Download Controversies in Glaucoma

Controversies in Glaucoma
Anthony B. Litwak, OD, FAAO
John Spalding, OD, FAAO
CCT – IOP fix or Something More?
CCT and Ocular Hypertension
CCT and Glaucoma
 Arch Ophth 2004 / Herndon LW
 350 eyes/190 patients - Cross sectional study of glaucoma patients and CCT
 Glaucoma patients with a thinner CCT had greater glaucoma damage (AGIS score, MD, C/D and # of G
meds)
 A thinner CCT in a glaucoma patient may place the patient at greater risk of glaucoma progression
Risk CalculatorBrilliant or Bonehead Idea?
Is One Ever Enough?
The IOP in Glaucoma Fluctuates More Than You Think
 Diurnal Changes More Common in Glaucoma (Greater 6 mm Hg)
 IOP Fluctuation Not Simply Based on Diurnal Variation
 IOP Can Vary From Day to Day
 You Can Never Rule Out an IOP Spike
What is the most important piece of information to determine if a patient has glaucoma?
Show Me The Nerve!!!
 Glaucoma is a disease of the optic nerve, specifically the ganglion cell axon
 Elevated IOP, AA race, + family history, older age, thinner CCT increase the RISK of developing
glaucoma
 Visual field loss is the end result
 Glaucoma is damage to the optic nerve
Does Size Really Matter?
A Big Cup Does Not Necessarily Mean Glaucoma
 There is No Demarcation Line Separating a Physiological Cup From a Glaucomatous Cup
 Physiological Cup Size Is Directly Related to Overall Disc Size
 Large Discs Will Have Large Physiologic Cups
 Small Discs Will Have Small Physiologic Cups
 Physiologic Disc and Cup Size Is Genetically Determined
 Physiologic Cup of .7 Or Greater Occurs in 2% of Normals
 A Small Disc With a Medium Size Cup Should Be As Suspicious As a Large Cup in a Medium Size
Disc
The NFL Doesn’t Stands for the National Football League
Interpreting VF’s – Back to Basics
Don’t Always Believe the Visual Field
 A Significant Number of Patients are Poor Visual Field Testers
 Poor Reliability - Look at Reliability Indicators
 Learning Curves - Repeat the Visual Field When the Field Does Not Match the Optic Nerve
 Always Correlate the Visual Field with the Optic Nerve
How Aggressive Should We Treat Glaucoma?
 1. Treat to “normalize” the pressure
 2. 30% reduction from the baseline IOP
 3. IOP target < 18
 4. IOP target < 15
 5. Extends all means to lower the IOP as low as possible
 6. Individualize the treatment for each patient
Setting Target Pressures
 “Estimated IOP where the risk of future visual impairment is balanced against the side effects of
treatment”
 Based on the Baseline IOP Readings (use the highest IOP reading)
 Based on the Amount of Optic Nerve Damage
 Based on the Rate of Glaucoma Progression
Glaucoma Drugs – Who’s on First?
Prostaglandin Agonists
 Xalatan
 Rescula
 Travatan
 Lumigan
Beta Blockers
Bad Drug or Bad Rap?
Beta-Blockers
 Most Cost Effective Glaucoma Medication
 Tolerate Very Well By The Majority of Glaucoma Patients
 Well Studied and Long Track Record (1979)
 Important to Screen Patients for Potential Contraindications
Uniocular Trials
Standard of Care or Substandard?
 Cross over affect of adrenergic agents
 Assuming diurnal variation is constant between the two eyes
 Compare a serial of IOP readings pre-medication and serial post-medication
 Make sure you have established the baseline diurnal variation
Lasers Wars – ALT vs SLT?
Judging Progression – Which Way is Best?
The Most Difficult Aspect of Glaucoma Management is Determining Progression
 Compare Serial Optic Nerve/NFL Photographs
 Compare Serial Visual Fields
 55% Progressed by Disc Photos and 35% Progressed by VF’s in OHTS Study
 89% Progressed on VFs and 11% Progressed by Optic Nerve Phototgraphs in NTG Study
 It is Difficult to Differentiate Long Term Fluctuation (can vary by 10db or greater) in the Visual Field
From Glaucoma Progression
 GDx, OCT, HRT
Normal Tension Glaucoma
Does It Really Exist?
NTG Clinical Pearls
 Common form of glaucoma (20%)
 Diagnosed by careful inspection of the optic nerve and NFL and screening VFs (FDT)
 Be sure to establish baseline IOP (Diurnal helpful)
 Check Pachymetry
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Similar in characteristics to POAG with some slight modifications
IOP lowering is beneficial in patients with NTG
Avoid non-selective beta blockers
Use Prostanglandins, alpha agonists, topical CAI’s, ALT and filtering surgery to achieve a 30%
reduction
NTG is Not A Diagnosis of Exclusion
The “C” Word
COMPLIANCE
Never Assume That Your Patient is Compliant
 Reasons For Poor Compliance
 Poor Patient Education
 Inconvenience of Instilling Eyedrops
 Hectic Lifestyle
 Side Effects of Medications
 Cost of Medications
Develop a Doctor-Patient Bond
 Starts From Day One
 Educate Patients About Their Disease
 Explain Benefits and Side Effects of Medications and Therapy
 Explain Other Glaucoma Treatment Options
 Use Dosing Schedule Sheets with Pictures of the Meds
 Emphasize the Positive
 Don’t Ignore the Negative
 Develop the Patient’s Trust