discussions

Highlights from a CME Symposium held during the American Academy of Ophthalmology 2010 Meeting

Program Chairman and Moderator Dale K. Heuer, MD Faculty Donald L. Budenz, MD, MPH Eric D. Donnenfeld, MD Richard Lewis, MD

Sponsored by The New York and Ear Infirmary Original Release: March 1, 2011 Last Review: February 16, 2011 Expiration: March 31, 2012

In joint sponsorship with MedEdicus LLC

Part 2 of 2 This continuing medical education activity is supported through an unrestricted educational grant from Pfizer Inc

March 2011 case discussions

faculty Eric D. Donnenfeld, MD, FAAO program chairman Founding Partner Dale K. Heuer, MD and moderator Ophthalmic Consultants of Long Island Professor and Chairman of Ophthalmology Rockville Centre, New York Medical College of Wisconsin Clinical Professor of Ophthalmology Director NYU Langone Medical Center Froedtert Hospital and the Medical College New York, New York of Wisconsin Eye Institute Trustee Milwaukee, Wisconsin Dartmouth Medical School Hanover, New Hampshire Donald L. Budenz, MD, MPH Professor of Ophthalmology, Epidemiology, Richard Lewis, MD and Public Health Co-Founder and Director University of Miami Miller School of Medicine Capital City Surgery Center Highlights from a CME Symposium Associate Medical Director Sacramento, California Bascom Palmer Eye Institute Past President held during the American Academy of Miami, Florida American Glaucoma Society Ophthalmology 2010 Meeting

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Donnenfeld, MD: Dr Donnenfeld has had a financial agreement or affiliation during the This educational activity is intended for comprehensive ophthalmologists. past year with the following commercial interests in the form of Consultant/Advisory Board: Abbott Medical Optics; Alcon, Inc; Allergan, Inc; Bausch + Lomb Incorporated; Cataract & Refrac - overview tive Surgery Today ; Glaukos Corporation; Inspire Pharmaceuticals; LenSx Lasers, Inc; QLT Inc; The number of Americans with major eye diseases is increasing. In fact, that population is and WaveTec Vision; Fees for promotional, advertising or non-CME services received directly expected to double within the next 3 decades largely because of diseases of aging in conjunction from commercial interest or their Agents (e.g., Speakers Bureaus): Abbott Medical Optics; Aller - with longer life expectancy. Low vision and blindness increase significantly with age, particularly gan, Inc; Bausch + Lomb Incorporated; and Pfizer Inc; Contracted Research: Abbott Medical in people older than 65 years. The common diseases affecting these older Americans are glau - Optics; Allergan, Inc; Bausch + Lomb Incorporated; and QLT Inc. coma, chronic dry eye, and cataract formation. This monograph will highlight clinical case dis - Dale K. Heuer, MD: Dr Heuer has had financial agreement or affiliation during the past year cussions to teach commonly encountered ophthalmic disorders of aging patients. It will cover the with the following commercial interests in the form of Honoraria : Pfizer Inc; Consultant/ use of visual field parameters in the early diagnosis of glaucoma and provide an update on medical Advisory Board: Allergan, Inc; Lux Biosciences, Inc; and Pfizer Inc. management of high intraocular pressure. 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Gerszberg, MD: Dr Gerszberg has no relevant commercial relationships to disclose. • Discuss current best-practice strategies in the medical management of glaucoma and ocular hypertension, including new strategies for medication adherence editorial support disclosures • Explain recent research in the etiology of chronic dry eye and implications for management Anthony Realini, MD, MPH; Cynthia Tornallyay, RD, MBA; Kimberly A. 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This CME activity is copyrighted to MedEdicus LLC ©2011. All rights reserved. Introduction Dale K. Heuer, MD

The aging eye is susceptible to a variety of diseases and conditions that affect visual acuity, ocular comfort, and quality of life for our older patients. Cataract is ubiquitous among older patients, and techniques for modern cataract surgery have evolved significantly in the past few years. Glaucoma is also a common disease of the aging eye, and treatment strategies for glaucoma have improved significantly in the past decade as well. Ocular surface disease (OSD), also a frequent disorder among older patients, often coexists with cataract and glaucoma. Through a series of case studies and discussion by our panelists, this monograph will illuminate some of the issues to be considered when approaching management of these conditions in the aging eye. The panelists will share cases from their own practices as well as discuss practical pearls for addressing the needs of this growing population.

