Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
(Usually not applicable in open-angle glaucoma as vision loss
is typically gradual and painless)
May mention peripheral vision loss if advanced.
History of Present Illness:
Current status of vision (any changes in sharpness, blurring, visual
fields).
Family history of glaucoma.
Ocular surgeries (cataract surgery, previous glaucoma procedures).
Use of topical medications for glaucoma (name, dosage, adherence).
Past Medical History:
Underlying medical conditions (e.g., diabetes, hypertension) that
may increase risk of glaucoma progression.
History of migraines or headaches (may be associated with normal-tension
glaucoma).
Ocular History:
Age of glaucoma diagnosis.
Baseline intraocular pressure (IOP) measurements.
Prior visual field testing results (if available).
History of laser procedures for glaucoma (e.g., trabeculoplasty).
Social History:
Not typically relevant for open-angle glaucoma unless occupation
increases risk of eye injury.
Family History:
Family history of glaucoma (first-degree relatives are at increased risk).
Physical Exam:
Visual acuity testing (Snellen chart or equivalent).
Slit lamp examination: Assess for corneal clarity, anterior chamber
angle appearance, and signs of iris neovascularization (blood vessel
growth on the iris).
Intraocular pressure (IOP) measurement with tonometry (important
indicator of glaucoma progression).
Ophthalmoscopy: Evaluate the optic nerve head for signs of glaucomatous
cupping or pallor.
Diagnostic Tests:
Visual field testing (perimetry): Gold standard for assessing functional
damage from glaucoma. Measures a patient’s peripheral vision and
identifies areas of vision loss.
Optical coherence tomography (OCT): Imaging test that provides
high-resolution cross-sectional images of the optic nerve fiber layer
(important for detecting early glaucomatous changes).
Assessment:
Open-angle glaucoma: Based on clinical findings (optic nerve
appearance on ophthalmoscopy) and characteristic visual field defects.
Glaucoma stage: Determined by severity of optic nerve damage and visual
field loss (early, moderate, advanced).
Intraocular pressure (IOP): Current IOP measurement and comparison
to baseline values.
Response to treatment: Evaluate if current medications effectively
control IOP and prevent progression.
Differential Diagnoses:
Consider other conditions that may mimic glaucoma:
Optic nerve drusen (harmless deposits on the optic nerve)
Ischemic optic neuropathy (damage to the optic nerve due to
poor blood flow)
Myopic optic neuropathy (associated with high nearsightedness)
Plan:
Treatment goals: Aim to lower IOP and prevent further glaucoma
progression and vision loss.
Medical management: May include topical medications (e.g.,
prostaglandin analogs, beta-blockers, carbonic anhydrase inhibitors) to
reduce IOP.
Laser trabeculoplasty (SLT or LTP): Minimally invasive laser procedure
to improve drainage of fluid from the eye (may be considered in
appropriate cases).
Glaucoma surgery (trabeculectomy or implant placement):
Surgical options for severe glaucoma or uncontrolled IOP with medications
(consult with a glaucoma specialist).
Monitoring: Schedule regular follow-up appointments for IOP
measurements, visual field testing, and OCT scans to monitor disease
progression.
Patient education: Educate the patient about glaucoma, treatment
options, importance of medication adherence, and the need for regular
follow-up care.