Office Examination of the Glaucoma Patient

  • Paul N. Schacknow


The initial examination of the patient with presumed glaucoma or glaucoma suspect status should be a problem-focused, enhanced version of the “new” patient set of clinical observations, diagnostic tests, and history taking routinely done by all ophthalmologists. My perspective in this chapter shall be that of a community-based glaucoma subspecialist, working in a group ophthalmology practice. I see patients referred for glaucoma-related diagnostic workup, consultation, and possible treatment. Everything I describe or recommend here should be well within the current or attainable skill sets of most eye care physicians and the facilities of average office environments. This chapter should serve as an informal guide for residents, fellows, and comprehensive ophthalmologists who wish to incorporate evidence-based diagnosis and patient management techniques into their glaucoma practices. I will also consider the occasional need for and use of advanced diagnostic technology that might be available for patients referred to academic medical centers, such as ultrasound biomicroscopy (UBM) and anterior segment ocular coherence tomography (AS-OCT).


Visual Field Retinal Nerve Fiber Layer Proliferative Diabetic Retinopathy Central Corneal Thickness Trabecular Meshwork 


  1. 1.
    Jacobs EA. Patient centeredness in medical encounters requiring an interpreter. Am J Med. 2000;109(6):515.CrossRefPubMedGoogle Scholar
  2. 2.
    Rivadeneyra R, Elderkin-Thompson V, Silver RC, Waitzkin H. Patient centeredness in medical encounters requiring an interpreter. Am J Med. 2000;108(6):470–474.CrossRefPubMedGoogle Scholar
  3. 3.
    Takemura Y, Sakurai Y, Yokoya S, et al. Open-ended questions: are they really beneficial for gathering medical information from patients? Tohoku J Exp Med. 2005;206(2):151–154.CrossRefPubMedGoogle Scholar
  4. 4.
    Sleath B, Roter D, Chewning B, Svarstad B. Asking questions about medication: analysis of physician-patient interactions and physician perceptions. Med Care. 1999;37(11):1169–1173.CrossRefPubMedGoogle Scholar
  5. 5.
    Kaimbo DK, Buntinx F, Missotten L. Risk factors for open-angle glaucoma: a case-control study. J Clin Epidemiol. 2001;54(2):166–171.CrossRefPubMedGoogle Scholar
  6. 6.
    Wilson MR, Hertzmark E, Walker AM, Childs-Shaw K, Epstein DL. A case-control study of risk factors in open angle glaucoma. Arch Ophthalmol. 1987;105(8):1066–1071.PubMedGoogle Scholar
  7. 7.
    Coleman AL, Miglior S. Risk factors for glaucoma onset and progression. Surv Ophthalmol. 2008;53(6 Suppl):S3-S10.CrossRefPubMedGoogle Scholar
  8. 8.
    Deva NC, Insull E, Gamble G, Danesh-Meyer HV. Risk factors for first presentation of glaucoma with significant visual field loss. Clin Experiment Ophthalmol. 2008;36(3):217–221.CrossRefPubMedGoogle Scholar
  9. 9.
    Rivera JL, Bell NP, Feldman RM. Risk factors for primary open angle glaucoma progression: what we know and what we need to know. Curr Opin Ophthalmol. 2008;19(2):102–106.CrossRefPubMedGoogle Scholar
  10. 10.
    Boland MV, Quigley HA. Risk factors and open-angle glaucoma: classification and application. J Glaucoma. 2007;16(4):406–418.CrossRefPubMedGoogle Scholar
  11. 11.
    Sommer A. Glaucoma risk factors observed in the Baltimore Eye Survey. Curr Opin Ophthalmol. 1996;7(2):93–98.CrossRefPubMedGoogle Scholar
  12. 12.
    Brandt JD, Beiser JA, Gordon MO, Kass MA. Central corneal thickness and measured IOP response to topical ocular hypotensive medication in the Ocular Hypertension Treatment Study. Am J Ophthalmol. 2004;138(5):717–722.CrossRefPubMedGoogle Scholar
  13. 13.
