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Title: Separating the Good, the Bad, and the Ugly:


1
Separating the Good, the Bad, and the UglyIs
It Glaucoma or not
  • Ron Melton, OD, FAAO
  • Randall Thomas, OD, MPH, FAAO
  • www.eyeupdate.com

1st World Congress of Optometry Medellin,
Columbia August 14-16, 2015
2
Underdiagnosis of POAG
  • Population studies suggest over half of all
    glaucoma patients have not been diagnosed
  • From the Baltimore Eye Study One-half of all
    people who were found to have glaucoma had seen
    an eye doctor within the past year and were
    unaware they had glaucoma!
  • Despite all the progress being made in the
    field, it is sobering that ophthalmologists fail
    to diagnose more than 50 of cases of glaucoma.
    (Quigley, Ophthalmology Times)

3
Risk Factors For POAG
  • Suspicious ONH cupping
  • Elevated or increasing IOP
  • Subnormal central corneal thickness (CCT)
  • Advancing age (particularly after 50)
  • African or Hispanic origin
  • - onset earlier (about 10 years), damage more
    severe, treatment less successful
  • Positive family history (age at Dx?)
  • Diurnal fluctuation ?
  • High myopia

4
Diastolic Blood Pressure Ocular Perfusion
Pressure and Glaucoma
  • OPP diastolic BP IOP
  • Theory OPP lt50mmHg is a risk factor for
    glaucoma, and glaucoma progression
  • Examples DBP of 65 and an IOP of 15
  • DBP of 85 and an IOP of 35
  • These two patients may be at equal risk because
    they have same theorized OPP of 50mmHg
  • Take home message Begin to check blood
    pressures on your glaucoma and glaucoma suspect
    patients, especially those with lower IOPs.
  • Reference Quaid, P et al, IOVS, Jan 2013

5
Under-Appreciation of Systemic Hypotension As It
Relates To Ocular Perfusion
  • OPP IOP minus the diastolic blood pressure
  • Ocular perfusion pressure may be the single
    biggest risk factor for glaucoma onset and
    progression
  • Reference Liebmann JM. Optometric Glaucoma
    Society, Boston, October 2011.

6
Diastolic Blood Pressure Ocular Perfusion
Pressure and Glaucoma
  • The driving force for ocular blood flow is the
    ocular perfusion pressure (OPP), defined as the
    ocular artery pressure minus the IOP.
  • Large cross-sectional prevalence studies in
    different populations found a significant
    association between low diastolic OPP and the
    prevalence of OAG.
  • The greater incidence of progression in patients
    with lower blood pressure, seen mainly in
    patients with lower IOP, suggests a vascular risk
    factor for progression independent of IOP.
  • Low blood pressure . . . may be the most
    important vascular risk factor for glaucoma
    progression.
  • Reference AJO. May 2010

7
OHTS Summary of Practice Implications
  • Risk for progression of ocular hypertension to
    POAG can be assessed
  • - Age, IOP, vertical C/D ratio, CCT
  • CCT should be measured in all patients with
    ocular hypertension and all glaucoma suspects
  • Patients at high risk should be treated
  • Therapy should be selected based on efficacy,
    tolerability, and likelihood of patient compliance

8
Treatment of Ocular Hypertension
  • In the end, the physician is stuck with the
    persistent problem of whom to treat and whom to
    watch.
  • It probably still makes sense that young
    patients with lots of high risk factors should
    receive prophylaxis, while elderly patients with
    few risk factors should not. The endless
    symposia and debates on how to best manage
    patients with ocular hypertension will probably
    continue unabated.
  • Reference Sommer A. Editorial. Treatment of
    Ocular Hypertension. Archives of Ophthalmology.
    March, 2010.

9
Delaying Treatment of Ocular Hypertension
  • In summary, the second phase of OHTS allows us
    to draw some important conclusions about the
    management of patients with OHT. Early medical
    treatment decreases the cumulative incidence of
    POAG. The absolute effect is greatest in
    high-risk individuals. Conversely, there is
    little absolute benefit of early treatment in
    individuals with OHT at low risk of developing
    POAG.
  • Reference Klass M et al. Delaying Treatment
    of Ocular Hypertension. Archives of
    Ophthalmology. March, 2010.