case 1 Surgical Planning in With Pseudoexfoliation Eric D. Donnenfeld, MD

A 77-year-old myopic female had a 10-year history of glaucoma con - trolled with a prostaglandin analogue. She presented with symptoms including decreased visual acuity and inability to drive at night, symptoms which were significantly limiting her daily activities. On examination, her best-corrected visual acuity was 20/50 in both eyes. She had 3+ nuclear sclerosis in both eyes. There was gray-white fibrillar material deposited on the lens capsule, the iris, and the corneal endothelium (Figure 1) . Her intraocular pressure (IOP) was 18 mmHg by Goldmann tonometry in both eyes. revealed increased pigmentation along Schwalbe’s line— the classic Sampaolesi’s line (Figure 2) . There was mild lenticulodonesis with eye movement. Her pupils dilated poorly, and her cup-to-disc ratio Figure 1. Case 1: Gray-white fibrillar material depositing on the anterior lens was approximately 0.5 in both eyes. She had no visual field defects on capsule in an eye with pseudoexfoliation syndrome. standard automated perimetry. She desired and warranted cataract sur - gery. Are there any special issues we should consider before proceeding with surgery?

Dr Lewis: There are 2 major issues. First, this patient has classic pseu - doexfoliation syndrome, which significantly increases the risk for intra - operative and postoperative complications with cataract surgery. The second is that she has glaucoma. The mechanism of glaucoma in eyes with pseudoexfoliation is interesting. The primary mechanism of glau - coma is secondary blockage of the outflow pathway by the pseudoexfo - liation material. Patients with both pseudoexfoliation and glaucoma do have a little higher incidence of angle closure than the rest of the popu - lation, however.

Dr Budenz: Angle closure can arise in patients with pseudoexfoliation syndrome because the lens can be loose enough to move forward and cause pupillary block.

Dr Donnenfeld: The complications of pseudoexfoliation that can be seen Figure 2. Case 1: Pigment accumulation on Schwalbe’s line in pseudoexfoliation — with cataract surgery include lens dislocation, vitreous loss, decentration of known as Sampaolesi’s line.

3 the intraocular lens implant, and postoperative IOP spikes. This patient has aside, when anterior capsular phimosis develops, I think it is crucial that some loose zonules, which is not uncommon. The lenses can dislocate and the cataract surgeon do an anterior YAG capsulotomy as soon as possible. certainly this creates a much more difficult situation for the cataract surgeon. The sooner you laser this, the sooner you prevent the capsule from col - lapsing on itself and causing late lens dislocation. As a matter of fact, some Dr Heuer: What are some steps we can take to reduce the risk of surgical surgeons will do larger capsulotomies with the original surgery, and some complications? will even insert capsular tension rings for all cases of pseudoexfoliation. Dr Donnenfeld: Rule #1 is to be prepared for everything. Always enter the operating room with a plan—and a back-up plan. Also, optimize every part of your surgical approach to give these patients the best chance pos - sible for superlative outcomes. Specifically, start with a 3-day preoperative case 2 course of nonsteroidal anti-inflammatory agents. This can prevent or reduce the risk of the pupil constricting intraoperatively. My colleagues Overcoming Nonadherence to and I published a paper on this, showing that 1.5 mm of extra dilation can be achieved by starting a nonsteroidal 3 days preoperatively rather Medical Glaucoma Therapy than 1 hour preoperatively. 1 Richard Lewis, MD

