2.

6 HOURS

Continuing Education

PRIMARY OPEN-ANGLE
GLAUCOMA
Catching and treating the ‘sneak thief of sight.’
Overview: Primary open-angle glau- By Nancy C. Sharts-Hopko, PhD, RN, FAAN,
and Catherine Glynn-Milley, RN, CRNO, CPHQ
coma (POAG), by far the most common

form of glaucoma, currently afflicts more

A
than 2 million Americans, more than half t a recent national con-
vention, three nurses
of whom probably don’t know they have who had met decades
earlier in graduate school
it. Asymptomatic in the early stages, it discovered that each was
being treated for primary open-angle
gradually and progressively reduces the glaucoma (POAG). One of us (NCSH)
was one of those nurses, and that star-
visual field and leads to blindness if
tling coincidence, together with the
untreated. Elevated intraocular pressure is fact that CGM’s mother also has it, prompted us to write this article. For
both of us, POAG is personal because it runs in our families.
believed to play a role, yet some people There are several types of glaucoma, all of which damage the optic
nerve. POAG, by far the most common, is a progressive disease often—
with normal pressure develop POAG. though not always—characterized by increased intraocular pressure
(IOP) caused by a buildup of aqueous humor. The fluid, produced by the
There is no single diagnostic test; screen- ciliary body, normally flows from the posterior to the anterior chamber
of the eye through the pupil, exiting the eye via a sievelike structure
ing and diagnosis involve periodic com-
called the trabecular meshwork that lies at the angle where the iris meets
prehensive eye evaluations. Treatment is the cornea. If the angle is normal (“open”) but the meshwork is blocked,
the aqueous humor cannot drain and it builds up in the anterior cham-
aimed at delaying onset, slowing pro- ber. The increased IOP that results is thought to compress the optic
nerve, causing cell death and a progressive, gradual reduction in the
gression, and preserving vision. visual field. Blindness results if POAG is untreated. But the role of IOP
in this process is controversial because POAG also occurs when IOP is
not elevated (this form is sometimes called normal-tension glaucoma); in
addition, many people with elevated IOP never develop POAG. Other
Podcasts at ajnonline.com
types of glaucoma include angle-closure glaucoma, in which fluid is
blocked because the iridocorneal angle is too narrow, and secondary
AJN editor-in-chief Diana J. glaucoma, which follows injury to or disease of the eye. In this article we
Mason and Nancy C. Sharts-Hopko focus on POAG.
discuss the authors’ experience with Risk factors for POAG include older age (over age 60; for blacks, over age 40),
primary open-angle glaucoma, black race, Hispanic ethnicity, a family history of glaucoma, elevated IOP, a thin
which led them to write this article. central cornea, and an increased cup–disk ratio.1, 2 (Some cupping of the optic
disk is normal if it’s stable; any increase indicates pathology. The cup–disk ratio
compares the diameter of the cupped portion of the disk to its overall diameter.)

