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Wadhwa Optikos -Rajesh Wadhwa M.Optom B.Sc.Hons.(Ophth.Tech.)(AIIMS) B.Sc.Hons.(DU); FIACLE;PGDHRM Slide 2 Wadhwa Optikos Thank you for educating us: It was just stated.. Dr.Sudhamathi: A B Dr.Sood: A> B> Rajesh Wadhwa Slide 3 Wadhwa Optikos Thank you for educating us: It was just stated.. Dr.Sudhamathi: Glaucoma is a silent thief of sigh Optoms can look for VH grading ACG more often In Hypermetropes Rubeosis Irides is a sign Rajesh Wadhwa Slide 4 Wadhwa Optikos Thank you for educating us: It was just stated.. Dr.Sood: Loss due to glaucoma is irreversible Classical symptoms of acute glaucoma are often missing Talked about categories of high-risk patients Important investigations are Tonometry, gonioscopy, document the state of optic disc & visual fields. We primarily work towards lowering the IOP Rajesh Wadhwa Slide 5 Wadhwa Optikos Glaucoma-India-Optometrist link Without gonioscopy With or Without a perimeter/ OCT/ HRT Is there a link ? Yes ! Rajesh Wadhwa Golden because of great out-reach at very low cost Slide 6 Wadhwa Optikos We found the link We worked towards it We succeeded in preventing several more eyes from blindness What is the Key to Success Rajesh Wadhwa Slide 7 Wadhwa Optikos Why did we look for the key to success: a confession Way back in the year 2000 We analyzed our available clinic data Over 50,000 patients seen in 20 years (1979 to 1999 ) Total positive glaucoma cases detected= 6 Rajesh Wadhwa Slide 8 Wadhwa Optikos Was that good enough? WHO score Indian population has over 2% incidence of glaucoma We should have detected at least 1000 positive glaucoma cases We had missed many: Disheartening and added to the feeling of guilt Many clinics are making this mistake inadvertently all over the world Rajesh Wadhwa Slide 9 Wadhwa Optikos This needed an immediate intervention: Identified the limitations Rajesh Wadhwa Clinical attitude towards detection of glaucoma No tonometry Legislation Space & time How much is glaucoma detection dependent on these? Slide 10 Wadhwa Optikos How dependent is glaucoma detection on these? Most important screening tests are: IOP: for over a century Optic Nerve head analysis Visual fields Need the trio together Though todays science is way beyond this--but doing this much can save several eyes (as it did for centuries). Rajesh Wadhwa 6 Slide 11 Wadhwa Optikos Why are we asking for trio together? IOP: alone is not a stand alone indicator (over 40% of Px have normal IOP at the time of diagnosis) Optic nerve cupping: it's common for some people to have optic nerve cups that are larger than normal Visual fields: even the visual fields can change back and forth and can sometimes be influenced by medication. (may not be available) We can add other details (to be discussed in later slides). Rajesh Wadhwa 4 Slide 12 Wadhwa Optikos 2 instrumental limitations (1=Tonometry) No S/L initially Lack of space for Schiotz Applanation after acquiring slit lamp Sterilization of Appln. very difficult Needs topical anesthetic. Rajesh Wadhwa 5 Slide 13 Wadhwa Optikos Not practiced at optometry school Also needs topical anaesthetic Rajesh Wadhwa 2 instrumental limitations (2= gonioscopy) 2 Slide 14 Wadhwa Optikos With inward compulsion to save more eyes We broke the barrier: tonometry & gonioscopy Tonometry: We invested into an expensive non- contact tonometer Gonioscopy: Fletcher in his book says:The Van Hericks grading of peripheral AC depth is so accurate that I did not feel the need to learn the skills of gonioscopy Rajesh Wadhwa Slide 15 Wadhwa Optikos In routine-refraction, we became more attentive to following: Symptoms Family history IOP assessment Optic nerve head assessment High-risk categories Details.(cont.). Rajesh Wadhwa Limitation that remained was of clinical attitude 7 Slide 16 Wadhwa Optikos Symptoms Most often: Reported for routine refraction but rarely (On close probing) Headache/ Eye-pain/Colored halos Transient blackouts/ Heaviness in eyes Nyctalopia Frequent change of glasses. Rajesh Wadhwa 5 Slide 17 Wadhwa Optikos Categories encouraged for tonometry: Age above 40years Diabetics /Hypertensives Hypermetropes Family history of glaucoma or Diabetes H/o previous eye injury/ disease or surgery Cataract / Iritis Relevant drugs being taken (systemic/topical). Rajesh Wadhwa 5 Slide 18 Wadhwa Optikos What tests do we perform in optometric set-up VA assessment Refraction Cover-test Direct ophthalmoscopy S/L exam if needed Tonometry (filter exists) Among these what will hint towards glaucoma suspect ?. Rajesh Wadhwa 7 Slide 19 Wadhwa Optikos Noteworthy findings that add to suspicion of glaucoma Accepts for near an "Add" value higher than what usually corresponds with age Frequent change in refractive error Rajesh Wadhwa 2 