Dr Heuer: In pseudoexfoliation the pupil is often really small to start with. Dr Lewis: I first saw this 46-year-old insurance executive in 1993 when he was referred to me with a 3-year history of glaucoma. On examination Dr Donnenfeld: If a patient’s pupil is borderline, I use a sulfite-free for - at that time, he was a moderate myope with 20/20 vision, normal pupils, mulation of epinephrine 1:1000, intraoperatively, mixed with 3 parts of normal slit lamp examination, IOP of 25 mmHg on timolol and dipive - balanced salt solution to achieve and maintain pupil dilation. This is par - frin, and grade IV angles; his optic nerves had cups of 0.8. His peak IOP ticularly useful in eyes with intraoperative floppy iris syndrome 2—I use it had been approximately 30 mmHg. Recall that in 1993 we did not know for all cases in which the patient is using an alpha-adrenergic blocker. about the importance of central corneal thickness. In terms of this Healon® 5 also plays a significant role here as well, as it can help hold a patient’s visual fields (Figure 3a) , the right eye had diffuse depression, pupil open. I’m not a big fan of iris hooks because they can sometimes but also maybe something that qualifies as a nerve fiber layer defect infe - tear the sphincter, but I do like to use the Malyugin Ring®. 3 How do others riorly. The left eye showed diffuse depression but no definite sort of pat - manage small pupils during cataract surgery? tern that I would say looked classically like glaucoma. Dr Lewis: In that situation, intraoperative epinephrine is really of value. 4 Moving ahead to 1998, repeat visual fields (Figure 3b) showed that the Recently, in certain parts of the country, there has been a shortage of field loss in the right eye was significantly different—the inferior arcuate intraoperative epinephrine for injectable use. This has forced some sur - disappeared and a new superior nasal step appeared. The left field, which gery centers to use preserved epinephrine in these cases. Are there any had been essentially full, now looked more convincing for glaucoma, with concerns about using preserved epinephrine? the super nasal step and an inferior arcuate defect. The patient subse - Dr Donnenfeld: I do not feel comfortable putting anything preserved quently underwent in the left eye as well as photorefractive into the anterior segment because it may increase risk for endothelial tox - keratectomy (PRK) in the left eye, and returned to me in 2001. At this point, icity and it may even damage the trabecular meshwork, which has been his IOP was 22 mmHg in the right eye using latanoprost and timolol, and known to cause glaucoma. I would probably stay away from using a pre - 4 mmHg in his left eye on no medications. He admitted that he was putting served medication inside the eye. his drops in the right eye only when he comes to see me and not very often between visits. His visual field (Figure 3c) in the right eye was down to a Dr Heuer: Any other intraoperative tips? central island of vision, and his left eye looked essentially unchanged. The trabeculectomy in the left eye had stabilized his visual function, but now Dr Donnenfeld: The hydrodissection is the moment of truth with pseu - the right eye needed an intervention. We considered our options: empha - doexfoliation cases. If you are very aggressive with your hydrodissection, sizing adherence with his current regimen, adding another medication, you are going to blow out the capsule and then you are going to have vit - performing laser trabeculoplasty, or performing a trabeculectomy. reous loss and lens dislocation. I like to irrigate very slowly and steadily to get a fluid wave that dives behind the lens and pushes the lens forward. He underwent trabeculectomy in the right eye and did well on no med - And if the capsule seems weak during the case, I would not hesitate to ications until I saw him again in 2009. His vision remained 20/25 in both put in a capsular tension ring. eyes. His IOP was 17 mmHg in the right eye and 11 mmHg in the left eye. His corneal thicknesses measured 538 microns and 535 microns, respec - Dr Lewis: Do you think it matters whether you put a single piece versus tively. He had 0.9 cups in both eyes. The visual fields have been essentially a 3-piece lens in? stable after bilateral trabeculectomy. Dr Donnenfeld: There are some people who think that 3 pieces give a little more capsule support, but if you insert a capsular tension ring, it Dr Heuer: There are several interesting discussion points in this case. doesn’t matter at all, in my opinion. Let’s start with adherence. Nonadherence to medical therapy is a huge issue in glaucoma and is a frequent cause of treatment failure. Dr Heuer: What about postoperative complications following cataract surgery in pseudoexfoliation eyes? Dr Lewis: Yes, nonadherence was, to some extent, what led to this patient’s problem. The assumption that patients are taking medications, Dr Donnenfeld: Late decentration of the lens implant can also occur fol - for the most part, is not true. This patient was a bit unusual in that he lowing surgery, and anterior capsular phimosis can develop as the anterior admitted his nonadherence. Many patients do not admit to nonadher - capsule collapses on itself and pulls the zonules from the periphery. As an ence, and so we do not always know who are our nonadherent patients.

4 It is worth pointing out that nonadherence is not limited to 1 particular socioeconomic group, or to 1 race or sex—nonadherence is pervasive throughout our practices.

Dr Heuer: What are some options for helping the nonadherent patient?

Dr Lewis: We could provide medication schedules and put into writing exactly what the patients are to do and when. Using dark bold print is helpful. So is recording dates to avoid confusion. We have colored-coded caps on our medication bottles and note the medications by cap color on the schedule. Many patients find it helpful to associate dosing with rou - tine life activities such as meals or bedtime, or waking up. We cannot overemphasize the importance of simplifying a medication regimen as much as possible, as this has been shown to affect therapeutic adherence. 5 Figure 3a. Case 2: Baseline visual fields in 1993. Once-daily medications and combination drugs to reduce the number of bottles needed are good simplification methods.

Dr Donnenfeld: We often involve a spouse or caregiver in adherence techniques. In this particular case, the patient’s wife could remind him to put his drops in every day. Or better yet, suggest that she put the drops in for him. My patients’ spouses often ask if there is anything they can do to help their loved ones. Here is a perfect opportunity.

Dr Budenz: There are companies now that will contact your patients by text-messaging, e-mail, phone calls, to remind them to take their drops. That might be a useful new tool in the digital age. Other approaches that can help include avoiding giving speeches about the importance of adher - ence. The better approach is to ask open-ended questions such as, “How often are you taking your drops?” or “How often do you forget to take your drops?” It’s also helpful to ask patients why they have difficulty being adherent. If you can identify reasons, you can develop individual - ized solutions.

