05/07/2014 Outline Definitions Referral Decisions Glaucoma Service Update to LOC July 2014 Mr. Areeb Moosavi Glaucoma Consultant Milton Keynes Hospital NHS Foundation Trust What is Glaucoma? – NICE 2009 etc IOP in context CCT Glaucoma in Milton Keynes – Background – management & pathways Case Discussions Definitions What is Glaucoma? – Group of diseases resulting in a loss of retinal ganglion cells, progressive optic neuropathy and a characteristic pattern of corresponding visual field loss ‘IOP-sensitive’ No cure Progression slowed by reducing IOP from baseline / highest (by at least a third) Medical Retina Firm, June 2008 What is Ocular Hypertension? Definitions What is Ocular Hypertension (OHT)? – Higher than average IOP (>21mmHg) without any evidence for nerve damage or visual field loss Can convert to glaucoma OHT Patients are often related to glaucoma patients Consider treating if IOP > 30mmHg Medical Retina Firm, June 2008 1 05/07/2014 Outline Can you come and give a talk to the LOC? Definitions Referral Decisions – NICE 2009 etc IOP in context CCT Glaucoma in Milton Keynes – Background – management & pathways Case Discussions Medical Retina Firm, June 2008 NICE 2009 10% UK blindness due to Glaucoma 2% > 40 years old have COAG 10% >75 years old in white europeans Approx 0.5 million affected by COAG in England > 1 million HES glaucoma outpatient visits / year NICE 2009 >590um CCT Association of Optometrists (AOP) response 555um Any Untreated IOP (mmHg) >21 to >25 to 25 32 >21 to 25 >25 to 32 >21 to 25 >25 to 32 >32 Age (yrs) Any Any Any Treat until 60 Treat until 60 Treat until 80 Any Treatment None None None BB PGA PGA PGA NICE 2009 What did it mean to you? 555590um Refer or not? Case 1 81 year old male caucasian Fit & well IOP 25 mmHg Normal examination (VF, Discs, Van Herick) – Refer all patients with IOP > 21mmHg Case 2 Each community optometrist sending 4 extra glaucoma referrals 65 year old female asian Fit & well IOP 24 mmHg Normal examination (VF, Discs, Van Herick) 2 05/07/2014 Subsequent Guidelines (Asymptomatic patients only) Subsequent Guidelines (Asymptomatic patients only) (Joint college of Optemetrists & Ophthalmologists, 2010) (Joint college of Optemetrists & Ophthalmologists, 2010) Consider not referring patients at “low risk” of significant visual loss in lifetime – ≥80, IOP <26mmHg (with normal examinations) – ≥65, IOP <25mmHg (with normal examinations) Do not qualify for treatment under NICE Review by community Optometrist every 12 months Subsequent Guidelines (Asymptomatic patients only) (Joint college of Optemetrists & Ophthalmologists, 2010) Guidelines only! If unsure - refer Suspicious Optic Discs IOP > 21mmHg – 4 readings of NCT – Mean >21mmHg – Repeat set of readings if never had NCT before Glaucomatous VF Narrow angle on Van Herick Conditions associated with Glaucoma – Pigment Dispersion – Pseudoexfoliation Food for thought If Community Optometrists refined referrals using; – GAT – Pachymetry criteria – Joint Colleges’ Guidelines….. Referrals of OHT suspects could be reduced by 20% (compared to original AOP guidance) Vernon SA et al Br J Ophthal 2011;95:1534-1536 Emergency / Urgent Referrals Outline Emergency (same day to A/E) – Acute Angle Closure Glaucoma – IOP > 40mmHg (unless chronic rubeotic glaucoma in blind eye) Definitions Referral Decisions – NICE 2009 etc Urgent Referrals – Symptoms suggestive of angle closure with narrow angles – Intermittent pain/blurring/haloes esp at night – Raised IOP with uveitis (35-40mmHg) Routine Referrals – All suspected glaucoma & OHT – Referral screened by consultant – Currently seen in clinic in < 2/12 IOP in context CCT Glaucoma in Milton Keynes – Background – management & pathways Case Discussions 3 05/07/2014 Intraocular Pressure (IOP) IOP in context 67 yo Male POAG IOP 11 on 2 drops Fields progressing Why? “normal” range 10-21mmHg (Caucasian Europeans) Up to 4mmHg difference between eyes normal. Abnormal > 8mmHg IOP very dynamic and variable – Diurnal variation (Highest early morning, >10mmHg abnormal) – Eye movements – Breathing Patterns – Physical activity – Supine vs sitting up – Seasonal variations (higher jan-feb and lowest in may-aug) Medical Retina Firm, June 2008 Medical Retina Firm, June 2008 Medical Retina Firm, June 2008 Liu et al, IOVS 1999 40:12 Todani et al IOVS 2011 Barkana et al Arch Ophthalmol. 2006;124:793-797 4 05/07/2014 SENSIMED Triggerfish® (Sensimed, Lusanne, Switzerland) Methods of IOP measurement Mansouri & Shaarawy BJO 2011 95;627 60 y.o Male. POAG. Latanoprost at 22.00. GAT 13 at baseline, 15 after 24 hrs Goldman applanation is still “Gold Standard” Perkins accepted as alternative by NICE. Highly correlated with Goldman (r = 0.91, Baskett et al 1986) iCare rebound tonometry reads 2mmHg higher than Goldman. – Affected a lot by CCT. – No anaesthetic required – good in children. 