Case Glaucoma

Clinical Pharmacy and Pharmacotherapeutics 1 Case 1 Glaucoma
Name/s: Date submitted:

Section and Schedule Group no.
OBJECTIVES:
At the end of this exercise, the student should be able to:
 Identify the importance of regular eye examinations and the early diagnosis of
glaucoma.
 List the risk factors for developing open-angle glaucoma.
 Select and recommend agents from different pharmacologic classes when indicated and
provide the rationale for drug selection, including combination products to increase
adherence.
 Recommend conventional glaucoma therapy as well as other options in glaucoma
management when indicated.
 Formulate basic ophthalmologic monitoring parameters used in glaucoma therapy.
 Counsel patients on medication regimens and proper ophthalmic administration
technique.
 Discuss potential adverse drug reactions with patients to increase therapy adherence.
CASE
CC
“My vision is closing down and I am having difficulty seeing cars at intersections while driving.”
HPI
Macy Connor is a 75-year-old woman who presents for follow-up of advanced primary open-
angle glaucoma (POAG). She reports adherence with latanoprost nightly and
timolol/brimonidine (Combigan) two times daily in the right eye and dorzolamide three times
daily in the left eye. She feels that her vision in the left eye is beginning to blur, and she is having
more difficulty seeing objects in the top part of her vision. She finds that she has to move her
head more to see objects in her periphery. She denies eye pain, flashes, or floaters. She is
feeling more tired recently.
Mrs. Connor was first diagnosed with POAG 20 years ago during a routine eye exam to update
her eyeglass prescription. She had no visual disturbances at that time, and her best corrected
vision was 20/20 OU. She was started on pilocarpine 1% three times daily in both eyes and
developed brow ache and blurred vision. This was discontinued and she was started on timolol
0.5% twice daily in both eyes. Her highest IOP prior to treatment was 30 mm Hg, which
improved to 25 mm Hg on timolol. Her eye pressure gradually increased requiring the addition
of brimonidine three times daily and latanoprost nightly in both eyes. She underwent cataract
surgery 2 years ago and experienced an IOP spike to 55 mm Hg and was given acetazolamide
250 mg PO four times daily for 5 days after surgery until her pressure improved. Three months
after surgery, her IOP control had improved, and therapy in her left eye was changed to
dorzolamide three times daily only.
PMH
Hypertension, well controlled on lisinopril for 6 years
Kidney stones (occurred while taking acetazolamide)
Migraine headaches; well controlled on sumatriptan with one to two migraines per year
Depression; controlled with exercise and counseling only; has never taken medications for
depression
Myopia; corrected with glasses
Astigmatism; corrected with glasses
Pseudophakia; cataract surgery 3 years ago
FH
Parents are both deceased; father had POAG requiring surgery and was blind in right eye;
mother died of breast cancer; has one brother who is alive with myopia
SH
Nonsmoker; drinks one to two glasses of wine per week
ROS
Decreased energy with two falls in the last month at home. All other systems negative.
Meds
Latanoprost 0.005% one drop nightly OD
Combigan 0.2%/0.5% one drop twice daily OD
Dorzolamide 2% one drop three times daily OS
Sumatriptan 25 mg PO as needed for headache
Lisinopril 20 mg PO once daily
All
Penicillin—rash
Physical Examination
VS: BP 112/72, P 82, R 18, T 36.4°C
Eyes: Visual acuity: ODcc: 20/25; OScc: 20/60 (cc = with glasses)
Intraocular pressure: OD: 23; OS: 24 (normal range: 10–21 mm Hg)
Central corneal thickness (CCT): OD: 515: OS: 510 (normal 540 µm)
Gonioscopy: Iridocorneal angle is open with ciliary body band visible OU (open angle).
Pupils: Equal round and reactive OU; no relative afferent pupillary defect (rAPD)
Extraocular movements: Full OU
Slit lamp exam
 Lids: Normal
 Conjunctiva: 1+ injection OU
 Cornea: Clear OU
 Anterior chamber: Deep and quiet OU
 Iris: Round and reactive OU
 Lens: Posterior chamber intraocular lens OU
 Vitreous: Normal
Optic nerve
 OD: Superior and inferior rim thinning with focal notch superiorly; cup-to-disk (C/D)
ratio 0.85
 OS: Superior rim loss, inferior rim thinning; disk hemorrhage inferotemporal disk; C/D
ratio 0.95 (normal C/D 0.25)
CN II–XII grossly intact

Humphrey visual fields
 OD: Good reliability, inferior arcuate depression; stable
 OS: Good reliability, denser superior altitudinal defect splitting fixation, decreased foveal
threshold
Assessment
Advanced POAG
 OD: Stable visual field, IOP slightly higher today
 OS: Dense visual field loss now affecting central vision. IOP improved from baseline;
however, it remains elevated and patient continues to progress.
Pseudophakia: Excellent result of cataract surgery
Myopia/Astigmatism
Decline in energy and recent falls
Depression well controlled on lifestyle modifications
Hypertension well controlled on lisinopril
Migraines well controlled on sumatriptan
I. General Activity Instruction: Pharmacist Work-up of drug therapy

1. Analyze the case properly
2. Identify principal problems from the scenario, create problem list and prioritize identified
problems
3. Create systematic documentation following the SOAP format
I. SUBJECTIVE DATA
*Subjective
information
that indicates
this patient
has POAG
II. OBJECTIVE DATA

*Objective
information
that indicates
this patient
has POAG
III. ASSESSMENT
A. What are the patient’s risk factors for POAG?
B. Assess the severity of POAG based on the subjective and objective information available.
B. Drug therapy problems: Assess the patient’s medication therapy and evaluate if there are any
drug therapy problems.
Drug Therapy Problem

Indication
 Unnecessary
medication therapy
 Needs additional
medication therapy
Effectiveness
 Ineffective medication
 Dosage too low
monitoring
Safety
ADR caused to the
Medication ADR Classification
patient
 Adverse Drug Reaction
(ADR)
Mechanism of toxicity
Object Precipitant
(MOT)
 Drug Interactions
 Dosage too high

monitoring
Adherence
C. Prioritized problem list: Create a list of patient’s healthcare problems and/or drug-therapy
problems. Prioritized them according to severity. Briefly describe the problem based on your
assessment of their severity.
Priorit Health Care Problems Description
y#
IV. PLANNING: This section is where the final treatment plan is given for each of the active
problems as justified in the assessment.
Pharmacist’s Care Plan

Monitoring
Health care Recommendation Parameters
Goals Endpoints
problem (Drug or Non-drug) (frequency of
monitoring)
II. Targeted Questions

1. How can glaucoma medications be combined to improve patient adherence?
2. Which medications should be avoided in this patient?
3. What information should the patient receive about the disease of glaucoma, proper
medication administration technique, and possible side effects of treatment?
REFERENCES (APA format):

Case Glaucoma

Uploaded by

Copyright:

Available Formats

Case Glaucoma

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Case Glaucoma

Uploaded by

Copyright:

Available Formats

Clinical Pharmacy and Pharmacotherapeutics 1 Case 1 Glaucoma

Name/s: Date submitted:

CN II–XII grossly intact

I. General Activity Instruction: Pharmacist Work-up of drug therapy

II. OBJECTIVE DATA

A. What are the patient’s risk factors for POAG?

Drug Therapy Problem

 Dosage too high

Pharmacist’s Care Plan

II. Targeted Questions

REFERENCES (APA format):

You might also like