Dr Heuer: Let’s talk for a moment about refractive surgery in a glaucoma - Figure 3b. Case 2: Visual fields in 1998. tous eye. Dr Donnenfeld, as our refractive surgery expert, how do you feel about performing PRK in a patient with moderately advanced glaucoma?

Dr Donnenfeld: I would not have a problem doing PRK in such a patient. I have no problem doing LASIK (laser assisted in situ ) on a patient with mild or moderate glaucoma. The visual field in this case is not threatening. There is minimal intraoperative risk—the real risk is the devel - opment of haze and dependence upon steroids afterwards. But nowadays, if you use mitomycin, you almost never see haze. 6 PRK is reasonable in this patient as long as you have an honest informed consent process.

Dr Lewis: What about the keratome for a LASIK procedure? Is that an issue for a patient with this type of glaucoma? Does the brief period of high pressure not bother you?

Dr Donnenfeld: No, especially with the femtosecond laser that is now available: the pressures are much lower, the suction is only on for about 20 seconds or so, and the pressure is not that much higher than you get when you rub your eyes for 5 or 10 seconds. I would have no problem Figure 3c. Case 2: Visual fields in 2001. with either procedure here.

Dr Budenz: The interesting issue is that the left eye has a bleb. Have you ever seen a bleb affected by the very high pressures with LASIK? Has any - one every sprung a leak from that? Or had the bleb explode?

5 Dr Donnenfeld: I stay away from doing LASIK on patients with blebs. Those are the patients in whom I favor PRK. If the bleb was shallow and diffuse, I might consider LASIK, but certainly if the patient had one of those overhanging blebs that extends onto the corneal surface, I would not perform LASIK.

Dr Heuer: There is a fair amount of intertest variability between visual Avg RNFL field tests. How many tests are needed to establish a good baseline, and OD - 88 how many are needed to establish change from baseline? OS - 77 Dr Lewis: There is no set answer if you are looking at the tests manually. But if you use the Glaucoma Progression Analysis™ (GPA) program avail - able on the Humphrey® Field Analyzers, you need 2 reliable baseline fields, which are merged to make a single baseline. Then you need at least 3 more to detect definite progression. If the first test after the 2 baselines is different from the baseline, the software labels it “possible” progression. RNFL=retinal nerve fiber layer If the next test remains different from baseline, it becomes “probable” pro - gression. If the third test is also different, it is “confirmed” progression. So the answer is 5 total tests to detect change: 2 baselines and 3 follow-up tests. Figure 4. Case 3: Optical coherence tomography.

case 3 Diagnosing Early Glaucoma Donald L. Budenz, MD, MPH

A 55-year-old white female was referred by a local optometrist for glau - coma evaluation. She was a high myope and had LASIK procedures 6 years prior. She also had a history of breast cancer but was in remission. Her visual acuity was 20/20 in both eyes without correction. Her pres - sures were 14 and 15 mmHg and her central corneal thickness was 475 C:D 0.5 C:D 0.7 and 480 microns. She had open angles. She had significant cup-to-disc asymmetry, 0.5 in the right eye and 0.7 in the left eye. Standard automated perimetry was completely normal. Optical coherence tomography (OCT) Figure 5. Case 3: Optic disc photographs with resolving disc hemorrhage at demonstrated some thinning of the nerve fiber layer in the left eye com - 3 o’clock in the left eye. pared with the right eye (Figure 4) . At this point, I chose to observe the patient without treatment and referred her back to the optometrist. A year Dr Budenz: I use the slit lamp examination and my 90 diopter lens and later she was referred back with a new onset disc hemorrhage in the left measure the vertical disc diameter. With the 90 diopter lens, if you add eye (Figure 5) following a posterior vitreous detachment in that eye. 30% to the millimeter measurement, that will give you the vertical disc There was no significant change in her visual field or OCT, but based on diameter, accounting for magnification error. I tend to classify optic discs the cup asymmetry, OCT thinning, and the disc hemorrhage, she was into 3 categories: small, medium, and large. As my rule of thumb, I con - started on unilateral prostaglandin therapy in the left eye. Nearly a year sider an optic nerve to be small if its vertical diameter is 1.5 mm or less. later, her left eye remained stable and she requested bilateral therapy Likewise, it’s large if it’s 2 mm or greater. Anything in between is medium. because of asymmetric eyelash growth. Dr Heuer: If I can’t find my 90 diopter lens, is there something else I can do? Dr Heuer: This is an excellent case that demonstrates the challenges of distinguishing between glaucoma suspects and true glaucoma patients. Dr Budenz: The direct ophthalmoscope is still useful. If you use the The patient in this case had asymmetric cupping. Can you tell us anything medium-sized of the 3 circles from the direct ophthalmoscope, that about the size of her optic discs? should approximate a normal disc area. In this case, you aren’t measuring anything. You just look in and compare the optic nerve size to the size of Dr Budenz: The right disc is a little smaller than the left. When there is that medium circle. If the disc is larger than the circle, you call it large; asymmetry in disc size, there is allowed to be a little bit of asymmetry in and if it’s significantly smaller, call it small. cup size. There may be the same number of axons going through both. Dr Heuer: How does the history of LASIK affect our risk assessment of Dr Lewis: I think the real value of the imaging systems is that they are the glaucoma suspect? Because LASIK changes both the central corneal now reliably measuring disc size and cup, and they have a normative data - thickness and the IOP measurement. base. This patient has a large cup and a large disc in a normal retinal rim. Dr Lewis: There have been a variety of calculators to try to relate pre- Dr Heuer: If I cannot afford an imaging system, is there some way I can and post-LASIK IOP measurements based on the known change in cen - get an idea of how big those discs are? tral corneal thickness. No one of these has really stood the test of time.