40 AJN ▼ February 2009 ▼ Vol. 109, No. 2 ajnonline.com

 Figure 1. SAGITTAL VIEW OF THE NORMAL EYE

Schlemm’s canal

Retina
Cornea
Iris Vitreous humor
Pupil
Lens
Optic
disk

Anterior
chamber
Optic nerve
(aqueous humor)
Ciliary process

Vitreous body
Optic nerve

Inferior rectus muscle

Other possible risk factors include peripheral vasospasm, Diseases Prevalence Research Group found that
systemic hypertension, cardiovascular disease, diabetes, when age was controlled for, there was no signifi-
hypothyroidism and other thyroid disorders, myopia, cant difference in prevalence based on sex.13 The
migraine, smoking, long-term steroid use, and heavy Rotterdam Study also found that women with
computer use by those with refractive errors (such as early-onset menopause (before age 45) were more
astigmatism, myopia, or hyperopia).3-11 likely to develop POAG, suggesting that female sex
Prevalence. By 2010 the number of glaucoma hormones might have a protective effect.17
cases worldwide is expected to reach 61 million,
including 45 million cases of POAG.12 In this coun- ETIOLOGY AND DIAGNOSIS
try POAG affects more than 2.2 million people, When optic nerve cells begin to die in POAG, the
most ages 40 and older; with the baby boom gen- peripheral vision is affected first, with blind spots
eration aging, that number is expected to reach 3.3 (scotomas) and tunnel vision occurring. If the dis-
million by 2020 and about half may not know they ease isn’t treated, central vision will eventually be
have the disease.13 Glaucoma is the third most com- lost. Both eyes are usually involved, although the
mon age-related eye disease in the United States, degree of damage may differ. All optic nerve dam-
following cataract and diabetic retinopathy.14 The age and vision loss are irreversible.
overall prevalence rate of POAG among U.S. resi- Areas of debate over POAG’s cause include the
dents ages 40 and older is about 2%.13 uncertain role of IOP. A normal IOP ranges from
Blacks have an age-adjusted prevalence rate of 10 to 21 mmHg. However, the degree of IOP eleva-
POAG that is three times that of whites13; the tion doesn’t necessarily correlate with the amount
prevalence rate in Hispanics is “intermediate” of optic nerve damage. The American Academy of
between these two groups.15 The association Ophthalmology (AAO) has reported that from 4%
between sex and prevalence of POAG is less clear. to 61% of patients with glaucomatous changes to
In the ophthalmic part of the Rotterdam Study, a the optic disk and visual field have IOPs in the nor-
prospective cohort study of 6,756 older men and mal range.1 While efforts to clarify the role of IOP
women in the Netherlands, the prevalence rate in continue, recent research has shifted to explore the
men was twice that in women.16 But the Eye entire neurodegenerative process, such as the mech-

