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ophtho.open-angle-glaucoma.core.v1PRODUCTION
ophtho.open-angle-glaucoma.core.v1

Primary open-angle glaucoma (POAG)

general_internal_medicinechronicadultgeriatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame POAG as a chronic, progressive optic neuropathy where the SINGLE evidence-based modifiable risk factor is IOP. The engine drives confirmation of OPEN angle, baseline structural + functional damage, agent-gated IOP-lowering ladder with SLT first-line per LiGHT (PMID 30862377 / 41043781), and progression-rate-aware escalation. Acute angle closure and other secondary glaucomas are recognised and routed OUT by engine_id (AAO PPP POAG 2025).

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POAG framing set; route-out engine_ids noted

Patient inputs (14)

Thin CCT (<555 microns) under-reads true IOP and is an independent risk factor (OHTS); thick CCT over-reads — calibrates IOP target and risk stratification (AAO PPP POAG 2025)

Black ancestry: earlier onset, faster progression, higher prevalence; Hispanic: rising late-life prevalence; age >60 baseline screening trigger (AAO PPP POAG 2025)

Topical / intra-vitreal / inhaled / intra-articular / systemic corticosteroids cause steroid-responder IOP elevation — must be screened in any IOP rise in a steroid user (AAO PPP POAG 2025)

Goldmann applanation tonometry (corrected for central corneal thickness) is the modifiable risk factor and the treatment target; sets percent-reduction target from untreated baseline (AAO PPP POAG 2025)

Gonioscopy confirms the anterior chamber angle is OPEN — distinguishes POAG from primary/secondary angle closure (which routes to ophtho.acute-angle-closure-glaucoma.core.v1) and is required before initiating long-term therapy (AAO PPP POAG 2025)

OCT retinal nerve fibre layer + ganglion-cell complex is the structural progression target; baseline and serial scans detect change before functional loss in early disease (AAO PPP POAG 2025)

Humphrey 24-2 (or 10-2 for central macular threat) defines functional severity by Hodapp-Anderson-Parrish (mild MD>-6 / moderate -6 to -12 / advanced <-12 dB); at least 2 reliable baseline fields required (AAO PPP POAG 2025)

Baseline disc photo / imaging documents cup-disc ratio, neuroretinal-rim thinning, disc haemorrhage (Drance haemorrhage — strong progression risk), and parapapillary atrophy (AAO PPP POAG 2025)

POAG drop non-adherence approaches 50% at 1 year; failure to lower IOP must be distinguished from non-adherence before escalation (AAO PPP POAG 2025)

Topical β-blocker (timolol) is systemically absorbed and can precipitate bronchospasm / sinus bradycardia / heart block — absolute contraindication in asthma / severe COPD / 2nd-3rd degree AV block (AAO PPP POAG 2025)

First-degree family history raises POAG risk roughly 4-fold and shifts screening threshold (AAO PPP POAG 2025)

Brimonidine is CONTRAINDICATED under age 2 (CNS depression, apnoea, hypotension risk) — gates the α2-agonist arm in paediatric glaucoma (AAO PPP POAG 2025)

Topical CAIs (dorzolamide / brinzolamide) carry historical sulfa-allergy labelling; severe reactions rare topically but documented (AAO PPP POAG 2025)

Prostaglandin analogues theoretical uterine-tone concern; brimonidine excreted in milk (and contraindicated in infants); β-blockers cross placenta — agent choice gated on pregnancy/lactation (AAO PPP POAG 2025)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningangle_closure_features_mid_dilated_pupil_cloudy_cornea
    Acute IOP spike with fixed mid-dilated pupil + cloudy cornea + pain + haloes
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereadvanced_field_loss_hap_advanced
    Hodapp-Anderson-Parrish ADVANCED stage (mean deviation worse than -12 dB or split fixation) at presentation or progression
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererapid_progression_despite_iop_target
    Documented OCT-RNFL or Humphrey VF progression while at the previously-set IOP target
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebeta_blocker_contraindication_asthma_or_heart_block
    Asthma / severe COPD / sinus bradycardia / 2nd-3rd degree AV block in a patient on or considered for topical timolol
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepediatric_under_2_years_brimonidine_avoid
    Glaucoma in a child under age 2 considered for α2-agonist
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedisc_hemorrhage_drance
    Drance disc-margin haemorrhage observed at any visit
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesteroid_induced_iop_rise
    IOP rise in a chronic topical / intra-vitreal / inhaled / intra-articular / systemic corticosteroid user
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