10
Perspective on Central
Corneal Thickness (CCT)
  • CCT has become standard-of-care inthe POAG (or
    suspect) work-up
  • Thinner corneas are a strong risk factor for POAG
    because true IOP is actually higher than the
    measured IOP.
  • Some patients with measured ocular hypertension
    may simply have a thicker CCT, thus reducing POAG
    risk because the true IOP is actually less than
    the measured IOP
  • CCT is the most heritable aspect of ocular
    structure (more than refraction, axial length, or
    optic disc size), suggesting that it is under
    exquisite genetic control. (Ophthalmology, Nov.
    2007)

11
Role of CCT and Glaucoma
  • Thinner CCT may be a significant, independent
    risk factor for open-angle glaucoma among persons
    with ocular hypertension.
  • It is unclear whether the impact of CCT as a
    risk factor for glaucoma is mediated largely
    through its role in determining measured IOP, or
    whether the thickness of the cornea is a
    surrogate for greater susceptibility of the eye
    to damage.
  • Reference AJO, May, 2006

12
The general clinical evaluation of a new glaucoma
suspect / patient
  • This clinical evaluation builds upon a careful
    family history, personal medical history, current
    health status, and medication(s)
  • Best corrected vision
  • Document pupil size and reactivity
  • Careful slit lamp biomicroscopy noting A/C depth,
    any iris abnormalities such as pigment
    dispersion, retroillumination defects, pseudo
    exfoliation, corneal guttata, etc.
  • Applanation tonometry, noting time
  • Pachymetry to determine CCT

13
Clinical Perspective on Rebound Tonometry
  • The advantages of rebound tonometry include
    portability, lack of dependence on slit lamp
    mounting or even an external electrical source
    (battery powered), no need for topical
    anesthetic, ease of use, suitability for use by
    non-medically trained personnel, and toleration
    by young children and non-cooperative adults.
    These characteristics make it quite useful in
    screening situations. In my practice, this is
    our go to instrument for children as young as 3
    years, for the intellectually challenged adults,
    and those with blepharospasm.
  • Reference R. Stamper, MD, Optometry and Vision
    Science. January 2011

14
Glaucoma Work-Up (continued)
  • Baseline gonioscopy (4-mirror preferred) looking
    for PAS, angle recession, angle pigmentation, and
    the anatomic patterns of the angle anatomy
  • Thorough BIO to r/o any peripheral pathology
  • Stereoscopic evaluation of the optic nerve heads
    (60D, 78D, or Hruby lens) glaucoma detected most
    often through dilated pupils
  • Baseline static threshold visual fields
  • Image analyzer of optic nerve head (GDX-VCC/OCT)
  • Optic disc photographic documentation

15
Breakthrough on Gonioscopic Training
  • A most wonderful website exists to help teach
    superb gonioscopic anatomy and technique
  • Please seek and study
  • www.gonioscopy.org

16
Optic Nerve Head Evaluation
  • Cup depth is critical - Stereopsis!
  • Are cup walls steep or sloping?
  • Note rim translucency and vertical elongation of
    the cup
  • Is the cup concentric with the disc, or is the
    cup displaced?
  • Is the neuroretinal rim thinned more at certain
    clock hours than others? Especially look for any
    accentuated erosion of the inferotemporal or
    superotemporal regions.
  • Is the disc generally pink, yellowish, or pale?

17
ISNT
  • Helpful diagnostic observation in ONH evaluation
  • Normal neuroretinal rim anatomy follows the
    ISNT rule
  • - Inferior rim should be thickest
  • - Superior rim is slightly less thick
  • - Nasal rim is slightly less thick
  • - Temporal rim should be the thinnest
  • Most ONHs are round or slightly vertically oval
  • ISNT rule may not hold if ONH horizontally oval

18
Optic Disc Size and Glaucoma
  • Bergtson (25 yrs ago)
  • Normal small discs have small cups
  • Normal large discs have large cups.
  • Average disc diameter 1.5 mm
  • Implications for glaucoma diagnosis and
    management
  • A high ratio may not be pathologic
  • C/Ds for large discs change by a smaller amount
  • C/D changes caused by glaucoma occur more slowly
    in large discs than in small discs (baseline
    photos large discs especially important
  • C/D asymmetry is not always pathological