ajn@wolterskluwer.com AJN ▼ February 2009 ▼ Vol. 109, No. 2 41

 chart, and of IOP, using an applanation
tonometer. The visual field is evaluated
AREAS OF DEBATE INCLUDE with confrontational testing (with the
patient looking straight ahead, the
THE UNCERTAIN ROLE OF examiner moves one finger slowly
from the far to the near periphery of
INTRAOCULAR PRESSURE IN the visual field in four quadrants; the
patient responds when the finger moves
into her or his peripheral vision). The
PRIMARY OPEN-ANGLE GLAUCOMA. pupils are dilated and direct or indirect
ophthalmoscopy is used to visualize
the posterior segment of the eye,
anisms involved in the destruction of retinal gan- including the retina and optic nerve, under magni-
glion cells and optic nerve fibers.18 fication. Slit-lamp examination (biomicroscopy)
There is some evidence that IOP fluctuation permits three-dimensional visualization of the ante-
“may be more dangerous than slightly elevated, but rior segment under magnification aided by high-
stable, pressure.”19 Two large, multicenter studies intensity light.
found that both mean IOP and IOP deviation over When glaucoma is suspected, additional tests
time were statistically significant factors for pro- will be performed. Perimetry, in which the patient’s
gression of visual field loss.20, 21 But another trial responses to light stimuli at various locations
found that only mean IOP was a risk factor for pro- within the visual field are mapped, allows more
gression.22 And two more-recent studies found precise evaluation of visual field defects. (A new
either a weak or no association between IOP fluc- form, short-wavelength automated perimetry, can
tuation and increased risk of progression.23, 24 reportedly detect glaucomatous changes three to
Although findings are inconsistent, there is some five years earlier than conventional perimetry.31)
evidence that early treatment of elevated IOP with Gonioscopy permits evaluation of the iridocorneal
ophthalmic drugs or laser surgery or both can delay angle. Stereoscopic fundus photography may be
the onset of POAG-induced nerve damage.2, 25-27 But used to visualize the optic nerve and assess the
early treatment is controversial because many peo- cup–disk ratio. Pachymetry uses ultrasonography
ple with elevated IOP will not develop POAG, and to assess corneal thickness.
there is some evidence that early treatment can Although some epidemiologic studies have used
cause cataracts.2 Moreover, as Fleming and col- different diagnostic criteria, a positive diagnosis
leagues observe, as yet there is no standard measure traditionally has been made when two of these
of visual field loss by which to mark disease pro- signs are present: elevated IOP, degeneration of the
gression.27 Also, studies have reported varying optic disk, and visual field loss.11, 32 In addition,
results on how the progression of POAG affects changes in the retinal nerves adjacent to the optic
patients’ vision and quality of life.27-29 disk are characteristic of POAG.11 The AAO’s clin-
ical practice guidelines on diagnosing POAG call
SCREENING AND TESTING for examination of eight elements: the pupil, ante-
Because POAG is initially asymptomatic, it’s rior ocular segment, IOP, central corneal thickness,
referred to as “the sneak thief of sight.” Screening anterior chamber angle, optic nerve head and reti-
efforts have involved measuring the IOP, examining nal nerve fiber layer, fundus of the eye, and visual
the retinal nerve fiber layer and the optic nerve, and field.1
testing the visual field, but no single measure has
demonstrated good sensitivity and specificity.30 TREATMENT OPTIONS
Thus, the AAO recommends that adults obtain The aim of treatment is to slow disease progression
comprehensive eye evaluations as follows30: and preserve vision “while minimizing the adverse
• people with risk factors: from ages 40 to effects of therapy.”1 The AAO specifies three goals:
54, every one to three years; from ages 55 to 64, stabilizing the optic nerve and retinal nerve fiber
every one to two years; ages 65 and older, every layer, stabilizing the visual field, and controlling
six to 12 months IOP.1 The adverse effects of treatment should also
• people without risk factors: from ages 40 to 54, be addressed, as should educating the patient about
every two to four years; from ages 55 to 64, every coping with vision loss.1, 11
one to three years; ages 65 and older, every one Studies have shown that lowering IOP slows
to two years progression of the disease33, 34; IOP is currently the
A comprehensive eye evaluation, usually con- only risk factor that’s responsive to treatment.35 The
ducted by an ophthalmologist, includes assessment target IOP varies in each patient, but is generally
of visual acuity, typically done using a Snellen 20% to 50% lower than the pressure at which
42 AJN ▼ February 2009 ▼ Vol. 109, No. 2 ajnonline.com
 Figure 2. PRIMARY OPEN-ANGLE GLAUCOMA
damage occurred.11 The AAO recom- Aqueous flow
mends maintaining IOP at or below Schlemm’s canal
24 mmHg.1 But if nerve damage and Iris
visual loss progress, more aggressive
treatment and further reduction of IOP
are indicated. Trabecular
meshwork
IOP can be lowered by decreasing
production of aqueous humor, increas-
ing its outflow, or both. Reduction can
be achieved through pharmacotherapy,
laser surgery, incisional surgery, or a
combination of all three.
Pharmacotherapy is the first line of
treatment. Prostaglandin analogs such
Lens
as latanoprost (Xalatan), bimatoprost
(Lumigan), and travoprost (Travatan)
are usually tried first, because of their
low incidence of adverse effects and
once-daily dosing. These drugs increase Ciliary body
the uveoscleral outflow of aqueous
humor through the ciliary muscle by, it’s
thought, relaxing the muscle or remod-
eling the surrounding extracellular
matrix.36, 37 Common adverse effects
Aqueous humor normally flows from the posterior to the anterior chamber of the eye
may include irreversible but apparently through the pupil, exiting the eye at the angle where the iris meets the cornea via
benign darkening of the iris and the trabecular meshwork and the Schlemm’s canal. If the angle is normal (“open”)
increased growth and thickening of the but the meshwork and canal are blocked, the aqueous humor cannot drain. The
eyelashes.38, 39 fluid builds up in the anterior chamber and, in most cases, intraocular pressure rises.
Topical β -adrenergic antagonists Damage to the optic nerve results.
(also known as β-blockers), including
Open Angle Glaucoma
timolol hemihydrate (Betimol), timolol maleate fering with an enzyme involved in sodium and fluid
(Timoptic), levobunolol (Betagan), carteolol (Ocu- transport within the ciliary body.43 Systemic CAIs are
press), betaxolol (Betoptic), and metipranolol rarely used because of the risk of serious, potentially
(OptiPranolol), are also frequently used as first-line fatal adverse effects such as the development of
treatment. They lower production of aqueous aplastic anemia. The topical forms, brinzolamide
humor by blocking β receptors in ciliary epithelium (Azopt) and dorzolamide (Trusopt), are generally
and possibly by mediating sympathetic nerve stim- used only as adjunct therapy with other drugs. All
ulation.40 Although these drugs have few adverse CAIs are contraindicated in people who are allergic
ocular effects, their significant adverse systemic to sulfa drugs. The ocular adverse effect most com-
effects can include bradycardia, hypotension, bron- monly seen with the topical forms is discomfort; the
chospasm, and respiratory failure, particularly in most common systemic complaint is altered taste.
people with asthma, chronic obstructive pul- Other, less frequently reported systemic adverse
monary disease, cardiac conduction defects, and effects include headache, depression, anorexia,
heart failure. nausea, fatigue, paresthesia, urolithiasis, and rash.43, 44
The α2-adrenergic agonists, such as apracloni- Cholinergic agonists, including pilocarpine
dine (Iopidine) and brimonidine (Alphagan P), (Isopto Carpine) and carbachol (Isopto Carbachol),
reduce aqueous humor secretion and increase increase aqueous outflow by contracting the ciliary
uveoscleral outflow by a mechanism that isn’t well musculature to open the trabecular meshwork. But
understood. Although these drugs are less effective they also contract the circular muscle and the pupil,
at lowering IOP than the prostaglandin analogs, leading to myopia and impaired night vision.40, 45
animal studies reportedly suggest that they might These adverse effects and the need for multiple daily
have neuroprotective effects on retinal ganglion dosing limit their use.
cells.41, 42 Common systemic adverse effects include Researchers are also investigating drugs that
dry nose and mouth. Other adverse effects reported have been approved or are being studied for treat-
include allergic reactions, conjunctival hyperemia, ing other neurodegenerative illnesses (such as
and visual disturbances. dementia, amyotrophic lateral sclerosis, and
Carbonic anhydrase inhibitors (CAIs) lessen Parkinson’s disease) for possible use in managing
production of aqueous humor, apparently by inter- the neurodegenerative effects of glaucoma.11, 46