POAG — SLT-first then stepwise IOP-lowering pharmacotherapy + surgery (AAO PPP POAG 2025; LiGHT)
axis: poag_iop_lowering_ladderstep 1 - Step 1 — Selective laser trabeculoplasty (SLT) FIRST-LINE per LiGHT
Selected step "Step 1 — Selective laser trabeculoplasty (SLT) FIRST-LINE per LiGHT" — Newly-diagnosed mild-moderate POAG or ocular hypertension warranting treatment; no contraindication to SLT
  • selective_laser_trabeculoplasty_first_line
    first line
    laser_procedure
    triggers: new_diagnosis_mild_moderate_oag, oht_warranting_treatment, drop_burden_or_adherence_concern
    LiGHT (Gazzard Lancet 2019 PMID 30862377): SLT first-line was non-inferior on HRQoL, 74.2% drop-free at 3 y, 0 vs 11 glaucoma-surgery patients, more time within target IOP (93.0% vs 91.3% of visits), and cost-effective. 6-year extension (Montesano/Gazzard Ophthalmology 2025 PMID 41043781) showed slower VF MD progression -0.26 vs -0.37 dB/y (P=0.007).

outpatient playbook — drug actions (4)

  1. 1. SLT first-line per LiGHT (no rxcui — procedure)
    standard 360-degree SLT • laser • once (re-treatable)
    trigger: New-diagnosis mild-moderate POAG/OHT (LiGHT Lancet 2019 PMID 30862377; 6-y Ophthalmology 2025 PMID 41043781)
    SLT-first preserves VF better at 6 y and avoids drops in ~74% of patients at 3 y
  2. 2. latanoprost 0.005% nightly (most-used PGA)
    rxcui 43611
    1 drop • topical • once nightly
    trigger: SLT alone insufficient or PGA chosen as concurrent first-line drop (AAO PPP POAG 2025)
    Most potent topical monotherapy class; ~25-33% IOP reduction; once-nightly favours adherence
  3. 3. timolol 0.5% BID (β-blocker adjunct)
    rxcui 10600
    1 drop • topical • BID
    trigger: PGA inadequate, no asthma/COPD/heart-block (AAO PPP POAG 2025)
    Established second-class adjunct with ~20-25% additional IOP-lowering; systemic side-effect screen needed
  4. 4. netarsudil 0.02% nightly (ROCK inhibitor)
    rxcui 1992863
    1 drop • topical • once nightly
    trigger: IOP above target on maximally-tolerated 2-3-class topicals (AAO PPP POAG 2025)
    Adds ~3-5 mmHg lowering via trabecular outflow + episcleral venous pressure; expect conjunctival hyperaemia

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Asymptomatic patient with cupped optic disc, elevated IOP, RNFL thinning on OCT, or unreliable visual field — POAG is typically silent until late, so most entries are screening-detected (AAO PPP POAG 2025); First-degree family history of glaucoma, Black or Hispanic ancestry, age >60, high myopia, diabetes, or thin central cornea — high-risk asymptomatic screening cohort (AAO PPP POAG 2025); Patient-reported peripheral vision loss, missed steps, near-misses while driving — already moderate-to-advanced disease at presentation (Hodapp-Anderson-Parrish staging).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Primary open-angle glaucoma (POAG)** (ophtho.open-angle-glaucoma.core.v1).
Phenotype framing: Terminal differential: POAG (open angle, glaucomatous disc + RNFL + field, no secondary cause) vs ocular hypertension (raised IOP, normal disc + field — OHTS-stratified for prophylactic treatment) vs normal-tension glaucoma (IOP-low subtype, vascular risk) vs pseudoexfoliative OAG vs pigmentary OAG vs steroid-induced OAG vs uveitic/neovascular/post-traumatic secondary OAG (route to ophtho.uveitis or ophtho.acute-angle-closure-glaucoma) vs non-glaucomatous optic neuropathy (pallor>cup, neuro-imaging) (AAO PPP POAG 2025).
Scope: Frame POAG as a chronic, progressive optic neuropathy where the SINGLE evidence-based modifiable risk factor is IOP. The engine drives confirmation of OPEN angle, baseline structural + functional damage, agent-gated IOP-lowering ladder with SLT first-line per LiGHT (PMID 30862377 / 41043781), and progression-rate-aware escalation. Acute angle closure and other secondary glaucomas are recognised and routed OUT by engine_id (AAO PPP POAG 2025).