Disc Diameter Mean C/D Upper Limit Small 1.0-1.3m
m .35 .55 Medium 1.4-1.7mm .45 .65 Large 1.8-2.0mm
.55 .75
19
Sizing the Optic Nerve Head
  • There is poor agreement between slit lamp
    ophthalmoscopy, HRT, and OCT in classifying disk
    size as small, average, or large.
  • Jonas proposed that in routine practice, the
    clinician conduct a quick, crude estimate of
    whether the disk in question is average-sized
    (medium), smaller-than-average, or
    larger-than-average.
  • Reference AJO, September, 2006, pp. 375-379

20
ONH Hemorrhage
  • Highly specific for glaucoma
  • Commonly inferotemporal in POAG
  • Commonly superotemporal in NTG
  • Prevalence higher in NTG (20-35)
  • Disc hemorrhages may precede a VF defect or a
    change in nerve head
  • Ominous sign in glaucoma patients
  • Associated with aspirin use and diabetes
  • (Ophthalmology 09/04)
  • Among glaucomatous eyes receiving treatment,
    those with a larger baseline MD and older age had
    a faster rate of VF loss after a DH developed.
  • There is no association between CCT and the
    later development of DH.
  • Recurrence of DH during follow-up was not
    associated with a fast rate of VF loss in this
    study.
  • (Ophthalmology, January 2010)

21
Glaucoma - Visual Fields
  • Program Strategies
  • Perspectives on Perimetry
  • Visual Field Interpretation
  • Foundational guidelines
  • Catch trials
  • Grey scale
  • Total and Pattern deviation
  • Glaucoma hemifield test
  • Global indices
  • Summary
  • Plaquenil Visual Field Testing

22
Debunking Myths
  • Once thought rare, optic disc hemorrhages occur
    in most glaucoma patients.
  • It has been proposed that IOP fluctuations
    represent a key risk factor for glaucoma
    progression, however, there is no clear evidence
    to support this concept.
  • Another myth is that selective perimetric testing
    (such as SWAP or FTD) can detect VF loss before
    standard white-on-white perimetry.
  • Reference International Glaucoma Review of the
  • World Glaucoma Association, Vol. 10, 2008

23
Ultrasummary
  • A combined cerebral assessment of
  • Pattern Deviation probability plots as compared
    to Total Deviation probability plots
  • Pattern Standard Deviation probability values
  • These probability plots give the greatest VF data
    guidance to the functional status of the
    patients optic nerves
  • Remember ALWAYS CORRELATE THE CLINICAL FINDINGS
    WITH THE VISUAL FIELD STUDIES!

24
Optic Nerve Head Image Analyzers
  • GDX-VCC, OCT-3, HRT, RTA, etc.
  • Can be helpful in early diagnosis
  • Limited value in advanced glaucoma
  • Excellent for detection of progression
  • A COMPONENT of the glaucoma evaluation
  • Not a litmus test for glaucoma

25
Nerve Fiber Layer Analyzers in Perspective
  • These so-called objective nerve fiber layer
    scanning devices are only relatively objective
    compared to highly subjective perimetry. Looking
    at this next series of GDx scans very nicely
    demonstrates this clinical truth.

26
Imaging vs VF to Assess Glaucoma
  • Evidence indicates that RNFL and optic disc
    assessment by imaging technologies may not
    provide adequate sensitivity to follow-up
    patients who manifest severe glaucomatous change.
    In this situation, visual field testing losses
    are still the best method to quantify the effect
    of the disease and monitor its progression.
  • More succinctly There is an inverse
    relationship between disease severity and the
    ability to detect change with imaging devices.
  • Reference Archives of Ophthalmology, September
    2012

27
RNFL, Neuroretinal Rim, and Visual Field
Progression
  • Regarding optic disc photos, the agreement for
    assessment of progressive optic disc changes is
    poor even among glaucoma specialists.
  • RNFL is mostly ganglion cell axons, whereas
    neuroretinal rim tissues contain nonneural
    structures
  • Because rate of change within these two tissues
    may vary with the stage of disease,
    interpretation of progression should be evaluated
    on an individual basis
  • It is plausible that detection of progression
    with OCT RNFL thickness may not be as effective
    as visual field measurement in moderate and
    advanced glaucoma.
  • Oph. August 2011

