Current Trends in Diagnosis and Management of Glaucoma

1. Current Trends in Diagnosis and
Management

2. Characteristic damage to the optic nerve leading to
progressive, irreversible vision loss with or without
elevated intraocular pressure

3. Characteristic damage to the optic nerve leading to
progressive, irreversible vision loss with or without
elevated intraocular pressure.
Significantly elevated intraocular pressure with or
without visual field changes or obvious nerve or
nerve fiber layer damage

5. 3-4 million in US
2.2 million over 40 have glaucoma
50% undiagnosed
Present in 1 in 200 over 50 and 1in10 over 80
The percentage of Americans over 65 will grow by 50%
in the next 15 years

6. Age
Refractive error
Race, ethnicity
Family history
Systemic disease: HT, diabetes, obstr. sleep apnea
Medications - systemic and ocular, NAG and OAG
Previous ocular trauma or surgery
Developmental and other ocular conditions

7. 1980 - 90’s - initial state laws for OD’s to treat glaucoma
NM one of the first
2000-2005 - most states pass glaucoma therapy for OD’s.
Oklahoma allows lasers
Even now, up to 50% 0f OD's still refer non-complex,
non-surgical glaucoma cases to OMD’s
Multiple reasons for not treating – experience, cost of
instruments, practice focus, office size, patient mix

8. Miotics, sympathomimetics and orals – used in early to
late 1900's
Trabeculectomy developed in the 1960's
Beta blockers introduced in the mid 1970's
Lasers since the mid to late 70's
Multiple new meds and procedures from 2000 to
present have led to a 50% reduction in vision loss in
glaucoma patients from 1980 to present

9. Open Angle - POAG/Low Tension
Secondary - pigmentary, pseudoexfoliative, inflammatory,
phacogenic, traumatic, hemorrhagic, neovascular, drug-
induced, malignant - intraocular surgery related
Developmental- those associated with inherited disorders
Narrow and closed angle

10. 90% of all cases
Good response to meds and lasers
Most patients controlled with meds
Many undiagnosed
Rate rising with increasing BMI, DM and the aging
population

11. Relatively rare, but still underdiagnosed
Many forms/multi-factorial/mixed mechanism
Typically more severe than OAG
Most common in older female hyperopes and
Chinese- smaller eyes, fatter lenses
Intermittent or chronic narrow angle
Acute angle closure – emergency

12. Lens vault – forward position of lens relative to SS –
pupillary block most common mechanism
Plateau iris – abnormally positioned ciliary body
pushes peripheral iris on to TM
Phacogenic – cataract-induced lens thickening, PXE
- 10% of cases have angle closure component
Thickened, dense iris – less sponge effect on dilation
Shallow anterior chamber – anterior iris insertion
Scleral buckles, malignant glaucoma

13. PI for those with hidden posterior TM > 180 deg.
Gonioscopy – small beam, outside pupil, dark
conditions
Verify with OCT if possible
Position at 11 or 1o’clock, usually hidden by eyelid
Away from superior lacrimal river
YAG most common
Done early, before significant, persistent pressure rise
30% have minimal response – done too late, plateau

14. Occasionally done for non-responsive PI cases
No well designed studies to validate effectiveness
Most often performed in plateau iris that does not
move from apposition to TM after PI
Argon laser to mid periphery of iris, shrinks tissue at
laser site, pulling iris away from angle
Sectoral or circumferential

15. Especially effective for plateau iris, recent acute angle
closure and lens vault cases
Less effective in chronic NAG cases
Much less risk than trab in narrow angles
Can be combined with iStent for better IOP reduction

16. Slow process of conversion
Initially, intermittent iris / TM contact is seen
Later persistent pigment on TM and synechiae
formation
Pressure slowly rises, sometimes fluctuating with iris
position
Watch for angle closure in POAG patients who
fluctuate

17. Often severe pain, but not always
Cloudy vision in all cases, fixed pupil, cells in AC
IOP can be 40-60+
Don’t use PA’s- inflammatory - instead Prednisolone
Start with combigan 0r simbrinza q10-15 min
Once IOP lower than 30, add pilocarpine 1-2% qid
Use oral CAI or 50% glycerine if unresponsive, > 50
Diamox 250 or 500 po q 4-6 hrs, not Sequels
Arrange for PI, keep pt. on low dose pilo until laser

18. Extrinsic- medication, trauma, burns,
infection/inflammatory, toxic, post surgery
Intrinsic- phacogenic, pigmentary, pseudoexfoliative
auto-immune/inflammatory, neovascular, tumors, RD,
others

19. Extremely rare
Surgery needed
Prognosis poor
Classic presentations
congenital, infantile, juvenile and glaucoma assoc.
with hereditary familial diseases

20. Large cups
Asymmetry in IOP or cup/disc ratio
High IOP
Low CCT
Family history or history of trauma
No NFL dropout or classic optic nerve signs
No VF defects
No SLO, OCT or GDX defects
LTG suspects – collagen and autoreg. disorders

21. Serial tonometry prior to tx if no history of IOP’s
available
ON evaluation/stereo photos
Gonioscopy
Visual fields
Pachymetry
OCT, SLO, GDX
BP for Ocular Perfusion Pressure calculation
Family oc. hx. and patient medical/sx history

22. Goldmann is the standard but has some limitations
Alternatives - Pascal, Tonopen, pneumatic, rebound
CCT affects accuracy of measurements in some
CCT a guide to modifying risk - not a true and
accurate adjustment factor
RK, PRK, LASIK, corneal scars and KC can all affect
corneal thickness and hysteresis
ORA – measures hysteresis and “corrected IOP”

