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Clinical Pearls for Challenging Cases Glaucoma: Clinical Pearls for Challenging Cases MOA 2014 Case 34 yo, white, male Ant Segment: – K-Spindle, + ITD, 3+ TM pigment Michael Chaglasian, OD, FAAO Illinois Eye Institute Illinois College of Optometry [email protected] Disclosure GAT= 28/31 mmHg OD/OS Pachymetry = 595 µ Gonio and Slit Lamp Photos Michael Chaglasian has the following disclosures: – 1. Advisory Board: Allergan, Inc., Alcon Labs, Carl Zeiss Meditec The content of this presentation is in no manner influenced by any of the aforementioned parties or companies Agenda Common Secondary Glaucomas Ocular Perfusion Pressure Ocular Hypertension Adjunctive Therapy Options Suspicious Optic Nerves M. Chaglasian, OD 1 Clinical Pearls for Challenging Cases MOA 2014 PIGMENTARY GLAUCOMA GDx VCC see clinical triad of: – Krukenberg's spindle – Iris transillumination defects – heavy TM pigmentation PDS refers to those with these clinical findings but without any glaucomatous changes to the optic nerve glaucoma may develop in up to 50% of patients with PDS – Typically only 10-15%, literature shows wide variation RTVue 100 (Optovue) Case Assessment – PDS, High IOP, thick Pach – Normal ONH, Normal VF, Normal OCTs Plan / Discussion – Other Tests? » ___________________ – Treatment Trial : ______________ – Other considerations: ________________ M. Chaglasian, OD 2 Clinical Pearls for Challenging Cases MOA 2014 From: Primary Care of Glaucoma, Lewis & Fingeret 2000 Natural History of PDS/PG Scheie Strip pigment on the crystalline lens equator Mechanism photogrammetric and histological studies have shown that a concave posture (posteriorly) of the peripheral iris allows for rubbing against the lens zonules Exercise-induced pigment liberation: Pharmacologic pupillary dilation may result in marked pigment liberation accompanied by a rise in IOP. The same phenomenon may occur in some patients with PDS during strenuous exercise, particularly exercise involving jarring movements, such as jogging or basketball. Pretreatment with low-dose pilocarpine prior to exercise can limit both the pigment liberation and the IOP spike. Reverse Pupillary Block concept M. Chaglasian, OD 3 Clinical Pearls for Challenging Cases Pigmentary Glaucoma MOA 2014 PIGMENTARY GLAUCOMA The glaucoma part of this condition has the same requirements as POAG, that is ONH damage and or VF loss MIOTICS are a theoretical drug of choice in PG because of the mechanics: – Lifting the peripheral iris iris off the zonules – However their ocular side effects limit their success: » Low % (0.5) Pilocarpine solution Since they are poorly tolerated in young patients, they often cannot be used – Only, helpful in pigment liberation stage (early) Management Laser Trabeculoplasty Management of PG has two strategies: Argon or SLT 1) control of elevated IOP and prevent glaucomatous damage (primary) Both work well at first, – with up to 25% decrease in IOP, but then quickly lose treatment effect, often within 2-3 years 2) eliminate irido-zonular contact - if this is possible, it can reduce pigment liberation and over time allow the TM to get rid of the pigment granules PIGMENTARY GLAUCOMA Prostaglandins Alternatives: – Primary, first line therapy, best overall Laser Iridotomy – It eliminates the “reverse pupillary block” – By allowing direct aqueous flow into the AC, an equilibration of pressure is obtained which may help to move the peripheral iris off the lens zonules. – Brimonidine, CAI, Beta-Blocker, Fixed-Combination Use these and look for a significant decrease in IOP. – Still monitor pigment liberation via slit lamp and gonio. Many patients require multiple meds M. Chaglasian, OD Is another treatment option