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Philosophies in Glaucoma Paul S. Jensen, O.D. Renton, WA

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Presentation on theme: "Philosophies in Glaucoma Paul S. Jensen, O.D. Renton, WA"— Presentation transcript:

1 Philosophies in Glaucoma Paul S. Jensen, O.D. Renton, WA

2 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 2

3 Philosophies in Glaucoma OHTS: Ocular Hypertension Treatment Study –The mother ship –OHTS is a gift to optometry 3

4 OHTS Corneal Thickness Separate the ocular hypertensives from the low tension glaucoma 4

5 OHTS Conclusions: –Decreased IOP = decreased morbidity –Glaucoma suspects should be considered candidates for treatment 5

6 OHTS Conclusions: -There was little evidence of increased systemic or ocular risk associated with ocular hypotensive medications 6

7 OHTS Risks of Ocular Hypotensives Meds show: - Near zero plasma levels - Measurable urine and cardiac out-put changes 7

8 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 8

9 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 180 o 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 180 o 9

10 The Philosophies of Glaucoma 1956-1986: –IOP, ONH, VF 1986: IOP doesnt matter 10

11 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 11

12 Dont be a plumber! Go to the original research Google Scholar, Medline, Elsevier, AOA 12

13 Clinical Pearls The only thing better that learning from your mistakes, is learning from other peoples mistakes. - P. Jensen 13

14 Clinic Pearls Treatment Pitfalls: - Blame the patient! - Compliance (importance of treatment, ability to follow Tx plan) - Poor gtt technique - gtt Allergy/Intolerance/Sensitivity 14

15 Clinical Pearls ITD/K-spindle - Blue irides (myd) - Myopic - Middle aged - Male & …. - Anyone…. Pigment Dispersion Syndrome & cataracts (?) 15

16 Clinical Pearls Pseudo-exfoliation Syndrome Older men Watch for angle closure Cataract extraction helps? Difficult to control Fluctuating IOP 16

17 Clinical Pearls Cupping/SLO? VF? IOP? ONH Drusen 17

18 Clinical Pearls Increased bioavailability Dramatically increased efficacy…. Dramatically increased allergy Lacrimal Occlusion 18

19 Clinical Pearls Beta blockade Steroids: - increasing incidence - all routes of administration Systemic Medications 19

20 Clinical Pearls Ask at each visit Prostaglandin analogs – body, joint ache Systemic Side Effects of gtt 20

21 Clinical Pearls Drop usage and technique Documentation, flow sheet Monocular medical trials Mundane Details 21

22 Technologies SLO - GDx - HRT II/III - OCT Other Dont be a plumber, understand the technologies 22

23 GDx Based on RNFL changes around disc Excellent at detecting early changes Good statistical analysis - Good change plots Portable: easy to share/move 23

24 GDx Interpreting the results OD/OS comparisons Color coding is intuitive Be careful with tilted discs NFI 24

25 GDx 25

26 GDx 26

27 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 Americans 27

28 HRT II/III 28

29 HRT II/III Corneal Module, tissue eval, not contour FA Poor Portability (HRT II) 29

30 HRT II/III 30

31 HRT II/III Interpreting the results Vascular tissue and nerve tissue all look alike HRT III: GPS, a number! 31

32 OCT Optical Coherence Tomography Most beautiful images in ophthalmic practice Eval peripapillary bundles ONH cupping - changes can be seen, but measurements not standardized 32

33 OCT 33

34 OCT Interpreting the results RNFL Thickness: Data similar to GDx Cupping: Subjectivity No standardization 34

35 OCT 35

36 Other Technologies Glaucoma LASIK Pre-op Corneal edema/Fuchs dystrophy Keratoconus (?) Inexpensive, reimbursable, easy as tono Pachymetry 36

37 Other Technologies Looks like Goldmann, but - Concave tip - CCT independent - Reads OPA (mean max – mean min) Pascal ® Dynamic Contour Tonometer 37

38 Other Technologies Pascal® Dynamic Contour Tonometer 38

39 Other Technologies Helpful in understanding glaucoma Necessary for Tx/management? Excellent tool for following numerous systemic/pharm effects on vascular perfusion Ocular Blood Flow 39

40 Other Technologies Paradigm OBF Analyzer 40

41 Other Technologies - OBF Reads: - IOP/tonography - OBF microl/min - Pulse TonoPlus 41

42 TonoPlus 42

43 Other Technologies Ocular Response Analyzer Measures corneal hysteresis (corneal resistance), distinct from CCT 43

44 Other Technologies Diaton Tonometer Transpalbebral Limbal +/- 2 to 20 mmHg, +/- 10% to 60 mmHg 44

45 Other Technologies Diaton Tonometer 45

46 Other Technologies Billing Technologies Accufee® and others EMR 46

47 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 47

48 Thanks! Special thanks to Lindsey Sewell, OD, FAAO for help in preparing this presentation.

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