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Glaucoma Basics

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Glaucoma Basics 2/10/2016 Overview Normal • Define Glaucoma • Diagnosis that make-up What is Glaucoma? glaucoma • Patients that are pre- dispose to Glaucoma • Discuss risk factors Lynn E. Lawrence, CPOT, ABOC, COA associate with Glaucoma • Treatment • Patient Education Opportunities Glaucoma Military Medical New 10 Jan11 Definitions January is Glaucoma Awareness Month Nearly 3 million people have glaucoma • Glaucoma is an optic • An eye disease in which Glaucoma comes without warning symptoms neuropathy characterized by the normal fluid pressure Glaucoma is the second leading cause of a loss of ganglion cells and inside the eyes slowly blindness in the U.S. and first leading cause of their axons, in the RNFL. The rises, leading to vision preventable blindness loss of retinal ganglion cells in loss– or even blindness. 120, 000 Americans are blind from glaucoma glaucoma is irreversible • NEI: Glaucoma is a group African Americans account for 9-12%, 6-8 times • Neuropathy is any disease of of diseases that damage more likely than Caucasians…ages 45-65 more the nervous system the eye’s optic nerve and likely to go blind from the disease can result in vision loss Other high risk groups are: diabetics, Fam Hx, and blindness people over 60, those severely nearsighted Glaucoma Research Foundation Anatomy and Physiology of the Eyeball • Glaucoma is a group of 3 Layers diseases that can steal • Fibrous Layer without warning or *Cornea *Sclera symptoms a persons • Vascular Layer vision. Over 3 million *Choroid *Ciliary body Americans have it, only *Iris half know it • Nerve Layer *Retina *Macula http://www.glaucoma.org *Optic nerve What is the main function of each layer? 1 2/10/2016 Aqueous Chamber Types of Glaucoma • Manufactured by ciliary body • Characteristics: – Clear Not curable/but treatable – Watery consistency (99% in most cases H2O) • Functions • Low-tension/ normal – Refraction of light – Intraocular Pressure (IOP) tension glaucoma – Probably nourishes posterior • surface of the cornea and Angle-closure glaucoma the crystalline lens • Congenital glaucoma • Flows from posterior chamber through the pupil into the • anterior chamber Secondary glaucoma How does aqueous flow out of anterior chamber? IOP Low Tension Glaucoma • Optic nerrve damage and narrowed side vision occur in people with normal eye pressure. Lowering eye pressure at least 30 percent through medicines slows the disease in some people. Glaucoma may worsen in others despite low pressure. • Potential risk factor: low blood pressure Angle Closure Glaucoma Dilation Hazards • The fluid at the front of the eye cannot reach the angle and drain from the eye. The angle gets • Cross Contamination blocked by the part of the iris. People with this type of glaucoma have a sudden increase in eye • Narrow anterior pressure. Symptoms include severe pain and chamber angle nausea, as well as redness of the eye and blurred vision. • Potential risk in dilating • Dilating a patient with narrow angles can induce an acute angle glaucoma attack • Plan for acute angle • This is a medical emergency, now is the time to act glaucoma attack • Explain the YAG-PI, why is it necessary 2 2/10/2016 Secondary Glaucoma Congenital Glaucoma • These can develop as complications from other medical conditions. These types of glaucomas • Children are born with a defect in the angle of are associated with eye surgery or advanced the eye that slows drainage of aqueous. The cataracts, eye injuries, certain eye tumors, or children usually have obvious symptoms such uveitis as cloudy eyes, sensitivity to light, and excessive tearing. • Pigmentary glaucoma occurs when pigment from the iris flakes off and blocks the meshwork, • Early intervention could lead to a great slowing fluid drainage outcome • Neovascular glaucoma is linked to diabetes Major Risk Factors • Inter-ocular pressure At Risks • Age • Everyone over 65 • Race • African Americans ages – African Americans 6 x 20-39 should have eye • Family Hx exams every 3-5 years • Myopia • People with diabetes • Corneal thickness • Family Hx of glaucoma • Medical conditions • Corticosteroid patients – Trauma • African Americans are • Everyone can get it! five times more likely • 1 out of 10K babies • 15 times more likely to born in the U.S. have blindness in 45-64 • Pt with RP • + Hypertension • Diabetes At Risk 11 year old girl • B-12 Deficiency • Auto-immune disorders • Playing wind instruments (trumpet) • Tobacco use • Sleep Apnea • Lupus • Rheumatoid Arthritis • Tuberculosis • Females • Lyme Disease 3 2/10/2016 Assessment of Glaucoma Glaucoma Assessment Case Hx Optic Nerve Head (ONH) Visual function…field • . Identify testing testing procedures associated Retinal Nerve Fiber Layer with POAG Expert