for PDS/PG. Only for active PDS, not for older patients. Medications are tried first 4 Clinical Pearls for Challenging Cases MOA 2014 Prognosis = Caution Some patients with PG: – Have a severe, difficult to treat form, of the disease and end up with severe vision loss at an early age – Are diagnosed at a late stage because of low suspicion of glaucoma in younger patients and high fluctuation in IOP (patients seen with normal IOP) Case Case JB 54 yo WF Referred in for Glaucoma Suspect No significant Medical History GAT= 24 OD and 23 OS Pachs= 560 and 565 Gonio= – Open angle with moderate pigment Photos Assessment – PDS, High IOP, thick Pach – Normal ONH, Normal VF, Normal OCTs Plan / Discussion – Other Tests? » ___________________ – Treatment Trial : ______________ – Other considerations: ________________ There’s a Facebook page for Pigmentary Dispersion Syndrome?? Visual Field Guess how many “friends”? M. Chaglasian, OD 5 Clinical Pearls for Challenging Cases MOA 2014 Summary / Questions Slit Lamp Does this patient have glaucoma? If not, how high is the risk for developing glaucoma? What other tests need to be done? When do you see this patient back? When/How do you start treatment? What is the prognosis for this patient? RTVue Terminology Exfoliation Syndrome Exfoliation Glaucoma – XFS – XFG – “Psuedoexfoliation” term is still used by some » “PEX”, “PXS”, “PXG” Introduction and Background Exfoliation syndrome (XFS) is the most common identifiable cause of open-angle glaucoma worldwide. It is characterized by excess synthesis and progressive accumulation of abnormal extracellular fibrillar material – The continuous accumulation of exfoliation material (XFM) and pigment in the outflow system leads to elevated intraocular pressure (IOP) and eventually to the development of exfoliative glaucoma (XFG) M. Chaglasian, OD 6 Clinical Pearls for Challenging Cases MOA 2014 Introduction and Background It has been estimated that the worldwide number of individuals with XFS is between 60 and 70 million, – or equal to the total number of people in the world with glaucoma. About 25% of persons with XFS have elevated IOP, and one-third of these have glaucoma. Taking all epidemiological studies as a whole, XFG appears to account for about 15–20% of open-angle glaucoma in Caucasians. XFS in the Eye Classic Three Zones XFM frequently found at the pupillary boarder Pigment loss from pupillary ruff and deposition in TM – “Sandpaper” effect – Iris transillumination at margin Increased IOP post dilation – Via pigment liberation Genetics= LOXL1 Zonules, severe, coated by XFM, replaced, or frayed and broken leading to phacodenesis Lysyl oxidase-like 1 gene (LOXL1) – genomewide association study of 16,000 Icelandic and Swedish participants, – two mutation of single base differences in the sequence of the LOXL1 gene – accounted for 99% of all cases of exfoliative glaucoma (although not everyone with them gets glaucoma) – Same findings found in a recent US study lysyl oxidase family of genes is necessary for the formation and maintenance of elastic tissue, and the Extra Cellular Matrix (ECM) Thorleifsson G, et al Science. 2007 Fingert JH, Am J Ophthalmol. 2007 M. Chaglasian, OD 7 Clinical Pearls for Challenging Cases LOXL1 the effect of the genetic variants now detected in the LOXL1 gene seems to be to lower the production rate of the protein it specifies slightly lower production rate of LOXL1 may be harmless during most of a lifetime, the deficit may accumulate through many decades, explaining why exfoliative glaucoma is most common among the elderly MOA 2014 Results: Thorleifsson G, et al Science. 