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Fine Tuning Glaucoma Diagnosis and Management in Haiti Daniel Laroche MD Director of Glaucoma, St Lukes-Roosevelt Hospital, NY President, Advanced Eyecare.

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Presentation on theme: "Fine Tuning Glaucoma Diagnosis and Management in Haiti Daniel Laroche MD Director of Glaucoma, St Lukes-Roosevelt Hospital, NY President, Advanced Eyecare."— Presentation transcript:

1 Fine Tuning Glaucoma Diagnosis and Management in Haiti Daniel Laroche MD Director of Glaucoma, St Lukes-Roosevelt Hospital, NY President, Advanced Eyecare of New York Assistant Clinical Professor Ophthalmology New York Eye and Ear Infirmary New York Medical College Chair NMA Ophthalmology Section/AAO Task for on Haiti Disclosure: Speaker Bureau for Alcon, Allergan Merck Disclosure: Speaker Bureau for Alcon, Allergan Merck

2 Thanks to the SHO and CNPC for the invitation and congratulations on your ongoing efforts

3 I worked at the University Eye Hospital

4 Persistent Structural damage to buildings that need reconstruction

5 HUEH Faculty Dr. Jean Claude Cadet- Chief Dr. Jean Claude Cadet- Chief Dr. Ritza Eugene Dr. Ritza Eugene Dr. Jean Claude Cadet Jr. Dr. Jean Claude Cadet Jr. Dr. Valery Cadet Dr. Valery Cadet Visiting Professors Visiting Professors

6 Ophthalmology Residents Astrid St. Dic Astrid St. Dic Rachel Aglae Amedee Rachel Aglae Amedee Rachel Gauthier Rachel Gauthier Nathalie Francois Nathalie Francois Reginald Rejouis Reginald Rejouis Myriam Beliard Myriam Beliard Marie Dieumane Chaperon Marie Dieumane Chaperon Milon Osnel Milon Osnel

7 3 ½ Days of seeing patients May 13-16, glaucoma patients were presented 60 glaucoma patients were presented Under went tonometry, gonioscopy, optic disc examination, FDT VF Under went tonometry, gonioscopy, optic disc examination, FDT VF Diagnosis were: Diagnosis were: Open angle glaucoma, Angle closure glaucoma, Juvenile Open angle glaucoma Traumatic Glaucoma, Congenital Glaucoma, Physiologic cupping without glaucoma, Congenital glaucoma, Neovascular glaucoma

8 Haitian Ophthalmology Residents Learning Gonioscopy

9 Residents Used Perkin tonometry to check IOP Used Perkin tonometry to check IOP There was a shortage of slit lamps and goldman applanation tonometry available There was a shortage of slit lamps and goldman applanation tonometry available Only one 3 mirror gonio lens present Only one 3 mirror gonio lens present Residents were trained to use the lens and also performed gonioscopy on each other Residents were trained to use the lens and also performed gonioscopy on each other Residents learned importance of optic disc drawings and were evaluated Residents learned importance of optic disc drawings and were evaluated Each resident advised that they must invest in a four mirror lens to properly evaluate glaucoma Each resident advised that they must invest in a four mirror lens to properly evaluate glaucoma

10 Resident Education Residents were given lectures on gonioscopy, optic disc evaluation, Target IOP in treating glaucoma, glaucoma surgical video were reviewed on trabeculectomy, trabeculotomy, Ahmed valve. Residents were given lectures on gonioscopy, optic disc evaluation, Target IOP in treating glaucoma, glaucoma surgical video were reviewed on trabeculectomy, trabeculotomy, Ahmed valve.

11

12 Must perform gonioscopy to r/o angle closure

13 AS-OCT iris light and dark

14 Indentation Gonioscopy Allows viewing of angle structures when Allows viewing of angle structures when there is appositional there is appositional Angle closure Angle closure Angle will not open if Synechia is present

15 Pupillary Block/Indentation Gonioscopy PAS

16 Treatment for Angle Closure is iridotomy and sometimes with iridoplasty

17 Identify small and large optic discs Identify small and large optic discs Small discs: avg vertical diameter < 1.5 mm Small discs: avg vertical diameter < 1.5 mm Large discs: avg vertical diameter > 2.2 mm Large discs: avg vertical diameter > 2.2 mm Average Average Large Large Size of cup varies with size of optic disc Size of cup varies with size of optic disc Large optic discs have large cups in healthy eyes Large optic discs have large cups in healthy eyes Small Small Optic Disc Size

18 Rim width: Rim width: Distance between border of disc and position of blood vessel bending Distance between border of disc and position of blood vessel bending S N T ISNT rule: Inferior > Superior > Nasal > Temporal ISNT rule: Inferior > Superior > Nasal > Temporal I Look at the Neuroreintal rim: ISNT Rule

19 Notching Notching Localized Rim Thinning/Notching

20 Patterns of Glaucomatous Progression Adapted from Tuulonen and Airaksinen. Am J Ophthalmol Type of progression of disc abnormality First glaucomatous optic disc change Disc cup enlargement Disc cup enlargement with local notching Local notch Pale neuroretinal rim; no change of configuration Normal optic disc (left eye) Diffuse enlargement: round-shaped Diffuse enlargement: vertically oval Broader local notch Pale rim; no change of configuration 13% 9% 9% 56% 22% 22%

21 OCT was taught available with Dr. Tavern

22 Localized Retinal Nerve fiber layer loss can be seen with red free light on ophthalmoscopy

23 Event Analysis, Look for VF progression was taught although only FDT available at the clinic Baseline Different from baseline?