28
Treatment Goals For POAG
  • Establish a target IOP below which optic nerve
    damage is unlikely to occur
  • Maintain an IOP at or below this target level
    with appropriate therapy
  • Monitor VF's and ONH appearance to refine the
    adequacy of the target IOP
  • Optimally balance the benefits of therapy with
    any side effects
  • Educate and engage patients in the management of
    their disease

29
When to Treat?
  • Patients with normal optic disc and visual field
    could tolerate an IOP of 30 mmHg for many years
    without need of treatment.
  • What it comes down to is . . . treat young
    patients who are in the high-risk group, and it
    is worth watching the elderly in a low-risk
    group. The problem remains what to do for those
    in the middle.
  • Reference A Sommer / Johns Hopkins Univ.
    Ophthalmology Times. January 2011.
  • Melton-Thomas All glaucoma doctors struggle
    with the decision of whom to treat, and when.
    Remember medical care is an art, and equally
    well-trained doctors commonly differ in clinical
    decision-making.

30
Factors Regarding Treatment Initiation
  • Use of a risk calculator, and lack of glaucoma
    specialty training were associated with
    physicians being more likely to treat ocular
    hypertension
  • 2 / 58 glaucoma specialists and 4 / 118
    ophthalmologists reported treating all patients
    with an IOP gt21 mmHg
  • Most critical factors IOP, C/D ratio, and CCT
    (both groups)
  • Rational estimation of risk of conversion to
    OAG is essential for proper clinical
    decision-making
  • Treatment by default or faulty decision-making
    remains a healthcare crisis in glaucoma patient
    care management
  • Reference AJO, October, 2011

31
Target Pressure Use and Abuse
  • Despite recent breakthroughs in our knowledge of
    risk of progression, we still are making educated
    guesses. At all but the highest pressures, not
    all patients will progress. Some patients may
    have non-pressure dependent optic neuropathies
    that are beyond our current understanding and
    treatment capabilities. Around half of patients
    with normal tension glaucoma will not progress
    even without treatment.
  • Reference Werner M. Ophthalmology Web. March
    12, 2010.

32
Glaucoma Follow-Up
  • Most controlled glaucoma patients are seen every
    3 to 4 months for monitoring of the IOP and ONH
    status
  • Visual Fields and/or a scan are done as
    frequently as necessary, and at least once yearly
  • A dilated stereoscopic view of the optic nerve
    should be performed at least yearly, however, a
    quick look should be done at each visit.
  • If control is felt inadequate, more aggressive
    follow-up is in order until adequate control of
    the patient is achieved

33
Glaucoma Treatment Options
  • Prostaglandin Analogs
  • Beta-Adrenergic Blockers
  • Prostaglandin / Beta-Blocker combinations
  • Adrenergic Agonists
  • Adrenergic Agonist / Beta-Blocker combination
  • Carbonic Anhydrase Inhibitors (CAIs)
  • CAI / Beta-Blocker combination
  • Pilocarpine derivatives
  • Epinephrine derivatives
  • Laser Trabeculoplasty
  • Surgical Trabeculoplasty

34
Prostaglandin Receptor Agonists
  • Latanoprost (Xalatan and generic) 0.005
  • Travoprost (Travatan Z) 0.004
  • Bimatoprost (Lumigan) 0.01
  • Tafluprost (Zioptan) 0.0015

35
Prostaglandins
  • Pharmacology prostaglandin analog
  • Mechanism enhances uveoscleral outflow
  • Dosage once daily, usually in the evening
  • Effectiveness 30 reduction in IOP
  • Potential side effects Iris darkening,
    hypertrichosis, CME, iritis, HSK activation,
    migraine headache, inflammatory bowel disease
    (IBS)
  • Xalatan 0.005 by Pfizer (and generic), Travatan
    (Z) 0.004 by Alcon, Lumigan 0.01 by Allergan,
    and Zioptan 0.0015 by Merck

36
Tafluprost Ophthalmic Solution
  • FDA approved February 2012
  • First preservative-free prostaglandin
  • Reduces IOP similarly to the other prostaglandins
  • Dosage once daily, preferably in the evening
  • Most common side-effect conjunctival hyperemia
  • Available in unit dose containers
  • Marketed as Zioptan 0.0015 ophthalmic solution
    by Merck

