UPDATES IN GLAUCOMA MANAGEMENT CASCADE

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1 UPDATES IN GLAUCOMA MANAGEMENT CASCADE TAREK M. EID, MD PROFESSOR OF OPHTHALMOLOGY, TANTA UNIVERSITY GLAUCOMA MANAGEMENT CASCADE I.LEARN CLINICAL SKILLS AND TOOLS FOR DIAGNOSIS I.CATEGORIZE THE STATUS OF GLAUCOMA I.RECOGNIZE SURROUNDING (RISK) FACTORS I.FRAME THE COURSE OF GLAUCOMA I.REVIEW IN DETAILS VARIOUS TREATMENT MODALITIES I.INDIVIDUALIZE TREATMENT PLAN FOR EACH PATIENT I.DISCUSS TREATMENT PLAN WITH PATIENT I.EDUCATE YOUR PATIENT I.ALWAYS GIVE PATIENT HOPE, NOT FEAR I.CHECK COMPLIANCE OF PATIENT TO TREATMENT PLAN Updates in Glaucoma Management Cascade, Tarek Eid, RIO Meeting

I. LEARN CLINICAL SKILLS AND TOOLS FOR DIAGNOSIS 4 Angle Disc Gonioscopy, UBM, AS-OCT Scheimpflug camera ONH Blood Flow Biomicrosco py Drawing, Stereo Photo HRT, OCT, IV FA, HRF, CDI, OCT Angio IOP

2 I. LEARN CLINICAL SKILLS AND TOOLS FOR DIAGNOSIS 4 Angle Disc Gonioscopy, UBM, AS-OCT Scheimpflug camera ONH Blood Flow Biomicrosco py Drawing, Stereo Photo HRT, OCT, IV FA, HRF, CDI, OCT Angio IOP II IOP App., Diurnal curve Tonopen, Air puff, DCT ORA GLAUCOMA DIAGNOSTIC WORKUP VI I VIII Pachymetry, K-reading, Refraction ORA, Pentacam III VII Cornea Conventional VF, SWAP, FDP, MDP, Progression analysis V ERG, VER, C-S Test, Color vision MRI/CT CSF Pressure Field OCT, NFA, HRT Macular thickness, Ganglion cell count Neural Pathway RNFL 5 2

3 UPDATS FOR GLAUCOMA DIAGNOSTIC WORKUP: IOP MEASUREMENT Dynamic Contour Tonometry Ocular Response Analyzer Home Eye Tonometry 7 UPDATS FOR GLAUCOMA DIAGNOSTIC WORKUP: ANGLE ASSESSMENT Anterior segment OCT Ultrasound Biomicroscopy 8 3

4 UPDATS FOR GLAUCOMA DIAGNOSTIC WORKUP: ONH EXAMINATION OCT ANGIOGRAPHY SS OCT with adaptive optics for LAMINA CRIBROSA IMAGING 9 UPDATS FOR GLAUCOMA DIAGNOSTIC WORKUP: ONH EXAMINATION IMAGING OF APOPTOTIC GANGLION CELLS SS OCT with adaptive optics for RETINAL GANGLION CELL IMAGING Injection of contrast agents for in vivo visualization of apoptotic RGCs (DARC technique) 10 4

5 II. CATEGORIZE GLAUCOMA STATUS Eid & Spaeth, 2000 III. RECOGNZE SURROUNDING RISK FACTORS 12 5

Risk Factors for Glaucoma Disease & Progression Smoking Exercise (sedentary life style) Obesity Education

Demograp hic & Hereditary factors Old age & Longevity Sex Race Residence +ve family history: 1 st, 2 nd,

Diabetes mellitus Migraine Peripheral vascular disorders Ischemic vascular disorders Hyper/hypothyroidism

Ocular risk factors Pigment dispersion Pseudoexfoliation Iris neovascularization Myopia steroid responders

hypermaturity Previous ocular Sx Retinal ischemia other eye changes IV.