2007 Genetic Testing Our genetic health scans cover an ever growing range of conditions. http://www.decodeme.com How? How Much $$$? http://www.decodeme.com M. Chaglasian, OD 8 Clinical Pearls for Challenging Cases MOA 2014 Treatment for Hyperhomocysteinemia XFS in the Eye XFG patients exhibit a greater fluctuation in the 24-hour IOP curve than patients with POAG lens subluxation, phacodonesis – weakened lens zonules Potential treatment recommendation: – FOLTX™ tablets: » Folacin (Folic Acid) 2.5 mg » Pyridoxine (B6) 25 mg » Cyanocobalamin (B12) 2 mg – Potential complications in cataract extraction cataract formation poor dilation and posterior synechia narrow angles/angle closure Elevated Homocysteine Levels Highly cytotoxic amino acid derived from methionine metabolism. – It is found in plasma, aqueous humor, and tear fluid in XFS with and without glaucoma Elevated HC levels are a recognized cardiovascular risk factor, get levels!!!!! HC levels are inversely associated with intake of folate and vitamins B2, B6, and B12 Does FOLTX have a proven benefit? Treatment benefits have not been demonstrated yet. Folic Acid Treatment on High Risk Women. JAMA 2008 So? – Potential treatment recommendation Does a Normal, Healthy patient with a new diagnosis of XFS/XFG need labs and work up? – Unclear at this time – With Risk Factors = YES ! Diagnosis Plasma Levels Of Homocysteine in XFG Diagnosis made essentially as it is for POAG. Understand that the patient is a higher risk and thus treatment may be started earlier, but ALL patients with XFS do NOT need treatment. Elevated levels (>14 µg/l) in up to 43% of patients with XFS/XFG. Graefes Arch Clin Exp Ophthalmol (2011) 249:443–448 M. Chaglasian, OD 9 Clinical Pearls for Challenging Cases MOA 2014 Medical Therapy Prostaglandins – In a recent parallel diurnal study, latanoprost was slightly more effective than timolol in lowering IOP in eyes with XFG. – There was a trend for better diurnal IOP control with latanoprost and a significantly lower diurnal fluctuation and mean peak IOP with this therapy. Beta Blockers CAI’s Cholinergics – Reports are mixed on the success of this class of medications – Dorzolamide has had mixed success in several studies Key Points Careful slit lamp exam pre/post dilation Frequent IOP checks for patient with the syndrome Work with PCP on Homocysteine levels Treat glaucoma more aggressively Note findings for cataract surgeon – 1% pilocarpine at bedtime!!!, stop the pupil from moving Laser Therapy ALT is particularly effective, at least early on, in eyes with XFG The initial drop in IOP is greater in XFG Case JB Dx: 1. Exfoliation Syndrome/Glaucoma High Risk but No evidence of glaucoma damage at present Plan: 1. IOP recheck 1-2wks, diurnal flux 2. Then start PGA qhs OU 3. Repeat testing in ~9 months 4. Patient to discuss with PCP to check homocysteine level at next visit – Several studies, however, have reported a gradual reduction in success over time, with long-term success drops to approximately 35-55% at 3-6 years. Selective laser trabeculoplasty (SLT) may be an effective and safe alternative to ALT in the treatment of XFG Surgical Therapy The results of trabeculectomy in XFG are comparable to those with POAG. However, surgical complications are more common in patients with XFS. – Weakened zonular support may allow intraoperative lens movement or, in extreme cases, subluxation The most important and the most difficult choice for treating XFG is still the decision for timely surgery. M. Chaglasian, OD Case WS 75 yo male + HTN w/ multiple BP meds x 20+ yrs – 105/68 in office – 5’ 5”, 142 lbs CCT= 532µ Initial IOP 23 mmHg Current Medication: Good compliance and follow up – Now repeatedly 11-13 mmHg over 5+ years – PGA 10 Clinical Pearls for Challenging Cases MOA 2014 Photos Guided Progression Analysis™ (GPA™) 9 Years Later. Can you see the change? Stereo