37
The Efficacy and Safety of Once-Daily Versus
Once-Weekly Latanoprost Treatment for Increased
Intraocular Pressure
  • Latanoprost treatment for ocular hypertension or
    early glaucoma once-weekly was as effective as
    once-daily after 3 months of follow-up, and there
    were fewer, and only minor, side effects with
    this protocol.
  • Reference S. Kurtz, MD and G. Shemesh, MD.
    Journal of Ocular Pharmacology and Therapeutics,
    November 2004

38
Lumigan-Induced Periocular Skin Changes
  • Time to onset 3 to 15 months
  • Time to resolution following discontinuation 3-9
    months
  • Reversibility of prostaglandin-induced
    periocular hyperpigmentation is in contrast to
    the irreversible or very slow reversible nature
    of prostaglandin-induced iris hyperpigmentation.
  • Mechanistic explanation dermal melanocytes are
    continent relative to melanin granules, whereas
    iris melanocytes are incontinent
  • Switching to another prostaglandin may or may not
    evoke a lessened expression
  • Reference Ophthalmology, November 2006

39
Prostaglandin-Associated Periorbitopathy
  • A more newly recognized side effect of
    prostaglandin therapy
  • Periorbital fat atrophy gives rise to marked
    deepening of the superior lid sulcus, which can
    result in ptosis and enophthalmos
  • Beyond the obvious cosmetic concerns, such
    altered lid/orbital anatomy can make applanation
    tonometry quite challenging
  • Probably expressed more in middle-aged patients
    than in older patients
  • Tends to be at least partially reversible over a
    few months.
  • Advanced Ocular Care. July-August 2011.

40
Topical Beta-AndrenergicReceptor-Blocking Drugs
  • Timolol (Timoptic and Timoptic XE / Betimol)
    0.25 and 0.5 (Istalol) 0.5
  • Levobunolol (Betagan) 0.25 and 0.5
  • Metipranolol (Optipranolol) 0.3
  • Carteolol (Ocupress) 1.0
  • Betaxolol (Betoptic-S 0.25)
  • Have longer half-lives than other beta-blockers

41
Topical Beta-Blockers
  • Decrease aqueous production
  • Reduces IOP .25 no response 15
  • R/O asthma
  • Recommend monocular trial with lowest
    concentration once daily
  • Possible diminished effect if used with systemic
    beta-blockers
  • No advantage to gel-forming solution

42
Adrenergic Receptor Agonists
  • Brimonidine
  • Apraclonidine
  • Dipivefrin
  • Epinephrine

43
Brimonidine Tartrate
  • Alpha-2 adrenergic agonist tid FDA approval
  • Acts by reducing aqueous production with some
    enhancement of uveoscleral outflow
  • Reduces IOP similar to timolol 0.5 bid
  • Side effects fatigue and dry mouth most common
    side effects uveitis reported may reduce
    systolic BP 10 mmHg
  • Less tachyphylaxis or allergy development than
    the other alpha-2 agonists
  • Neuro-protective potential unknown
  • Alphagan (0.2) by Allergan, and generic
    Alphagan P (0.15) by
    Allergan and generic, and
    Alphagan P (0.1) by Allergan

44
Combigan Ophthalmic Solution
  • Combination of 0.2 brimonidine and 0.5 timolol
  • With ANY combination drug, always try one
    of the component drugs as
    monotherapy, and only use the combination product
    if or when the monotherapy drug comes close, but
    does not achieve target IOP
  • Remember, most all drugs have a non-response rate
    of about 10, so there is a 20 chance that one
    of the components of any combination drug is not
    performing
  • The IOP lowering effect, when administered twice
    daily, has been found to be slightly less than
    that seen with the concomitant use of 0.5
    timolol bid and 0.2 brimonidine tid.
  • Ocular Surgery News, Nov. 15, 2007

45
Combigan Ophthalmic Solution
  • If using timolol and not quite to target IOP,
    then trying Combigan would be rational
  • If using brimonidine and not quite to target IOP,
    then rational to try Combigan
  • If a prostaglandin does not reach target IOP,
    then try a once daily beta-blocker like timolol.
    If this two drop
    therapy approaches, but does not achieve
    target IOP, then trying a combination drug is
    rational
  • Marketed as Combigan by Allergan in 5, 10, and 15
    ml opaque white bottles, preserved with BAK .005