Progressors Early Intervention Late Intervention Level of visual disability Poor Birth Life Span Death

6 Risk Factors for Glaucoma Disease & Progression Smoking Exercise (sedentary life style) Obesity Education Employment Competence of the patient to medical care I. Life Style Characteris tics II. Demograp hic & Hereditary factors Old age & Longevity Sex Race Residence +ve family history: 1 st, 2 nd, or 3 rd degree relatives, w or w/out visual loss Diastolic perfusion press Hypertension/hypotension Diabetes mellitus Migraine Peripheral vascular disorders Ischemic vascular disorders Hyper/hypothyroidism Sleep apnea IV. Systemic risk factors III. Ocular risk factors Pigment dispersion Pseudoexfoliation Iris neovascularization Myopia steroid responders Shallow AC depth Iris inflammation Thin corneas Disc Hge, Large C/D R, Lens intumescence, subluxation, hypermaturity Previous ocular Sx Retinal ischemia other eye changes IV. FRAME COURSE OF GLAUCOMA Visual function over the life span Good Slow Progressors Visual function Fast Progressors Early Intervention Late Intervention Level of visual disability Poor Birth Life Span Death Spaeth GL, In Caprioli J, Zeyen T. A critical discussion of the rates of progression and causes of optic nerve damage in glaucoma: International Glaucoma Think Tank II July 25-26, 2008, Florence, Italy. J Glaucoma 2009;18 (6): S1-S

7 V. KNOW UPDATES IN VARIOUS TREATMENT MODALITIES OBSERVATION & FOLLOW-UP MEDICINAL TREATMENT LASER TREATMENT SURGICAL TREATMENT PALLIATIVE TREATMENT 15 II I III IV V VI VIII VII 17 7

II I III IV V VI VIII VII New Advances in Antiglaucoma Medications Rho kinase (ROCK) INHIBITORS phase 3 clinical trial Target TM, enhancing aqueous outflow Enhance RGC survival Increase ocular blood

8 II I III IV V VI VIII VII New Advances in Antiglaucoma Medications Rho kinase (ROCK) INHIBITORS phase 3 clinical trial Target TM, enhancing aqueous outflow Enhance RGC survival Increase ocular blood flow Stem cell Therapy for Glaucoma Gene Therapy for Glaucoma Gene Editing For POAG Proves Successful in Mice It has implications for persons with mutations in the myocilin gene which have been reported in 4% of POAG patients, most notably juvenile Neuroprotection: Mesenchymal stem cells secrete neurotrophic factors which is impaired with axoplasmic transport blockade RGC regeneration: unable yet to Regenerate long axons to the brain & develop efferent synapses for higher order visual processing 21 8

9 I II III IV V VI VII VIII 24 I II III IV V VI VII VIII 26 9

MINIATURE AQUEOUS SHUNTING DEVICES WITHOUT EXTERNAL RESERVOIR TO: Schlemm s canal (istent, Hydrus) Schlemm s canal Subconj space Intrascleral space Ciliary body Suprachoroidal space Iris Intrascleral

10 MINIATURE AQUEOUS SHUNTING DEVICES WITHOUT EXTERNAL RESERVOIR TO: Schlemm s canal (istent, Hydrus) Schlemm s canal Subconj space Intrascleral space Ciliary body Suprachoroidal space Iris Intrascleral space (Express shunting device) Cornea AC Suprachoroidal space (Solex, CyPass, istent Supra) Subconjunctival space (Xen gel stent) Updates in Glaucoma Management Cascade, Tarek Eid, VI. INDIVIDUALIZE TREATMENT PLAN (WEIGH UP RISKS VS BENEFITS FOR EVERY PATIENT 30 10

particular needs and circumstances 33 VIII.

11 VII. DISCUSS TREATMENT PLAN WITH PATIENT Let patient actively share in the decision making of his treatment plan by explaining to him his disease in simple words and the advantages and disadvantages of each treatment modality and why we need to apply this treatment to suite his particular needs and circumstances 33 VIII.Educate your patient About the disease About his condition in particular About treatment instructions About course of the disease & expectations Patients always hope for further visual improvement Doctors always hope to do no further harm to patients 34 11

IX. GIVE YOUR PATIENT HOPE, NOT FEAR Glaucoma for most patients is Bad disease Incurable Blinding And for most eye care providers is Frustrating No cure whatever you do No appreciation while you do

12 IX. GIVE YOUR PATIENT HOPE, NOT FEAR Glaucoma for most patients is Bad disease Incurable Blinding And for most eye care providers is Frustrating No cure whatever you do No appreciation while you do your best No patient should ever leave a visit with a physician without a sense of HOPE Harris JC, DeAngelis CD. The power of hope. JAMA 2008:300(24): X. CHECK COMPLIANCE TO TREATMENT PLAN & FOLLOW-UP Both physician and patient should be competent, actively involved in management plan and properly stick to this plan all the time Good doctor-patient relationship is a key to enhance compliance, so please remember to SMILE, LISTEN, & CARE to your glaucoma patient 12

Intro to Glaucoma/2006

Intro to Glaucoma/2006 Managing Patients with Glaucoma is Exciting Interesting Challenging But can often be frustrating! Clinical Challenges To identify patients with risk factors for possible glaucoma.