6 One of the big problems in diagnosing glaucoma—even in patients who have not had refractive surgery—is our inability to know what the true IOP is. We obtain an indirect measurement with a Goldmann applana - Physical examination tion tonometer. But we still lack reliable ways of measuring IOP in eyes • Corneal fluorescein with scarred or ultra-thin corneas. staining Dr Donnenfeld: Has the OCT imaging system become standard-of-care • Conjunctival lissamine in diagnosing glaucoma? green stain • Decreased tear meniscus Dr Budenz: In my opinion, it has not become standard-of-care. But it • Inspisated meibomian can be extremely useful in assessing glaucoma suspects like this one. glands Tear function Dr Lewis: The devices have become ubiquitous. They are in every eye • Schirmer testing care office, from the optometrist to the ophthalmologist glaucoma spe - • Tear break-up time cialist. Either medically or even medico-legally, OCT may represent a standard-of-care in establishing baseline status of the optic disc.

Dr Heuer: We need 2 visual fields to get a baseline because of high Figure 6. Case 4: Evaluation of dry eyes. intertest variability between fields. Is there much intertest variability with OCT? How much change between tests would you need to see in average nerve fiber layer thickness to be concerned about progression? unidose nonpreserved artificial tears, oral flax seed and fish oil. Her sur - face staining improved, but the foreign body sensation persisted. We Dr Budenz: Our studies show that the test-retest variability of the average added low-dose steroids and cyclosporine, with a significant improve - retinal nerve fiber layer (RNFL) with time domain OCT can be up to ment in symptoms, but she was still not completely comfortable. At this approximately 10 microns. 7 If the nerve fiber layer is more than 10 time, we placed Odyssey punctal plugs and I added topical azithromycin. microns thinner from one visit to the next, that difference in measure - Within 3 months, she was back into her contact lenses and using artificial ment would be considered statistically abnormal and suspicious for tears only 3 times a day with no residual symptoms of her OSD. change. If, using spectral domain OCT, one detects a change in average RNFL thickness greater than 5 microns, that is statistically significant and Dr Heuer: Let’s start out by talking a little about the evaluation of a dry may indicate change. 8 eye patient.

Dr Heuer: Is that true even between different machines? Dr Donnenfeld: I look at the ocular surface stained with both fluorescein and lissamine green. Fluorescein will show you where the dead cells are, Dr Budenz: There is a lot of variability among operators and machines. and lissamine green will show you where the mucin layer has been dis - That poses problems for patients who are comanaged, say, between an rupted. I also look at the lid margin for evidence of meibomian gland dys - optometrist and an ophthalmologist. It becomes hard to detect change from function and I measure tear break-up time. serial tests if they are done by different operators on different machines. Dr Heuer: You started her on a course of dietary supplements. Tell us a Dr Heuer: A final question. How did the disc hemorrhage affect clinical little about that. decision-making in this case? Dr Donnenfeld: This patient had a component of meibomian gland dys - Dr Budenz: It may not be directly applicable, but in the Ocular Hyperten - function in addition to inflammatory dry eye disease. She had an altered sion Treatment Study (OHTS), having a disc hemorrhage tripled the risk lipid layer to her tear film. Dietary supplementation of essential lipids, of developing glaucoma. 9 This patient also just had a posterior vitreous such as flax seed and fish oil, can stabilize the lipid layer and reduce evap - detachment in the same eye, so it is possible that the disc hemorrhage was orative tear loss. A recent paper showed that an oral omega-3 nutritional not related to glaucoma. It is worth noting that in OHTS, 84% of all disc supplement for dry eye increased tear volume in dry eye patients signifi - hemorrhages were missed by the examining clinician and detected only cantly and dramatically reduced dry eye symptoms. 10 by the optic nerve reading center personnel. We can improve our job of looking for disc hemorrhages. Dr Heuer: Your next step was to suppress inflammation. What is your immunosuppressive therapy of choice?

