Fine Tuning Glaucoma Diagnosis and Management in Haiti Daniel Laroche MD Director of Glaucoma, St Lukes-Roosevelt Hospital, NY President, Advanced Eyecare of New York Assistant Clinical Professor Ophthalmology New York Eye and Ear Infirmary New York Medical College Chair NMA Ophthalmology Section/AAO Task for on Haiti  Disclosure: Speaker Bureau for Alcon, Allergan Merck Thanks to the SHO and CNPC for the invitation and congratulations on your ongoing efforts I worked at the University Eye Hospital Persistent Structural damage to buildings that need reconstruction HUEH Faculty      Dr. Jean Claude Cadet- Chief Dr. Ritza Eugene Dr. Jean Claude Cadet Jr. Dr. Valery Cadet Visiting Professors Ophthalmology Residents Astrid St. Dic Rachel Aglae Amedee Rachel Gauthier Nathalie Francois Reginald Rejouis Myriam Beliard Marie Dieumane Chaperon Milon Osnel 3 ½ Days of seeing patients May 13-16, 2012    60 glaucoma patients were presented Under went tonometry, gonioscopy, optic disc examination, FDT VF Diagnosis were: Open angle glaucoma, Angle closure glaucoma, Juvenile Open angle glaucoma Traumatic Glaucoma, Congenital Glaucoma, Physiologic cupping without glaucoma, Congenital glaucoma, Neovascular glaucoma Haitian Ophthalmology Residents Learning Gonioscopy www.gonioscopy.org Residents       Used Perkin tonometry to check IOP There was a shortage of slit lamps and goldman applanation tonometry available Only one 3 mirror gonio lens present Residents were trained to use the lens and also performed gonioscopy on each other Residents learned importance of optic disc drawings and were evaluated Each resident advised that they must invest in a four mirror lens to properly evaluate glaucoma Resident Education  Residents were given lectures on gonioscopy, optic disc evaluation, Target IOP in treating glaucoma, glaucoma surgical video were reviewed on trabeculectomy, trabeculotomy, Ahmed valve. GAT  Applanation tonometry is currently the gold standard for measuring IOP, and GAT is the standard procedure.1  GAT assumes a constant CCT. However, variation in CCT can influence GAT reading.2 Hans Goldmann Goldmann equation3 P0 = (F/C) + Pv P0: IOP (mmHg) F: rate of aqueous formation (µL/min) Goldmann Applanation Tonometry C: facility of outflow (µL/min/mmHg) Reprinted with permission from AgingEye Times. Pv: episcleral venous pressure (mmHg) R: resistance to outflow; is the inverse of C and may replace C in rearrangements of the Goldmann equation 1. Tsai JC et al. In: Medical Management of Glaucoma. Professional Communications, Inc; 2003:15–37. 2. Brandt JD et al. Ophthalmology. 2001;108:1779–1788. 3. Web review of ophthalmology. Comprehensive review: glaucoma. Available at: http://www.webeyemd.com/wro/wro_comp_glaucoma.htm. Accessed September 2, 2004. 14 Must perform gonioscopy to r/o angle closure AS-OCT iris light and dark Indentation Gonioscopy  Allows viewing of angle structures when there is appositional Angle closure Angle will not open if Synechia is present Pupillary Block/Indentation Gonioscopy PAS Treatment for Angle Closure is iridotomy and sometimes with iridoplasty Optic Disc Size • • Size of cup varies with size of optic disc Large optic discs have large cups in healthy eyes 1.4 2.4 1.9 Small  Identify • • Average Large small and large optic discs Small discs: avg vertical diameter < 1.5 mm Large discs: avg vertical diameter > 2.2 mm Look at the Neuroreintal rim: ISNT Rule Rim width: Distance between border of disc and position of blood vessel bending rule: Inferior > Superior > Nasal > Temporal S N T ISNT I Localized Rim Thinning/Notching Notching Patterns of Glaucomatous Progression Normal optic disc (left eye) First glaucomatous optic disc change Type of progression of disc abnormality 22% Disc cup enlargement Diffuse enlargement: round-shaped 56% Disc cup enlargement with local notching Diffuse enlargement: vertically oval 9% Local notch Broader local notch 13% Pale neuroretinal rim; no change of configuration Adapted from Tuulonen and Airaksinen. Am J Ophthalmol. 