OPEN ANGLE OPEN ANGLE GLAUCOMAGLAUCOMA

Frank J. WeinstockFrank J. Weinstock, MD, , MD, FACSFACS

Professor of Ophthalmology- Professor of Ophthalmology- NEOUCOMNEOUCOM

Canton, OhioCanton, OhioUSAUSA

TYPES OF GLAUCOMATYPES OF GLAUCOMA

PRIMARY CHRONIC SIMPLE OPEN PRIMARY CHRONIC SIMPLE OPEN ANGLEANGLE

ANGLE CLOSURE- NARROW ANGLEANGLE CLOSURE- NARROW ANGLE SECONDARYSECONDARY TRAUMATICTRAUMATIC

PRIMARY CHRONIC PRIMARY CHRONIC SIMPLE OPEN ANGLE SIMPLE OPEN ANGLE

GLAUCOMAGLAUCOMA SERIES OF CONDITIONSSERIES OF CONDITIONS OPTIC NERVE AND VISUAL FIELD OPTIC NERVE AND VISUAL FIELD

LOSS SECONDARY TO ELEVATED LOSS SECONDARY TO ELEVATED INTRAOCULAR PRESSURE OR POOR INTRAOCULAR PRESSURE OR POOR NUTRITION TO OPTIC NERVENUTRITION TO OPTIC NERVE

ETIOLOGY- NOT TRULY KNOWNETIOLOGY- NOT TRULY KNOWN

VARIANTSVARIANTS

TRAUMATICTRAUMATIC SECONDARYSECONDARY LOW TENSIONLOW TENSION

OPEN ANGLE GLAUCOMAOPEN ANGLE GLAUCOMA US- 2.2 MILLION (3.4 MILLION BY US- 2.2 MILLION (3.4 MILLION BY

2020)2020) 175000 IN US BLIND (10% OF 175000 IN US BLIND (10% OF

BLINDNESS)BLINDNESS) BLACKS-HISPANICS (30% OF BLACKS-HISPANICS (30% OF

BLINDNESS)BLINDNESS) 1 IN 1000 OVER 40 YR OLD- BLIND1 IN 1000 OVER 40 YR OLD- BLIND OVER 75 YEARS- 2.7/1000 BLIND OVER 75 YEARS- 2.7/1000 BLIND

(6.7/1000 VISUALLY IMPAIRED)(6.7/1000 VISUALLY IMPAIRED)

SOPHISTICATED OFFICE EQUIPMENT

AUTOMATIC PERIMETER (VISUAL FIELD TESTING)

COMPLIANCECOMPLIANCE SCREENING $60/SCREENING AND SCREENING $60/SCREENING AND

$1000/CASE DISCOVERED$1000/CASE DISCOVERED (SCREEN HIGH RISK-RELATIVES-(SCREEN HIGH RISK-RELATIVES-

AFRICAN AMERICANS-HISPANICS-)AFRICAN AMERICANS-HISPANICS-) 25-40% OF PTS. TAKING Rx TO 25-40% OF PTS. TAKING Rx TO

STORE- DON’T PICK IT UPSTORE- DON’T PICK IT UP 60% PICKING UP Rx D/C XALATAN 60% PICKING UP Rx D/C XALATAN

DURING YR AND 76% WITH OTHER DURING YR AND 76% WITH OTHER MEDSMEDS

DIAGNOSISDIAGNOSIS OPTIC NERVE FIBER EVALUATION OPTIC NERVE FIBER EVALUATION

(OPHTHALMOCSCOPE)(OPHTHALMOCSCOPE) VISUAL FIELD EVALUATION- OFFICEVISUAL FIELD EVALUATION- OFFICE OPTIC NERVE IMAGING AND OPTIC NERVE IMAGING AND

ANALYSIS- OFFICEANALYSIS- OFFICE MEASUREMENT OF INTRAOCULAR MEASUREMENT OF INTRAOCULAR

PRESSURE (PORTABLE)PRESSURE (PORTABLE) MEASUREMENT OF CORNEAL MEASUREMENT OF CORNEAL

THICKNESSTHICKNESS GENETIC PREDISPOSITION ????GENETIC PREDISPOSITION ????