Dr Donnenfeld: Ocular surface disease has an important inflammatory component. Patients with dry eye have interleukins, cytokines, and other case 4 pro-inflammatory species in their tear film. Successfully treating OSD requires suppression of inflammation. Consensus-based guidelines for Managing the Dry Eye Patient the treatment of dry eye disease support this concept. 11 I prefer a combi - nation of steroids and cyclosporine. Steroid use for this condition is off- Eric D. Donnenfeld, MD label, by the way. I generally start with loteprednol twice daily for a This case is a 47-year-old female architect who complained of foreign month, and use that concurrently with cyclosporine, also twice daily. body sensation, burning, visual blurring, and excessive tearing, all of Dr Heuer: Many of us might have considered punctal plugs on that first which were affecting her ability to wear contact lenses. She used unpre - visit. Why didn’t you? served artificial tears frequently—with their use having increased steadily over the past 5 years—and she had serious limitations of her daily activi - Dr Donnenfeld: I never put in punctal plugs on a patient’s first visit. In ties. There was staining of the ocular surface with both fluorescein and addition, this patient had meibomian gland dysfunction, so she also had lissamine green (Figure 6) . We discontinued contact lens wear, instituted lots of soaps and fatty acids in the tear film. The last thing I want to do is

7 to block outflow and have these substances collecting at the ocular sur - face, potentially making things worse. So I always want to start with immunosuppressive therapy first to clear the tear film of as many noxious substances as I can before considering punctal plugs. Once the tear film has been stabilized, I am a strong advocate for punctal plugs. I prefer a parasol design that has an extremely high retention rate. 12

Dr Heuer: This patient is in the perimenopausal age range. Does this fac - tor provide opportunities for any other therapeutic options?

Dr Donnenfeld: Dry eye is seen very commonly in patients who are peri - menopausal. There are a few studies showing that oral hormone replace - ment therapy can sometimes be very helpful in reducing dry eye signs and symptoms. 13,14 This is a valid consideration for a woman with hot flashes who might otherwise benefit from the systemic advantages of hormone replacement therapy. You can recommend she consult her gyne - cologist, and offer her the possibility that hormonal therapy, if appropri - ate for her overall health, may also be a way of managing her dry eye.

Dr Heuer: Any other pearls for us on managing dry eye syndrome?

Dr Donnenfeld: There is sometimes an inclination not to treat mild dry eye. This might not be the best approach to mild disease. A recently pub - lished study showed that treating dry eye with cyclosporine can reduce the progression rate of the disease. 15 Over the course of a year, 30% of patients treated only with artificial tears showed progression of dry eye versus only 5% who progressed when treated with cyclosporine.

case 5 Detecting Progression of Glaucoma Figure 7. Case 5: Optic discs; note the disc hemorrhage in the left eye. Donald L. Budenz, MD, MPH

This 80-year-old thin Caucasian woman presented with advanced glau - coma. When I saw her first, 10 years ago, she had excellent visual acuity of 20/25 in both eyes limited only by a bit of nuclear sclerosis, IOP of 19 and 22 mmHg, and normal corneal thickness in both eyes. Her optic nerves showed moderate to advanced cupping, with a disc hemorrhage in the left eye at 12 o’clock (Figure 7) . The visual field in the right eye showed a superior arcuate defect breaking into a nasal step with a mean deviation of -10 dB, a finding that is in the moderate to severe category. The left eye visual field showed superior and inferior arcuate defects with a mean deviation of -7 dB, also moderate to advanced disease.

Certainly this was glaucoma, although whether it was primary open- angle or low-tension glaucoma was not entirely clear. I set a target pres - sure below 15 mmHg at all visits. The patient started on topical glaucoma therapy and progressed to laser trabeculoplasty. A few years later she underwent bilateral cataract surgery. Postoperatively, she ran IOPs in the Figure 8. Case 5: Progression of the visual field in the right eye detected using 13-15 mmHg range on maximal tolerated medical therapy. She had a disc Glaucoma Progression Analysis software. hemorrhage in the right eye, followed soon after by possible visual field progression in the right eye as noted by the GPA software for the Humphrey Field Analyzer. She underwent a trabeculectomy with mito - mycin C and remained stable with 20/20 acuity and IOP in the 8–10- mmHg range. The left eye also showed progression using the GPA software (Figure 8) and eventually required trabeculectomy with mito - mycin C, resulting in IOP in the 8–10-mmHg range.

