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Glaucoma Comanagement: Surgical 6/27/2017 Virginia Eye Consultants Tertiary Referral Eye Care Since 1963 • John D. Sheppard, MD, MMSc • Walter O. Whitley, OD, MBA, FAAO Innovations in Glaucoma • Stephen V. Scoper, MD • Mark Enochs, OD • David Salib, MD • Cecelia Koetting, OD, FAAO COPE#52116-GL • Elizabeth Yeu, MD • Christopher Kuc, OD • Thomas J. Joly, MD, PhD • Leanna Olennikov, OD • Dayna M. Lago, MD • Jillian Janes, OD • Constance Okeke, MD, MSCE Walter O. Whitley, OD, MBA, FAAO • Esther Chang, MD Director of Optometric Services • Jay Starling, MD Virginia Eye Consultants • Samantha Dewundara, MD Residency Program Supervisor • Surajit Saha, MD Pennsylvania College of Optometry Disclosures Walter O. Whitley, OD, MBA, FAAO has received consulting fees, honorarium or research funding from: • Alcon • Diopsys • Allergan • Ocusoft • Bausch and Lomb • Science Based Health • Biotissue • Shire • Beaver-Visitec • TearLab Corporation • Publications – Advanced Ocular Care – Co-Chief Medical Editor – Review of Optometry – Contributing Editor – Optometry Times – Editorial Advisory Board The Most Valuable Glaucoma Tool Glaucoma: Diagnosis • We know it when we see it IOP: 26 OU 1 6/27/2017 Glaucoma Diagnosis Glaucoma Diagnosis • Gonioscopy • Central corneal thickness • Visual fields • Fundus photography • Scanning lasers • Serial tonometry • Electrodiagnositics – VEP / PERG GLAUCOMA SEVERITY SCALE Managing Glaucoma Patients DEFINITIONS • Mild Stage: optic nerve changes consistent with glaucoma but • Monitor IOP reduction: 1-2 week, 1 month NO visual field abnormalities on any visual field test OR abnormalities present only on short-wavelength automated • Check IOP every 3-4 months perimetry or frequency doubling perimetry. • Repeat VF every 6-12 months • Moderate Stage: optic nerve changes consistent with • Disc photos every 1-2 years glaucoma AND glaucomatous visual field abnormalities in one hemifield and not within 5 degrees of fixation. • Gonioscopy every year • Optic nerve analysis every 6-12 months • Severe Stage: optic nerve changes consistent with glaucoma AND glaucomatous visual field abnormalities in both • Document everything hemifields and/or loss within 5 degrees of fixation in at least one hemifield. http://www.aoa.org/optometrists/tools-and-resources/clinical-care-publications/clinical-practice-guidelines?sso=y http://www.americanglaucomasociety.net/professionals/glaucoma_staging_codes_teaching_module/ https://www.aao.org/guidelines-browse?filter=preferredpracticepatterns 2 6/27/2017 Corneal Hysteresis How ORA Works 1st IOP 1st IOP 1st IOP Air-jet stops Air-jet stops 2nd IOP 3 6/27/2017 ORA—Signal Plot “In” signal peak “Out” signal peak Start Thinking Weak vs. Strong IOP 1 IOP 2 Wells AP, Garway-Heath DF, et a. Corneal hysteresis but not corneal thickness Correlates with optic nerve surface compliance in Relationship of IOP and Glaucoma patients. Invest Ophthalmol Vis Sci 2008 Corneal Hysteresis Corneal IOP Hysteresis Lower CH = More Likely to Respond to Topical Medications Higher CH = Less Likely to Respond to Topical Medication 4 6/27/2017 Anand A, De Moraes CG, Teng CC, et al. Corneal hysteresis and visual field asymmetry in open angle glaucoma. Invest Ophthalmol Vis Sci 2010;51:6514 More Likely to Respond to Topical Medications Association with Progressive Low CH Field Worsening Greater Structural Bowing of Congdon NG, Broman AT, Bandeen-Roche K, Lamina Cribrosa et al. Central corneal thickness and corneal hysteresis associated with glaucoma damage. Am J Ophthalmol 2006;141:868 Structure Function Structure Function Fundus Photograph Visual Field Optical Coherence Tomography ERG (Subjective) (Subjective) (Objective) (Objective) When Do I Use Electrophysiological Tests? Electrophysiology objectively measures strength and speed of the visual signal to the • Clarify Differential Diagnosis…. Is it Systemic or brain (VEP) or retina (PERG) Trauma vs. Ocular? • When Standard Tests are Unattainable or Unreliable VEP (neuro) • When Other Tests are Inconsistent or Borderline Result PERG (retinal) • To Monitor Subclinical Disease for Functional Changes and Alter Treatment and Efficacy 5 6/27/2017 ELECTROPHYSIOLOGY DETECTS CHANGES EARLIER THAN OCT AND VISUAL FIELD1 Visual Evoked Potential (VEP) • Main Indications – Glaucoma Asymptomatic Symptomatic OCT – Multiple Sclerosis Healthy OHT Glaucoma PERG/VEP VF – Ischemic Optic Neuropathy Non structural Documented – Traumatic Brain Injury structural damage damage documented – Amblopyia – Other Neuropathies 1. Parisi V, Miglior S, Manni G, Centofanti M, Bucci MG. Clinical ability of pattern-electroretinograms and visual evoked potentials in detecting visual dysfunction in ocular hypertension and glaucoma. Ophthalmology. 