ajn@wolterskluwer.com AJN ▼ February 2009 ▼ Vol. 109, No. 2 43

 ity required further laser or
IF A PERSON WITH PRIMARY OPEN-ANGLE incisional surgery.53 A recent
review reported some evidence
indicating that six and 12
GLAUCOMA IS HOSPITALIZED FOR
months after SLT and ALT,
results were comparable.54 But
ANOTHER CONDITION, PHARMACOTHERAPY FOR it also reported that laser tra-
beculoplasty was less effective
GLAUCOMA MUST BE CONTINUED THROUGHOUT than incisional trabeculectomy
in controlling IOP at six
months and at two years after
THE STAY. surgery, and that no evidence
comparing laser therapy to
drug therapy was available.
Other adverse effects. Up to 36% of the general Incisional surgery is usually considered when
population and 92% of people with POAG report- pharmacotherapy and laser surgery have failed.
edly are “steroid responders”: their IOPs rise Trabeculectomy (also called filtration surgery), the
markedly after topical or systemic administration most common incisional surgery performed for
of steroids.10, 47 Allergic reactions to various compo- glaucoma, entails excising a tiny portion of the tra-
nents in glaucoma eyedrops, from the active drugs becular meshwork to create an opening for
to the bacteriostatic and preservative agents, are drainage of aqueous humor. The goal is to achieve
common.48, 49 Preservative-free solutions such as incomplete healing of the surgical wound with for-
pilocarpine and timolol maleate expire more mation of a bleb at the excision site. An antimetabo-
quickly and are therefore costlier to use. lite such as mitomycin (Mutamycin) or fluorouracil
Laser surgery, specifically laser trabeculoplasty, (Adrucil) might be administered during surgery to
is indicated when POAG isn’t responsive to phar- prevent the formation of scar tissue that could
macotherapy or when patients can’t tolerate the obstruct the opening, although such use is currently
drugs or don’t adhere to the regimen. There are two off-label for both drugs.11, 52 The surgery is success-
types: argon laser trabeculoplasty (ALT) and selec- ful for at least one year in 70% to 90% of cases,
tive laser trabeculoplasty (SLT). In both, a laser according to the Glaucoma Research Foundation.55
beam is used to burn small areas in the trabecular But studies have shown that in many patients
meshwork, which by an unclear mechanism who’ve had the surgery, IOP rises over time and the
enhances drainage and increases aqueous humor disease progresses. In one study of the long-term
outflow. SLT, a newer technique, can target specific outcomes of trabeculectomy, the researchers
cells and thus causes less uveoscleral damage to the defined successful control of disease progression as
meshwork and less thermal injury to surrounding “no progression of cup–disc ratios or loss of visual
structures than ALT does.50 And because it’s less fields.”56 They found that in patients whose surger-
damaging, SLT can be repeated if needed. After ies were deemed successful at one year, there was
either procedure patients might experience some only a 61% likelihood that disease progression
inflammation and soreness, which can be managed would be controlled at 10 years and only a 48%
with topical ophthalmic agents such as nepafenac probability at 15 years. Possible complications of
(Nevanac), ketorolac (Acular), or bromfenac trabeculectomy include corneal damage, delayed
(Xibrom), all nonsteroidal antiinflammatories. A healing, infection, scarring, ocular hypotony, and
study sponsored by the National Eye Institute excess fluid loss from the eye.52, 57
found that about one third of patients having tra- Additional procedures are sometimes used when
beculoplasty had a transient increase in IOP, and other measures have failed. Deep sclerectomy entails
about one third developed adhesions between the the removal of a deep piece of sclera, part of the tra-
iris and cornea, although these had no clinical becular meshwork, and part of the scleral venous
impact.51 Typically one eye is treated at a time to sinus (the Schlemm’s canal); this allows the aqueous
allow the procedure’s effect to be assessed and to humor to drain into the bloodstream and into a reser-
avoid total impairment of vision; results are evalu- voir created between the outer and inner scleral lay-
ated after six weeks. ers.58 Viscocanalostomy also involves excision of a
Although success rates as high as 92% for tra- deep piece of sclera, but the surgeon then injects a gel-
beculoplasty have been reported,52 treatment failure like material into the ends of the Schlemm’s canal to
can occur years later. One study of ALT found that enlarge it and improve drainage.58 Tube-shunt surgery
at one, five, and 10 years after treatment, the pro- involves implanting a small, flexible tube into the
portion of successfully treated eyes went from 77% anterior chamber.58 Aqueous humor drains through
to 49% to 32%, respectively; at 10 years, a major- the tube onto a tiny drainage plate and is reabsorbed
44 AJN ▼ February 2009 ▼ Vol. 109, No. 2 ajnonline.com
into the eye tissue. This procedure is typically used yoga might reduce IOP over time, although the evi-
when trabeculectomy has failed; however, the tube dence is inconclusive.64, 65 However, the headstand
can become blocked and require repeated replace- position in yoga causes a significant rise in IOP and