No severity triggers fired against current inputs.

Plan

Regimen axis: **POAG — SLT-first then stepwise IOP-lowering pharmacotherapy + surgery (AAO PPP POAG 2025; LiGHT)** — step "Step 1 — Selective laser trabeculoplasty (SLT) FIRST-LINE per LiGHT".
1. selective_laser_trabeculoplasty_first_line (laser_procedure, first line) — LiGHT (Gazzard Lancet 2019 PMID 30862377): SLT first-line was non-inferior on HRQoL, 74.2% drop-free at 3 y, 0 vs 11 glaucoma-surgery patients, more time within target IOP (93.0% vs 91.3% of visits), and cost-effective. 6-year extension (Montesano/Gazzard Ophthalmology 2025 PMID 41043781) showed slower VF MD progression -0.26 vs -0.37 dB/y (P=0.007).

Setting playbook (outpatient) — Confirm OPEN angle, establish baseline structural + functional damage, set HAP-stage IOP target, deliver SLT first-line per LiGHT, escalate the IOP-lowering ladder on contraindication-aware drug selection, and run lifelong OCT + VF + disc-photo monitoring (AAO PPP POAG 2025; LiGHT PMID 30862377 / 41043781)
2. SLT first-line per LiGHT (no rxcui — procedure) standard 360-degree SLT laser once (re-treatable) — New-diagnosis mild-moderate POAG/OHT (LiGHT Lancet 2019 PMID 30862377; 6-y Ophthalmology 2025 PMID 41043781) (SLT-first preserves VF better at 6 y and avoids drops in ~74% of patients at 3 y)
3. latanoprost 0.005% nightly (most-used PGA) 1 drop topical once nightly — SLT alone insufficient or PGA chosen as concurrent first-line drop (AAO PPP POAG 2025) (Most potent topical monotherapy class; ~25-33% IOP reduction; once-nightly favours adherence)
4. timolol 0.5% BID (β-blocker adjunct) 1 drop topical BID — PGA inadequate, no asthma/COPD/heart-block (AAO PPP POAG 2025) (Established second-class adjunct with ~20-25% additional IOP-lowering; systemic side-effect screen needed)
5. netarsudil 0.02% nightly (ROCK inhibitor) 1 drop topical once nightly — IOP above target on maximally-tolerated 2-3-class topicals (AAO PPP POAG 2025) (Adds ~3-5 mmHg lowering via trabecular outflow + episcleral venous pressure; expect conjunctival hyperaemia)

Non-pharmacologic actions:
- Counsel adherence + drop-technique (punctal occlusion 1-2 minutes reduces systemic absorption; eyes closed; wait 5 min between drops) (AAO PPP POAG 2025)
- Lifestyle: avoid head-down yoga inversions (transient IOP rise); aerobic exercise modestly lowers IOP; smoking cessation; treat sleep apnoea in normal-tension cases
- Low-vision rehabilitation referral for moderate-advanced field loss; counsel driving-vision regulations
- MIGS at the time of cataract surgery in mild-moderate POAG with cataract (AAO PPP POAG 2025)

AVOID / contraindication checks:
- Timolol contraindicated in asthma severe copd sinus bradycardia or 2nd 3rd degree heart block (AAO PPP POAG 2025 — systemic β blocker absorption real; switch to non timolol class)
- Brimonidine contraindicated under age 2 years (CNS depression / apnoea / hypotension; AAO PPP POAG 2025)
- Pga cautioned in uveitis cme or herpetic keratitis (AAO PPP POAG 2025 — anecdotal flare; weigh risk vs IOP lowering need)
- Unmask steroid induced OAG in chronic corticosteroid users (AAO PPP POAG 2025 — taper/switch steroid before assuming primary OAG)
- Topical CAI historic sulfa allergy labelling (rare systemic reaction; AAO PPP POAG 2025)
- Netarsudil causes conjunctival hyperaemia in roughly half of users (tolerability not safety; AAO PPP POAG 2025)

Monitoring

Regimen monitoring:
- IOP every visit with adherence and technique audit (AAO PPP POAG 2025 — non-adherence approaches 50% at 1 y)
- OCT RNFL plus macular GCC every 6 to 12 months (AAO PPP POAG 2025 — structural progression precedes functional in early disease)
- Humphrey 24 2 visual field every 6 to 12 months with 5 baseline fields in first 2 years (AAO PPP POAG 2025 — establishes progression direction)
- Optic disc photo or imaging every 1 to 2 years and at every progression event (AAO PPP POAG 2025 — disc haemorrhage is a strong progression signal)
- Systemic side effect screen — β-blocker pulse/lung, brimonidine drowsiness/allergic conjunctivitis, CAI taste / paraesthesia, PGA periocular changes (AAO PPP POAG 2025)

