Philosophies in Glaucoma

Paul S. Jensen, O.D.Renton, WA

www.lacrimology.com

www.eyesmartz.com

jensen@rentonvision.com

Philosophies in Glaucoma

1. Making sense of information from disparate sources

2. Clinical Pearls

3. New Technologies (and new looks at some older stuff)

How not to be a plumber

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Philosophies in Glaucoma

• OHTS:

Ocular Hypertension Treatment Study– The mother ship– OHTS is a gift to optometry

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OHTS

Corneal Thickness

Separate the ocular hypertensives

from the low tension glaucoma

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OHTS

• Conclusions:– Decreased IOP = decreased morbidity– Glaucoma suspects should be considered

candidates for treatment

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OHTS

Conclusions:

- “There was little evidence of increased systemic or ocular risk associated with ocular hypotensive medications”

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OHTS

Risks of Ocular Hypotensives

• Meds show:

- Near zero plasma levels

- Measurable urine and cardiac out-put changes

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Philosophies in Glaucoma

• My conclusion:– Glaucoma Diagnosis is Treatment

– Never stop diagnosing:Minimum evaluation per year: • Tonometry X 4• VF X 1• SLO X 1• Gonioscopy X 1

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Philosophies in Glaucoma

• Case Study A:– IOP = 28, CCT = 556– VF = questionable – C/Ds = OD: 0.6 X 0.6

OS: 0.5 X 0.5

– Gonio = Grade 4 X 180o

• Case Study B:–IOP = 20, CCT = 556–VF = questionable–C/Ds = OD: 0.6 X 0.6

OS: 0.5 X 0.5–Gonio = Grade 4 X 180o

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The Philosophies of Glaucoma

• 1956-1986:– IOP, ONH, VF

• 1986: IOP doesn’t matter

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The Philosophies of Glaucoma

• Since OHTS:

- IOP matters, but in context of CCT

- C/D matters, esp. in context of SLO

- VF matters, but in context of Pattern SD

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Don’t be a plumber!

Go to the original research

Google Scholar, Medline, Elsevier, AOA

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Clinical Pearls

“The only thing better that learning from your mistakes, is learning from other people’s mistakes.”

- P. Jensen

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Clinic Pearls

Treatment Pitfalls:

- Blame the patient!

- Compliance (importance of treatment, ability to follow Tx plan)

- Poor gtt technique

- gtt Allergy/Intolerance/Sensitivity

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Clinical Pearls

• ITD/K-spindle

- Blue irides (myd)

- Myopic

- Middle aged

- Male & ….

- Anyone….

Pigment Dispersion Syndrome

& cataracts (?)

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Clinical Pearls

Pseudo-exfoliation Syndrome

• Older men

• Watch for angle closure

• Cataract extraction helps?

• Difficult to control

• Fluctuating IOP

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Clinical Pearls

• Cupping/SLO?

• VF?

• IOP?

ONH Drusen

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Clinical Pearls

• Increased bioavailability

• Dramatically increased

efficacy….

• Dramatically increased allergy

Lacrimal Occlusion

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Clinical Pearls

• Beta blockade

• Steroids:

- increasing incidence

- all routes of administration

Systemic Medications

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Clinical Pearls

• Ask at each visit

• Prostaglandin analogs – body, joint ache

Systemic Side Effects of gtt

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Clinical Pearls

• Drop usage and technique

• Documentation, flow sheet

• Monocular medical trials

Mundane Details

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Technologies

• SLO- GDx- HRT II/III- OCT

• Other

Don’t be a plumber, understand the technologies

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GDx

• Based on RNFL changes around disc

• Excellent at detecting early changes

• Good statistical analysis

- Good change plots

• Portable: easy to share/move

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GDx

Interpreting the results

• OD/OS comparisons

• Color coding is intuitive

• Be careful with tilted discs

• NFI

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GDx

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GDx

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HRT II/III

• Measures hydration, indirect eval of contour

• Excellent in defining details of ON anatomy

• Statistical analysis

• Retinal module: macular edema

- Glaucoma: 3 million Americans

- Diabetes: 21 million Americans27

HRT II/IIIHRT II/III

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HRT II/III

• Corneal Module, tissue eval, not contour

• FA

• Poor Portability (HRT II)

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HRT II/III

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HRT II/III

Interpreting the results

• Vascular tissue and nerve tissue all look alike

• HRT III: GPS, a number!

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OCT

Optical Coherence Tomography

• Most beautiful images in ophthalmic practice

• Eval peripapillary bundles

• ONH cupping - changes can be seen, but measurements not standardized

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OCT

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OCT

Interpreting the results

RNFL Thickness:

• Data similar to GDx

Cupping:

• Subjectivity

• No standardization34

OCT

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Other Technologies

• Glaucoma

• LASIK Pre-op

• Corneal edema/Fuch’s dystrophy

• Keratoconus (?)

• Inexpensive, reimbursable, easy as tono

Pachymetry

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Other Technologies

• Looks like Goldmann, but

- Concave tip

- CCT independent

- Reads OPA (mean max – mean min)

Pascal ® Dynamic Contour Tonometer

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Other Technologies

Pascal®

Dynamic Contour Tonometer

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Other Technologies

• Helpful in understanding glaucoma

• Necessary for Tx/management?

• Excellent tool for following numerous systemic/pharm effects on vascular perfusion

Ocular Blood Flow

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Other Technologies

Paradigm OBF Analyzer

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Other Technologies - OBF

• Reads:

- IOP/tonography

- OBF microl/min

- Pulse

TonoPlus™

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TonoPlus ™

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Other Technologies

Ocular Response Analyzer

• Measures corneal hysteresis (corneal resistance), distinct from CCT

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Other Technologies

Diaton Tonometer

• Transpalbebral

• Limbal

• +/- 2 to 20 mmHg, +/- 10% to 60 mmHg

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Other Technologies

Diaton Tonometer

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Other Technologies

Billing Technologies

• Accufee® and others

• EMR

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Philosophies in Glaucoma

How to not be a plumber:

• Read research in terms of patient care

• Discover the truth for yourself

• Be flexible, make smart mistakes

• Eval technology based on your practice and patients, not just disease

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Thanks!

Special thanks to Lindsey Sewell, OD, FAAO

for help in preparing this presentation.