ment. Laser cycloablation may be used in end-stage should be avoided.66 The use of saunas has been
or intractable glaucoma to decrease aqueous pro- associated with reduced blood pressure and is not
duction by destroying the ciliary body.59 contraindicated in people with glaucoma.67
Some studies have reported no association
PROMOTING EYE HEALTH between smoking and glaucoma,64 but a recent meta-
Comprehensive patient education is essential for analysis found that smoking was associated with a
successful POAG management. Encourage patients significantly increased risk of POAG.68 Caffeinated
to both ask questions and take notes to ensure that beverages cause a moderate transient increase in IOP;
they understand the information and to request although complete abstention may not be necessary,
referral to a glaucoma specialist if they so desire. one study concluded that intake of 180 mg or more
Providers working with people who have visual of caffeine daily “may not be recommended for
losses should be familiar with and provide referrals patients with normotensive glaucoma or ocular
to community services. For a list of resources, go to hypertension.”69 Alcohol intake can lower IOP; this
http://links.lww.com/A684. has been used as a treatment strategy in emergency
Adherence. One recent review cited 24% to situations.5 Although sublingual administration of a
59% nonadherence rates to a drug regimen in peo- low dose of cannabis has been shown to lower IOP,70
ple with glaucoma.60 The author concluded that the AAO’s Task Force on Complementary Therapies
adherence could be improved by providing better has concluded that there is no scientific evidence to
patient education, easier dosing schedules, support its use in glaucoma management.71
increased access to health care services, and better Maintaining general fitness is recommended for
provider–patient relationships. The use of an auto- people with POAG, including getting enough sleep,
mated prescription data system might help clini- eating well, engaging in regular exercise, losing
cians identify patients who aren’t ordering refills on weight if necessary, and managing high lipid levels
schedule, allowing them to initiate a discussion to and hypertension.72, 73 There is some evidence that
explore the reasons. One study of patients with tight collars or neckties can elevate IOP.74 Many
glaucoma found that providing them with written people with POAG can and do wear contact lenses
instructions improved adherence and promoted for vision correction. Because some glaucoma med-
more accurate reports of use.61 Another found that ications can interact with and alter the structure of
offering written materials appropriate to a patient’s some types of lenses, wearers should check with their
literacy level improved adherence62; other helpful lenses’ manufacturer. “Smart” contact lenses that
measures include demonstrating drug administra- can continuously monitor IOP with embedded sen-
tion, using as few drugs as possible, and tailoring sors and dispense medication are in development.75, 76
the regimen to the patient’s schedule. The course of glaucoma during pregnancy is
Most glaucoma drugs are administered topically variable, and close monitoring is warranted. The
as eyedrops. Once instilled, the solution drains effects of glaucoma medications on fetuses remain
through the nasolacrimal duct into the sinuses, largely unstudied.77 Most are currently rated preg-
where it can be absorbed systemically. To minimize nancy category C because, in the absence of ade-
such absorption, patients should be instructed to quate and well-controlled studies in humans,
keep the eyelids closed or to apply pressure at the animal studies have shown adverse effects on
inner corners of the eyes (or both) for up to five fetuses. However, the potential benefits to the
minutes after administration.40, 63 mother of treatment with these drugs might out-
If a person with POAG is hospitalized for another weigh the potential risks to the fetus. Also, people
condition, pharmacotherapy for glaucoma must be with POAG should undergo testing to determine
continued throughout the stay. It’s our observation whether it’s safe for them to drive.78 ▼
that many hospital nurses and pharmacies are unfa-
Nancy C. Sharts-Hopko is a professor and director of the
miliar with these drugs and their administration, par- doctoral program at Villanova University College of Nursing
ticularly if several types of eyedrops are used. The in Pennsylvania. Catherine Glynn-Milley is ophthalmology
patient (or a family member) might need to monitor coordinator at the Department of Veterans Affairs Palo Alto
administration. Patients should be given information Health Care System in California. Contact author, Nancy C.
Sharts-Hopko: nancy.sharts-hopko@villanova.edu.
about all their medications, with particular attention
paid to potential drug–drug or drug–food interac-
tions, adverse effects, and contraindications. For more than 83 additional continuing nursing educa-
Lifestyle factors. Psychological stress has been tion articles related to the topic of geriatrics, go to
shown to cause significant transient increases in www.nursingcenter.com/ce.
IOP; managing stress with relaxation training or

