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Philosophies in Glaucoma

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Presentation on theme: "Philosophies in Glaucoma"— Presentation transcript:

1 Philosophies in Glaucoma
Paul S. Jensen, O.D. Renton, WA Dr. Walker’s class Plumber story, the most noble of all vocations

2 Philosophies in Glaucoma
How not to be a plumber Making sense of information from disparate sources Clinical Pearls New Technologies (and new looks at some older stuff) Not talking about drugs, mechanisms of action, indications/contra-indications What is not found in textbooks, this is Berkeley, you can read and memorize better than I can Decision making at chair side No protocols for glaucoma, if nothing else don’t get wrapped up in a cookbook approach Allows for some creativity, time, limits are pt based Clinical Pearls – what I wish I’d known before I started treating glaucoma Too much information – like early corneal topography Commonality: how to think, not be a plumber – separating techs from docs 2

3 Philosophies in Glaucoma
OHTS: Ocular Hypertension Treatment Study The mother ship OHTS is a gift to optometry How to make research work for you OHTS as an example of how to take in info, and prioritize Gift to optometry: all patients treated topically No train wreck patients 3

4 OHTS Corneal Thickness Separate the ocular hypertensives
from the low tension glaucoma Examples of thick and thin patients. IOP mid 20s, clear VF, SLO, pachy = 620 micrometers Also, IOP mid teens, .6 cupping, pachy = 480 Pachy helps make cases obvious, most technology is not needed for dx of obvious cases OHTS doesn’t tell us why. Explicitly stated, thin corneas may be inaccurate Goldmann tonos or may be thin lamina supporting the nerve tissue at the disc. 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” Don’t be afraid to prescribe 6

7 Risks of Ocular Hypotensives
OHTS Risks of Ocular Hypotensives Meds show: - Near zero plasma levels - Measurable urine and cardiac out-put changes Don’t be fool hardy when prescribing Elderly with congestive heart failure and COPD, no beta-blockers Journal: Ophthalmology – Pts on Beta Blockers have higher risk death from of cardiovascular disease. Controversial! 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 Dx gets tougher, because the decisions are increasingly subtle. That is when technology helps. 8

9 Philosophies in Glaucoma
Case Study A: IOP = 28, CCT = 556 VF = questionable C/Ds = OD: 0.6 X 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 OS: 0.5 X 0.5 Gonio = Grade 4 X 180o No protocol, ten docs will give you ten different tx plans Decision tree, all over again How do you establish target iop? 30% iop reduction 9

10 The Philosophies of Glaucoma
: IOP, ONH, VF 1986: IOP doesn’t matter Reliance on a single number to diagnose! 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 IOP: we are certainly getting away from the idea of a single number indicating the presence or absence of glaucoma I am inherently distrustful of any oversimplification, single numbers Onh in context of good binocular cupping view. Nothing replaces a careful stereo view. 11

12 Don’t be a plumber! Go to the original research
Google Scholar, Medline, Elsevier, AOA Plumber’s rely on low hanging fruit. Single numbers, shortcuts, hearsay 12

13 Clinical Pearls “The only thing better that learning from your mistakes, is learning from other people’s mistakes.” - P. Jensen Numerous unrelated items, comes under the heading of"I wish I had known..." or I wish I had listened better... We could all come up with this list if we sit down and think, but now you don't have to. Your chance to learn form my mistakes. I like to experient, with the jury watching and a back up plan, Protocol eg: Lumigan bid, turned out to be a good experiement, if it didn’t work, would have been a smart mistake. 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 Clinical Pearls: What I wish I had been told before I started treating glaucoma Patton(?) “Never give an order that can’t be obeyed”. More than bid is a problem, tid means carrying/remembering Geriatric, shaky, Parkinson’s Some patients are laser/surgery candidates based on compliance Alphagan – P from .2% to .15% brimonidine Oct 23 samples available, Travatan-Z, without BAK, by Alcon (decreased penetrance?) Lumigan and Xalatan (and almost all other glaucoma drugs) have BAK Ironically, Alphagan has Purite, not BAK Should help with dry eye, possibly for allergy, too! 14

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

16 Pseudo-exfoliation Syndrome
Clinical Pearls Pseudo-exfoliation Syndrome Older men Watch for angle closure Cataract extraction helps? Difficult to control Fluctuating IOP Don’t fall in love with non-myd cameras 16

17 Clinical Pearls ONH Drusen Cupping/SLO? VF? IOP?
Look for studies regarding onh drusen and iop Admit bias, cya If cupping is noncontributory to dx, will GDx be helpful? RNFL thinning by GDx is correlated to VF loss, but not nec diagnostic of glaucoma. Practice management: discuss with pt. Non-eye care providers may see it and panic, or worse yet, another eye doctor will mention it, and the pt will wonder about you. 17

18 Clinical Pearls Lacrimal Occlusion Increased bioavailability
Dramatically increased efficacy…. Dramatically increased allergy 5 drops per day to 1 Glaucoma is not an indication for occlusion 18

19 Clinical Pearls Systemic Medications Beta blockade Steroids:
- increasing incidence - all routes of administration Depot or intravitreal Kenalog expert: Dr. Barez Her job is not to treat glaucoma, that is primary care, our job Same as with cataract extraction 19

