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Make the Diagnosis: Glaucoma

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Prior Probability of Glaucoma

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Primary open-angle glaucoma (POAG) occurs in 2.6% of the population (95% CI, 2.1%-3.1%). This type of glaucoma often occurs with high intraocular pressure, but can also occur with normal intraocular pressure (≤ 21 mm Hg).

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Patients in Whom Glaucoma Should Be Considered

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Increasing age is the most common risk factor for POAG, with patients older than 80 years at the highest risk (prevalence, 7.8%; 95% CI, 5.2%-12%). Among all risk factors, high myopia (> 6 diopters) is the strongest risk factor (prevalence, 11%; 95% CI, 8.3-18). Other important risk factors are family history and black race (see Table 91-1).

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Table 91-1.Common Risk Factors for Primary Open-Angle Glaucoma
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Assessing the Likelihood of Glaucoma

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Ophthalmologists have an advantage compared with other physicians in detecting glaucoma because they use indirect ophthalmoscopy, which provides a 3-dimensional view of the optic disc, as opposed to the 2-dimensional view with direct ophthalmoscopy. No studies of the ocular examination for glaucoma have assessed the performance of generalist physicians. Nonetheless, a generalist physician may notice the findings of an abnormal cup-to-disc ratio, a disc hemorrhage, or asymmetry between the discs (see Table 91-2). An intraocular pressure ≥ 22 mm Hg increases the likelihood of POAG (LR, 13; 95% CI, 8.2-17). While a lower intraocular pressure makes glaucoma less likely (LR, 0.65; 95% CI, 0.55-0.76), patients may still have normal tension glaucoma (see Table 91-1).

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Table 91-2.Common Ocular Findings Used for Diagnosing Primary Open-Angle Glaucoma
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Reference Standard Tests

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Glaucoma is an optic neuropathy characterized by irreversible loss of retinal ganglion cells. It is often associated with higher intraocular pressure and is broadly classified as either open-angle (the most common) or closed-angle. The reference standard examination must be determined by an ophthalmologic examination by a trained specialist, viewing the optic disc in stereo, with corroborative retinal nerve fiber loss and corresponding visual field loss.1

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Reference

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American Academy of Ophthalmology Glaucoma Panel. Preferred Practice ...

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