    Gordon MO, Beiser JA, Brandt JD, et al. The Ocular Hypertension Treatment Study: baseline factors that predict the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002;120(6):714-720; discussion 829–730.PubMedGoogle Scholar
  14. 14.
    Brandt JD, Beiser JA, Kass MA, Gordon MO. Central corneal thickness in the Ocular Hypertension Treatment Study (OHTS). Ophthalmology. 2001;108(10):1779–1788.CrossRefPubMedGoogle Scholar
  15. 15.
    Herndon L. Rethinking pachymetry and intraocular pressure. Rev Ophthalmol. 2002;9:07(7/15/02). <>.Google Scholar
  16. 16.
    Brandt JD. Central corneal thickness, tonometry, and glaucoma risk-a guide for the perplexed. Can J Ophthalmol. 2007;42(4):562–566.CrossRefPubMedGoogle Scholar
  17. 17.
    Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2003.Google Scholar
  18. 18.
    Bobak SP, Goodwin JA, Guevara RA, Arya A, Grover S. Predictors of visual acuity and the relative afferent pupillary defect in optic neuropathy. Doc Ophthalmol. 1998;97(1):81–95.CrossRefPubMedGoogle Scholar
  19. 19.
    Annette H, Kristina L, Bernd S, Mark-Oliver F, Wolfgang W. Effect of central corneal thickness and corneal hysteresis on tonometry as measured by dynamic contour tonometry, ocular response analyzer, and Goldmann tonometry in glaucomatous eyes. J Glaucoma. 2008;17(5):361–365.CrossRefPubMedGoogle Scholar
  20. 20.
    Detry-Morel M. Currents on target intraocular pressure and intraocular pressure fluctuations in glaucoma management. Bull Soc Belge Ophtalmol. 2008;308:35–43.PubMedGoogle Scholar
  21. 21.
    Damji KF, Behki R, Wang L. Canadian perspectives in glaucoma management: setting target intraocular pressure range. Can J Ophthalmol. 2003;38(3):189–197.PubMedGoogle Scholar
  22. 22.
    Weinreb RN, Liu JH. Nocturnal rhythms of intraocular pressure. Arch Ophthalmol. 2006;124(2):269–270.CrossRefPubMedGoogle Scholar
  23. 23.
    Liu JH, Gokhale PA, Loving RT, Kripke DF, Weinreb RN. Laboratory assessment of diurnal and nocturnal ocular perfusion pressures in humans. J Ocul Pharmacol Ther. 2003;19(4):291–297.CrossRefPubMedGoogle Scholar
  24. 24.
    Liu JH, Kripke DF, Hoffman RE, et al. Nocturnal elevation of intraocular pressure in young adults. Invest Ophthalmol Vis Sci. 1998;39(13):2707–2712.PubMedGoogle Scholar
  25. 25.
    Mosaed S, Liu JH, Weinreb RN. Correlation between office and peak nocturnal intraocular pressures in healthy subjects and glaucoma patients. Am J Ophthalmol. 2005;139(2):320–324.CrossRefPubMedGoogle Scholar
  26. 26.
    Nakakura S, Nomura Y, Ataka S, Shiraki K. Relation between office intraocular pressure and 24-hour intraocular pressure in patients with primary open-angle glaucoma treated with a combination of topical antiglaucoma eye drops. J Glaucoma. 2007;16(2):201–204.CrossRefPubMedGoogle Scholar
  27. 27.
    Dev S, Damji KF, DeBacker CM, Cox TA, Dutton JJ, Allingham RR. Decrease in intraocular pressure after orbital decompression for thyroid orbitopathy. Can J Ophthalmol. 1998;33(6):314–319.PubMedGoogle Scholar
  28. 28.
    Johnstone MA, Albert DM. Prostaglandin-induced hair growth. Surv Ophthalmol. 2002;47(Suppl 1):S185–202.CrossRefPubMedGoogle Scholar
  29. 29.