8 Dr Heuer: You mentioned setting a target IOP. How does the panel feel nerve appearance, any suggestion that you may not be dealing with glau - about setting and documenting a target IOP in the chart? coma, then perhaps there is a role for neuroimaging. I did not think this patient fit into any of those categories. Dr Lewis: I am not a big fan of target IOP because I think it is misleading. You may have the pressures at target level on one visit, but you do not know Dr Heuer: A good pearl is: If the disc does not fit, then you must image it. what will happen over the next 4 to 6 months. I just like to get their pres - Would obtaining a diurnal IOP curve in this type of patient be helpful? sures 25% to 30% below whatever the highest pressure was. If we could get this patient’s pressure down to the low teens, I would be comfortable. Dr Budenz: I think it can help you ascertain the peaks in IOP and better characterize IOP fluctuations. Whether the fluctuation that we measure Dr Budenz: I do document the peak or starting IOP, but I do not docu - in the office from visit to visit comes from medication nonadherence or ment the target. the peaks and troughs arising from medical therapy, I believe you need to Dr Lewis: I think it sets up a medico-legal issue. It allows attorneys to stabilize the IOP. When you have a progressive patient with IOP fluctu - say that you did not achieve it and it is your fault if the patient gets worse. ations, a glaucoma procedure such as trabeculectomy or tube implanta - tion is a great way to stabilize the IOP fluctuations while also lowering Dr Budenz: Exactly, but I do it in my head, calculating down 30% to 50% IOP and decreasing dependence on medical therapy. This patient has from the starting peak IOP. come in at multiple times of day and she seems well controlled pressure- wise all throughout the day. Dr Heuer: Setting a target IOP is what the American Academy of Oph - thalmology’s Preferred Practice Pattern says we are supposed to do. I Dr Heuer: Lastly, let’s talk about detecting visual field progression. What think that we all recognize that a target is a goal, a range, and it has to be is the state-of-the-art in this area? modified based on what it takes to get there. It sounds like you both do set a target; you just are not willing to call it that. Dr Budenz: Most clinicians would conduct GPA. This is the program we talked about earlier that is available on Humphrey Field Analyzers. It Dr Heuer: How comfortable were you in calling this glaucoma, given requires 2 reliable baseline fields and compares all subsequent fields to that the IOP was normal or nearly so? In other words, when do you con - the average of those 2 baselines. GPA flags “possible”, “probable”, and sider optic nerve damage from etiologies other than glaucoma, and when “confirmed” progression when 1, 2, or 3 consecutive tests are different do you consider neuroimaging? from the baseline values. So it takes a minimum of 5 visual fields to detect Dr Lewis: Imaging, blood tests, or any kind of extensive workup is really definite progression. of very little value in well-defined glaucoma. 16 On the other hand, if you Dr Heuer: We have covered a great deal of material today. The case dis - really had a suspicion based on visual function studies or other clinical cussions of patients with common diseases of the aging eye have been findings, or if there were focal neurological signs, a clinical workup illustrative of many patients in our practices. Our panelists have shared a would be worthwhile. great deal of data and some excellent clinical pearls to aid us in the man - Dr Budenz: If there is decreased central acuity, impaired color perception, agement of these patients. I am sure that these case discussions will be of pallor of the optic nerve, or a visual field defect that does not fit the optic value to all of us as we go back to the office tomorrow.

