognosis, follow-up, and warning signs for which to seek medical attention.
Assess the resident's level of independence before admission.
Evaluate how the resident's current illness will impact independence.
Determine the appropriate posthospital setting to which the resident will be discharged.
Identify the resident's formal and informal supports.
Identify the resident's and family's goals, preferences, comprehension, and concerns about discharge.
Confirm arrangements for initial follow-up visits.
Provide a list of prescribed drugs, including the dosage, prescribed time schedule, and adverse reactions to report to the practitioner. Provide the resident (and family or caregiver, as needed) with written information on the medications that the resident should take after discharge.
Assess the resident's and family's understanding of prescribed medication, including dosage, administration, expected results, duration, and possible adverse effects.
Assess the resident's ability to obtain medications; identify the party responsible for obtaining medications.
Instruct the resident to provide a list of medications to the practitioner who will be caring for the resident after discharge; to update the information when the practitioner discontinues medications, changes doses, or adds new medications (including over-the-counter products); and to carry a medication list that contains all of this information at all times in the event of an emergency.
Assess the resident's mobility and balance, and educate the resident and family about fall prevention.
Ensure arrangements for home health care services, if needed.
Ensure that the resident and caregivers receive medical contact information.
Ensure that the resident (and family or caregiver, as needed) receives a copy of the discharge instructions and that a copy is placed in the resident's medical record.
Document the discharge planning evaluation in the resident's clinical record, including who was involved in discharge planning and teaching, their understanding of the teaching provided, and any need for follow-up teaching.