Ophthalmic Education:

International Curriculum Guidelines on Medical Student Education in Ophthalmology: 12. Glaucoma

On this page:

• i) Anatomy
  
  
• ii) How to examine the patient
  
  
• iii) How to interpret history
  
  
• iv) Pharmacological treatment for open angle glaucoma**
  
  
• v) Surgical treatment***
  
  
• Competencies
  
  
• References
  
  
• Educational Priorities

The International Council of Ophthalmology Task Force on Medical Student Education in Ophthalmology

Draft, September 16, 2003

I. Anatomy

1. Aqueous humor**
   
   1. Production
      a. Ciliary body
   2. Circulation
      a. From posterior chamber through pupil into anterior chamber
   3. Outflow Pathway
      a. Trabecular meshwork in anterior chamber angle
2. Optic Nerve*
   
   1. "Glaucoma" as a chronic progressive optic neuropathy usually associated with increased intraocular pressure
      
      1. Injury to axons from retinal ganglion cells at lamina crib Rosa
         
      2. Signs of optic nerve injury
         (1) Increased size of central cup
         (2) Asymmetric cupping
   2. Palpaebral
3. Organization of axons and associated visual field defects***
   

II. How to examine the patient

1. Central visual acuity measurement*
   
2. Visual field testing*
   
   1. Confrontation testing in 4 quadrants in each eye
      
   2. Central color testing ? red top bottle
3. Pupillary reaction*
   
   1. Relative afferent pupillary defect as sign of unilateral optic nerve injury
4. Penlight examination*
   
   1. Anterior chamber depth estimation
      a. Normal
      b. Narrow
5. Intraocular pressure***
   
   1. Applanation tonometry
      
   2. Normal value range
6. Direct ophthalmoscopy*

III. How to interpret history

1. Primary open angle glaucoma*
   
   1. Risk factors
      a. African and Caribbean African ancestry*
      b. Age greater than 75 years*
      c. Primary family member with glaucoma*
   2. Genetic influence***
      a. GlC1a (myocillin gene) juvenile open angle glaucoma
   3. Symptoms*
      b. Lack of symptoms until late in disease
2. Normal tension glaucoma***
   
   1. Optic nerve injury and visual field loss similar to primary open angle glaucoma
      
   2. Not associated with elevated intraocular pressure
3. Primary Angle Closure Glaucoma*
   
   1. Risk Factors
      a. Anatomically narrow anterior chamber angle
      b. Hyperopia
      c. Dilating drops in eyes with narrow angles
      d. Anti-cholinergic medications
   2. Symptoms*
      a. Ocular pain (may be severe)
      b. Ocular redness*
      c. Blurred vision and colored haloes; nausea
   3. Signs*
      a. Dilated fixed pupil
      b. Narrow anterior chamber angle
      c. Pupillary block
      d. Corneal edema

IV. Pharmacological treatment for open angle glaucoma**

1. Medications that increase aqueous humor outflow
   
   1. Parasympathomimetics
      
   2. Prostaglandin analogues
2. Medications that decrease aqueous production
   
   1. Beta blockers
      
   2. Carbonic anhydrase inhibitors
      
   3. Alpha2-agonists

V. Surgical treatment***

1. Primary acute angle closure glaucoma
   
   1. Peripheral iridectomy
2. Primary open angle glaucoma***
   
   1. Argon laser trabeculoplasty
      
   2. Filtering surgery

Competencies

• Student should
  • Measure visual acuity with near card*
    
  • Perform confrontation visual field testing in four quadrants in each eye*
    
  • Assess pupillary reaction for relative afferent pupillary defect*
    
  • Estimate anterior chamber depth with penlight to determine angle width*
    
  • Diagnose primary acute angle closure glaucoma by history and penlight examination*
    
  • Recognize signs of optic nerve injury ? increased cupping and asymmetric cupping*
    
  • Obtain history to determine risk factors for primary open angle glaucoma*

Educational Priorities

In the listing above, essential ophthalmic knowledge and clinical eye care skills are marked with a single asterisk *. This material is basic for all international medical student education.

Information that reflects a greater level of understanding is marked with two asterisks**.

Areas of cognitive and clinical skills that are more appropriate for students who seek further training in ophthalmology are marked with three asterisks***.

While important to ophthalmic care, the Task Force does not regard the cognitive or skill set designated ** or *** as essential to the basic curriculum of most international medical students.

Next: Allied Ophthalmic Personnel Training

Also see:

• Introduction to the "International Curriculum Guidelines on Medical Student Education in Ophthalmology"
  
  
• Table of Contents for the Curriculum
  
  
• Education of Medical Students in Ophthalmology