2006 Feb;113(2):216-28. WHY USE VEP? Pattern ERG = PERG • VEP is an objective, functional test when standard tests cannot provide sufficient Main Indications information for diagnosis and treatment. • Many optic nerve diseases are asymptomatic Glaucoma because central vision is not affected until late Maculopathies in the disease1 • Diagnosis and management of optic nerve disorders are often based on structural or Can also help the clinician differentiate 2 between retinal and optic nerve disorders subjective visual field tests when used in conjunction with Visual Evoked Potential (VEP). How Does PERG Work? AAO Basic Science Course 2015/2016: Since the PERG (in contrast to the flash ERG) is a local response PERG is a useful tool for the early diagnosis of glaucoma from the area covered by the retinal stimulus image, specifically GCC, it can be used as a sensitive indicator of dysfunction within the macular region and it reflects the integrity of the optics, photoreceptors, bipolar cells and retinal ganglion cells. *Source: http://www.iscev.org/standards/pdfs/ISCEV-PERG-Standard-2013.pdf 6 6/27/2017 Visual Assessment Per NIH and Bascom-Palmer “In patients who are glaucoma suspects, PERG signal anticipates an equivalent loss of OCT signal by several years (as many as 8 years).” IOP 26 mmHg IOP 18 mmHg IOP 18 mmHg Treatment initiation Invest Ophthalmol Vis Sci. 2013;54:2346–2352) DOI:10.1167/iovs.12-11026 Ganglion Cell Function Measured By ERG Dynamic Visual Function Assessment After IOP Reduction in POAG • Researchers concluded that significant IOP- lowering therapy could improve RGC function measured by PERG in patients with preperimetric and early stages of POAG – IOP significantly decreased avg 31% – Increase in MOPP avg 14% – PERG amplitude of P50 and N95 waves increased in 75% and 79% eyes IOP 26 mmHg IOP 18 mmHg Treatment initiation IOP 18 mmHg Karaśkiewicz J, Penkala K, Mularczyk M, et al. Evaluation of retinal ganglion cell function after intraocular pressure reduction measured by pattern electroretinogram in patients with primary open-angle glaucoma. Doc Ophthalmol. 2017; Feb 7. [Epub ahead of print]. Dynamic Visual Function Assessment Glaucoma: Treatment • Goal of treatment – Halt further visual loss – Halt further optic nerve damage • How We Treat PERG – Reduction of IOP slows progression of glaucoma • Treatment options – Medications – Laser therapy – Surgical intervention 7 6/27/2017 Glaucoma: Medications First Line Therapy: Prostaglandins • All active first line drugs are effective compared with placebo in reducing IOP at 3 mos • Bimatoprost, latanoprost, and travoprost are most efficacious and within-class difference were small Tianjing Li, Lindsley K, Rouse B, et al. Comparative effectiveness of first-line medicationsfor primary open-angle glaucoma. Ophthalmology. 2016;123(1):129-40. How Do Patients Feel about their Drop Overall Compliance Rates Usage? • 10% - 25% take none of their prescribed medication • 68 glaucoma pts • 54% stated their drops were expensive • 25% - 35% take all of their medication as prescribed • 72% were suffering from side effects • 91% said medical therapy represented • Majority are partially compliant minimal/no inconvenience • 82% were interested in learning about procedures that could reduce or possible eliminate their need for drops 1. Weintraub M. Compliance in the elderly. Clin Geriatr Med. 1990;6:445-452. 2. Lamy PP. Compliance in long term care. Geriatrika. 1985;1(8):32. 3. Coleman TJ. Non-redemption of prescriptions: linked to poor consultations. BMJ. 1994;308(6921):135. Patient Compliance and Dosing Continuous Use • Literature review of 76 studies show – Compliance increases with decreased dosage regimen and complexity1 – 79% compliance with QD Compliance regimen vs 51% for QID regimens (p=0.001)1 – Simpler, less-frequent dosing results in better Dosing (Times/day) compliance in a variety of Nordstrom, Friedman, et al. Ophthalmology 2005 therapeutic classes1 1. Claxton et al. Clinical Therapeutics. 2001; 23:1296-1310. 8 6/27/2017 How Adherent are Glaucoma Patients Poor Adherence To Glaucoma Therapy with QD Medication? • By one year after first eye drop Rx, less than 50% are still filling prescription • Among New Jersey Medicaid seniors, 25% never filled the second prescription • Average number of treated days = 70 Reardon, Schwartz, Mozaffari. Clin Therap 2003;25:1172 Gurwitz et al. Am J Public Health 1993;83:711-6. Glaucoma: Medications Glaucoma Surgical Options • When COMPLIANCE with drops is low • Laser Therapy • When MEDICAL THERAPY FAILS – SLT • When the PROGRESSION continues to WORSEN – ALT – LPI • Surgical Options • Treatment options – Trabeculectomy – Medications – Trabectome – Laser therapy – Express Shunt – Surgical intervention – Tube shunt – Canaloplasty – ECP 9 6/27/2017 The ABC(DE)’s of Choosing a Surgery Glaucoma Clinical Trials Ronald
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