ajn@wolterskluwer.com AJN ▼ February 2009 ▼ Vol. 109, No. 2 45

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glaucoma.asp. ment for elevated intraocular pressure: multicenter trial in
the United States. J Glaucoma 2005;14(2):161-7.
19. Harby K. Intraocular pressure fluctuation is a risk factor for
visual loss in glaucoma patients. Medscape Medical News 42. Cantor L. Achieving low target pressures with today’s glau-
2003 Nov 18. http://www.medscape.com/ coma medications. Surv Ophthalmol 2003;48 Suppl 1:S8-S16.
viewarticle/464687. 43. Schuman JS. Antiglaucoma medications: a review of safety
20. Lichter PR, et al. Interim clinical outcomes in the and tolerability issues related to their use. Clin Ther
Collaborative Initial Glaucoma Treatment Study comparing 2000;22(2):167-208.
initial treatment randomized to medications or surgery. 44. Sugrue MF. Pharmacological and ocular hypotensive prop-
Ophthalmology 2001;108(11):1943-53. erties of topical carbonic anhydrase inhibitors. Prog Retin
21. Nouri-Mahdavi K, et al. Predictive factors for glaucomatous Eye Res 2000;19(1):87-112.
visual field progression in the Advanced Glaucoma 45. Distelhorst JS, Hughes GM. Open-angle glaucoma. Am
Intervention Study. Ophthalmology 2004;111(9):1627-35. Fam Physician 2003;67(9):1937-44.
22. Bengtsson B, et al. Fluctuation of intraocular pressure and 46. McKinnon SJ, et al. Current management of glaucoma and
glaucoma progression in the Early Manifest Glaucoma the need for complete therapy. Am J Manag Care 2008;14(1
Trial. Ophthalmology 2007;114(2):205-9. Suppl):S20-S27.
23. Caprioli J, Coleman AL. Intraocular pressure fluctuation: a 47. Kersey JP, Broadway DC. Corticosteroid-induced glaucoma:
risk factor for visual field progression at low intraocular a review of the literature. Eye 2006;20(4):407-16.
pressures in the Advanced Glaucoma Intervention Study. 48. Baudouin C. Allergic reaction to topical eyedrops. Curr
Ophthalmology 2008;115(7):1123-29. Opin Allergy Clin Immunol 2005;5(5):459-63.