Photos Obtain Baseline Photographs – Stereo is preferred » Screen-Vu Stereo Viewer™ www.berezin.com – Read, Review, and Document in record – Repeat periodically, or when change is suspected M. Chaglasian, OD 11 Clinical Pearls for Challenging Cases MOA 2014 OPP and Glaucoma: Hemodynamics Case WS Q= What is the Explanation? Compliance? – Progression with IOP in low teens. Other Potential Risk Factors: 24 Hour IOP – Highest IOP in Nocturnal Period (midnight-5AM) DOPP – Diastolic Ocular Perfusion Pressure • SPP = SBP – IOP • DPP = DBP – IOP Diastolic Measure • easiest to use, best current evidence • MPP = 2/3 mean arterial pressure – IOP • Arterial Pressure = DBP + 1/3 (SBP – DBP) • May best reflect perfusion physiology Higher IOP Negatively Impacts Perfusion Pressure Ocular Perfusion Pressure and Glaucoma Ocular Perfusion Pressure Lower Diastolic, Systolic, or Mean Pressure Reduces Perfusion Pressure risk factor for glaucoma New Evidence Ocular Perfusion Pressure (OPP) = BP – IOP (BP is mean arterial pressure, diastolic BP, or systolic BP) Ocular Perfusion Pressure Lower Perfusion Pressure Is Associated with Increased Risk for Open Angle Glaucoma Higher IOP Negatively Impacts Perfusion Pressure Perfusion Pressure Is a Result of A Delicate Balance Between IOP and Blood Pressure Leske MC, et al. Ophthalmology 2007; 114,: 1965-72 Leske MC, et al. Ophthalmology 2008;115, 65-93. Hayreh SS. Trans Am Acad Ophthalmol 1974;78:240-54 Ocular Perfusion Pressure and Glaucoma The differential between arterial BP and IOP – Ocular perfusion is regulated to maintain constant blood flow to the optic nerve despite fluctuating blood pressure and IOP – The major cause of reduced blood flow is thought to be secondary to vascular dysregulation in susceptible patients, resulting from abnormal/insufficient autoregulation. M. Chaglasian, OD Lower Diastolic, Systolic, or Mean Pressure Reduces Perfusion Pressure Lower Perfusion Pressure Is Associated with Increased Risk for Open Angle Glaucoma Perfusion Pressure Is a Result of A Delicate Balance Between IOP and Blood Pressure Leske MC, et al. Ophthalmology 2007; 114,: 1965-72 Leske MC, et al. Ophthalmology 2008;115, 65-93. Hayreh SS. Trans Am Acad Ophthalmol 1974;78:240-54 12 Clinical Pearls for Challenging Cases MOA 2014 Ocular Perfusion Pressure and Glaucoma Progression POAG Risk Factors at year 9 Barbados Eye Study Ocular Perfusion Pressure (OPP) = BP – IOP (BP is mean arterial pressure, diastolic BP, or systolic BP) Highest Risk Low ocular perfusion pressure has been shown to be strongly associated with the prevalence of glaucoma progression in multiple population-based surveys Tielsch JM, et al. Arch Ophthalmol. 1995. Leske MC, et al. Arch Ophthalmol. 1995. Leske MC, et al. Arch Ophthalmol. 2002. Quigley HA, et al. Arch Ophthalmol. 2001. Bonomi L, et al. Ophthalmol. 2000. Leske et al.Ophthalmology 114 (11), November 2007 Leske MC, Wu S-Y, Nemesure B, et al. Ophthalmol 2008;115:85-93. OPP and Glaucoma Progression: Population Studies Studies Summary Baltimore Eye Survey (AA and Caucasian)1 – 6x excess of POAG in subjects with lowest category of Ocular Perfusion Pressure (OPP) Egna-Numarkt Study These large studies provide strong evidence among different populations for the relationship between vascular deficits and the prevalence, incidence and progression of glaucoma Some Limitations, (Caucasian)2 – Lower Diastolic Ocular Perfusion Pressure (DOPP) associated with marked, progressive increase in frequency of POAG Barbados 4 yr Eye Study (African-Caribbean)3 – 4-year risk of developing glaucoma increased dramatically at lower perfusion pressure Proyecto Ver (Hispanic)4 – Found lower Diastolic Perfusion Pressure (DPP) associated with increased risk of POAG 1. 2. 3. 