79 y.o Female. POAG. Alphagan 9 & 17.30. Latanoprost at 22.00. GAT 14 at baseline, 16 after 24 hrs NCT approx 2mmHg higher than Goldman – Deviates more significantly when IOP >25mmHg. – Upper limit of normal with NCT should be taken as 24mmHg. 56 y.o Male. PXF. Latanoprost at 23.00. GAT 21 at baseline, 23 after 24 hrs Tonopen measures within 10-20mmHg of Goldman (Frenkel et al 1988). Underestimates IOP for pressures >20mmHg (Horowitz et al 2004). Change in therapy in 11/15 (73%) of patients. 5 05/07/2014 Outline Definitions Referral Decisions – NICE 2009 etc IOP in context Central Corneal Thickness (CCT) Independent risk factor for development of glaucoma Tendency to overestimation of IOP in thick corneas (>555um) Tendency to underestimation of IOP in thin corneas (<555um) CCT CCT (microns) IOP (mmHg) Glaucoma Risk Glaucoma in Milton Keynes >555 (thick) <21 (normal) average >555 (thick) >24 (high) + <555 (thin) <21 (normal) ++ <555 (thin) >24 (high) +++++ 555 (average) <21 (normal) Average 555 (average) >24 (high) +++ – Background – management & pathways Case Discussions Outline CCT Effect of CCT on IOP relates to corneal “hysteresis” rather than CCT alone Generally increasing thickness correlates with increasing hysteresis but not always! Effect on IOP not linear Use of “correction factors” not scientific – DO NOT USE! Definitions Referral Decisions – NICE 2009 etc IOP in context CCT Glaucoma in Milton Keynes – Background – management & pathways Case Discussions Background to Glaucoma in MK Rapidly Growing Population of MK – 38,000 between 2001-2011 Background to MK Glaucoma Service Population projections 2001 2014 2026 Recently opened to New Glaucoma referrals Repatriation of glaucoma patients from other trusts Also see ‘glaucoma suspects’ (ocular hypertension, OHT) – 5 year cumulative risk of glaucoma = 9.5% 6 05/07/2014 Background to Glaucoma Service How is the Glaucoma Clinic Doing? Medical Retina Firm, June 2008 MK Glaucoma management MK Glaucoma management B-blockers 1st line in < 60 year olds (NICE) Consultant led assessment (NICE) Full information given Future Plan explained Outcomes; – – – – – – – – – Observe (OHT 3-5 years) Start Treatment (unusual at first visit) Refer to Devolved Care (Optom led) clinic for follow up Refer for other condition Discharge Prostaglandin Analogues (1st line) – If BB contraindicated or older patients Follow up – – – – Consider changing to prostaglandin if >75 years old Avoid in > 85 year olds (need for it at all?) Consider surgery if IOP not controlled without it If absolutely necessary, consider changing to Tiopex (0.1% timolol pres free once a day) Carbonic Anhydrase Inhibitors (2 nd Line) Alpha Agonist (3rd Line) Offer Surgery if > 2 drops SLT (may work better in “virgin” eyes) 6-9 months with repeat fields (Observe) 12 months (low risk) 4 months (High risk) 2 months if initiating / changing treatment Glaucoma Service projections % population Glaucoma OHT (4%) >40 years old patients (2%) Patients per week 2013 113,020 2260 4520 130 / week 2021 138,100 2762 5524 159 / week Short term improvement Plans New and f/up patient clinic proforma Update clinic info sheets and guidelines Expansion of use of OCT – Narrow angles – Macula scans Fundus camera – Dilated disc photos and red-free Current rate = 84 patients / week Training up nurses / Optoms Glaucoma patient information/education days Add Optoms to the clinic? 7 05/07/2014 What to tell your patients What to tell your patients Mr Moosavi doesn’t bite….. Outline What to tell your patients Mr Moosavi doesn’t bite Less detail the better – unless specific reasonable enquiry Referral is a precaution Not definite diagnosis yet Glaucoma is a slow condition You are the same person that walked in here Keep internet information in perspective Full information will be given at the HES Make a list of question to take along Definitions Referral Decisions – NICE 2009 etc IOP in context CCT Glaucoma in Milton Keynes – Background – management & pathways Case Discussions 8 05/07/2014 History 14 ♀ Caucasian GP Referral Seen with mother Recurrent intermittent blurring – 10 mins to 3 hours ↑ frequency of headaches & progressive nausea Mother reports intermittent “large pupil” Examination LogMar RE 0.3 (6/12) LE 0.2 (6/9.5) Near Vision N12 BE Cov Test, eye movements, pupils NAD Frisby stereopsis 340’ of arc Ishihara Colour Vision NAD Fields restricted on confrontation BE Summary Definitions Referral Decisions – NICE 2009 etc IOP in context CCT Glaucoma in Milton Keynes – Background – management & pathways Case Discussions Thank You Any Questions… 9