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AN EXAMPLE OF GLAUCOMA DETECTION IN INDIAN OPTOMETRY CLINIC

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Presentation on theme: "AN EXAMPLE OF GLAUCOMA DETECTION IN INDIAN OPTOMETRY CLINIC"— Presentation transcript:

1 AN EXAMPLE OF GLAUCOMA DETECTION IN INDIAN OPTOMETRY CLINIC
-Rajesh Wadhwa M.Optom B.Sc.Hons.(Ophth.Tech.)(AIIMS) B.Sc.Hons.(DU); FIACLE;PGDHRM

2 Thank you for educating us: It was just stated..
Dr.Sudhamathi: A B Dr.Sood: A> B> Rajesh Wadhwa

3 Thank you for educating us: It was just stated..
Dr.Sudhamathi: Glaucoma is a silent thief of sigh Optoms can look for VH grading ACG more often In Hypermetropes Rubeosis Irides is a sign Rajesh Wadhwa

4 Thank you for educating us: It was just stated..
Dr.Sood: Loss due to glaucoma is irreversible Classical symptoms of acute glaucoma are often missing Talked about categories of high-risk patients Important investigations are Tonometry, gonioscopy, document the state of optic disc & visual fields. We primarily work towards lowering the IOP Rajesh Wadhwa

5 Glaucoma-India-Optometrist “link”
Without gonioscopy With or Without a perimeter/ OCT/ HRT Is there a link ? Yes ! Golden because of great out-reach at very low cost Rajesh Wadhwa

6 What is the “Key to Success”
We found the link We worked towards it We succeeded in preventing several more eyes from blindness What is the “Key to Success” Rajesh Wadhwa

7 Why did we look for the key to success: a confession
Way back in the year 2000 We analyzed our available clinic data Over 50,000 patients seen in 20 years (1979 to 1999 ) Total positive glaucoma cases detected= 6 Rajesh Wadhwa

8 Was that good enough? WHO score
Indian population has over 2% incidence of glaucoma We should have detected at least 1000 positive glaucoma cases We had missed many: Disheartening and added to the feeling of guilt Many clinics are making this mistake inadvertently all over the world Rajesh Wadhwa

9 This needed an immediate intervention: Identified the limitations
Legislation Clinical attitude towards detection of glaucoma No tonometry How much is glaucoma detection dependent on these? Space & time Rajesh Wadhwa

10 How dependent is glaucoma detection on these?
Most important screening tests are: IOP: for over a century Optic Nerve head analysis Visual fields Need the trio together Though today’s science is way beyond this--but doing this much can save several eyes (as it did for centuries). Rajesh Wadhwa 6

11 Why are we asking for trio together?
IOP: alone is not a stand alone indicator (over 40% of Px have normal IOP at the time of diagnosis) Optic nerve cupping: it's common for some people to have optic nerve cups that are larger than “normal” Visual fields: even the visual fields can change back and forth and can sometimes be influenced by medication. (may not be available) We can add other details (to be discussed in later slides). 4 Rajesh Wadhwa

12 2 instrumental limitations (1=Tonometry)
No S/L initially Lack of space for Schiotz Applanation after acquiring slit lamp Sterilization of Appln. very difficult Needs topical anesthetic. Rajesh Wadhwa 5

13 2 instrumental limitations (2= gonioscopy)
Not practiced at optometry school Also needs topical anaesthetic 2 Rajesh Wadhwa

14 With inward compulsion to save more eyes We broke the barrier: tonometry & gonioscopy
Tonometry: We invested into an expensive non-contact tonometer Gonioscopy: Fletcher in his book says:”The Van Hericks grading of peripheral AC depth is so accurate that I did not feel the need to learn the skills of gonioscopy” Rajesh Wadhwa

15 Limitation that remained was of “clinical attitude”
In routine-refraction, we became more attentive to following: Symptoms Family history IOP assessment Optic nerve head assessment High-risk categories Details……….(cont.). 7 Rajesh Wadhwa

16 Symptoms Most often: Reported for routine refraction but rarely (On close probing) Headache/ Eye-pain/Colored halos Transient blackouts/ Heaviness in eyes Nyctalopia Frequent change of glasses . 5 Rajesh Wadhwa

17 Categories encouraged for tonometry:
Age above 40years Diabetics /Hypertensives Hypermetropes Family history of glaucoma or Diabetes H/o previous eye injury/ disease or surgery Cataract / Iritis Relevant drugs being taken (systemic/topical). 5 Rajesh Wadhwa

18 What tests do we perform in optometric set-up
VA assessment Refraction Cover-test Direct ophthalmoscopy S/L exam if needed Tonometry (filter exists) Among these what will hint towards “glaucoma suspect” ? 7 Rajesh Wadhwa

19 Noteworthy findings that add to suspicion of glaucoma
Accepts for near an "Add" value higher than what usually corresponds with age Frequent change in refractive error 2 Rajesh Wadhwa

