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
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• “Thief in the night”
• What is the complementary disease?
Lateral View of Optic Nerve
Epidemiology
• Most common diseases in eye clinics:
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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
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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?
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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
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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
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Pain
Red eye
Blurry vision
Mid‐dilated pupil
Steamy cornea
High pressure
Closed angle
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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
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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
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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
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Case Report
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Diagnosis?
Traumatic Glaucoma
Pressure rising due to blood (hyphema)
Treatment?
Anterior chamber washout
What is Low‐Tension Glaucoma?
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Chronic Glaucoma
• Open Angle (aka Primary Open Angle Glaucoma POAG)
• Chronic Narrow Angle (Occludible) Glaucoma
• Steroid‐Induced Glaucoma
S
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• 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
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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
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Visual Field Examples
• Optic Nerve
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Visual inspection
Photographs
OCT
HRT
IOP
CCT
HVF
Gonioscopy
Macular Nerve Fiber Layer Patterns
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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?
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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?
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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
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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
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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
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Laser lens
Gonioscopic View of TM
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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
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