    Galloway GD, Eke T, Broadway DC. Periocular cutaneous pigmentary changes associated with bimatoprost use. Arch Ophthalmol. 2005;123(11):1609–1610.CrossRefPubMedGoogle Scholar
  30. 30.
    Lagreze WD, Kardon RH. Correlation of relative afferent pupillary defect and estimated retinal ganglion cell loss. Graefes Arch Clin Exp Ophthalmol. 1998;236(6):401–404.CrossRefPubMedGoogle Scholar
  31. 31.
    Martin TJ. Horner’s syndrome, Pseudo-Horner’s syndrome, and simple anisocoria. Curr Neurol Neurosci Rep. 2007;7(5):397–406.CrossRefPubMedGoogle Scholar
  32. 32.
    Adie WJ. Complete and incomplete forms of the benign disorder characterised by tonic pupils and absent tendon reflexes. Br J Ophthalmol. 1932;16(8):449–461.CrossRefPubMedGoogle Scholar
  33. 33.
    Lam DS, Tham CC, Lai JS, Leung DY. Current approaches to the management of acute primary angle closure. Curr Opin Ophthalmol. 2007;18(2):146–151.CrossRefPubMedGoogle Scholar
  34. 34.
    La Hey E, Baarsma GS, De Vries J, Kijlstra A. Clinical analysis of Fuchs’ heterochromic cyclitis. Doc Ophthalmol. 1991;78(3-4):225–235.CrossRefPubMedGoogle Scholar
  35. 35.
    O'Connor GR. Doyne lecture. Heterochromic iridocyclitis. Trans Ophthalmol Soc UK. 1985;104(Pt 3):219–231.PubMedGoogle Scholar
  36. 36.
    Barr CC, Vine AK, Martonyi CL. Unexplained heterochromia. Intraocular foreign body demonstrated by computed tomography. Surv Ophthalmol. 1984;28(5):409–411.CrossRefPubMedGoogle Scholar
  37. 37.
    Weinstein JM, Zweifel TJ, Thompson HS. Congenital Horner’s syndrome. Arch Ophthalmol. 1980;98(6):1074–1078.PubMedGoogle Scholar
  38. 38.
    Gartner S, Henkind P. Neovascularization of the iris (rubeosis iridis). Surv Ophthalmol. 1978;22(5):291–312.CrossRefPubMedGoogle Scholar
  39. 39.
    Ritch R. A unification hypothesis of pigment dispersion syndrome. Trans Am Ophthalmol Soc. 1996;94:381-405; discussion 405–389.PubMedGoogle Scholar
  40. 40.
    Wishart PK, Spaeth GL, Poryzees EM. Anterior chamber angle in the exfoliation syndrome. Br J Ophthalmol. 1985;69(2):103–107.CrossRefPubMedGoogle Scholar
  41. 41.
    Laganowski HC, Kerr Muir MG, Hitchings RA. Glaucoma and the iridocorneal endothelial syndrome. Arch Ophthalmol. 1992;110(3):346–350.PubMedGoogle Scholar
  42. 42.
    Bonfioli AA, Orefice F. Sarcoidosis. Semin Ophthalmol. 2005;20(3):177–182.CrossRefPubMedGoogle Scholar
  43. 43.
    Miki A, Saishin Y, Kuwamura R, Ohguro N, Tano Y. Anterior segment optical coherence tomography assessment of iris bombe before and after laser iridotomy in patients with uveitic secondary glaucoma. Acta Ophthalmol. 2008 October 24 [epub ahead of print].Google Scholar
  44. 44.
    Bruno CA, Alward WL. Gonioscopy in primary angle closure glaucoma. Semin Ophthalmol. 2002;17(2):59–68.CrossRefPubMedGoogle Scholar
  45. 45.
    Spencer NA, Hall AJ, Stawell RJ. Nd:YAG laser iridotomy in uveitic glaucoma. Clin Experiment Ophthalmol. 2001;29(4):217–219.CrossRefPubMedGoogle Scholar
  46. 46.