Setting (outpatient) monitoring:
- IOP + adherence audit every visit (AAO PPP POAG 2025)
- OCT-RNFL + GCC + Humphrey 24-2 every 6-12 months (more frequent in moderate-advanced disease)
- Optic-disc photo / imaging every 1-2 years and at every progression event; watch for disc haemorrhage
- Systemic side-effect screen for each class on the ladder (AAO PPP POAG 2025)

Follow-up plan: Lifelong therapy with stage-appropriate cadence. Escalate IOP target or step up the ladder if progression detected on OCT or VF despite hitting IOP target. Drop-burden reduction via SLT re-treatment or MIGS is appropriate in stable patients with adherence struggles. Co-manage steroid-induced OAG by taper/switch of the offending steroid in collaboration with the prescribing service. Counsel patients on driving-vision regulations, fall-risk in advanced disease, low-vision rehabilitation (AAO PPP POAG 2025).
- Close-out criterion: long-term follow-up plan + low-vision considerations documented

Monitoring phase: At every visit: IOP, adherence + technique audit (the commonest cause of perceived treatment failure), side-effects review (PGA periocular changes, β-blocker pulse/lung, brimonidine drowsy + allergic conjunctivitis, CAI taste, ROCK conjunctival hyperaemia). Q6-12 mo: OCT-RNFL + GCC + Humphrey 24-2 (more frequent in moderate-advanced; >=5 fields in first 2 y to establish progression direction). Q1-2 y: optic-disc photo. Watch disc haemorrhage at every visit — strong progression signal (AAO PPP POAG 2025).

Disposition

Current setting: outpatient — Confirm OPEN angle, establish baseline structural + functional damage, set HAP-stage IOP target, deliver SLT first-line per LiGHT, escalate the IOP-lowering ladder on contraindication-aware drug selection, and run lifelong OCT + VF + disc-photo monitoring (AAO PPP POAG 2025; LiGHT PMID 30862377 / 41043781)

Disposition criteria:
- Continue outpatient ophthalmology / optometry co-management with stage-appropriate cadence (AAO PPP POAG 2025)
- Glaucoma-specialist referral for advanced disease, progression despite max medical therapy, or surgical candidates
- Route OUT to ophtho.acute-angle-closure-glaucoma.core.v1 if angle closes / acute IOP spike features

Escalation triggers (move to higher acuity):
- Documented structural OR functional progression at IOP target → re-set lower IOP target (drop another 20-30%) and step up the ladder (AAO PPP POAG 2025)
- Disc haemorrhage (Drance) at any visit → strong progression signal, lower target
- Acute angle-closure features (high IOP, cloudy cornea, mid-dilated fixed pupil) → route to ophtho.acute-angle-closure-glaucoma.core.v1

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Acute IOP spike with fixed mid-dilated pupil + cloudy cornea + pain + haloes
- [SEVERE] Hodapp-Anderson-Parrish ADVANCED stage (mean deviation worse than -12 dB or split fixation) at presentation or progression
- [SEVERE] Documented OCT-RNFL or Humphrey VF progression while at the previously-set IOP target

Citations

- AAO Preferred Practice Pattern (PPP) Primary Open-Angle Glaucoma 2025 cycle + LiGHT primary RCT (Gazzard Lancet 2019, PMID 30862377) + LiGHT 6-year visual-field-progression extension (Montesano/Gazzard Ophthalmology 2025, PMID 41043781) [PMID:30862377](https://pubmed.ncbi.nlm.nih.gov/30862377/)
- Cited evidence (PMID 41043781) [PMID:41043781](https://pubmed.ncbi.nlm.nih.gov/41043781/)

Last reconciled with current guidelines: 2026-05-26.
References
  • AAO Preferred Practice Pattern (PPP) Primary Open-Angle Glaucoma 2025 cycle + LiGHT primary RCT (Gazzard Lancet 2019, PMID 30862377) + LiGHT 6-year visual-field-progression extension (Montesano/Gazzard Ophthalmology 2025, PMID 41043781) — PMID:30862377
  • Cited evidence (PMID 41043781) — PMID:41043781