Slide 20 Wadhwa Optikos Lens & Iris: Lens intumescent Rajesh Wadhwa intumescent cataract a mature cataract that progresses; the lens becomes swollen from the osmotic effect of degenerated lens protein, and this may lead to secondary angle closure (acute) glaucoma. Slide 21 Wadhwa Optikos Rubeosis iridis (especially in diabetics) New vessels appear on the iris. When this occurs, careful inspection of the anterior chamber angle is essential, as growth of neovascularization in this location can obstruct aqueous fluid outflow and cause neovascular glaucoma. Rajesh Wadhwa Slide 22 Wadhwa Optikos Peripheral anterior chamber depth: Eclipse test Eclipse Test: Shadow of iris eclipses/ does not eclipse the other side. Rajesh Wadhwa Slide 23 Wadhwa Optikos Peripheral anterior chamber depth:VH Grading Van Herick's Grading under S/L (Grade 1 is shallowest, Grade 4 is widest) Rajesh Wadhwa Slide 24 Wadhwa Optikos Van Herick's Grading under S/L: Corneal thickness:periph. AC ratio (60 illum. angle)1:1/2= Gr 4 Rajesh Wadhwa Slide 25 Wadhwa Optikos Optic nerve head assessment Rajesh Wadhwa Slide 26 Wadhwa Optikos ISNT criterion Rajesh Wadhwa T N I S Oval discRound cup Slide 27 Wadhwa Optikos Cup:Disc Ratio recorded in its widest axis Diameter of Cupping can be =pallor or Cupping>Pallor Pallor Ratio= Contour Ratio or not Rajesh Wadhwa A B Slide 28 Wadhwa Optikos Considered as Glaucoma suspect ISNT criterion not met C:D ratio >/=0.5:1 Interocular diff. of C:D=/>0.2 IOP > 20mmHg Interocular diff. Of IOP =>4mm Hg Rajesh Wadhwa Slide 29 Wadhwa Optikos Other reasons for suspecting glaucoma Cup: Oval along 6-12 oclock axis Asymmetry between discs of two eyes is present. Asymmetry does occur normally but the possibility of pathological significance is there especially in the absence of marked axial anisometropia Rajesh Wadhwa Slide 30 Wadhwa Optikos Other reasons for suspecting glaucoma Site of cup: Superior/ Superior temporal/ Inferior/ Infero-temporal. Inferior location of cup has higher index of suspicion due to the more frequent superior field defects seen in glaucoma Focal disc damage: Pit near 6 o'clock Rajesh Wadhwa Slide 31 Wadhwa Optikos Vessels Continuity: The blood vessels do not appear continuous at the disc margin Baring of circumlinear vessel Splinter shaped hemorrhage on disc margin Rajesh Wadhwa Slide 32 Wadhwa Optikos Other reasons for suspecting glaucoma Vessels Pulsation: NO spontaneous arterial pulsation. (A spontaneous arterial pulse is more likely to be seen if the IOP is high) Rajesh Wadhwa 2 Slide 33 Wadhwa Optikos Basis of inference All foregoing indicators are kept in mind for referral Fields, WDT, diurnal variation, Gonioscopy,OCT etc. are to be considered in suspected cases Did we gain anything by doing all this? Results. Rajesh Wadhwa Slide 34 Wadhwa Optikos Compared to previous 20 years Rajesh Wadhwa This is an amazing improvement over our previous results 6 in 20 years, 22 in 1 year Slide 35 Wadhwa Optikos Just 3 minutes more Slide 36 Wadhwa Optikos Limitation in statistics: This is retrospective analysis Population sample is from 1 clinic in north India Extra charges were taken for this checkup (therefore filtered) Actual incidence could be higher Rajesh Wadhwa 4 Slide 37 Wadhwa Optikos Do we really need tonometry? All said-and done, tonometery is important in detection of glaucoma If an optometrist is permitted to use that one drop of topical anesthetic then many more eyes can be saved Rajesh Wadhwa Slide 38 Wadhwa Optikos How clear is our knowledge about glaucoma ONE EXTREME: elevated IOP is not glaucoma. Elevated IOP is only a risk factor and is not prognostic (no magic figure) OTHER EXTREME: New research suggests that Glaucoma, what we know to be an eye disease, should instead be characterized as a neurologic disorder similar to what causes nerve cells in the brain to degenerate and die like what occurs in Parkinsons and Alzheimers diseases. The new research paradigm focuses on the damage that occurs in retinal ganglion cells (RGCs), which connect the eye to the brain through the optic nerve. Rajesh Wadhwa Slide 39 Wadhwa Optikos Where do we stand We have treatment for glaucoma We do not have treatment of glaucoma Rajesh Wadhwa Slide 40 Wadhwa Optikos Take home message IOP measurement is important in detection of glaucoma Optometrist is the first line of defense against blindness & optometrists are eagerly waiting for governments permission to use diagnostic drugs like topical anesthetics to save more eyes. Aspects other than IOP can also be indicators for glaucoma suspect It is better to refer out one extra glaucoma suspect than one less Rajesh Wadhwa Slide 41 Wadhwa Optikos Rajesh Wadhwa Let us plant a sapling of good practice today...and enjoy the fruits tomorrow My contact: r_wadhwa@yahoo.com