    Nichols JJ, Nichols KK, Puent B, Saracino M, Mitchell GL. Evaluation of tear film interference patterns and measures of tear break-up time. Optom Vis Sci. 2002;79(6):363–369.CrossRefPubMedGoogle Scholar
  47. 47.
    Paschides CA, Kitsios G, Karakostas KX, Psillas C, Moutsopoulos HM. Evaluation of tear break-up time, Schirmer's-I test and rose bengal staining as confirmatory tests for keratoconjunctivitis sicca. Clin Exp Rheumatol. 1989;7(2):155–157.PubMedGoogle Scholar
  48. 48.
    Noecker R. Effects of common ophthalmic preservatives on ocular health. Adv Ther. 2001;18(5):205–215.CrossRefPubMedGoogle Scholar
  49. 49.
    Leung EW, Medeiros FA, Weinreb RN. Prevalence of ocular surface disease in glaucoma patients. J Glaucoma. 2008;17(5):350–355.CrossRefPubMedGoogle Scholar
  50. 50.
    Korb DR, Herman JP, Finnemore VM, Exford JM, Blackie CA. An evaluation of the efficacy of fluorescein, rose bengal, lissamine green, and a new dye mixture for ocular surface staining. Eye Contact Lens. 2008;34(1):61–64.CrossRefPubMedGoogle Scholar
  51. 51.
    Feenstra RP, Tseng SC. What is actually stained by rose bengal? Arch Ophthalmol. 1992;110(7):984–993.PubMedGoogle Scholar
  52. 52.
    Calhoun FP Jr. Pigmentary glaucoma and its relation to Krukenberg's spindles. Am J Ophthalmol. 1953;36(10):1398–1415.PubMedGoogle Scholar
  53. 53.
    Posner A, Schlossman A. Syndrome of unilateral recurrent attacks of glaucoma with cyclitic symptoms. Arch Ophthal. 1948;39(4):517–535.PubMedGoogle Scholar
  54. 54.
    Pillai CT, Dua HS, Azuara-Blanco A, Sarhan AR. Evaluation of corneal endothelium and keratic precipitates by specular microscopy in anterior uveitis. Br J Ophthalmol. 2000;84(12):1367–1371.CrossRefPubMedGoogle Scholar
  55. 55.
    Jones NP. Fuchs’ heterochromic uveitis: a reappraisal of the clinical spectrum. Eye. 1991;5(Pt 6):649–661.PubMedGoogle Scholar
  56. 56.
    Moorthy RS, Mermoud A, Baerveldt G, Minckler DS, Lee PP, Rao NA. Glaucoma associated with uveitis. Surv Ophthalmol. 1997;41(5):361–394.CrossRefPubMedGoogle Scholar
  57. 57.
    Adamis AP, Filatov V, Tripathi BJ, Tripathi RC. Fuchs' endothelial dystrophy of the cornea. Surv Ophthalmol. 1993;38(2):149–168.CrossRefPubMedGoogle Scholar
  58. 58.
    Brooks AM, Grant G, Gillies WE. A comparison of corneal endothelial morphology in cornea guttata, Fuchs' dystrophy and bullous keratopathy. Aust NZ J Ophthalmol. 1988;16(2):93–100.CrossRefGoogle Scholar
  59. 59.
    Kayes J, Holmberg A. The fine structure of the cornea in Fuchs' endothelial dystrophy. Invest Ophthalmol. 1964;3:47–67.PubMedGoogle Scholar
  60. 60.
    Jakus MA. Further observations on the fine structure of the cornea. Invest Ophthalmol. 1962;1:202–225.PubMedGoogle Scholar
  61. 61.
    Shields MB, ed. Glaucomas associated with intraocular hemorrhage and glaucomas associated with ocular trauma. In: Textbook of Glaucoma. Baltimore, MD: Williams and Wilkins; 1992:381–399.Google Scholar
  62. 62.
    Kloek C, Brauner S, Chen TC. Corneal blood staining after traumatic hyphema. J Pediatr Ophthalmol Strabismus. 2007;44(4):256.PubMedGoogle Scholar
  63. 63.
