philosophies in glaucoma paul s. jensen, o.d. renton, wa jensen@rentonvision.com
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Philosophies in Glaucoma
Paul S. Jensen, O.D.Renton, WA
www.lacrimology.com
www.eyesmartz.com
jensen@rentonvision.com
Philosophies in Glaucoma
1. Making sense of information from disparate sources
2. Clinical Pearls
3. New Technologies (and new looks at some older stuff)
How not to be a plumber
2
Philosophies in Glaucoma
• OHTS:
Ocular Hypertension Treatment Study– The mother ship– OHTS is a gift to optometry
3
OHTS
Corneal Thickness
Separate the ocular hypertensives
from the low tension glaucoma
4
OHTS
• Conclusions:– Decreased IOP = decreased morbidity– Glaucoma suspects should be considered
candidates for treatment
5
OHTS
Conclusions:
- “There was little evidence of increased systemic or ocular risk associated with ocular hypotensive medications”
6
OHTS
Risks of Ocular Hypotensives
• Meds show:
- Near zero plasma levels
- Measurable urine and cardiac out-put changes
7
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
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
The Philosophies of Glaucoma
• 1956-1986:– IOP, ONH, VF
• 1986: IOP doesn’t matter
10
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
Don’t be a plumber!
Go to the original research
Google Scholar, Medline, Elsevier, AOA
12
Clinical Pearls
“The only thing better that learning from your mistakes, is learning from other people’s mistakes.”
- P. Jensen
13
Clinic Pearls
Treatment Pitfalls:
- Blame the patient!
- Compliance (importance of treatment, ability to follow Tx plan)
- Poor gtt technique
- gtt Allergy/Intolerance/Sensitivity
14
Clinical Pearls
• ITD/K-spindle
- Blue irides (myd)
- Myopic
- Middle aged
- Male & ….
- Anyone….
Pigment Dispersion Syndrome
& cataracts (?)
15
Clinical Pearls
Pseudo-exfoliation Syndrome
• Older men
• Watch for angle closure
• Cataract extraction helps?
• Difficult to control
• Fluctuating IOP
16
Clinical Pearls
• Cupping/SLO?
• VF?
• IOP?
ONH Drusen
17
Clinical Pearls
• Increased bioavailability
• Dramatically increased
efficacy….
• Dramatically increased allergy
Lacrimal Occlusion
18
Clinical Pearls
• Beta blockade
• Steroids:
- increasing incidence
- all routes of administration
Systemic Medications
19
Clinical Pearls
• Ask at each visit
• Prostaglandin analogs – body, joint ache
Systemic Side Effects of gtt
20
Clinical Pearls
• Drop usage and technique
• Documentation, flow sheet
• Monocular medical trials
Mundane Details
21
Technologies
• SLO- GDx- HRT II/III- OCT
• Other
Don’t be a plumber, understand the technologies
22
GDx
• Based on RNFL changes around disc
• Excellent at detecting early changes
• Good statistical analysis
- Good change plots
• Portable: easy to share/move
23
GDx
Interpreting the results
• OD/OS comparisons
• Color coding is intuitive
• Be careful with tilted discs
• NFI
24
GDx
25
GDx
26
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 Americans27
HRT II/IIIHRT II/III
28
HRT II/III
• Corneal Module, tissue eval, not contour
• FA
• Poor Portability (HRT II)
29
HRT II/III
30
HRT II/III
Interpreting the results
• Vascular tissue and nerve tissue all look alike
• HRT III: GPS, a number!
31
OCT
Optical Coherence Tomography
• Most beautiful images in ophthalmic practice
• Eval peripapillary bundles
• ONH cupping - changes can be seen, but measurements not standardized
32
OCT
33
OCT
Interpreting the results
RNFL Thickness:
• Data similar to GDx
Cupping:
• Subjectivity
• No standardization34
OCT
35
Other Technologies
• Glaucoma
• LASIK Pre-op
• Corneal edema/Fuch’s dystrophy
• Keratoconus (?)
• Inexpensive, reimbursable, easy as tono
Pachymetry
36
Other Technologies
• Looks like Goldmann, but
- Concave tip
- CCT independent
- Reads OPA (mean max – mean min)
Pascal ® Dynamic Contour Tonometer
37
Other Technologies
Pascal®
Dynamic Contour Tonometer
38
Other Technologies
• Helpful in understanding glaucoma
• Necessary for Tx/management?
• Excellent tool for following numerous systemic/pharm effects on vascular perfusion
Ocular Blood Flow
39
Other Technologies
Paradigm OBF Analyzer
40
Other Technologies - OBF
• Reads:
- IOP/tonography
- OBF microl/min
- Pulse
TonoPlus™
41
TonoPlus ™
42
Other Technologies
Ocular Response Analyzer
• Measures corneal hysteresis (corneal resistance), distinct from CCT
43
Other Technologies
Diaton Tonometer
• Transpalbebral
• Limbal
• +/- 2 to 20 mmHg, +/- 10% to 60 mmHg
44
Other Technologies
Diaton Tonometer
45
Other Technologies
Billing Technologies
• Accufee® and others
• EMR
46
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
Thanks!
Special thanks to Lindsey Sewell, OD, FAAO
for help in preparing this presentation.
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