History and Chief Complaint

History taking is one of the most important skills taught to ophthalmic technical personnel. Most troubles can be uncovered by taking a comprehensive history of the patient, which will greatly assist the physician in determining the patient's needs and risk factors.

The history of a patient with glaucoma should specifically include the following:

  • Any ocular redness, discomfort, or pain? In which eye? For how long?
  • Any blurred vision? In which eye? For how long?
  • Do you see any halos around lights? In which eye? For how long?
  • Are you experiencing glare? In which eye? For how long?
  • Which glaucoma eye drops are you taking? How frequently? In which eye? Are you taking the drops as prescribed?
  • Did you use the glaucoma drops today? When was the last time you used your drops? At what time? In which eye?
  • Any burning or stinging when you instill the glaucoma drops?
  • Are you performing punctal occlusion? For how long per eye?
  • Are you having difficulty with dark/light adaptation?
  • Are you having difficulty following fast-moving objects with your eyes?

Past Ocular History

A complete history of past surgery, trauma, and previous ocular disease is imperative. Key areas for direct questioning include

  • glaucoma, macular degeneration, retinal tears or detachment
  • amblyopia
  • diabetes
  • strabismus
  • contact lenses and spectacles
  • past ocular trauma

When taking the history of patients who were diagnosed in the past with glaucoma, ask the following:

  • How long ago were you diagnosed with glaucoma?
  • Do you use eye drops? Which one(s)? How frequently? In which eye?
  • Any history of surgery? Laser treatment? What type? In which eye? On what date?
  • Any history of refractive surgery? In which eye? On what date?
  • Do you have a family history of glaucoma? Who?
  • Have you taken any steroid medications? If yes, which type?
  • Have you ever suffered ocular trauma? If yes, what type?

Past Medical History

Carefully study the patient's records for a past diagnosis of glaucoma. Certain glaucoma medications are contraindicated should the patient suffer from other medical problems such as hypertension, asthma, chronic obstructive pulmonary disease, etc. It cannot be overstated that these are an absolute red flag for a potential glaucoma patient. If these facts are left out of the chart, they may compromise the physician's choice of glaucoma therapy and, in some cases, may become life threatening to the patient. Pertinent questions to ask the glaucoma patient include the following:

  • Do you have a history of high blood pressure? Low blood pressure?
  • Do you have a history of elevated cholesterol?
  • Do you have a history of migraines?
  • Do you suffer from cold hands or feet (Raynaud disease)?
  • Do you snore (sleep apnea)?
  • Do you have a history of any autoimmune disease?

Social History

A patient's lifestyle can also be a significant determining factor of how the physician ultimately decides to treat the glaucoma. A number of studies have shown an association between alcohol consumption and the risk of glaucoma.1 Emotional upsets and stress can increase external blood pressure and thus affect intraocular pressure. For this reason, the technician's documentation of the patient's lifestyle and use of alcohol and tobacco is imperative.

Allergies

Many physicians speculate whether allergies affect glaucoma. People who suffer from food or environmental allergies or from a compromised immune function can appear to be at higher risk of developing glaucoma. It is imperative that the technician chart any allergies in addition to the patient's current medications. The documentation of any adverse reaction to medications is urgent. Severe allergic reactions to medication can include

  • itching
  • redness
  • hives
  • difficulty breathing
  • death

Systemic Medications

Many nonocular medications can significantly increase intraocular pressure and even cause glaucoma. A few examples of these medications are

  • Corticosteroids, which can lead to ocular hypertension and open-angle glaucoma
  • Anticholinergics and tricyclic antidepressants, which can cause angle closure
  • Anticonvulsants, which can cause nasal peripheral visual field loss
  • Antihistamines
  • Topiramate (Topomax; Janssen Pharmaceuticals, Inc.)
  • Birth control medications

Ocular Medications

Many patients simply do not remember the names of their glaucoma medications. This is quite understandable when some of them are well beyond the layman's pronunciation capabilities. For this reason, technicians should familiarize themselves with the cap color associated with each different type of medication (Table).

Examinations

In addition to the patient's history, the following physical examinations should also be completed.

New Glaucoma Patient Workup

  • Ocular examinations
    • Visual acuity, which includes checking glasses and refraction
    • Confrontation visual fields (may defer if automated perimetry performed)
    • Motility and alignment
    • Pupils
    • Tonometry, using tonopen on corneal transplant patients
    • Corneal pachymetry (three measurements for each eye)
  • Gonioscopy
    • Before pupillary dilation
  • Glaucoma flow sheet
    • Patient identification information
    • Diagnosis
    • Date and time of tonometry
    • Tonometry measurements (right, left)
    • Medications, including dosing, allergies, ineffectiveness
    • Corneal pachymetry average
  • Prescriptions
    • Medication
    • Glasses

Returning Glaucoma Patient Workup

  • Review of last clinical notes and instructions
  • Photograph file placed with chart
  • IOP recorded on flow sheet
  • Last dilated examination and last visual field recorded

General Patient Workup

  • Detailed history
  • Ocular examinations
    • Visual acuity, which includes checking glasses and refraction
    • Confrontation visual fields
    • Motility and alignment
    • Pupils
    • Tonometry
  • Corneal pachymetry, glaucoma flow sheets, and stereodisc photography deferred
  • Review of last clinical notes and instructions
  • Last dilated examination recorded
  • Prescriptions for medication and glasses
  1. Pasquale LR, Kang JH. Lifestyle, nutrition, and glaucoma. J Glaucoma. 2009;18(6):423-428.
  2. Katz J, Sommer A. Risk factors for primary open angle glaucoma. Am J Prev Med. 1988; 4:110-114.
  3. Life Extension. Health concerns: glaucoma. http://www.lef.org/protocols/prtcl-053.shtml. Accessed May 22, 2012.
  4. Brian D, Kershner RM. Ophthalmic Medications and Pharmacology. 1st ed. Thorofare, NJ: Slack Inc.; 1998.