interpretation of results • - IOP Corneal thickness… Measurements pachymetry avg 500 microns • - OCT Gonioscopy POAG vs CAG • -Pachymetry Trauma IOP (asymmetric pressure) • -Visual Fields Goldmann (industry std) There must be a change in a retinal POAG condition to Dx glaucoma Low Tension Closed or narrow angle Optic Nerve Head ONH Inspection • Ophthalmoscope exam • C/D ratio (middle divot) • C/D Ratio • Rim thinning • ONH Color • Notching • Excavation • Dranz –bleeding around • Requires clear media the optic nerve • Dilation • Fundus photography • Imaging (HRT, OCT, GDx for early detecting! • Drance hemms on edge of disk 5 Rules for ONH Evaluations ISN’T IT Helpful • Observe the scleral ring to identify the limits and • Inferior rim thickest size of disc • Superior rim slightly less • Examine the RNFL thick • Look for retinal and optic • Nasal rim even less disc hemorrhages thick • Identify size of the • Temporal rim should be neuroretinal rim the thinnest • Examine the region of parapapillary atrophy These apply when you have a fairly (PPA) round or slightly vertically oblong disc 4 2/10/2016 Peripheral Field Loss Retinal Nerve Fiber Layer • Visual field assessment • Changes are more • Standard automated common than ONH changes perimetry • Quigley Study • Moderate –to- – RNFL atrophy in 49% advanced stages – ONH changes in 19% • Airaksinen Study – RNFL defects in 83% – ONH C/D changes in 42% • Red-free photography Corneal Thickness Imaging cont… Thicker corneas over estimate IOP • provides high-resolution imaging • of the retina layers, with detail and Thinner corneas under precision. estimate IOP • A range of scan patterns is available to Average 555nm fit the • imaging needs for retina pathology. African Americans These average corneal • patterns are designed to take thickness (520- advantage of the 540nm) • speed and resolution offered by White Americans Fourier-domain average corneal • OCT technology. thickness (580- 600nm) False reading due to Corneal Thickness Correction Value Inter-Ocular Pressure [um] [mmHg] 445 +7 • One risk factor for • 455 +6 • 555 -1 glaucoma • 465 +6 • 565 -1 • Tonometry is used to • 475 +5 • 575 -2 assess IOP • 485 +4 • 585 -3 • The damage thresh hole varies from person to • 495 +4 • 595 -4 person • 505 +3 • 605 -4 • Ocular Hypertensive- vs • 515 +2 • 615 -5 –glaucoma • 525 +1 • 625 -6 • Corneal thickness and What condition is this? IOP • 535 +1 • 635 -6 • A.M. vs P.M. • 545 0 • 645 -7 • 5 2/10/2016 Checking Blood Pressure Clinical Examination • Ocular Perfusion • BVA Pressure (OPP) diastolic • Pupillary function • OPP Formula= (BP 120/80) OPP = 80 – IOP • Anterior Seg eval • Gonioscopy • Theory: OPP • IOP (careful) • Pachymetry • Check BP on all • NFL Eval glaucoma patients • Visual Field (especially those with low IOP) Testing Glaucoma vs Ocular Hypertension DFE Numeric data FDT Gray scale • Glaucoma • Ocular Hypertension Heidelberg (new technology) Total deviation (OHT) OCT Pattern deviation –High or low – Elevated pressure HVF (reduces operator error Global Hemifield Test (GHT) pressure but no other signs Threshold testing Global indices (standards) –Large C/D FastPac Testing Pattern Standard Deviation (PSD) Rx is important Pupil Diameter (3mmmin) Mean Deviation (MD) Fixation Losses (gaze not on target) False-positive (trigger happy) False-negative (missed brighter stimulus) Acute Angle- Narrow Angles / Shallow Chamber Closure Glaucoma • Rapid onset • Painful • Very serious • Can lead to permanent blindness Page 36 Vicante OCT in Glaucoma 6 2/10/2016 Glaucoma Applications • Researchers are interested in quantitative Peripheral Iridotomy = YAG PI angle measurements and other characteristics of anatomical information quantified by Visante Glaucoma – RNFL Thickness Analysis Treatment of Glaucoma • Education . Center of disc is automatically identified for precise registration and repeatability • Medication . RNFL thickness display is of a 1.73mm radius circle around the disc . TSNIT graph is compared to normative database of about 300 patients • Surgery – YAG PI (PCAG) – SLT – Trabectulectomy – Tube Shunt – Laser ciliary body – Enucleation – Combinations Glaucoma - Shunt Shunt / Trabeculectomy • Visante is helpful in determining if a shunt is functioning 7 2/10/2016 Trabeculectomy New IStent • iStent Trabecular Micro-Bypass. is available in Europe for • The SOLX laser system, which received FDA the treatment of open-angle glaucoma. The device also is commercially available in the United States and Canada for approval in September 2008, is similar to use in conjunction with cataract surgery for the reduction selective laser trabeculoplasty (SLT), in that of IOP in patients with mild to moderate open-angle only pigmented cells are targeted, sparing glaucoma. adjacent tissue from potential heat damage.
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