    Aonuma H, Matsushita H, Nakajima K, Watase M, Tsushima K, Watanabe I. Uveitis-glaucoma-hyphema syndrome after posterior chamber intraocular lens implantation. Jpn J Ophthalmol. 1997;41(2):98–100.CrossRefPubMedGoogle Scholar
  64. 64.
    Ellingson FT. The uveitis-glaucoma-hyphema syndrome associated with the Mark VIII anterior chamber lens implant. J Am Intraocul Implant Soc. 1978;4(2):50–53.PubMedGoogle Scholar
  65. 65.
    Campbell DG, Simmons RJ, Grant WM. Ghost cells as a cause of glaucoma. Am J Ophthalmol. 1976;81(4):441–450.PubMedGoogle Scholar
  66. 66.
    Au Eong KG, Chua EC, Yip CC, Tun Y, Lim AS. Hypopyon - an unusual sign in acute angle-closure glaucoma. Int Ophthalmol. 1993;17(3):127–129.CrossRefPubMedGoogle Scholar
  67. 67.
    Yi DH, Rashid S, Cibas ES, Arrigg PG, Dana MR. Acute unilateral leukemic hypopyon in an adult with relapsing acute lymphoblastic leukemia. Am J Ophthalmol. 2005;139(4):719–721.CrossRefPubMedGoogle Scholar
  68. 68.
    Lobo A, Larkin G, Clark BJ, Towler HM, Lightman S. Pseudo-hypopyon as the presenting feature in B-cell and T-cell intraocular lymphoma. Clin Experiment Ophthalmol. 2003;31(2):155–158.CrossRefPubMedGoogle Scholar
  69. 69.
    Jalali S, Das T, Gupta S. Presumed noninfectious endophthalmitis after cataract surgery. J Cataract Refract Surg. 1996;22(10):1492–1497.PubMedGoogle Scholar
  70. 70.
    Sari I, Akkoc N. Hypopyon uveitis. J Rheumatol. 2006;33(10):2097–2098.PubMedGoogle Scholar
  71. 71.
    Chang JH, McCluskey PJ, Grigg JR. Recurrent hypopyon in chronic anterior uveitis of pauciarticular juvenile idiopathic arthritis. Br J Ophthalmol. 2006;90(10):1327–1328.CrossRefPubMedGoogle Scholar
  72. 72.
    Pearce A, Sugar A. Anterior uveitis and hypopyon. Am J Ophthalmol. 1992;113(4):471–472.PubMedGoogle Scholar
  73. 73.
    Zimmerman TJ, Kooner KS. Clinical Pathways in Glaucoma. New York: Thieme; 2001.Google Scholar
  74. 74.
    Casser L, Fingeret M, Woodcome HT. Atlas of Primary Eyecare Procedures. 2nd ed. Stamford, CT: Appleton & Lange; 1997.Google Scholar
  75. 75.
    Kaufman JH, Tolpin DW. Glaucoma after traumatic angle recession. A ten-year prospective study. Am J Ophthalmol. 1974;78(4):648–654.PubMedGoogle Scholar
  76. 76.
    Lehto I, Vesti E. Diagnosis and management of pigmentary glaucoma. Curr Opin Ophthalmol. 1998;9(2):61–64.CrossRefPubMedGoogle Scholar
  77. 77.
    Naumann GO, Schlotzer-Schrehardt U, Kuchle M. Pseudoexfoliation syndrome for the comprehensive ophthalmologist. Intraocular and systemic manifestations. Ophthalmology. 1998;105(6):951–968.CrossRefPubMedGoogle Scholar
  78. 78.
    Sampaolesi R, Zarate J, Croxato O. The chamber angle in exfoliation syndrome. Clinical and pathological findings. Acta Ophthalmol Suppl. 1988;184:48–53.PubMedGoogle Scholar
  79. 79.
    Browning DJ, Scott AQ, Peterson CB, Warnock J, Zhang Z. The risk of missing angle neovascularization by omitting screening gonioscopy in acute central retinal vein occlusion. Ophthalmology. 1998;105(5):776–784.CrossRefPubMedGoogle Scholar
  80. 80.
