International Council of Ophthalmology

Ophthalmic Education:

Principles and Guidelines of a Curriculum for Ophthalmic Education of Medical Students: Chapter VII: Glaucoma

Educational Goal:

Students should understand the anterior segment anatomy and understand the circulation of aqueous humor in the normal human eye and in primary open angle glaucoma and primary angle closure glaucoma. Students should recognize the risk factors, signs, and symptoms of primary open angle glaucoma and angle closure glucoma.

A. Anatomy.*

1. Aqueous humor.*

a. Production.**

i. Ciliary body.**

b. Circulation.** (REF. 2D Slide 10) (REF. 2B Slide 35, 46)

i. Movement from posterior chamber through pupil into anterior chamber.**

c. Outflow pathway.* (REF. 2D Slide 11, 13)

i. Trabecular meshwork in anterior chamber angle.* (REF. 22 Fig. C12)

ii. Uveoscleral outflow tract.***

2. Optic Nerve.*

a. “Glaucoma may be defined as an optic neuropathy usually with characteristic optic nerve head and visual field changes.”* (REF. 2B Slide 33) (REF. 2D Slide 3)

i. Injury to axons from retinal ganglion cells at lamina cribrosa.*

ii. Signs of optic nerve injury.*

(a) Increased size of central cup.* (REF. 22 Fig. C06, C54, C55)

(b) Asymmetric cupping.*

3. Organization of axons and associated visual field defects.*** (REF. 2D Slide 5) (REF. 22 Fig. C26)

B. Examination.*

1. Central visual acuity measurement.*

2. Visual field testing.*

a. Confrontation testing with finger counting in four quadrants of each eye.*

b. Central color testing – red top bottle.**

3. Pupillary reaction.*
Relative afferent pupillary defect as sign of unilateral optic nerve injury.*

4. Penlight examination.* (REF. 4 Fig. 1.10)
Anterior chamber depth estimation.*

a. Normal.*

b. Narrow.*

5. Intraocular pressure.***

a. Applanation tonometry.*** (REF. 22 Fig. C29)

b. Normal value range. Direct ophthalmoscopy of signs of glaucomatous optic neuropathy.* (REF. 2B Slide 33) (REF. 22 Fig. C53, C54, C55, C56)

C. How to interpret history and risk factors.*

1. Primary open angle glaucoma.* (REF. 2D Slide 9) (REF. 3 Case 12, Primary Open Angle Glaucoma, p.24)

a. Risk factors.* (REF. 2B Slide 32) (REF. 4 Table 3.1)

i. Increased intraocular pressure.*

ii. African and Caribbean ancestry.*

iii. Age greater than 75 years.*

iv. Primary family member with glaucoma.*

b. Genetic influence.***

GLC1A (myocilin gene) juvenile open angle glaucoma.***

c. Symptoms.*

Lack of symptoms until late in disease.*

2. Normal tension glaucoma.***

a. Optic nerve injury and visual field loss similar to primary open angle glaucoma.***

b. Not associated with elevated intraocular pressure.***

3. Primary angle closure glaucoma.* (REF. 2B Slide 46, 47) (REF. 22 Fig. C01, C05, C09)

a. Risk factors.**

i. Anatomically narrow anterior chamber angle.**

ii. Hyperopia.**

iii. Dilating drops in eyes with narrow angles.**

iv. Anti-cholinergic medications.**

v. Older age.**

vi. Some Asian populations.** (REF. 2B Slide 45)

b. Symptoms.*

i. Ocular pain (may be severe).*

ii. Ocular redness.*

iii. Blurred vision, colored halos, nausea.*

c. Signs.*

i. Dilated fixed pupil.* (REF. 2B Slide 47)

ii. Narrow anterior chamber angle.*

iii. Pupillary block.*

iv. Corneal edema.*

D. Pharmacological treatment for open angle glaucoma.**

(REF. 2B Slide 37, 38) (REF. 22 Fig. C02, C03, C04)

1. Topical medications that increase aqueous humor outflow.**

a. Parasympathomimetics.** (REF. 2B Slide 41)

b. Prostaglandin analogues.** (REF. 2B Slide 42)

2. Medications that decrease aqueous production.**

a. Topical beta blockers.** (REF. 2B Slide 39)

b. Oral carbonic anhydrase inhibitors.** (REF. 2B Slide 43)

c. Alpha-2-agonists.**

d. Adrenergic agonists.** (REF. 2B Slide 40)

E. Surgical treatment.***

1. Primary acute angle closure glaucoma.***

a. Peripheral iridectomy.*** (REF. 22 Fig. C46, C47, C48)

2. Primary open angle glaucoma.*** (REF. 2B Slide 44)

a. Laser trabeculoplasty.*** (REF. 22 Fig. C38)

b. Filtering surgery.*** (REF. 22 Fig. C41, C42, C43, C49, C50, C51)

Clinical Competencies

Students should:

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

* Basic Level: Necessary in the education of medical students worldwide.

** Standard Level: A higher level of ophthalmic understanding than the basic curriculum of most international medical students.

*** Advanced Level: Advanced cognitive and clinical skills more appropriate for students who seek further training in ophthalmology, which may be covered in an ophthalmology elective in medical school.

(Also see: More on Educational Priorities)

Next: VIII. Pediatric Ophthalmology and Strabismus

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