24. Billed once in glaucoma management
Importance documented in OHTS
One third with IOP over 26 and cct < 555 - dx GLC
6% with same iop and cct > 588 dx GLC
Relative risk increased 81% for every 40 microns < 555

25. Rim: focal erosions/generalized cupping
ISNT rule/verticalization of cup
Disc size and depth
Disc heme at or near rim margin
Bayonetting of vessels/saucerization of disc
Beta zone pigment changes
NFL dropout with red-free filter

26. SITA automated perimetry is the standard for
following progression on established cases 24 or 30
degrees – correlate with clinical findings
10 degree fields gaining acceptance
Matrix FDT is more sensitive for early detection but
not as reliable for progression analysis
Look at quality and repeatability of the test
Rarely make major decisions or changes with only
one field study

27. SD OCT now the standard of
care with cRNFL, GCC and
anterior chamber capability
Reliable and repeatable, but not
infallible
High myopes may be false
positives
Swept-Source an upcoming
technology, but
cost/reimbursement an ongoing
issue
SS is faster, less errors, more
detail, with additional choroid
thickness measurement

28. Older models best for nerve head contour analysis,
and PPRNFL thickness (no GCC)
NFL thickness analysis not as accurate as SD-OCT,
especially in larger nerves
Good database for normative comparison

29. Only PPNFL thickness measured using polarized
light
Fairly repeatable
Relatively inexpensive
Technology 15+ years old
Small footprint
Still useful for comparative data in questionable
cases

30. Manual technique for angle evaluation, not billable
using OCT, Pentacam, etc
Used to rule out closed/narrow angles and angle
recession and to determine risk of closure
Note most posteror structure in sup and inf angles and
iris approach – flat, convex, concave, plateau
Also used to assess pigment or debris in the angle,
grading 1-4
Takes experience and time, 3 vs 4 mirror
Not done as routinely as other testing by many

31. Relative pressure differential between diastolic
systemic blood pressure and intraocular pressure
OPP = DBP-IOP target >50-55
Important in establishing target IOP range in
treatment or in the evaluation of need for treatment
Very important in LTG, BP lowest at night
PA’s moderate effect, BB zero effect on nocturnal
IOP. CAI’s have best effect overnight but rx’d TID

32. ON damage with IOP never above 21
Lower blood flow and choroidal thickness in
parapapillary region
Collagen issues – sleep apnea
Auto-regulatory issues – Raynaud’s, migrane synd.
Low BP, over medicated htn pt?
Low OPP
Disc heme more common
No beta blockers, add NaCl to diet at evening meal

34. Topical or oral meds – safety, tolerability, efficacy
and compliance issues
Lasers – safe but short duration of effect
Trabeculectomy – good effect, but safety concern
Valves/Shunts gaining on trabs
MIGS – unproven in wide usage
Emerging treatments – Sub-conjunctival injections,
med-releasing plugs and CL's

35. Age
Race
ONH appearance, cNFL /GCC and VF damage
Systemic health
Baseline IOP
BP

36. General target 20-30 % reduction from Tmax
Mild cases 20-30%
Moderate cases 30-40%
Severe 40-50%
< 12.5 mmHg limits VF progression in most cases

37. Prostaglandin analogues
Alpha agonists
Beta blockers
Carbonic anhydrase inhibitors
Fixed combinations
Steroids in inflammatory cases

38. Xalatan – latanoprost lasts up to 36 hrs.
Travatan Z - BAK free, lasts up to 60 hrs.
Lumigan - same drug as Latisse, different conc.
Zioptan – PF unit doses
All increase uveoscleral outflow
Lumigan also said to increase TM outflow
No racial differences in effects
Contraindications – HSV, CME, iritis
Adverse effects – red eyes, PAP

39. Only one drug available in US for long term use
Not for pediatric patiets - pulmonary issues
Alphagan P or brimonidine (generic) 0.1-0.2 %
Different preservatives/vehicles
Proprietary version ? less prone to allergic response
Available in combination with a beta-blocker as
Combigan and with CAI as Simbrinza

40. Timolol, Levobunolol, Betaxolol
Tomolol 0.25 and 0.5 % solutions and 0.5% gel forming
suspension, dosed bid and qd
Originated in mid 70’s, reduces aqueous prod.
Adverse effects include bradycardia, reduced energy,
depression, pulmonary probs and ED
Monitor blood pressure and pulse in high risk indiv.
Available as PF unit dose
In combo drug with CAI as Cosopt

41. Dorzolamide
Brinzolamide
both decrease aqueous production
Used TID if monotherapy
BID if in fixed combo with beta blocker timolol-
Cosopt – available as generic and PF
TID in combo of brinzolamide/brimonidine –
Simbrinza. Avoid in sulfa allergies
PO options – short term, diamox, neptazane

42. Combigan – brimonidine and timolol
Cosopt – brinzolamide and timolol – avail. generic
Simbrinza – brinzolamide and brimodine
All good as primary or additive therapy to
prostaglandin analog

43. SLT- Selective Laser Trabeculoplasty – 3-5 yr effect,
repeatable
ALT- Argon Laser Trabeculoplasty – 3-5 yr effect, not
repeatable

44. Trabeculectomy
Valves – Molteno, Ahmed, Barveldt
Canaloplasty
MIGS – iStent with cat. sx., ECP, Trabectome
Cataract sx in lens vault narrow angles and
pseudoexfoliative cases, open angle cases due to
molecular mechanism from ultrasound/phaco

45. Glaucoma workup- typically two to three visits
Ongoing care – intermediate E/M visit q 3-4 mo.
VF 3-12 months depending on reliability, IOP’s
HRT/OCT/GDX q12 months
Stereo disc photos q12 months
Patient/physician referrals