46
Topical CAIs
  • Dorzolamide 2 sol. and Brinzolamide 1 susp.
  • Mechanism decreases aqueous humor secretion
  • Reduces IOP approximately 15
  • FDA dosage tid, practical dosage bid
  • Contraindications Allergy to sulfa and/or
    history of blood dyscrasias
  • Side effects minimal some burning, bitter
    taste, rare allergic reaction
  • Most all patients controlled with oral
    acetazolamide were successfully controlled with a
    topical CAI
  • Azopt 1 susp-Alcon Trusopt 2 sol-Merck

47
Dorzolamide Hydrochloride 2 Timolol Maleate .5
(Cosopt)
  • Both components decrease IOP by reducing aqueous
    humor secretion
  • Because of the CAI, must be used bid, which
    results in excessive beta-blocker therapy
  • Contraindications patients with asthma, heart
    disease, or allergy to sulfa drugs
  • Ocular side effects burning/stinging and
    perversion in taste
  • Marketed as Cosopt by Merck bottle and PF and
    generic

48
Simbrinza - (brinzolamide 1.0 and brimonidine
0.2 combination)
  • Combination drug without a beta blocker where
    both ingredient drugs are dosed the same (b.i.d.)
  • Combines 1 brinzolamide (Azopt ophthalmic
    suspension) with 0.2 brimonidine
  • Offers a wide range of treatment possibilities
    due to its strong efficacy and ability to
    decrease elevated IOP by 21- 35
  • Marketed by Alcon under the brand name Simbrinza

49
Contemporary Glaucoma Medication Flow
  • 1st Tier Prostaglandin q d or timolol q am
  • 2nd Tier Topical CAI or brimonidine
  • 3rd Tier Combigan. Cosopt. or Simbrinza
  • 4th Tier Pilocarpine
  • Oral CAI (preferably methazolamide)

50
Alert on Topiramate (Topamax)
  • Approved 12-96 for seizure disorders
  • Unapproved Migraine HA, weight loss, depression,
    bipolar disorder
  • Mechanism of action is unknown
  • Because of a topiramate-associated risk for oral
    clefts, the FDA has now designated topiramate as
    a pregnancy category D drug.
  • Numerous reported cases of acute, bilateral,
    simultaneous angle-closure glaucoma
  • Onset usually within first 2 weeks of therapy
  • Most common presenting symptom blurred vision
  • Exact mechanism of increased IOP is unknown
  • Tx Stat consult with prescribing physician to
    begin to reduce topiramate dosage then aqueous
    suppressants, oral CAI, cycloplegia (retracts
    ciliary body) - no miotics
  • IOP normalizes in 1-4 days, no laser treatment
    indicated

51
Topiramate (Topamax) and Vision
  • Uses anticonvulsant, migraine prevention,
    bipolar disorder, obesity, OCD, IIH, neuropathic
    pain, essential tremor, post-herpetic neuralgia,
    and other esoteric uses.
  • Topiramate is a sulfa derivative (like CAIs)
  • Idiosyncratic ciliochoroidal effusion is the most
    common ocular side effect, and most always
    results in a myopic shift with or without
    increased IOP
  • This rare event usually occurs within 2 weeks of
    initiation (or doubling) of dosing
  • First described in 2001 70 are female
  • Tx D/C the medicine use (PRN) beta-blocker,
    brimonidine, or, in refractory case, oral
    prednisone or IV methylprednisolone. Also,
    instill cycloplegic agent, and do not use
    pilocarpine.
  • Reference Clinical Ophthalmology. January 2012

52
Qsymia Potential for Decreased Weight and
Increased Risk of Angle Closure
  • New drug for weight loss patients who are
    overweight or obese and also have at least one
    weight-related condition such as high blood
    pressure, diabetes or high cholesterol.
  • Combination of two older drugs
  • Phentermine (appetite suppressant)
  • Topiramate (feeling of satiation)
  • Lesser dosages of each component drug tend to act
    synergistically
  • On average, patients lose about 10 of their body
    weight over one year
  • Marketed by Vivus Inc (Mountain View, California)
  • FDA approval July 17, 2012
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