4. – no direct measure of ocular blood flow – Varied definitions of hypertension Tielsch JM, Katz J, Sommer A, Quigley HA, Javitt J. Arch Ophthalmol 1995;113:216-21 Bonomi L, Marchini G, Marraffa M et al. Ophthalmology 2000;107:1287-93 Leske MC, Wu S-Y, Nemesure B, et al. Arch Ophthalmol 2002;120:954-9. Quigley HA, West SK, Rodriguez J, et al. Arch Ophthalmol. 2001;119:1819-26. Los Angeles Latino Eye Study Clinical Control of OPP Lower IOP improves OPP Cross-sectional study of 6,357 Latinos, >40 years in Los Angeles, CA. • • Persons with low diastolic and systolic perfusion pressures had a higher risk of POAG. • Measure blood pressure on your patients • • DOPP <50 mmHg, the prevalence of glaucoma rapidly increases linearly. Higher systemic BP improves OPP, but you do not necessarily want to raise BP: • • Remains number 1 goal !! • Stroke #3 cause of death in US behind CVD & CA! • Avoid drugs that lower systemic BP beyond patient’s desired systemic control. • Communicate with PCP Varma R, et al. Ophthalmology. 2004;111:1439-1448. M. Chaglasian, OD • Look for nocturnal hypotension. 13 Clinical Pearls for Challenging Cases MOA 2014 Nocturnal Hypotension and OPP • 24 hr IOP Measure via SCL SENSIMED Triggerfish® - Continuous IOP Monitoring Low blood pressure (BP) at night, coupled with high IOP in supine position, compromise OPP. Not approved in USA • ? Up to 50% of patients with HTN • Using systemic BP meds in the AM to minimize nocturnal hypotension makes sense. • Using IOP lowering drugs that lower IOP while sleeping makes sense. • Avoiding IOP meds that LOWER systemic BP at night (beta blockers, alpha agonists) makes sense. Graham SL, Drance S. Surv Ophthalmol. 1999;43(suppl 1):S10-16. Hayreh SS, et al. Am J Ophthalmol. 1994;117:603-624. Colligan JC, et al. Int Ophthalmol 1998;22:19-25. Br J Ophthalmol 2011;95:627e629/ Back to Case 24 Hour Blood Pressure Holter Monitor Case WS Supine DOPP= – DBP of 68 mmHg @ 2PM and IOP of 12 mmHg – Gives 56 mmHg Nocturnal BP with Holter Monitor Nocturnal IOP (estimate) – DBP @ 2AM = 58 Sitting Blood Pressure – IOP of 12 mmHg @ 2PM = ?? @ 2AM ~ 18 mmHg Nocturnal DOPP – 58 -18 = 40 mmHg, potentially a high risk PCON October 1, 2005 M. Chaglasian, OD 14 Clinical Pearls for Challenging Cases MOA 2014 CASE AC Case WS Is there anything else that can be done? Possibly: – Offer Nocturnal IOP control – Offer Improved DOPP Add a CAI BID 45 yo, woman Myopia, no sig. medical history + family history glaucoma GAT= 27 OD 25 OS Pachs = 565 µ Letter to PCP, explain OPP and Low BP related Risk ? Adjust BP Meds 24-hour habitual IOP Azopt vs. timolol add-on efficacy DIURNAL/WAKE IOP (mm Hg) 22 NOCTURNAL/SLEEP CASE AC DIURNAL/WAKE latanoprost only (N=26) Azopt add-on (N=26) timolol add-on (N=26) 20 18 16 11:30 AM 1:30 PM 7:30 AM 9:30 AM 3:30 AM 1:30 AM 11:30 PM 9:30 PM 5:30 PM 7:30 PM 3:30 PM 5:30 AM 14 Clock Time Liu JHK, et al.. Ophthalmology 2008. I Summary VFs IOP Fluctuation plus Increased Nocturnal IOP plus Low Nocturnal Blood Pressure equals Low Diastolic Perfusion Pressure equals M. Chaglasian, OD 15 Clinical Pearls for Challenging Cases MOA 2014 Pachymetry Correction Values Corneal Thickness (µm) Correction Value 405 7 425 6 445 5 465 4 485 3 505 2 525 1 Conversion Charts: don’t really work NOT VALID! 