Current Trends in Diagnosis and Management

Characteristic damage to the optic nerve leading to progressive, irreversible vision loss with or without elevated intraocular pressure

Characteristic damage to the optic nerve leading to progressive, irreversible vision loss with or without elevated intraocular pressure.

Significantly elevated intraocular pressure with or without visual field changes or obvious nerve or nerve fiber layer damage

3-4 million in US2.2 million over 40 have glaucoma50% undiagnosedPresent in 1 in 200 over 50 and 1in10 over 80The percentage of Americans over 65 will grow

by 50% in the next 15 years

AgeRefractive errorRace, ethnicityFamily historySystemic disease: HT, diabetes, obstr. sleep

apnea Medications - systemic and ocular, NAG and

OAGPrevious ocular trauma or surgeryDevelopmental and other ocular conditions

1980 - 90’s - initial state laws for OD’s to treat glaucoma

NM one of the first 2000-2005 - most states pass glaucoma therapy

for OD’s. Oklahoma allows lasersEven now, up to 50% 0f OD's still refer non-

complex, non-surgical glaucoma cases to OMD’s

Multiple reasons for not treating – experience, cost of instruments, practice focus, office size, patient mix

Miotics, sympathomimetics and orals – used in early to late 1900's

Trabeculectomy developed in the 1960'sBeta blockers introduced in the mid 1970'sLasers since the mid to late 70'sMultiple new meds and procedures from 2000

to present have led to a 50% reduction in vision loss in glaucoma patients from 1980 to present

Open Angle - POAG/Low Tension Secondary - pigmentary, pseudoexfoliative, inflammatory, phacogenic, traumatic, hemorrhagic, neovascular, drug-induced, malignant - intraocular surgery related

Developmental- those associated with inherited disorders

Narrow and closed angle

90% of all casesGood response to meds and lasersMost patients controlled with medsMany undiagnosedRate rising with increasing BMI, DM and the

aging population

Relatively rare, but still underdiagnosedMany forms/multi-factorial/mixed mechanismTypically more severe than OAGMost common in older female hyperopes and

Chinese- smaller eyes, fatter lensesIntermittent or chronic narrow angle Acute angle closure – emergency

Lens vault – forward position of lens relative to SS – pupillary block most common mechanism

Plateau iris – abnormally positioned ciliary body pushes peripheral iris on to TM

Phacogenic – cataract-induced lens thickening, PXE - 10% of cases have angle closure component

Thickened, dense iris – less sponge effect on dilation

Shallow anterior chamber – anterior iris insertionScleral buckles, malignant glaucoma

PI for those with hidden posterior TM > 180 deg.Gonioscopy – small beam, outside pupil, dark

conditionsVerify with OCT if possiblePosition at 11 or 1o’clock, usually hidden by eyelidAway from superior lacrimal riverYAG most commonDone early, before significant, persistent pressure

rise30% have minimal response – done too late, plateau

Occasionally done for non-responsive PI casesNo well designed studies to validate

effectivenessMost often performed in plateau iris that does

not move from apposition to TM after PIArgon laser to mid periphery of iris, shrinks

tissue at laser site, pulling iris away from angle

Sectoral or circumferential

Especially effective for plateau iris, recent acute angle closure and lens vault cases

Less effective in chronic NAG casesMuch less risk than trab in narrow anglesCan be combined with iStent for better IOP

reduction

Slow process of conversionInitially, intermittent iris / TM contact is seenLater persistent pigment on TM and

synechiae formationPressure slowly rises, sometimes fluctuating

with iris positionWatch for angle closure in POAG patients

who fluctuate

Often severe pain, but not alwaysCloudy vision in all cases, fixed pupil, cells in ACIOP can be 40-60+Don’t use PA’s- inflammatory - instead PrednisoloneStart with combigan 0r simbrinza q10-15 minOnce IOP lower than 30, add pilocarpine 1-2% qidUse oral CAI or 50% glycerine if unresponsive, > 50Diamox 250 or 500 po q 4-6 hrs, not SequelsArrange for PI, keep pt. on low dose pilo until laser

Extrinsic- medication, trauma, burns, infection/inflammatory, toxic, post surgery

Intrinsic- phacogenic, pigmentary, pseudoexfoliative auto-immune/inflammatory, neovascular, tumors, RD, others

Extremely rareSurgery neededPrognosis poorClassic presentations congenital, infantile, juvenile and glaucoma

assoc. with hereditary familial diseases

Large cupsAsymmetry in IOP or cup/disc ratioHigh IOPLow CCTFamily history or history of traumaNo NFL dropout or classic optic nerve signsNo VF defectsNo SLO, OCT or GDX defectsLTG suspects – collagen and autoreg. disorders

Serial tonometry prior to tx if no history of IOP’s available

ON evaluation/stereo photosGonioscopyVisual fieldsPachymetryOCT, SLO, GDXBP for Ocular Perfusion Pressure calculationFamily oc. hx. and patient medical/sx history

Goldmann is the standard but has some limitations

Alternatives - Pascal, Tonopen, pneumatic, rebound

CCT affects accuracy of measurements in someCCT a guide to modifying risk - not a true and

accurate adjustment factorRK, PRK, LASIK, corneal scars and KC can all

affect corneal thickness and hysteresisORA – measures hysteresis and “corrected

IOP”

Billed once in glaucoma management Importance documented in OHTSOne third with IOP over 26 and cct < 555 - dx

