OPEN ANGLE GLAUCOMA Frank J Weinstock MD FACS

OPEN ANGLE GLAUCOMA Frank J. Weinstock, MD, FACS Professor of Ophthalmology. NEOUCOM Canton, Ohio USA

TYPES OF GLAUCOMA PRIMARY CHRONIC SIMPLE OPEN ANGLE n ANGLE CLOSURE- NARROW ANGLE n SECONDARY n TRAUMATIC n

PRIMARY CHRONIC SIMPLE OPEN ANGLE GLAUCOMA SERIES OF CONDITIONS n OPTIC NERVE AND VISUAL FIELD LOSS SECONDARY TO ELEVATED INTRAOCULAR PRESSURE OR POOR NUTRITION TO OPTIC NERVE n ETIOLOGY- NOT TRULY KNOWN n

VARIANTS TRAUMATIC n SECONDARY n LOW TENSION n

OPEN ANGLE GLAUCOMA US- 2. 2 MILLION (3. 4 MILLION BY 2020) n 175000 IN US BLIND (10% OF BLINDNESS) n BLACKS-HISPANICS (30% OF BLINDNESS) n 1 IN 1000 OVER 40 YR OLD- BLIND n OVER 75 YEARS- 2. 7/1000 BLIND (6. 7/1000 VISUALLY IMPAIRED) n

SOPHISTICATED OFFICE EQUIPMENT

AUTOMATIC PERIMETER (VISUAL FIELD TESTING)

COMPLIANCE SCREENING $60/SCREENING AND $1000/CASE DISCOVERED n (SCREEN HIGH RISK-RELATIVES-AFRICAN AMERICANS-HISPANICS-) n 25 -40% OF PTS. TAKING Rx TO STOREDON’T PICK IT UP n 60% PICKING UP Rx D/C XALATAN DURING YR AND 76% WITH OTHER MEDS n

DIAGNOSIS OPTIC NERVE FIBER EVALUATION (OPHTHALMOCSCOPE) n VISUAL FIELD EVALUATION- OFFICE n OPTIC NERVE IMAGING AND ANALYSISOFFICE n MEASUREMENT OF INTRAOCULAR PRESSURE (PORTABLE) n MEASUREMENT OF CORNEAL THICKNESS n GENETIC PREDISPOSITION ? ? n

SCREENING n OPTIC NERVE EVALUATION- OPHTHALMOLOSCOPE n INTRAOCULAR PRESSURE (IOP) MEASUREMENT- APPLANATION TYPE TONOMETER n IOP HAS DIURNAL VARIATION

GOALS OF SCREENING EDUCATION n DETECTION OF GLAUCOMA (NOT PROVEN) n n TESTS NOT SPECIFIC OR SENSITIVE SCREENING- NO VALUE IF: NOT ABLE TO REFER FOR DEFINITIVE DIAGNOSIS, TREATMENT AND FOLLOWUP

SCREENING CHOOSE HIGH RISK GROUPS E. G. HISPANICS, BLACKS (OVER AGE 40, WHITES (OVER 65 YEARS OLD), HISTORY OF EYE TRAUMA; DIABETICS; n FAMILY HISTORY OF GLAUCOMA n DIABETICS n PATIENTS WITH SEVERE MYOPIA n

INTRAOCULAR PRESSURE VERY EASY TO DO- PORTABLE INSTRUMENTS n POOR SENSITIVITY AND SPECIFICITY n NORMAL- 20 mm. Hg OR LESS n MEASURED BY: APPLANATION TONOMETER- NOT PRACTICAL n FINGER PALPATION- INACCURATE n APPLANATION TONOMETRY

SCHIOTZ TONOMETER ADVANTAGES: INEXPENSIVE PORTABLE EASY TO USE READILY AVAILABLE DISADVANTAGES: NOT THE MOST ACCURATE REQUIRES TOPICAL ANESTHETIC

OPHTHALMOSCOPY EASY; QUICK n REQUIRES OPHTHALMOSCOPE- AVAILABLE n REQUIRES EXPERT AT OPHTHALMOSCOPY n PICKS UP DEFINITIVE GLAUCOMA ( A LATE STAGE)- MAY BE TOO LATE TO HAVE MUCH BENEFIT n INTER-OBSERVER VARIABILITY n NORMAL C: D RATIO- 0. 3 OR LESS THAN 0. 2 DIFFERENCE n (STEREO VIEWS ARE BEST (NOT PRACTICAL) n

E-11 Normal and Cupped Disc NORMAL ENLARGED CUPPED DISC

PERIPHERAL VISUAL FIELD TESTING PICKS UP LATER GLAUCOMA n REQUIRES EXPENSIVE EQUIPMENTDIFFICULT TO PERFORM- NOT PRACTICAL FOR SCREENING n OPTIC NERVE ANALYSIS- PICKS UP PROBLEMS EARLIER (REQUIRES EXPENSIVE EQUIPMENT AND TECHNNICAL SUPPORT)- NOT PRACTICAL FOR SCREENING n

REFERRAL SET CRITERIA FOR EACH SCREENING n E. G PRESSURE OVER 20 MM h. G n INDIVIDUALS WITH SUSPICIOUS DISCS (LARGE CUPS) n OPTIC NERVE- HEMORRHAGES; LARGE CUP: DISC RATIO (OVER 0. 4) OR ASYMMETRY OF CUPS (HORIZONTAL AND VERTICAL CUP: DISC RATIO)- 0. 3 DIFFERENCE n

BEST SCREENING n COMPREHENSIVE EYE EXAM IN OFFICE SETTING- BY SPECIALIST

ADDITIONAL SCREENING BENEFITS POSSIBLY MORE IMPORTANT THAN DIAGNOSING GLAUCOMA n EDUCATION OF NEED FOR EYE CARE n OPHTHALMOSCOPIC EXAM WILL PICK UP: n CATARACTS n CORNEAL SCARS n RETINAL DISEASE- DIABETES, HYPERTENSION, TUMORS n

TREATMENT OF GLAUCOMA n n n n MEDICATIONS- MANY NEW MEDICATIONSPOTENTIAL SIDE-EFFECTS ONCE A DAY DOSAGE- BEST COMPLIANCE TREAT EARLIER LASER OR SURGERY- EARLIER ? ? - BEING EVALUATED WHICH FIRST? – BEING EVALUATED NEW PROCEDURES GOAL- < 20 mm. Hg. (LOWER IN MANY SITUATIONS)

SUMMARY GLAUCOMA SCREENING n QUESTIONNABLE BENEFIT FOR PREVENTING BLINDNESS n WILL PICK UP A NUMBER OF CASES GLAUCOMA AND OTHER EYE CONDITIONS n CONCENTRATE ON HIGH-RISK GROUPS n EASY TO DO n MARKED EDUCATIONAL AND PUBLIC RELATIONS BENEFIT n