20 Lens & Iris: Lens intumescent
intumescent cataract a mature cataract that progresses; the lens becomes swollen from the osmotic effect of degenerated lens protein, and this may lead to secondary angle closure (acute) glaucoma. Rajesh Wadhwa

21 Rubeosis iridis (especially in diabetics)
New vessels appear on the iris.  When this occurs, careful inspection of the anterior chamber angle is essential, as growth of neovascularization in this location can obstruct aqueous fluid outflow and cause neovascular glaucoma. Rajesh Wadhwa

22 Peripheral anterior chamber depth: Eclipse test
Eclipse Test: Shadow of iris eclipses/ does not eclipse the other side . Rajesh Wadhwa

23 Peripheral anterior chamber depth:VH Grading
Van Herick's Grading under S/L (Grade 1 is shallowest, Grade 4 is widest) Rajesh Wadhwa

24 Van Herick's Grading under S/L:
Corneal thickness:periph. AC ratio (60° illum. angle) <1:1/4= Gr 1 1:1/4 = Gr 2 1:1/4 to 1:1/2= Gr 3 = or > 1:1/2= Gr 4 Rajesh Wadhwa

25 Optic nerve head assessment
Rajesh Wadhwa

26 ISNT criterion Oval disc Round cup T N I S Rajesh Wadhwa

27 Cup:Disc Ratio recorded in its widest axis
Diameter of Cupping can be =pallor or Cupping>Pallor Pallor Ratio= Contour Ratio or not A B Rajesh Wadhwa

28 Considered as Glaucoma suspect
ISNT criterion not met C:D ratio >/=0.5:1 Interocular diff. of C:D=/>0.2 IOP > 20mmHg Interocular diff. Of IOP =>4mm Hg Rajesh Wadhwa

29 Other reasons for suspecting glaucoma
Cup: Oval along 6-12 o’clock axis Asymmetry between discs of two eyes is present. Asymmetry does occur normally but the possibility of pathological significance is there especially in the absence of marked axial anisometropia Rajesh Wadhwa

30 Other reasons for suspecting glaucoma
Site of cup: Superior/ Superior temporal/ Inferior/ Infero-temporal. Inferior location of cup has higher index of suspicion due to the more frequent superior field defects seen in glaucoma Focal disc damage: Pit near 6 o'clock Rajesh Wadhwa

31 Vessels Continuity: The blood vessels do not appear continuous at the disc margin Baring of circumlinear vessel Splinter shaped hemorrhage on disc margin Rajesh Wadhwa

32 Other reasons for suspecting glaucoma
Vessels Pulsation: NO spontaneous arterial pulsation. (A spontaneous arterial pulse is more likely to be seen if the IOP is high) 2 Rajesh Wadhwa

33 Basis of inference Did we gain anything by doing all this? Results…….
All foregoing indicators are kept in mind for referral Fields, WDT, diurnal variation, Gonioscopy ,OCT etc. are to be considered in suspected cases Did we gain anything by doing all this? Results……. Rajesh Wadhwa

34 Compared to previous 20 years
This is an amazing improvement over our previous results 6 in 20 years, 22 in 1 year Compared to previous 20 years Rajesh Wadhwa

35 …Just 3 minutes more

36 Limitation in statistics:
This is retrospective analysis Population sample is from 1 clinic in north India Extra charges were taken for this checkup (therefore filtered) Actual incidence could be higher 4 Rajesh Wadhwa

37 Do we really need tonometry?
All said-and done, tonometery is important in detection of glaucoma If an optometrist is permitted to use that one drop of topical anesthetic then many more eyes can be saved Rajesh Wadhwa

38 How clear is our knowledge about glaucoma
ONE EXTREME: elevated IOP is not glaucoma. Elevated IOP is only a risk factor and is not prognostic (no magic figure) OTHER EXTREME: New research suggests that Glaucoma, what we know to be an ‘eye disease’, should instead be characterized as a neurologic disorder similar to what causes nerve cells in the brain to degenerate and die – like what occurs in Parkinson’s and Alzheimer’s diseases. The new research paradigm focuses on the damage that occurs in retinal ganglion cells (RGCs), which connect the eye to the brain through the optic nerve. Rajesh Wadhwa

39 Where do we stand We have treatment “for” glaucoma
We do not have treatment “of” glaucoma Rajesh Wadhwa

40 Take home message IOP measurement is important in detection of glaucoma Optometrist is the first line of defense against blindness & optometrists are eagerly waiting for government’s permission to use diagnostic drugs like topical anesthetics to save more eyes. Aspects other than IOP can also be indicators for “glaucoma suspect” It is better to refer out one extra “glaucoma suspect” than one less Rajesh Wadhwa

41 Thank you! My contact: r_wadhwa@yahoo.com
Let us plant a sapling of good practice today…. ..and enjoy the fruits tomorrow Rajesh Wadhwa


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