GLC6% with same iop and cct > 588 dx GLC Relative risk increased 81% for every 40

microns < 555

Rim: focal erosions/generalized cuppingISNT rule/verticalization of cupDisc size and depthDisc heme at or near rim marginBayonetting of vessels/saucerization of discBeta zone pigment changesNFL dropout with red-free filter

SITA automated perimetry is the standard for following progression on established cases 24 or 30 degrees – correlate with clinical findings

10 degree fields gaining acceptanceMatrix FDT is more sensitive for early

detection but not as reliable for progression analysis

Look at quality and repeatability of the testRarely make major decisions or changes with

only one field study

SD OCT now the standard of care with cRNFL, GCC and anterior chamber capability

Reliable and repeatable, but not infallible

High myopes may be false positives

Swept-Source an upcoming technology, but cost/reimbursement an ongoing issue

SS is faster, less errors, more detail, with additional choroid thickness measurement

Older models best for nerve head contour analysis, and PPRNFL thickness (no GCC)

NFL thickness analysis not as accurate as SD-OCT, especially in larger nerves

Good database for normative comparison

Only PPNFL thickness measured using polarized light

Fairly repeatable Relatively inexpensiveTechnology 15+ years oldSmall footprintStill useful for comparative data in

questionable cases

Manual technique for angle evaluation, not billable using OCT, Pentacam, etc

Used to rule out closed/narrow angles and angle recession and to determine risk of closure

Note most posteror structure in sup and inf angles and iris approach – flat, convex, concave, plateau

Also used to assess pigment or debris in the angle, grading 1-4

Takes experience and time, 3 vs 4 mirrorNot done as routinely as other testing by many

Relative pressure differential between diastolic systemic blood pressure and intraocular pressure

OPP = DBP-IOP target >50-55Important in establishing target IOP range in

treatment or in the evaluation of need for treatment

Very important in LTG, BP lowest at nightPA’s moderate effect, BB zero effect on nocturnal

IOP. CAI’s have best effect overnight but rx’d TID

ON damage with IOP never above 21Lower blood flow and choroidal thickness in

parapapillary regionCollagen issues – sleep apneaAuto-regulatory issues – Raynaud’s, migrane synd.Low BP, over medicated htn pt?Low OPPDisc heme more commonNo beta blockers, add NaCl to diet at evening

meal

Topical or oral meds – safety, tolerability, efficacy and compliance issues

Lasers – safe but short duration of effectTrabeculectomy – good effect, but safety

concernValves/Shunts gaining on trabsMIGS – unproven in wide usageEmerging treatments – Sub-conjunctival

injections, med-releasing plugs and CL's

AgeRaceONH appearance, cNFL /GCC and VF

damageSystemic healthBaseline IOPBP

General target 20-30 % reduction from TmaxMild cases 20-30%Moderate cases 30-40%Severe 40-50%< 12.5 mmHg limits VF progression in most

cases

Prostaglandin analoguesAlpha agonistsBeta blockersCarbonic anhydrase inhibitorsFixed combinations

Steroids in inflammatory cases

Xalatan – latanoprost lasts up to 36 hrs.Travatan Z - BAK free, lasts up to 60 hrs.Lumigan - same drug as Latisse, different conc.Zioptan – PF unit dosesAll increase uveoscleral outflowLumigan also said to increase TM outflowNo racial differences in effectsContraindications – HSV, CME, iritisAdverse effects – red eyes, PAP

Only one drug available in US for long term use

Not for pediatric patiets - pulmonary issuesAlphagan P or brimonidine (generic) 0.1-0.2 %Different preservatives/vehiclesProprietary version ? less prone to allergic

responseAvailable in combination with a beta-blocker

as Combigan and with CAI as Simbrinza

Timolol, Levobunolol, BetaxololTomolol 0.25 and 0.5 % solutions and 0.5% gel

forming suspension, dosed bid and qdOriginated in mid 70’s, reduces aqueous prod.Adverse effects include bradycardia, reduced

energy, depression, pulmonary probs and ED Monitor blood pressure and pulse in high risk

indiv.Available as PF unit doseIn combo drug with CAI as Cosopt

Dorzolamide Brinzolamide both decrease aqueous productionUsed TID if monotherapyBID if in fixed combo with beta blocker

timolol- Cosopt – available as generic and PFTID in combo of brinzolamide/brimonidine –

Simbrinza. Avoid in sulfa allergiesPO options – short term, diamox, neptazane

Combigan – brimonidine and timolol Cosopt – brinzolamide and timolol – avail.

genericSimbrinza – brinzolamide and brimodine

All good as primary or additive therapy to prostaglandin analog

SLT- Selective Laser Trabeculoplasty – 3-5 yr effect, repeatable

ALT- Argon Laser Trabeculoplasty – 3-5 yr effect, not repeatable

TrabeculectomyValves – Molteno, Ahmed, BarveldtCanaloplastyMIGS – iStent with cat. sx., ECP, TrabectomeCataract sx in lens vault narrow angles and

pseudoexfoliative cases, open angle cases due to molecular mechanism from ultrasound/phaco

Glaucoma workup- typically two to three visits Ongoing care – intermediate E/M visit q 3-4 mo.VF 3-12 months depending on reliability, IOP’sHRT/OCT/GDX q12 monthsStereo disc photos q12 monthsPatient/physician referrals