545 0 565 -1 585 -2 605 -3 625 -4 645 -5 665 -6 685 -7 705 -8 Correction values according to corneal thickness of 545 µm What do you do now? M. Chaglasian, OD 16 Clinical Pearls for Challenging Cases MOA 2014 IOP and CCT Risk Calculator “Assuming that CCT can be used as a correction factor for GAT is a misinterpretation of the results of OHTS… that couldn’t be further from the truth. Adjusting IOP based on CCT is attempting to instill a degree of precision into a flawed measurement. You may actually correct in the wrong direction. The issues related to the most accurate tonometry need to include the material properties of the cornea” » James Brandt, MD, Director, Glaucoma Services, UC Davis http://ohts.wustl.edu/risk/calculator.html Risk Calculator Outcomes: Recommendation Guide to Patient Management (by expert panel) Pachymetry: 3 Outcomes <555 µ 5-Year Risk for Progression of OHTN Glaucoma Thin: High Risk Average: 555-588 µ No change in Risk Low Thick: Low Risk Moderate Risk Level >588 µ High Applied to patients with ocular hypertension 5% Monitor 5%-15% Consider treatment 15% Treatment OHTS – RC Limitations? http://ohts.wustl.edu/risk/calculator.html Recommendations The predictions derived using these methods are designed to aid but not to replace clinical judgment. Risk Calculator No Longer Available Range A number of factors described as predictive in previous studies either did not add to the explanatory power of the OHTS–EGPS pooled model or were not assessed in this study. These include: 1. 2. 3. 4. Family History Life Expectancy Diabetes (?) Race (?) Also iPhone App M. Chaglasian, OD 17 Clinical Pearls for Challenging Cases MOA 2014 SAP Case EG VFs GDx 67 yo, AA male, Retired school teacher Good health, no medications + Family History of glaucoma OHTN/Early Glaucoma CCT= 567, 571 Pre- Tx IOP ~ 30 mmHg OD, OS With PGA: – Always 20-23 mmHg x 5+yrs – Good Compliance Photos (initial) M. Chaglasian, OD Photos (5 yrs later) 18 Clinical Pearls for Challenging Cases MOA 2014 Can you see the change? VF GPA Case EG Discussion Cirrus OCT RTVue 100 M. Chaglasian, OD Is this progression? Other things you’d like to see/do? Options for adjunctive treatment? SECOND LINE AGENTS 19 Clinical Pearls for Challenging Cases MOA 2014 No Nocturnal IOP Lowering with Timolol Options for Adjunctive Therapy Sitting Supine Sitting No treatment Trusopt® 1.2 mm Hg3 16 14 Beta-blockers 2.7 mm Hg4 Timolol 1:30 PM 2.1 mm Hg2 11:30 AM Azopt® 18 7:30 AM Carbonic anhydrase inhibitors (CAIs) 20 9:30 AM 3.3 mm Hg2 ALPHAGAN® P 22 5:30 AM Alpha-agonists 24 3:30 AM 5.2 mm Hg1 1:30 AM Cosopt® 26 9:30 PM 6.9 mm Hg1 11:30 PM Combigan® 7:30 PM Fixed Combinations Timolol gel 5:30 PM (at 3 months) 3:30 PM Products: 28 Habitual IOP (mm Hg) Additional Mean IOP Reduction when Added to a PGA Clock Time 1. Nixon et al. Curr Med Res Opin. 2009; 2. Day. Curr Med Res Opin. 2008; 3. Maruyama and Shirato. J Glaucoma 2006; 4. Miura et al. J Glaucoma 2008. Liu, Am J Ophthalmol. 2004;138:389-395. Criteria for the Choice of Adjunctive Therapy Incremental efficacy – The main reason for changing initial monotherapy is the need for additional IOP lowering1 – The purpose of adjunctive therapy is to obtain target IOP2 Alpha Agonists Alphagan-P 0.1% (Allergan) – BAK Purite ( toxicity) – Less ocular allergy Aqueous suppressant and: » uveoscleral outflow » ? Neuroprotection? Other considerations – Compliance – Tolerability – Safety Bid vs. Tid dosing NO Neuroprotection! 1Rouland JF et al. Eur J Ophthalmol. 2003;13(suppl 4):S5-S20;2 European Glaucoma Society. Terminology and Guidelines for Glaucoma. Savona, Italy: DOGMA Srl; 2003. Topical CAIs Beta Blockers as Adjunctive Therapy to a Prostaglandin Analogue Currently available: - Brinzolamide (Azopt) - Dorzolamide (Trusopt) » Generic availability Consistent, moderate, monotherapy IOP reductions » (15-20%, 4 to 6 mm Hg) ------ p = 0.15------- FDA Labeled as TID agents J Glaucoma 1999;8:24-30. M. Chaglasian, OD 20 Clinical Pearls for Challenging Cases MOA 2014 Advantages of Fixed Combinations Post Dose: IOP Change from Baseline Dosing—1 drop vs 2 drops Convenience Potential to improve compliance1 No risk of washout from second drug2 – Washout impedes absorption, thereby reducing efficacy3 Possible cost savings – Only 1 copay Ophthalmology 2007 July; 114(7):1248-54 Best Adjunctive Therapy? 