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Philosophies in Glaucoma

Philosophies in Glaucoma. Paul S. Jensen, O.D. Renton, WA www.lacrimology.com www.eyesmartz.com jensen@rentonvision.com. Philosophies in Glaucoma. How not to be a plumber. Making sense of information from disparate sources Clinical Pearls

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Philosophies in Glaucoma

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  1. Philosophies in Glaucoma Paul S. Jensen, O.D. Renton, WA www.lacrimology.com www.eyesmartz.com jensen@rentonvision.com

  2. Philosophies in Glaucoma How not to be a plumber • Making sense of information from disparate sources • Clinical Pearls • New Technologies (and new looks at some older stuff) 2

  3. Philosophies in Glaucoma • OHTS: Ocular Hypertension Treatment Study • The mother ship • OHTS is a gift to optometry 3

  4. OHTS Corneal Thickness Separate the ocular hypertensives from the low tension glaucoma 4

  5. OHTS • Conclusions: • Decreased IOP = decreased morbidity • Glaucoma suspects should be considered candidates for treatment 5

  6. OHTS Conclusions: • “There was little evidence of increased systemic or ocular risk associated with ocular hypotensive medications” 6

  7. OHTS Risks of Ocular Hypotensives • Meds show: - Near zero plasma levels - Measurable urine and cardiac out-put changes 7

  8. Philosophies in Glaucoma • My conclusion: • Glaucoma Diagnosis is Treatment • Never stop diagnosing: Minimum evaluation per year: • Tonometry X 4 • VF X 1 • SLO X 1 • Gonioscopy X 1 8

  9. Philosophies in Glaucoma • Case Study A: • IOP = 28, CCT = 556 • VF = questionable • C/Ds = OD: 0.6 X 0.6 OS: 0.5 X 0.5 • Gonio = Grade 4 X 180o • Case Study B: • IOP = 20, CCT = 556 • VF = questionable • C/Ds = OD: 0.6 X 0.6 OS: 0.5 X 0.5 • Gonio = Grade 4 X 180o 9

  10. The Philosophies of Glaucoma • 1956-1986: • IOP, ONH, VF • 1986: IOP doesn’t matter 10

  11. The Philosophies of Glaucoma • Since OHTS: - IOP matters, but in context of CCT - C/D matters, esp. in context of SLO - VF matters, but in context of Pattern SD 11

  12. Don’t be a plumber! Go to the original research Google Scholar, Medline, Elsevier, AOA 12

  13. Clinical Pearls “The only thing better that learning from your mistakes, is learning from other people’s mistakes.” - P. Jensen 13

  14. Clinic Pearls Treatment Pitfalls: - Blame the patient! - Compliance (importance of treatment, ability to follow Tx plan) - Poor gtt technique - gtt Allergy/Intolerance/Sensitivity 14

  15. Clinical Pearls Pigment Dispersion Syndrome • ITD/K-spindle - Blue irides (myd) - Myopic - Middle aged - Male & …. - Anyone…. & cataracts (?) 15

  16. Clinical Pearls Pseudo-exfoliation Syndrome • Older men • Watch for angle closure • Cataract extraction helps? • Difficult to control • Fluctuating IOP 16

  17. Clinical Pearls ONH Drusen • Cupping/SLO? • VF? • IOP? 17

  18. Clinical Pearls Lacrimal Occlusion • Increased bioavailability • Dramatically increased efficacy…. • Dramatically increased allergy 18

  19. Clinical Pearls Systemic Medications • Beta blockade • Steroids: - increasing incidence - all routes of administration 19

  20. Clinical Pearls Systemic Side Effects of gtt • Ask at each visit • Prostaglandin analogs – body, joint ache 20

  21. Clinical Pearls Mundane Details • Drop usage and technique • Documentation, flow sheet • Monocular medical trials 21

  22. Technologies Don’t be a plumber, understand the technologies • SLO - GDx - HRT II/III - OCT • Other 22

  23. GDx • Based on RNFL changes around disc • Excellent at detecting early changes • Good statistical analysis - Good change plots • Portable: easy to share/move 23

  24. GDx Interpreting the results • OD/OS comparisons • Color coding is intuitive • Be careful with tilted discs • NFI 24

  25. GDx 25

  26. GDx 26

  27. HRT II/III • Measures hydration, indirect eval of contour • Excellent in defining details of ON anatomy • Statistical analysis • Retinal module: macular edema - Glaucoma: 3 million Americans - Diabetes: 21 million Americans 27

  28. HRT II/III HRT II/III 28

  29. HRT II/III • Corneal Module, tissue eval, not contour • FA • Poor Portability (HRT II) 29

  30. HRT II/III 30

  31. HRT II/III Interpreting the results • Vascular tissue and nerve tissue all look alike • HRT III: GPS, a number! 31

  32. OCT Optical Coherence Tomography • Most beautiful images in ophthalmic practice • Eval peripapillary bundles • ONH cupping - changes can be seen, but measurements not standardized 32

  33. OCT 33

  34. OCT Interpreting the results RNFL Thickness: • Data similar to GDx Cupping: • Subjectivity • No standardization 34

  35. OCT 35

  36. Other Technologies Pachymetry • Glaucoma • LASIK Pre-op • Corneal edema/Fuch’s dystrophy • Keratoconus (?) • Inexpensive, reimbursable, easy as tono 36

  37. Other Technologies Pascal ® Dynamic Contour Tonometer • Looks like Goldmann, but - Concave tip - CCT independent - Reads OPA (mean max – mean min) 37

  38. Other Technologies Pascal® Dynamic Contour Tonometer 38

  39. Other Technologies Ocular Blood Flow • Helpful in understanding glaucoma • Necessary for Tx/management? • Excellent tool for following numerous systemic/pharm effects on vascular perfusion 39

  40. Other Technologies Paradigm OBF Analyzer 40

  41. Other Technologies - OBF TonoPlus™ • Reads: - IOP/tonography - OBF microl/min - Pulse 41

  42. TonoPlus ™ 42

  43. Other Technologies Ocular Response Analyzer • Measures corneal hysteresis (corneal resistance), distinct from CCT 43

  44. Other Technologies Diaton Tonometer • Transpalbebral • Limbal • +/- 2 to 20 mmHg, +/- 10% to 60 mmHg 44

  45. Other Technologies Diaton Tonometer 45

  46. Other Technologies Billing Technologies • Accufee® and others • EMR 46

  47. Philosophies in Glaucoma How to not be a plumber: • Read research in terms of patient care • Discover the truth for yourself • Be flexible, make smart mistakes • Eval technology based on your practice and patients, not just disease 47

  48. Thanks! Special thanks to Lindsey Sewell, OD, FAAO for help in preparing this presentation.

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