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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 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 , 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 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 * * symptoms a persons • Vascular Layer vision. Over 3 million * * Americans have it, only *

half know it • Nerve Layer * *Macula http://www.glaucoma.org *Optic nerve

What is the main function of each layer?

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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 – (IOP) tension glaucoma – Probably nourishes posterior • surface of the cornea and Angle-closure glaucoma the crystalline • Congenital glaucoma • Flows from posterior chamber through the 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 , as well as redness of the eye and . • 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

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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 or advanced the eye that slows drainage of aqueous. The , eye injuries, certain eye tumors, or children usually have obvious symptoms such 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

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 • • People with diabetes • Corneal thickness • Family Hx of glaucoma • Medical conditions • 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

• + • Diabetes At Risk 11 year old girl • B-12 Deficiency • Auto-immune disorders • Playing wind instruments (trumpet) • Tobacco use • Sleep Apnea • • Rheumatoid Arthritis • Tuberculosis • Females • Lyme Disease

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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  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 • • 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

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Peripheral Field Loss Retinal Nerve Fiber Layer

• 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 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 •

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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  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  Rx is important Deviation (PSD)  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

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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 • . 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 – ciliary body – Enucleation – Combinations

Glaucoma - Shunt Shunt / • Visante is helpful in determining if a shunt is functioning

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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 surgery for the reduction selective laser (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. The DeepLight Gold Micro-Shunt operates differently from other types of glaucoma implants, because drainage is confined to the eye's interior with the idea of reducing surgical complications.

Durasert Education • Explain the diagnosis • Suspected cause of condition • Durasert. In June 2011, pSividia Corp. announced • Document well the pt • Planned treatment an early stage clinical trial of its Durasert glaucoma medical charts • implant is underway in the United States. The • Tell patient to keep a chart Possible affects on of progress vision now and in the bioerodible implant is inserted under the scleral future • Monitor progress and is designed to provide long-term • Watch for any particular • The importance of sustained release of the glaucoma medicine symptoms and contact following the doctors , reducing or eliminating the need for us if they occur instruction/compliance daily medicated eye drops to treat glaucoma. • Suggested lifestyle • Document non- changes compliance • Changes in iris color • Encourage honesty

Nonpenetrating to lower IOP (NPGS) • Prostagladins • A deep sclerectomy involves a minimally invasive incision • Betablockers…slows the into the white of the eye (sclera), a portion of which is heart rate removed to create a drainage space for relief of eye • Alpha-agonists pressure • Carbonic anhydrase • A new surgical method known as viscocanalostomy inhibitors creates an opening for insertion of a highly pliable, gel- • Miotic or cholinergic like material known as viscoelastic, which helps provide agents… enough space for adequate drainage and eye pressure • Epinephrine relief. Compounds #1 reason for IOP not going down…not taking meds

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Viscocanalostomy ED and Glaucoma • Several studies in the 1980s found that ED was a • New surgical method known as side effect of systemic and topical beta-blocker viscocanalostomy creates an opening for therapy.1-4 insertion of a highly pliable, gel-like • “It has been postulated that the sexual material known as viscoelastic, which dysfunction accompanying β-blockade may be helps provide enough space for adequate due to a number of mechanisms including: drainage and eye pressure relief. increased α-sympathetic tone causing shunting of blood away from the penis, depression and sedation mediated by the central nervous system, and overall decreased activity of the central

https://col125.mail.live.com/?tid=cm6CTmIwPp5BGZMwAiZMIC0A2&fid=flinboxnervous sympathetic system,” the study’s authors write

No Need For Weed () ED and Glaucoma Meds • Vancouver, British Columbia—A recent study found an association between erectile dysfunction (ED) and glaucoma that is not • The smoke contains THC attributed to the use of beta-blocker therapy. • No research supports the • History of beta-blockers and ED benefits of smoking medical • Several studies in the 1980s found that ED was a side effect of marijuana systemic and topical beta-blocker therapy.1-4 • Marijuana can lower IOP • “It has been postulated that the sexual dysfunction accompanying β- but the benefits have not blockade may be due to a number of mechanisms including: increased α-sympathetic tone causing shunting of blood away from been substantiated the penis, depression and sedation mediated by the central nervous therefore it is not system, and overall decreased activity of the central nervous recommended for patients sympathetic system,” the study’s authors write. • Rosanne Barr http://optometrytimes.modernmedicine.com/optometrytimes/news/marijuan http://optometrytimes.modernmedicine.com/optometrytimes/news/rise- a-and-optometry-practicing-post-legalization erectile-dysfunction-association-glaucoma

Caffeine Effects

The Next slides are for Reference • Studies are Only showing that raises IOP in patients

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Medications References • IOP Lowering Medications • Dosages vary • Quigley HA, Katz J, Derick RJ, GD Sommer: – Azopt • Insurances may not pay for 1992 An Evaluation of and Nerve – Betimol brand names Fiber Layer – Betoptic S • Some medications work on • Airaksinen PJ, Alnako HI: 1983 Effect of Nerve – some pts but not on others Combigan Fiber Loss on Optic Nerve Configuration in – Iopodine • Pt should run out of their Early Glaucoma – Istalol medications – Lumigan • Compliance is a big issue • University of Illinois Eye Digest 2006: Corneal – with many patients Thickness and Glaucoma – Travatan • http://www.allaboutvision.com/conditions/gla – Xalatan ucoma-surgery.htm

Thank you

[email protected] Thank you to Optos, Optovue, Zeiss, and Eyemaginations for use of their photos

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