1. Razeghinejad et al. Expert Opin Pharmacother. 2010; 2. Choudhri et al. Am J Ophthalmol. 2000.; .3 Khouri. Drugs Aging. 2007. Timolol Fixed Combinations Cosopt® Generic dorzolamide / timolol maleate ophthalmic solution – Dorzolamide hydrochloride/timolol maleate solution Overall = CAI Tanna AP, et al Arch Ophthalmol 2010;128:7:825-33. Adjunctive Therapy Conclusions Fixed Combination: Combigan 1) PGAs are often not enough 2) BB don’t work at night if measuring in the supine habitual position 3) An Expert panel Suggests: -Adding CAIs is an agreeable option to a PGA -Adding an alpha agonist is less agreeable -Adding Fixed Combination should be reserved for failure of adding a single agent ??? Combigan (Allergan) – Brimonidine 0.2% and timolol 0.5% – BID dosing Less allergy than brimonidine alone – timolol is a buffer Singh K. et al. Am J Ophthalmolgy. 2008. M. Chaglasian, OD 21 Clinical Pearls for Challenging Cases MOA 2014 Introducing... SIMBRINZA™ Suspension Photos A fixed-dose combination of brinzolamide 1% and brimonidine 0.2% Additional 1-3 mm Hg IOP-lowering compared to the individual components1-3 Delivers 21-35% IOP-lowering efficacy1-3 Only fixed-combination without a beta blocker1-3 Adverse events profile consistent with those of its individual components1-3 Creates new treatment possibilities for lowering IOP 1. 2. 3. Katz G, et al. Three‐Month Randomized Trial of Fixed‐Combination Brinzolamide 1%/Brimonidine 0.2%. JAMA Oph. 2013. Nguyen QH, et al. Phase 3 Randomized 3‐Month Trial With an Ongoing 3‐Month Safety Extension of Fixed‐Combination Brinzolamide 1%/Brimonidine 0.2%. J Ocul Pharmacol Ther. 2013;29:290‐7. SIMBRINZA™ Suspension Package Insert. MG13241SK 127 Left Case GS SAP VFs Right GDx 55 yo C, F, Seeking second opinion History of being treated for glaucoma – Currently on PGA and beta blocker – Was recommended to have laser trabeculoplasty No insurance currently IOP= 17 mmHg – Reports PreTx IOP around 21mmHg CCT= 555µ M. Chaglasian, OD 22 Clinical Pearls for Challenging Cases MOA 2014 Several Years Later: Left Matrix FDT VFs Right Case GS More aggressive treatment was recommended, including: – Adding Alphagan – Adding CAI – Switching to Cosopt (Combigan not available yet) – ALT/SLT Patient wanted a third opinion M. Chaglasian, OD 23 Clinical Pearls for Challenging Cases MOA 2014 Next Steps Treatment Options Longer Term Considerations Scleral Ring and Disc Size Scleral Ring= Outer Disc Margin – What is the right target pressure? First Step in Determining Disc Size Scleral Ring and Disc Size Clinical Pearls Optic Nerve Evaluation “The 5Rs” Ring, Rim, RNFL, Region, Retinal disc heme At the Slit Lamp Volk Lenses: 60D = x 1.0 78D = x 1.1 90D = x 1.3 Adapted from FORGE program R. Weinreb, F. Medeiros, R. Susanna http://www.optometryjaoa.com Scleral Ring and Disc Size Small Average Large Disc/Cup Size ≠ Risk M. Chaglasian, OD 24 Clinical Pearls for Challenging Cases Rule #2: Size of Neuroretinal Rim MOA 2014 Width of the NRR around the disc Rim Width= – Distance between outside border of disc and bending of blood vessel on inner rim ISN’T Rule: Inferior> Superior>Nasal>Temporal Localized Notching / Thinning Color of Rim CASE EB Neuroretinal Rim Rim Width: Distance between border of disc and position of blood vessel bending 57 yo, woman Annual Exam Normal Slit Lamp Open Angles GAT= 21 OD 21 OS Pachs = 540 µ Localized Rim Thinning/Notching Case EB Notch M. Chaglasian, OD 25 Clinical Pearls for Challenging Cases MOA 2014 Five years later Case EB M. Chaglasian, OD 26 Clinical Pearls for Challenging Cases MOA 2014 Questions / Discussion [email protected] M. Chaglasian, OD 27