24 Follow-up (years) % of visits % of visits % of visits % of visits Mean change in visual defect score AGIS 7 Sustained IOP reduction below 18 mmHg is correlated with stability of visual field Percent of Visits with IOP Less Than 18 mmHg AGIS Investigators, 2000, Am. J. Ophthalmol., 130, MEAN IOP 20.2 mmHg 16.9 mmHg 14.7 mmHg 12.3 mmHg

25 Medical Management vs Surgery Both Stabilize Visual Fields Collaborative Initial Glaucoma Treatment Study (CIGTS) Time in Months Visual Field Score Lichter et al, Ophthalmology, 2001 Nov: 108 (11) (reference IOP + VF score)/100 x Reference IOP =40% reduction 35%vs 48% 35%vs 48% IOP lowering IOP lowering

26 Ensuring Compliance With Antiglaucoma Treatment Communication Communication More than 40% of pts being treated with glaucoma do not realize it can lead to blindness More than 40% of pts being treated with glaucoma do not realize it can lead to blindness GRF survey Education Education Use the minimum number of medications required to safely achieve the target IOP Use the minimum number of medications required to safely achieve the target IOP QD and BID dosing offers best compliance regimens QD and BID dosing offers best compliance regimens Non-compliance can be as high as 50% for one med, 61% for two meds, 70% for multiple meds Non-compliance can be as high as 50% for one med, 61% for two meds, 70% for multiple meds Patel, Spaeth: Compliance in patients taking eyedrops for glauocma: Ophthalmic Surg ;3 ;

27 Do not forget Laser and filtering surgery if medical therapy fails or pts cannot obtain medications.

28 Dr. Eugene to perform Ahmed valve with corneal patch with resident watching

29 Haitian Ophthalmology 2 nd year Ophthalmology Residents performing trabeculectomy

30 Glaucoma Surgery 3 Ahmed valves performed 3 Ahmed valves performed 13 Trabeculectomies 13 Trabeculectomies 3 pediatric examination under anesthesia 3 pediatric examination under anesthesia 2 Trabeculotomy/Trabeculectomy 2 Trabeculotomy/Trabeculectomy

31 1 st year residents watching 2 nd year ophthalmology Residents performing glaucoma surgery

32 Congenital glaucoma Congenital glaucoma with trabeculotomy with trabeculotomy under general Anesthesia at the University Hospital Main Operating Room Able to be performed

33 Still a great need for sutures, instruments, Glaucoma valves and patches, and medications Special thanks to New World Medical, Alabama Eye Bank, and Alcon. 1 tube inserter also donated

34 Glaucoma Challenges for developing World Compliance Compliance Cost (Medicaitons per month vs Trabeculectomy ) Cost (Medicaitons per month vs Trabeculectomy ) Lack of manpower Lack of manpower Stigma associated with surgery Stigma associated with surgery Lack of glaucoma awareness Lack of glaucoma awareness Poor equipment maintenance Poor equipment maintenance Not enough visual rehabilitation programs Not enough visual rehabilitation programs

35 Potential Action items for Glaucoma Train a new generation of trainers in glaucoma subspecialty Train a new generation of trainers in glaucoma subspecialty Encourage sandwich fellowships with physicians in the US and Canada Encourage sandwich fellowships with physicians in the US and Canada Provide educational, training materials and resources from other countries and translate into French/Creole Provide educational, training materials and resources from other countries and translate into French/Creole Systematically link professional development with institution capacity development Systematically link professional development with institution capacity development Further develop and take advantage of online educational resources and link with HSO website Further develop and take advantage of online educational resources and link with HSO website

36 Towards the future in Haiti Important for eyecare providers and officials to ensure that glaucoma becomes a high priority along with cataracts as a treatable disease for blindness and to prevent blindness. Important for eyecare providers and officials to ensure that glaucoma becomes a high priority along with cataracts as a treatable disease for blindness and to prevent blindness. We need continued development, refinement and validation of clinical and educational programs We need continued development, refinement and validation of clinical and educational programs

37 Thank you Keep up the great efforts Keep up the great efforts You are not alone You are not alone Many are thinking of you and willing to work with you. Many are thinking of you and willing to work with you. I believe the private practice/public practice with sliding scale payments will succeed. I believe the private practice/public practice with sliding scale payments will succeed. Ongoing free eyecare by NGOs undermines ophthalmology in Haiti Ongoing free eyecare by NGOs undermines ophthalmology in Haiti Must support the residency program that is the future of ophthalmology in Haiti. Must support the residency program that is the future of ophthalmology in Haiti. Must support capacity in the ophthalmologists of HSO Must support capacity in the ophthalmologists of HSO WITH LIMITED RESOURCES AND SUPPLIES COLLABORATION IS ESSENTIAL WITH LIMITED RESOURCES AND SUPPLIES COLLABORATION IS ESSENTIAL


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