9/5/2013 Financial Disclosure • Speaker, Allergan, Inc. Diagnosis and Treatment of Glaucoma • Conflicts of Interest: none Kevin D. O’Neal, MD, PhD Sept. 21, 2013 What is Glaucoma? • An optic neuropathy that causes loss of peripheral vision • Most cases are asymptomatic • Most cases are chronic h i • “Thief in the night” • What is the complementary disease? Lateral View of Optic Nerve Epidemiology • Most common diseases in eye clinics: – – – – Macular Degeneration Dry Eye Cataracts Glaucoma • Over 2 million people in the US have glaucoma—about half are unaware (Glaucoma Research Foundation.) • 60 million people worldwide—second leading cause of blindness (WHO) • 8X more common in blacks vs. whites – 15x more likely for visual impairment Excessive intraocular pressure damages optic nerve 1 9/5/2013 • • • • Diagram of optic nerve cupping Viewing Optic Nerves How does Glaucoma affect Visual acuity? Requirements to Drive in North Carolina Mild glaucoma? Moderate glaucoma? Severe glaucoma? “End‐stage” glaucoma? • 20/40 visual acuity • Visual field: 30 deg. on either side of fixation (60 deg. total) • Normal visual field? l i l fi ld? – 60 deg. nasally; 90 deg. temporally Open Angle Glaucoma What do glaucoma patients see? 2 9/5/2013 How Gonioscopy works Gonioscopic View: Open Angle Gonioscopic View: Closed Angle Summary • Most people have open angles • Most glaucoma is open angle glaucoma • Narrow angle glaucoma can be divided into acute (angle closure) and chronic ( l l ) d h i Symptoms and signs of acute angle closure glaucoma Ocular Emergencies Attack of angle closure glaucoma Trauma/ruptured globe Central retinal artery occlusion 3rd nerve palsy with aneurysm Acute endophthalmitis Acute Horner’s Syndrome Acute Retinal Detachment • • • • • • • Pain Red eye Blurry vision Mid‐dilated pupil Steamy cornea High pressure Closed angle 3 9/5/2013 Acute angle‐closure presentation Acute angle‐closure Slit‐lamp view of normal anterior chamber Anatomy of Angle Closure Glaucoma Open Angle outflows and Angle Closure Treatment • Control pressure • Reduce inflammation • Perform laser peripheral iridotomy 4 9/5/2013 Patient undergoing laser treatment Slit‐lamp view post Laser peripheral iridotomy Chronic vs. Acute Glaucoma Acute Cases of Glaucoma • Most cases are chronic • Most people are initially unaware • Acute cases can be painful and can severely damage eye • Angle‐Closure‐primary and secondary • Posner‐Schlossman Syndrome • Traumatic – – – – • • • • Hyphema Ghost cell Ghost cell Trabecular Angle recession Aqueous Misdirection Lens Subluxation Suprachoroidal Hemorrhage Orbital Hemorrhage Case Report • 18 yo WM hit OD with baseball • Day 1 – VA CF 2’ – IOP 18 – Anterior chamber shows some blood just over top of pupil (70%) Case Report • Day 5 – VA 20/200 – IOP 32 – Blood about 40% Blood about 40% • Day 2 – VA CF 5’ – IOP 24 – Slight reduction of blood 5 9/5/2013 Case Report • • • • • Diagnosis? Traumatic Glaucoma Pressure rising due to blood (hyphema) Treatment? Anterior chamber washout What is Low‐Tension Glaucoma? • • • • • • Chronic Glaucoma • Open Angle (aka Primary Open Angle Glaucoma POAG) • Chronic Narrow Angle (Occludible) Glaucoma • Steroid‐Induced Glaucoma S id d d Gl • Low‐Tension (Normal Tension) Glaucoma Optic Nerve get pressure from both sides Measure intraocular pressure (IOP) Ranges Typical Glaucoma patient? LTG patient? How do we know? What is the mechanism?? Cross‐section of Optic Nerve Low/Normal‐Tension Glaucoma • Be aware that “normal” pressures (say 15) can be associated with glaucoma • How do we treat? • Same way as regular “high” pressure S l “hi h” glaucoma • Can have optic disc hemorrhage, migraines • Visual fields tend to be more paracentral 6 9/5/2013 Visual Fields Tests for Glaucoma Typical Open‐Angle Glaucoma Patient No symptoms No red eye +/‐ family history Often in office for routine exam or even minor trauma • More likely middle‐aged or older • • • • Visual Field Examples • Optic Nerve – – – – • • • • Visual inspection Photographs OCT HRT IOP CCT HVF Gonioscopy Macular Nerve Fiber Layer Patterns 7 9/5/2013 Correlating Structure and Function (Optic Nerve conformation and Visual Field Results) Visual Field Defects of Varying Severity What’s Your Diagnosis? Case continued • 48 yo WM referred from Urgent Care with fluctuating vision OS. No pain, mildly red • Exam – VA cc 20/20 OD 20/30 OS VA 20/20 OD 20/30 OS – Optic nerves c/d ratio ~0.3 OU – Slit‐lamp‐a few cell in anterior chamber OS – TA 18 OD, 52 OS What other tests? What’s Your Diagnosis? • • • • 58 yo BM Presents for routine exam Last exam –”could be 10 years ago” Exam – VA cc 20/20 OD, 20/25 OS – SLE‐mild cataracts – Optic Nerves c/d 0.8 OD, 0.5 OS – TA 24 OD, 19 OS – Gonioscopy‐‐open • Gonioscopy • Open Angles • Diagnosis? 1. 2. 3. 4. Angle‐Closure Glaucoma Acute Endophthalmitis Open Angle Glaucoma, high pressure type Posner‐Schlossman Syndrome Case continued… • Exam contd. – Visual Field shows small nasal step OD, point depression OS Diagnosis? 1. Chronic Angle Closure Glaucoma 2. Open Angle Glaucoma 3. Low‐pressure Glaucoma 8 9/5/2013 Treatment of Glaucoma • Drops – Topical medications given 1‐4x/day • Laser – LPI for Narrow Angles – Argon Laser Trabeculoplasty (ALT) or Selective Laser Trabeculoplasty (SLT) for POAG • Incisional Surgery – Trabeculectomy, Tube Shunts, Canaloplasty, new devices • Remove offending agent (blood, tumor, drug) Side Effects Topical Glaucoma Drops • • • • • • • Prostaglandin Analogues Beta Blockers Alpha Antagonists Carbonic Anhydrase Inhibitors Pilocarpine Combination Agents Generics? Iris color change with Latanoprost • Prostaglandin‐associated Periorbitopathy (PAP) • Asthma, COPD Somnolence in children • Somnolence in children • Allergic • Burning/stinging • Cost • Compliance Prostaglandin‐Associated Periorbitopathy (PAP) Laser Treatment of Open Angle Glaucoma • Argon Laser Trabeculoplasty (ALT)—1979 • Selective Laser Trabeculoplasty (SLT)‐1998 – “cold” laser, less destructive • Theories – Mechanical, Biochemical, Cellular 9 9/5/2013 Laser lens Gonioscopic View of TM 10 9/5/2013 Clinical View during laser Area of Trabeculoplasty Treatment Summary • Most people have asymptomatic, open‐angle glaucoma • Glaucoma is best detected by a well‐trained p g ophthalmologist • The IOP is not the whole story • The vast majority of patients can be controlled with drops and/or laser treatments • Advanced, late diagnosis, or intractable cases: – surgery 11
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