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.