references

1. Donnenfeld ED, Perry HD, Wittpenn JR, Solomon R, Nattis A, Chou T. 9. Budenz DL, Anderson DR, Feuer WJ, et al. Detection and prognostic sig - Preoperative ketorolac tromethamine 0.4% in out - nificance of optic disc hemorrhages during the Ocular Hypertension Treat - comes: pharmacokinetic-response curve. J Cataract Refract Surg . 2006; ment Study. Ophthalmology . 2006;113(12):2137-2143. 32(9):1474-1482. 10. Wojtowicz JC, Butovich I, Uchiyama E, Aronowicz J, Agee S, McCulley JP. 2. Shugar JK. Use of epinephrine for IFIS prophylaxis. J Cataract Refract Pilot, prospective, randomized, double-masked, placebo-controlled clini - Surg. 2006;32(7):1074-1075. cal trial of an omega-3 supplement for dry eye. . 2010; Oct 28. Epub 3. Malyugin B. Small pupil phaco surgery: a new technique. Ann Ophthal - ahead of print. mol (Skokie) . 2007;39(3):185-193. 11. Behrens A, Doyle JJ, Stern L, et al. Dysfunctional tear syndrome: a Delphi 4. Myers WG, Shugar JK. Optimizing the intracameral dilation regimen for approach to treatment recommendations. Cornea . 2006;25(8):900-907. cataract surgery: prospective randomized comparison of 2 solutions. 12. Odyssey Medical Announces 92% Retention Rate for the Parasol® Punctal J Cataract Refract Surg. 2009;35(2):273-276. Occluder [press release]. http://www.prlog.org/10545169-odyssey- 5. Robin AL, Covert D. Does adjunctive glaucoma therapy affect adherence to medical-announces-92-retention-rate-for-the-parasol-punctal- the initial primary therapy? Ophthalmology . 2005;112(5):863-868. occluder.pdf. PR Log. February 3, 2010. 6. Shah RA, Wilson SE. Use of mitomycin-C for phototherapeutic keratec - 13. Taner P, Akarsu C, Atasoy P, Bayram M, Ergin A. The effects of hormone tomy and photorefractive keratectomy surgery. Curr Opin Ophthalmol. replacement therapy on ocular surface and tear function tests in post - 2010;21(4):269-273. menopausal women. Ophthalmologica . 2004;218(4):257-259. 7. Budenz DL, Chang RT, Huang X, Knighton RW, Tielsch JM. Reproducibil - 14. Scott G, Yiu SC, Wasilewski D, Song J, Smith RE. Combined esterified ity of retinal nerve fiber thickness measurements using the stratus OCT in estrogen and methyltestosterone treatment for dry eye syndrome in post - normal and glaucomatous eyes. Invest Ophthalmol Vis Sci. 2005; menopausal women. Am J Ophthalmol. 2005;139(6):1109-1110. 46(7):2440-2443. 15. Rao SN. Topical cyclosporine 0.05% for the prevention of dry eye disease 8. Mwanza JC, Chang RT, Budenz DL, et al. Reproducibility of peripapillary progression. J Ocul Pharmacol Ther. 2010;26(2):157-164. retinal nerve fiber layer thickness and optic nerve head parameters meas - 16. Greenfield DS, Siatkowski RM, Glaser JS, Schatz NJ, Parrish RK 2nd. The ured with cirrus HD-OCT in glaucomatous eyes. Invest Ophthalmol Vis cupped disc. Who needs neuroimaging? Ophthalmology . 1998;105(10): Sci. 2010;51(11):5724-5730. 1866-1874.

9 cme post test Case Discussions: Diseases of the Aging Eye Highlights from a CME Symposium held October 18, 2010; Chicago, Illinois

To obtain AMA PRA Category 1 Credit ™ for this activity, you must complete the CME Post Test by writing the best answer to each question in the Answer Box located on the Activity Evaluation/Credit Request form on the following page.

1. Which of the following is not a typical sign of pseudoexfoliation? 6. In the Ocular Hypertension Treatment Study, how often were disc a. Poor pupillary dilation hemorrhages overlooked by the examining clinician? b. Gray-white material deposited on the lens capsule a. 48% of the time and throughout the anterior segment b. 8% of the time c. Lenticulodonesis c. Never d. Reduced pigment in the iridocorneal angle d. 84% of the time

2. Common complications of cataract surgery in eyes with 7. Which of the following methods can be used to evaluate a patient pseudoexfoliation include all of the following, except: with suspected dry eyes? a. Lens dislocation a. Fluorescein staining b. Hyphema b. Lissamine green staining c. Vitreous loss c. d. Postoperative IOP spikes d. Both a and b

3. Which of the following is a useful way to improve therapeutic 8. Which of the following may be a useful therapy for dry eyes adherence? in a perimenopausal woman? a. Writing out a schedule of medication dosing times a. Oral hormone replacement therapy b. Asking open-ended questions b. Dietary supplementation with fatty acids c. Both a and b c. Topical immunosuppressive therapy d. Neither a nor b d. All the above

4. Which of the following is not a reason to avoid LASIK in eyes 9. Which of the following findings does not suggest the with glaucoma? need for neuroimaging of a patient being evaluated for a. IOP is briefly but significantly raised during flap construction normal-tension glaucoma? b. Postoperative haze might require chronic steroid use a. Altered color vision c. Blebs could be endangered by the microkeratome b. Focal neurological signs d. Eyes with glaucoma tend to end up overcorrected using c. Myopia standard nomograms d. Decreased central acuity

5. Optic nerve size asymmetry is usually not associated which 10. Using Glaucoma Progression Analysis software, how many visual of the following? field tests are required to document progression? a. Asymmetric cup-disc ratio a. 2 b. Brain cancer b. 3 c. Two different-sized optic nerves that may both be normal c. 4 d. Glaucoma d. 5

10 activity evaluation/credit request

Case Discussions: Diseases of the Aging Eye Original Release: March 1, 2011 Last Review: February 16, 2011 Highlights from a CME Symposium held October 18, 2010; Chicago, Illinois Expiration: March 31, 2012

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