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Running Head: Teaching Project: Glaucoma
Teaching Project: Glaucoma
Katie Scanlon, Sheilah Scofield & Amanda Piel
State University of New York Institute of Technology
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Teaching Project: Glaucoma
Glaucoma
Teaching Topic
Definition. Glaucoma is often referred to as the “silent thief of sight” (Dunphy et
al., 2011). It often has an insidious onset and a gradual progression, leading to permanent
loss of vision (Dunphy et al., 2011). Many people may be at risk, and if not addressed in
a timely manner, one’s life can dramatically be changed.
Incidence. Glaucoma is the second leading cause of blindness in white
Americans and the leading cause of blindness in African Americans (Gerzevitz, Porter, &
Dunphy, 2011). According to Turkoski 2012, approximately 15 million Americans are
living with the threat of glaucoma. 90-95% of all cases of glaucoma are primary openangle. Closed-angle glaucoma is uncommon with approximately 0.1% of the population
being affected (Gerzevitz, Porter, & Dunphy, 2011).
Identification of Health Need
Community Selection. The community selected for this teaching project was
Oneida County. Oneida County is located in central New York and considered a rural
location (Oneida County Health Dept., 2013). This is the location of many heath care
providers and more specifically, the location of an accredited nurse practitioner program.
Target population. The individuals targeted for our glaucoma presentation
include healthcare providers and nursing students from Oneida County and other regions
of upstate and central New York State. Therefore, the main focus of this teaching project
is to educate the current and future practitioners that care for this community’s members.
Reasons for targeted population. Primary care providers, nurses, and hospitals
are providing care on a daily basis for individuals within Oneida County who are living
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Teaching Project: Glaucoma
with and managing chronic diseases (Community Health Assessment, 2010-2013).
Health care providers are targeted for our glaucoma presentation because they are often
providing medical care to individuals with risk factors for glaucoma and need to be aware
of the types of glaucoma, risk factors, signs and symptoms, diagnosis, and treatment of
the disease (Gerzevitz, Porter, & Dunphy, 2011; Mayo Clinic, 2012).
Community assessment. The Internet was utilized as the main tool for
assessment. The most recent Community Health Assessment was located and revealed
significant information regarding the health of Oneida County. There were several health
related anomalies identified. According to the Community Health Assessment of 20102013, two of the leading diseases for adults are hypertension and diabetes in this county.
In 2009, and estimated prevalence rate of 27.1 percent of adults were inflicted with
hypertension (Oneida County Health Dept., 2013). In 2008, an estimated eight percent
of adults had diabetes (Oneida County Health Dept., 2013).
Diseases as risk factors. Hypertension and diabetes can have severe effects on
one’s overall health status. Being that these diseases are considered fairly common, they
tend to be the focus for most practitioners. Treatment of these diseases is usually the
ultimate goal. However, it is the other, more subtle diseases, that hypertension and
diabetes can cause, that are often overlooked. Amongst them is glaucoma. Both
hypertension and diabetes are risk factors for the development glaucoma (Mayo Clinic,
2013).
Goals and Objectives of Teaching Project
Goals of educational experience:
1. Make learners aware of the risk factors associated with glaucoma
development.
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Teaching Project: Glaucoma
2. Teach learners of the common subjective and objective clinical findings
presented with glaucoma.
3. Review the proper screening techniques used in the primary care setting to
assess for glaucoma.
Learner objectives:
1. Learners will be familiar with the risk factors of glaucoma development.
2. Learners will identify the signs/symptoms of glaucoma.
3. Learners will be able to perform the proper screening techniques to assess for
glaucoma.
Process of Measurement: Goals and objectives will be measured by a pre and post
presentation quiz. This quiz will include five fill-in-the-blank questions pertinent to the
presentation. Comparing the pre and post quizzes will determine if learning was
executed.
Description and Setting of Teaching Project
Description of Project
Teaching plan. The plan is formulated with regard to the topic chosen. It is
focused on teaching the learning objectives in a clear concise manner with visual aids,
handouts and models. This approach to fulfilling the learning objectives seeks more than
to just transmit knowledge, the latest evidence based treatments and modalities are
incorporated to advance the science of nursing/participant education (Patterson, B. &
McAleer-Klein, J., 2012). The plan consists of an outline of Glaucoma which will
include epidemiology, pathophysiology, screening, diagnosis and treatments. The
following will be presented on poster boards: facts of disease, incidence, epidemiological
factors, diagnosis and treatments.