SCREENINGSCREENING

OPTIC NERVE EVALUATION- OPTIC NERVE EVALUATION- OPHTHALMOLOSCOPEOPHTHALMOLOSCOPE

INTRAOCULAR PRESSURE INTRAOCULAR PRESSURE (IOP) MEASUREMENT- (IOP) MEASUREMENT- APPLANATION TYPE APPLANATION TYPE TONOMETER TONOMETER

IOP HAS DIURNAL VARIATIONIOP HAS DIURNAL VARIATION

GOALS OF SCREENINGGOALS OF SCREENING EDUCATIONEDUCATION DETECTION OF GLAUCOMA (NOT DETECTION OF GLAUCOMA (NOT

PROVEN)PROVEN) TESTS NOT SPECIFIC OR SENSITIVETESTS NOT SPECIFIC OR SENSITIVE

SCREENING- NO VALUE IF:SCREENING- NO VALUE IF:

NOT ABLE TO REFER FOR NOT ABLE TO REFER FOR DEFINITIVE DEFINITIVE DIAGNOSIS, DIAGNOSIS, TREATMENT AND TREATMENT AND FOLLOWUPFOLLOWUP

SCREENINGSCREENING CHOOSE HIGH RISK GROUPS E.G. CHOOSE HIGH RISK GROUPS E.G.

HISPANICS, BLACKS (OVER AGE 40, HISPANICS, BLACKS (OVER AGE 40, WHITES (OVER 65 YEARS OLD), WHITES (OVER 65 YEARS OLD), HISTORY OF EYE TRAUMA; HISTORY OF EYE TRAUMA; DIABETICS; DIABETICS;

FAMILY HISTORY OF GLAUCOMAFAMILY HISTORY OF GLAUCOMA DIABETICSDIABETICS PATIENTS WITH SEVERE MYOPIAPATIENTS WITH SEVERE MYOPIA

INTRAOCULAR INTRAOCULAR PRESSUREPRESSURE VERY EASY TO DO- PORTABLE VERY EASY TO DO- PORTABLE

INSTRUMENTSINSTRUMENTS POOR SENSITIVITY AND SPECIFICITYPOOR SENSITIVITY AND SPECIFICITY NORMAL- 20 mmHg OR LESSNORMAL- 20 mmHg OR LESS MEASURED BY: APPLANATION MEASURED BY: APPLANATION

TONOMETER- NOT PRACTICALTONOMETER- NOT PRACTICAL FINGER PALPATION- INACCURATEFINGER PALPATION- INACCURATE

APPLANATION TONOMETRY

SCHIOTZ TONOMETERSCHIOTZ TONOMETER

ADVANTAGES:ADVANTAGES:

INEXPENSIVEINEXPENSIVE

PORTABLEPORTABLE

EASY TO USEEASY TO USE

READILY AVAILABLEREADILY AVAILABLE

DISADVANTAGES:DISADVANTAGES:

NOT THE MOST NOT THE MOST ACCURATEACCURATE

REQUIRES TOPICAL REQUIRES TOPICAL ANESTHETICANESTHETIC

OPHTHALMOSCOPYOPHTHALMOSCOPY EASY; QUICKEASY; QUICK REQUIRES OPHTHALMOSCOPE- AVAILABLEREQUIRES OPHTHALMOSCOPE- AVAILABLE REQUIRES EXPERT AT OPHTHALMOSCOPYREQUIRES EXPERT AT OPHTHALMOSCOPY PICKS UP DEFINITIVE GLAUCOMA ( A LATE PICKS UP DEFINITIVE GLAUCOMA ( A LATE

STAGE)- MAY BE TOO LATE TO HAVE MUCH STAGE)- MAY BE TOO LATE TO HAVE MUCH BENEFITBENEFIT

INTER-OBSERVER VARIABILITYINTER-OBSERVER VARIABILITY NORMAL C:D RATIO- 0.3 OR LESS THAN 0.2 NORMAL C:D RATIO- 0.3 OR LESS THAN 0.2

DIFFERENCEDIFFERENCE (STEREO VIEWS ARE BEST (NOT PRACTICAL)(STEREO VIEWS ARE BEST (NOT PRACTICAL)