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49. Ventura MT, et al. Hypersensitivity reactions to ophthalmic
products. Curr Pharm Des 2006;12(26):3401-10.
50. Latina MA, Tumbocon JA. Selective laser trabeculoplasty: a
new treatment option for open angle glaucoma. Curr Opin
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51. National Eye Institute. Laser surgery is safe and effective
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53. Shingleton BJ, et al. Long-term efficacy of argon laser tra- nurses with comprehensive information on primary
beculoplasty. A 10-year follow-up study. Ophthalmology open-angle glaucoma, including its prevalence, etiol-
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54. Rolim de Moura C, et al. Laser trabeculoplasty for open angle well as the latest treatment options.
glaucoma. Cochrane Database Syst Rev 2007;(4):CD003919.
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56. Chen TC, et al. Long-term follow-up of initially successful • outline the prevalence, etiology, risk factors, diag-
trabeculectomy. Ophthalmology 1997;104(7):1120-5. nosis, and manifestations of primary open-angle
57. Zacharia PT, et al. Ocular hypotony after trabeculectomy glaucoma.
with mitomycin C. Am J Ophthalmol 1993;116(3):314-26. • describe the various treatment options for primary
58. University of Maryland Medical Center. Glaucoma: surgery. open-angle glaucoma.
2007. http://www.umm.edu/patiented/articles/what_surgical_
treatments_glaucoma_000025_9.htm. TEST INSTRUCTIONS
59. Bartamian M, Higginbotham EJ. What is on the horizon for To take the test online, go to our secure Web site at www.
cycloablation? Curr Opin Ophthalmol 2001;12(2):119-23. nursingcenter.com/ce/ajn.
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optimizing patient compliance. Curr Opin Ophthalmol • record your answers in the test answer section of the
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therapy. Am J Ophthalmol 2006;142(2):223-6.
fee of $24.95 to Lippincott Williams and Wilkins CE
63. Prevent Blindness America. The vision learning center: tak-
Group, 2710 Yorktowne Blvd., Brick, NJ 08723, by
ing eye drop medicine. 2004. http://www.preventblindness.
org/vlc/eye_drops.html. February 28, 2011. You will receive your certificate in
64. Brody S, et al. Intraocular pressure changes: the influence of
four to six weeks. For faster service, include a fax number
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relaxation training in open-angle glaucoma patients. J to review your results. There is no minimum passing
Behav Med 1996;19(6):587-98. grade.
66. Gallardo MJ, et al. Progression of glaucoma associated with
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73. Mori K, et al. Relationship between intraocular pressure
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74. Teng C, et al. Effect of a tight necktie on intraocular pres-
sure. Br J Ophthalmol 2003;87(8):946-8.
75. Bertsch A, et al. The sensing contact lens. Med Device
Technol 2006;17(5):19-21. 77. Dinn RB, et al. Ocular changes in pregnancy. Obstet
76. UC Davis News Service. Smart contact lenses [press release]. Gynecol Surv 2003;58(2):137-44.
2008 Jul 30. http://www.news.ucdavis.edu/search/news_ 78. Owsley C, McGwin G, Jr. Vision impairment and driving.
detail.lasso?id=8722. Surv Ophthalmol 1999;43(6):535-50.

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