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Teaching Project: Glaucoma
Setting. The learning environment will take place in an appropriately heated
room or auditorium located at SUNY IT, Utica, NY. The topic of Glaucoma will be
presented at the annual teaching day of SUNY IT. This topic will be presented at a
wellness fair in the spring of 2014, it will be one of many topics presented by SUNY IT
students.
Application of Principles to Meet Education Needs
Principles of Teaching and Learning
Assessment. Prior to teaching, the instructor will cover the education process and
discuss the need to find out what the student already knows, what they want (and need) to
know and what they are capable of learning. This will be accomplished by a short pretest and discussion period. Also, the teacher should distinguish if there are any factors
that might impact the learning such as excessive noise, decreased lighting and so forth
(Rohrbaugh, 2011). Assessing readiness to learn includes looking for cues in verbal and
nonverbal behavior, thus readiness is verified by teacher assumptions. Readiness is
important in determining what the patient/learner wants to know and what he or she was
capable of learning (French, 2011).
Planning/tools. The community health risk assessment was reviewed as well as
the risk appraisal and a teaching plan was determined based on the results. A simple easy
to read poster board presentation and handout is of utmost importance. Research has
shown that simple language is the first step in clear communication (Zarcadoolas, 2009).
Intervention. This step consists of implementing the actual teaching at the site.
Plain language will be used (Zarcadoolas, 2009). The content of the printed handout will
be taught in a relaxed manner and reviewed with the participants.
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Teaching Project: Glaucoma
Evaluation. A short, clearly written evaluative tool will be utilized post teaching
as a way to document effectiveness of teaching. Also, a teach-back method will be
conducted in a short question and answer period. The teach- back method is a proven
useful communication tool (Kimbrough, 2011).
Project Topics
Open-angle glaucoma. PAOG is caused by an increased IOP, which generally
occurs when the trabecular meshwork or outflow channels are obstructed or there is an
over production of aqueous humor (Dunphy et al., 2011; Turkoski, 2012). Change in the
trabecular meshwork is thought to occur when there is a change in the biochemical makeup of the cells that line the meshwork. It appears that these changes occur with the aging
process (Gerzevitz, Porter, & Dunphy, 2011). Another theory is that the optic nerve is
damaged because of poor perfusion (American Optometric Association, nd).
Secondary open-angle glaucoma develops slowly and may result from ocular
trauma, illness including uncontrolled diabetes and hypertension, previous ocular surgery,
recurrent retinal hemorrhages, or inflammation. The use of chronic topic or system
corticosteriods may also increase the risk of an individual developing secondary
glaucoma (Turkoski, 2012).
There is a debate regarding how IOP leads to atrophy of the optic nerve. One
theory supports the idea that the direct mechanical damage and loss of retinal ganglionic
cells are caused by IOP. Another theory suggests that small vessels that provide the optic
nerve and extracellular matrix is impaired by the IOP (Gerzevitz, Porter, & Dunphy,
2011).
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Teaching Project: Glaucoma
Closed-angle. Closed-angle glaucoma is a less common form of glaucoma
caused by an anatomic narrowing of the anterior chamber angle resulting from the iris
being displaced forward toward the cornea, narrowing the iridocorneal angle and
obstructing outflow of aqueous fluid from the anterior chamber. The narrowing of the
anterior chamber is determined by genetics and becomes more likely with age as the lens
of the eye increases in size (Gerzevitz, Porter, & Dunphy, 2011 & American Optometric
Association, nd.). Acute angle-closure glaucoma is a medical emergency because
permanent vision loss can occur within 24 hours of onset of symptoms and often requires
surgery. Chronic closed angle glaucoma is less severe and genetics may play a role in
development (Turoski, 2012).
Risk factors. Damage to the optic nerve is reduced and blindness minimized
when glaucoma is detected and treated in its early stages (Gerzevitz, Porter, & Dunphy,
2011). Hypertension, coronary artery disease, and diabetes are all chronic health diseases
that are risk factors for the development of glaucoma (Mayo Clinic, 2012).
