CKS Clinical solutions - Open-angle glaucoma

The case A 65-year-old woman has chronic open-angle glaucoma, which is currently well controlled on a topical prostaglandin analogue.

Eye drops can alleviate symptoms (Photograph: SPL)
Eye drops can alleviate symptoms (Photograph: SPL)

What is chronic open-angle glaucoma?
Glaucoma is a group of eye diseases in which progressive damage to the optic nerve causes impaired vision and blindness in a small proportion of people.

It is characterised by visual field defects, changes to the head of the optic nerve and nerve fibre layer defects. The damage to the optic nerve is most commonly caused by abnormally high intraocular pressure because of an imbalance in the production and drainage of aqueous humour.

Open-angle glaucoma refers to the angle between the iris and the cornea being open.

Should the patient inform the DVLA?
Drivers must have good central visual acuity and adequate peripheral vision. If the visual field is lost in one eye only, the DVLA does not have to be informed provided the patient has good vision in the other eye.

If there are visual field defects in both eyes, the patient is legally required to inform the DVLA, and to stop driving until a specific test has been performed under DVLA guidance.

What glaucoma support services are available?

Information sources include the Royal National Institute of Blind People (www.rnib.org.uk), the International Glaucoma Association (www.glaucoma-association.com), the Royal College of Ophthalmologists (www.rcophth.ac.uk) and the Eye Health Alliance (www.lookafteryoureyes.org).

What should I advise on eye drops?
Prior to using eye drops, the patient should wash their hands, shake the eye drop bottle and remove any soft contact lenses.

After use, wash hands and wait 15 minutes before replacing contact lenses.

To minimise systemic absorption and adverse effects, advise the patient to close their eyes after administering the drops, gently but firmly pressing the tear duct against the nose for at least one minute, and then removing excess solution with a tissue. The patient should store the drops according to the manufacturer's instructions and use by the indicated date.

If the patient has difficulty applying the eye drops, recommend an eye drop dispenser. These may be available free from the manufacturer or can be prescribed or bought.

Evidence
Information about driving is published by the DVLA (www.dft.gov.uk/dvla) and DirectGov (www.direct.gov.uk).

The recommendations about administering eye drops are based on information from manufacturers' summaries of product characteristics and prescription formularies. The recommendation of an eye drop dispenser to promote adherence is in line with guidance from NICE.1

Reliable, evidence-based answers to real-life clinical questions, from the NHS Clinical Knowledge Summaries in association with GP. www.cks.nhs.uk

Reference
1. NICE. Glaucoma: diagnosis and management of chronic open angle glaucoma and ocular hypertension. CG85. NICE, London, 2009.

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