According to the Centers for Disease Control and Prevention (CDC), an estimated three million people have glaucoma in the United States. Glaucoma — a group of diseases that damage the eye’s optic nerve – is the second leading cause of blindness across the world. Yet, despite its prevalence, 50% of people with glaucoma don’t know they have it.
Without early symptoms or a known cure for these diseases, it is instrumental that patients and providers have the knowledge they need to catch glaucoma early to prevent vision loss. In observance of National Glaucoma Awareness Month, the American Association of Nurse Practitioners® (AANP) spoke to AANP Ophthalmology Community co-chair Tulay Cakiner-Egilmez, NP-C, PhD, CRNO, COMT, about how nurse practitioners (NPs) within and outside of her specialty can help screen for and treat glaucoma in their communities.
Cakiner-Egilmez: Glaucoma is the leading cause of irreversible blindness worldwide. We do not know the exact mechanisms of glaucoma, but we know reducing the eye pressure may slow the progression of the disease. Since it is a chronic disease, long-term use of eye drops is required to lower eye pressure, following lasers and surgical management. Patients should understand that there is no cure for glaucoma and comply with glaucoma treatment and regular follow-ups. As with other chronic diseases, medication compliance can be challenging, and missing appointments may cause a faster progression.
Patients need to understand the silent nature of disease, potentially leading to vision loss and blindness without treatment. Providers should check medication compliance at every visit by asking, "Are you taking your glaucoma medications?" and "How often do you miss a dose?" It's important to discuss any barriers to adherence and emphasize the significance of follow-up visits.
Missing eye appointments makes it difficult to monitor eye pressure, which affects the optic nerve. Some glaucoma offices offer home eye pressure devices to detect critical intraocular pressure spikes. Collaboration between the patient and providers is essential to lower eye pressure and protect vision.
Cakiner-Egilmez: Glaucoma is a silent disease with no apparent vision problems, pain or other eye symptoms. Due to its asymptomatic nature, the diagnosis of this condition is frequently delayed.
Screening the entire population for glaucoma is not cost-effective. However, screening at-risk populations — older adults, individuals over 40 with a family history of glaucoma and people of African American descent — is more effective in identifying undiagnosed cases. Family history is especially significant, requiring referrals to optometry or ophthalmology for further evaluation. In primary care, NPs can perform initial eye exams, checking visual acuity and intraocular pressure with hand-held devices, performing confrontational visual tests and administering Amsler grid tests. Patients with abnormal results should be referred to a specialist.
How can health care providers outside of ophthalmology effectively screen for glaucoma? If a patient reports, “I think my vision is getting worse,” the first step is to check their visual acuity and peripheral vision. Since glaucoma primarily affects peripheral vision, a confrontational visual field test can help to identify defects. Some primary care clinics may have non-mydriatic fundus cameras, which allow them to capture images of the optic nerve. However, using a direct ophthalmoscope can also be quite effective for this purpose.
When examining the optic nerve, look for any difference in the cup-to-disc ratio between a patient’s left and right eye. If there is any asymmetry in the optic nerves, it may strongly suggest glaucoma. Even without specialized equipment, a confrontational visual field, direct ophthalmoscopy exam and the Amsler grid can detect some glaucoma defects. Then, the patient can be referred to an optometrist or ophthalmologist for further evaluation.
Cakiner-Egilmez: Glaucoma is a chronic disease that requires patient collaboration to slow its progression. It's important to emphasize medical management during each visit, including informing patients about potential medication side effects and how to report them. Discussing the goals of glaucoma management and treatment options — like laser therapy and surgeries — is essential. For those with decreased vision, a low vision or blind rehabilitation evaluation may help maximize their remaining vision for activities like reading and watching TV.
For example, if a patient’s vision loss affects daily life, we may send them to a low-vision clinic or one of the vision rehabilitation clinics. There, they can receive the necessary equipment and aid to read and function daily. They have magnifiers, TV tools and phone apps that will read aloud what is on a patient’s phone screen. With these tools, patients can learn how to manage their lives before losing their vision. If patients have lost their vision, blind rehabilitation specialists can evaluate their home environment and suggest ways to improve safety.
I would like to discuss Charles Bonnet syndrome. Patients who are losing their vision due to conditions such as glaucoma, cataracts or macular degeneration may begin to see shapes or figures that do not exist. They might believe they are experiencing a psychological issue, but this phenomenon is a result of low vision. It is important for us to explain to patients that these visual experiences are not real. Once, a patient came to me and said, "I don't see those spiders on the wall anymore after my cataract surgery." I explained that there were never any spiders there. When a person's vision is poor, the amount of visual input to the brain is limited, which can cause the brain to misinterpret shadows on the wall as spiders.
Cakiner-Egilmez: New intravitreal injections are available for macular degeneration, diabetic retinopathy and retinal vein occlusions. These medications require fewer injections, allowing for improved vision for a longer period.
Now, patients have access to more affordable biosimilars for macular degeneration. New intraocular lenses will also be available to improve visual outcomes following cataract surgery. I expect more advanced developments in 2025, so I will be able to update you around this time next year!
Cakiner-Egilmez: NPs provide excellent care to hundreds of thousands of patients daily. They play a vital role in efficiently screening potential glaucoma patients and referring patients to eye specialists in a timely manner if they suspect any vision difficulties or optic nerve issues. Primary care NPs play a vital role in the early diagnosis of glaucoma before it affects visual acuity and are invaluable in assisting eye care providers to manage complex cases.
If you’re interested in ophthalmology, the AANP Ophthalmology Community offers a unique opportunity to collaborate with colleagues who share interest or clinical expertise in health care conditions that affect the eye. As an AANP Community member, you’ll have access to a cutting-edge, online forum where you can engage in discussions, document sharing and knowledge exchange with your fellow NPs.