Being over the age of 60, family history of glaucoma, increased IOP, myopia,
diabetes, hypothyroidism, prolonged use of corticosteriods, African Americans over the
age of 40, and Mexican Americans over the age of 50 are risk factors for the development
of open-angle glaucoma (Turoski, 2012; Allinson, 2013).
The development of closed-angle glaucoma is linked to hyperopia, female sex,
family history of glaucoma, over the age of 40, shallow anterior chamber, Asian or Inuit
descent, thick crystalline lens, and medications including ACE inhibitors,
anticholinergics, antihistamines, antidepressants, cholinergic agents, and adrenergic
agonists (Barros, O'Connell & Kent, 2013).
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Teaching Project: Glaucoma
Subjective clinical findings
Open-angle. Open-angle glaucoma is generally asymptomatic until there is
advanced damage to the optic nerve. Individuals may experience headaches and “tired
eyes”, however these symptoms are often ignored. Bilateral painless loss of peripheral
vision, blurred vision, floaters, sensitivity to light and poor night vision are often
symptoms a patient could present with. Patients may also state that they feel like they are
looking through a tunnel (Gerzevitz, Porter, & Dunphy, 2011; Turoski, 2012).
Acute closed angle. There is a rapid onset, unilateral pain or pressure, blurred
vision, seeing halos around lights, and photophobia followed by a loss of peripheral
vision and then central vision with acute angle-closure glaucoma (Gerzevitz, Porter, &
Dunphy, 2011). Headache, nausea, and vomiting are also symptoms a patient may present
with (Gerzevitz, Porter, & Dunphy, 2011).
Chronic closed angle. The onset of chronic narrow angle glaucoma is often
insidious and patients will often have a history of intermittent blurred vision and a vague
discomfort of the eyes (Gerzevitz, Porter, & Dunphy, 2011).
Objective clinical findings. The physical exam of those with chronic glaucoma
will most likely unremarkable. Their visual acuity may or may not be affected and there
will be abnormalities to confrontation in very late cases (Gerzevitz, Porter, & Dunphy,
2011).
Gerzevitz, Porter, & Dunphy, 2011, state IOP rapidly rises and the eye will be
red, painful, and there may be a “steamy” appearance to the cornea with angle-closure
glaucoma. On fundoscopic examination the optic disc may appear pale; there maybe an
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Teaching Project: Glaucoma
increased cup to disc ratio and asymmetry when compared to the other eye. Visual acuity
is severely affected due to visual field defects (Gerzevitz, Porter, & Dunphy, 2011).
Testing for glaucoma. Tonometry, which is the testing of the intraocular
pressure, fundoscopic exam, visual acuity testing, and visual field examination should be
performed by the primary care provider in the office if glaucoma is suspected (Mayo
Clinic, 2012). Currently, there are no firmly established guidelines for the screening of
glaucoma in primary care (Gerzevitz, Porter, & Dunphy, 2011). Improvement in
diagnostic skills required for the early detection of glaucoma and clear guidelines of
when to refer to ophthalmology could positively impact the eye health of patients at risk
and who have glaucoma (Gerzevitz, Porter, & Dunphy, 2011).
Pachymetry to measure the thickness of the cornea, examination and pictures of
the retina, gonioscopy, and measurement of nerve fiber examination are additional tests
that maybe preformed by the ophthalmologist to diagnose glaucoma (American
Optometric Association, nd).
Complications. If glaucoma is left untreated, progressive vision loss will occur.
Vision loss may begin with blind spots within the peripheral vision, progress to tunnel
vision, and eventually total blindness will occur (Mayo Clinic, 2012).
Treatment options
Pharmacological. Pharmacological therapy is most often the first-line approach
in treating patients requiring reduction of IOP. The goal of treatment is to reduce
elevated IOP, prevent further damage, and preserve eyesight. In many cases, more than
one medication is required to reduce IOP to an appropriate level, multiple dosing often
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Teaching Project: Glaucoma
leads to an increase in noncompliance with the treatment regimen (Realini et al., 2013;
Gerzevitz, Porter, & Dunphy, 2011).