1991. Pale rim; no change of configuration OCT was taught available with Dr. Tavern Localized Retinal Nerve fiber layer loss can be seen with red free light on ophthalmoscopy Event Analysis, Look for VF progression was taught although only FDT available at the clinic Baseline Different from baseline? Mean change in visual defect score AGIS 7 Sustained IOP reduction below 18 mmHg is correlated with stability of visual field 5 Percent of Visits with IOP Less Than 18 mmHg 4 100% of visits 3 75 - 99% of visits MEAN IOP 20.2 mmHg 2 50 - 74% of visits 0 - 49% of visits 16.9 mmHg 14.7 mmHg 1 0 -1 12.3 mmHg 0 1 2 3 4 Follow-up (years) AGIS Investigators, 2000, Am. J. Ophthalmol., 130, 429-440 5 6 7 8 Medical Management vs Surgery Both Stabilize Visual Fields Collaborative Initial Glaucoma Treatment Study (CIGTS) 8 Medicine Surgery 7 6 35%vs 48% IOP lowering 5 4 3 2 1 0 0 6 12 18 24 30 36 42 Time in Months Lichter et al, Ophthalmology, 2001 Nov: 108 (11) 1943-53 48 54 60 1- (reference IOP + VF score)/100 x Reference IOP =40% reduction Ensuring Compliance With Antiglaucoma Treatment  Communication      More than 40% of pts being treated with glaucoma do not realize it can lead to blindness GRF survey Education Use the minimum number of medications required to safely achieve the target IOP QD and BID dosing offers best compliance regimens Non-compliance can be as high as 50% for one med, 61% for two meds, 70% for multiple meds Patel, Spaeth: Compliance in patients taking eyedrops for glauocma: Ophthalmic Surg 1995 26 ;3 ;233-236 Do not forget Laser and filtering surgery if medical therapy fails or pts cannot obtain medications. Dr. Eugene to perform Ahmed valve with corneal patch with resident watching Haitian Ophthalmology 2nd year Ophthalmology Residents performing trabeculectomy Glaucoma Surgery     3 Ahmed valves performed 13 Trabeculectomies 3 pediatric examination under anesthesia 2 Trabeculotomy/Trabeculectomy st 1 nd 2 year residents watching year ophthalmology Residents performing glaucoma surgery Congenital glaucoma with trabeculotomy under general Anesthesia at the University Hospital Main Operating Room Able to be performed Still a great need for sutures, instruments, Glaucoma valves and patches, and medications Special thanks to New World Medical, Alabama Eye Bank, and Alcon. 1 tube inserter also donated Glaucoma Challenges for developing World        Compliance Cost (Medicaitons per month vs Trabeculectomy ) Lack of manpower Stigma associated with surgery Lack of glaucoma awareness Poor equipment maintenance Not enough visual rehabilitation programs Potential Action items for Glaucoma       Train a new generation of trainers in glaucoma subspecialty Encourage sandwich fellowships with physicians in the US and Canada Provide educational, training materials and resources from other countries and translate into French/Creole Systematically link professional development with institution capacity development Further develop and take advantage of online educational resources and link with HSO website www.web-sho.org Towards the future in Haiti   Important for eyecare providers and officials to ensure that glaucoma becomes a high priority along with cataracts as a treatable disease for blindness and to prevent blindness. We need continued development, refinement and validation of clinical and educational programs Thank you         Keep up the great efforts You are not alone Many are thinking of you and willing to work with you. I believe the private practice/public practice with sliding scale payments will succeed. Ongoing free eyecare by NGO’s undermines ophthalmology in Haiti Must support the residency program that is the future of ophthalmology in Haiti. Must support capacity in the ophthalmologists of HSO WITH LIMITED RESOURCES AND SUPPLIES COLLABORATION IS ESSENTIAL