    Becker B, Shaffer RN, Hoskins HD, Kass MA. Becker-Shaffer’s Diagnosis and Therapy of the Glaucomas. 6th ed. St. Louis: Mosby; 1989.Google Scholar
  81. 81.
    Huang D, Swanson EA, Lin CP, et al. Optical coherence tomography. Science. 1991;254(5035):1178–1181.CrossRefPubMedGoogle Scholar
  82. 82.
    Pavlin CJ, Harasiewicz K, Foster FS. Ultrasound biomicroscopy of anterior segment structures in normal and glaucomatous eyes. Am J Ophthalmol. 1992;113(4):381–389.PubMedGoogle Scholar
  83. 83.
    Pavlin CJ, Harasiewicz K, Sherar MD, Foster FS. Clinical use of ultrasound biomicroscopy. Ophthalmology. 1991;98(3):287–295.PubMedGoogle Scholar
  84. 84.
    Nolan WP, See JL, Chew PT, et al. Detection of primary angle closure using anterior segment optical coherence tomography in Asian eyes. Ophthalmology. 2007;114(1):33–39.CrossRefPubMedGoogle Scholar
  85. 85.
    Pavlin CJ, Vasquez LM, Lee R, Simpson ER, Ahmed II. Anterior segment optical coherence tomography and ultrasound biomicroscopy in the imaging of anterior segment tumors. Am J Ophthalmol. 2009;147(2):214–219.CrossRefPubMedGoogle Scholar
  86. 86.
    Pavlin CJ, McWhae JA, McGowan HD, Foster FS. Ultrasound biomicroscopy of anterior segment tumors. Ophthalmology. 1992;99(8):1220–1228.PubMedGoogle Scholar
  87. 87.
    Garcia JP Jr, Rosen RB. Anterior segment imaging: optical coherence tomography versus ultrasound biomicroscopy. Ophthalmic Surg Lasers Imaging. 2008;39(6):476–484.CrossRefPubMedGoogle Scholar
  88. 88.
    Pavlin CJ, Ritch R, Foster FS. Ultrasound biomicroscopy in plateau iris syndrome. Am J Ophthalmol. 1992;113(4):390–395.PubMedGoogle Scholar
  89. 89.
    Radhakrishnan S, Goldsmith J, Huang D, et al. Comparison of optical coherence tomography and ultrasound biomicroscopy for detection of narrow anterior chamber angles. Arch Ophthalmol. 2005;123(8):1053–1059.CrossRefPubMedGoogle Scholar
  90. 90.
    Kashiwagi K, Shinbayashi E, Tsukahara S. Development of a fully automated peripheral anterior chamber depth analyzer and evaluation of its accuracy. J Glaucoma. 2006;15(5):388–393.CrossRefPubMedGoogle Scholar
  91. 91.
    Crick RP, Khaw PT. A Textbook of Clinical Ophthalmology: A Practical Guide to Disorders of the Eyes and Their Management. 3rd ed. River Edge, NJ: World Scientific; 2003.Google Scholar
  92. 92.
    Jonas JB, Gusek GC, Naumann GO. Optic disc, cup and neuroretinal rim size, configuration and correlations in normal eyes. Invest Ophthalmol Vis Sci. 1988;29(7):1151–1158.PubMedGoogle Scholar
  93. 93.
    Harizman N, Oliveira C, Chiang A, et al. The ISNT rule and differentiation of normal from glaucomatous eyes. Arch Ophthalmol. 2006;124(11):1579–1583.CrossRefPubMedGoogle Scholar
  94. 94.
    Vilser W, Nagel E, Seifert BU, Riemer T, Weisensee J, Hammer M. Quantitative assessment of optic nerve head pallor. Physiol Meas. 2008;29(4):451–457.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Paul N. Schacknow
    • 1
    • 2
  1. 1.Division of OphthalmologyNova Southeastern UniversityFort LauderdaleUSA
  2. 2.Visual Health CenterPalm SpringsUSA

Personalised recommendations