Pharmaceutical treatment includes the use of oral or topical medications that will
either enhance aqueous outflow, reduce production of aqueous fluid, or both with the
choice of medication being decided by the ophthalmologist. Primary care providers must
be aware of how the medications chosen by the ophthalmologist for the treatment
glaucoma work and their side effects (Realini et al., 2013; Gerzevitz, Porter, & Dunphy,
2011).
Medication
Prostaglandins
Ex: latanoprost (Xalatan)
and bimatoprost (Lumigan)
Action
Increases outflow of
aqueous fluid and reduces
intraocular pressure
Beta blockers
Ex: timolol (Betimol,
Timoptic)
Decreases fluid production,
and decrease intraocular
pressure
Alpha-adrenergic agonists
Ex: brimonidine (Alphagan)
Decreases aqueous humor
production and increases
outflow of fluid
Reduce production of fluid
in the eye
Carbonic anhydrase
inhibitors (rarely used)
Ex: dorzolamide (Trusopt)
and brinzolamide (Azopt).
Miotic or cholinergic agents
Ex: pilocarpine (Isopto
Carpine) and carbachol
(Isopto Carbachol)
(Mayo Clinic, 2012).
Increases out flow of fluid
from the eye
Side effects
Mild reddening and stinging
of the eye, blurred vision,
darkening of the iris,
changes in eyelid
pigmentation
Difficulty breathing, slowed
heart rate, low blood
pressure, impotence, and
fatigue
Irregular heart rate, high
blood pressure, fatigue, and
dry mouth
Frequent urination, tingling
of fingers and toes
Smaller pupils, dim or
blurred vision,
nearsightedness
Surgical. Conventional and laser surgery are also options for the treatment of
glaucoma, which improve the drainage of aqueous fluid from the eye (American
Optometric Association, nd.).
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Teaching Project: Glaucoma
Conclusion
There is currently no cure for glaucoma, early diagnosis and the life long
continuation of treatment can preserve eyesight. The early detection, prompt treatment,
and regular monitoring can help in controlling glaucoma and reduce the risk of additional
vision loss. Research continues to be conducted on the diagnosis and treatment of
glaucoma in adults and children. (Gerzevitz, Porter, & Dunphy, 2011& Hollands et al.,
2013)
References
Allinsion, R. W. (2013). Glaucoma, primary open-angle. In Domino (Ed). The 5- Minute
Clinical Consult 2013 (21st ed) (528-529). Philadelphia, PA:
& Wilkins.
Lippincott
Williams
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Teaching Project: Glaucoma
American Optometric Association. (nd.). Glaucoma. Retrieved from :
http://www.aoa.org/patients-and-public/eye-and-vision-
problems/glossary-of-
eye-and-vision-conditions/glaucoma
Barros, M. C., O’Connell, J. M., Kent, S. C. Glaucoma, primary closed-angle. Domino
(Ed).
The 5-Minute Clinical Consult 2013 (21st ed) (528-529). Philadelphia,
PA: Lippincott Williams & Wilkins.
French, B. M. (2011). Teach patients to communicate. Patient Education Management,
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Gerzevitz, D., Porter, B. O., & Dunphy, L. M. (2011). Eyes, ears, nose, and throat
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D.
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Hollands, H., Johnson, D., Hollands, S., Simel, D. L., Jinapriya, D., & Sharma, S.
(2013).
Do findings on routine examination identify patients at risk for primary
open-angle glaucoma? Journal of the American Medical Association (309), 19,
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Kimbrough, J. (2011, December). Patient/provider communication critical- pick the best
method. Patient Education Management, 18, (12), 133-135.
Mayo Clinic. (2012). Glaucoma. Retrieved from:
http://www.mayoclinic.com/health/glaucoma/DS00283/METHOD=print
Oneida County Health Department. (2013). Community Health Assessment 2010-2013.
Retrieved from http://www.ocgov.net/health/CommunityHealthAssess2010-2013
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Teaching Project: Glaucoma
Patterson, B., Klein, J. & Mcleer, J. (July/August 2012). Evidence for teaching: what
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Realini, T., Nguyen, Q. H., Katz, G., & DuBiner, H. (2013). Fixed-combination
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10.1038/eye.2013.83
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materials. Patient Education Management, 16 (1), 1-12