E-11 Normal and Cupped E-11 Normal and Cupped DiscDisc

NORMAL CUPPED DISC

ENLARGED CUP

PERIPHERAL VISUAL FIELD PERIPHERAL VISUAL FIELD TESTINGTESTING

PICKS UP LATER GLAUCOMAPICKS UP LATER GLAUCOMA REQUIRES EXPENSIVE EQUIPMENT- REQUIRES EXPENSIVE EQUIPMENT-

DIFFICULT TO PERFORM- NOT DIFFICULT TO PERFORM- NOT PRACTICAL FOR SCREENINGPRACTICAL FOR SCREENING

OPTIC NERVE ANALYSIS- PICKS UP OPTIC NERVE ANALYSIS- PICKS UP PROBLEMS EARLIER (REQUIRES PROBLEMS EARLIER (REQUIRES EXPENSIVE EQUIPMENT AND EXPENSIVE EQUIPMENT AND TECHNNICAL SUPPORT)- NOT TECHNNICAL SUPPORT)- NOT PRACTICAL FOR SCREENINGPRACTICAL FOR SCREENING

REFERRALREFERRAL SET CRITERIA FOR EACH SCREENINGSET CRITERIA FOR EACH SCREENING E.G PRESSURE OVER 20 MM hGE.G PRESSURE OVER 20 MM hG INDIVIDUALS WITH SUSPICIOUS INDIVIDUALS WITH SUSPICIOUS

DISCS (LARGE CUPS)DISCS (LARGE CUPS) OPTIC NERVE- HEMORRHAGES; OPTIC NERVE- HEMORRHAGES;

LARGE CUP:DISC RATIO (OVER 0.4) LARGE CUP:DISC RATIO (OVER 0.4) OR ASYMMETRY OF CUPS OR ASYMMETRY OF CUPS (HORIZONTAL AND VERTICAL (HORIZONTAL AND VERTICAL CUP:DISC RATIO)- 0.3 DIFFERENCECUP:DISC RATIO)- 0.3 DIFFERENCE

BEST SCREENINGBEST SCREENING

COMPREHENSIVE EYE EXAM IN COMPREHENSIVE EYE EXAM IN OFFICE SETTING- BY OFFICE SETTING- BY SPECIALISTSPECIALIST

ADDITIONAL SCREENING ADDITIONAL SCREENING BENEFITSBENEFITS

POSSIBLY MORE IMPORTANT THAN POSSIBLY MORE IMPORTANT THAN DIAGNOSING GLAUCOMADIAGNOSING GLAUCOMA

EDUCATION OF NEED FOR EYE CAREEDUCATION OF NEED FOR EYE CARE OPHTHALMOSCOPIC EXAM WILL OPHTHALMOSCOPIC EXAM WILL

PICK UP:PICK UP: CATARACTSCATARACTS CORNEAL SCARSCORNEAL SCARS RETINAL DISEASE- DIABETES, RETINAL DISEASE- DIABETES,

HYPERTENSION, TUMORSHYPERTENSION, TUMORS

TREATMENT OF GLAUCOMATREATMENT OF GLAUCOMA

MEDICATIONS- MANY NEW MEDICATIONS- MEDICATIONS- MANY NEW MEDICATIONS- POTENTIAL SIDE-EFFECTSPOTENTIAL SIDE-EFFECTS

ONCE A DAY DOSAGE- BEST COMPLIANCEONCE A DAY DOSAGE- BEST COMPLIANCE TREAT EARLIERTREAT EARLIER LASER OR SURGERY- EARLIER ????- BEING LASER OR SURGERY- EARLIER ????- BEING

EVALUATEDEVALUATED WHICH FIRST? – BEING EVALUATEDWHICH FIRST? – BEING EVALUATED NEW PROCEDURESNEW PROCEDURES GOAL- < 20mmHg. (LOWER IN MANY SITUATIONS)GOAL- < 20mmHg. (LOWER IN MANY SITUATIONS)

SUMMARYSUMMARY GLAUCOMA SCREENINGGLAUCOMA SCREENING QUESTIONNABLE BENEFIT FOR QUESTIONNABLE BENEFIT FOR

PREVENTING BLINDNESSPREVENTING BLINDNESS WILL PICK UP A NUMBER OF CASES WILL PICK UP A NUMBER OF CASES

GLAUCOMA AND OTHER EYE CONDITIONSGLAUCOMA AND OTHER EYE CONDITIONS CONCENTRATE ON HIGH-RISK GROUPSCONCENTRATE ON HIGH-RISK GROUPS EASY TO DOEASY TO DO MARKED EDUCATIONAL AND PUBLIC MARKED EDUCATIONAL AND PUBLIC

RELATIONS BENEFITRELATIONS BENEFIT