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

21 Clinical Pearls Mundane Details Drop usage and technique
Documentation, flow sheet Monocular medical trials These are things that I was told about. Documentation – reminds you of your plan. When you plan the fork in the road, have a decision making process for either outcome. Medico-legal defense. Flow to remind you which testing needs to be done. Monocular trials, check in one month for any change in Tx (med or dosage). Mild controversy: some have come out against monocular trials. Don’t have too high of expectations. Beta blockers definitely have overflow between the two eyes. Single tono checks to determine treatment success is not wise. Monocular trial is standard of care Icon from the 21

22 Don’t be a plumber, understand the technologies
SLO - GDx - HRT II/III - OCT Other SLO: Scanning Laser Ophthalmoscopy – many questions on these older technologies Medicare: Scanning Computerized Ophthalmic Diagnostic Imaging, SCODI Porsche, Mercedes, BMW, which one should you get? Because of high costs, you must justify your decision! Don’t hang around with those HRT criminals and those OCT morons 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 Zeiss Retardation of polarized light proportional to thickness of RNFL around disc. If I only had one chance at diagnosis of glaucoma, this is the instrument. Words about sharing, schedule by month, glaucoma is not acute. 23

24 Interpreting the results
GDx Interpreting the results OD/OS comparisons Color coding is intuitive Be careful with tilted discs NFI Nerve fiber index 1 – 100 scale 1 – 30 = normal 31 – 50 = borderline 51 – 100 = abnormal I am inherently skeptical of single number answers 24

25 GDx Left good Center ok Right poor
Shows the polarization around the disc 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 Original HRT (I?) was a research tool – slow cpu, data crunching, no normative analysis Indirect measure of contour and thickness Moorfields Regression Analysis 27

28 HRT II/III HRT II/III Pictures and color print outs are like gray scale in VF. Good for showing pt, but the numbers are where the action is. 28

29 HRT II/III Corneal Module, tissue eval, not contour FA
Poor Portability (HRT II) Corneal module, hydration, not contour. Clinical use? Looks like electron micrograph, not topography 29

30 HRT II/III Best inst to show anatomy to pts, change stats more important 30

31 Interpreting the results
HRT II/III Interpreting the results Vascular tissue and nerve tissue all look alike HRT III: GPS, a number! Can’t be a plumber in interpretation Not to be out done be Zeiss, Heidelberg has the GPS: Glaucoma Probability Score, single number that reflects back on the simpler days when we had a single number for diagnosis: IOP. 31

32 Optical Coherence Tomography
OCT Optical Coherence Tomography Most beautiful images in ophthalmic practice Eval peripapillary bundles ONH cupping - changes can be seen, but measurements not standardized OCT best for space consuming lesions eg edema, central serous neovasc, nevi, pig hypertrophy, melanoma. Or breaks as in RD, macular holes, or Bruch’s membrane RNFL eval much better than ONH eval 32

33 OCT 33

34 Interpreting the results
OCT Interpreting the results RNFL Thickness: Data similar to GDx Cupping: Subjectivity No standardization Zeiss Color coding, red and magenta – color deficiency-ists 34

35 OCT Pigmentary crescent, myopic crescent can pollute data
End of Scanning Laser Ophthalmoscopy – studies are mixed about which is better. Again, read the studies not as a plumber, but as how they relate to your patients and practice, not just a disease. 35

36 Other Technologies Pachymetry Glaucoma LASIK Pre-op
Corneal edema/Fuch’s dystrophy Keratoconus (?) Inexpensive, reimbursable, easy as tono Billing other than glaucoma? So easy, even a doctor can do it. 36

37 Pascal ® Dynamic Contour Tonometer
Other Technologies Pascal ® Dynamic Contour Tonometer Looks like Goldmann, but - Concave tip - CCT independent - Reads OPA (mean max – mean min) Each instrument manufacturer uses terminology slightly different than other mfg. Confusing as to which instrument measures which parameter. Better mousetrap? Tonography? OPA = ocular pulse amplitude (= Ocular Blood Flow)? Eliminates CCT and ocular rigidity as polluting factors $4,000 to $6,000 depending on volume purchased and accessories such as remote printer. 37

38 Dynamic Contour Tonometer
Other Technologies Pascal® Dynamic Contour Tonometer Printout looks like MacKay-Marg 38

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

40 Other Technologies Paradigm OBF Analyzer ophthaldynomometer 40

41 Other Technologies - OBF
TonoPlus™ Reads: - IOP/tonography - OBF microl/min - Pulse Tonography = IOP over time Originally designed to measure aqueous outflow Modified to measure pulsitile ocular blood flow Great for measuring the effects of systemic and ocular medications and systemic and ocular disease on retinal perfusion 41

42 TonoPlus ™ POD = Portable Ophthalmic Devises 42

43 Ocular Response Analyzer
Other Technologies Ocular Response Analyzer Measures corneal hysteresis (corneal resistance), distinct from CCT Hysteresis is a measure of strength 43

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

45 Other Technologies Diaton Tonometer
End of clinical technologies – the problem is and will be: too much information! 45

46 Other Technologies Billing Technologies Accufee® and others EMR
Electronic Medical Records will eventually keep us from making coding, billing, prescription, and follow up care mistakes. 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 These are real people with real lives, eg Neal S. Jensen, O.D. UCBSO class of 1957 47

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

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