DISCLOSURE: What to do? 2/22/2016

Transcription

1 DISCLOSURE: Dr. Joseph Sowka is a member of the Speakers Bureau for Alcon Laboratories, and Carl Zeiss Meditec. He is on the advisory boards for Alcon, Zeiss, and Allergan. He is a consultant for Alcon. Dr. Sowka has no direct financial interest in any of the diseases, products or instrumentation mentioned in this presentation. Joseph W. Sowka, OD, FAAO, Diplomate What to do? 52 YOWM Treated for presumptive OHTN One parent had POAG (maybe) Initial IOP: 32 mm Hg OD, 30 mm Hg OS Treated PGA IOP: 17 mm Hg Corneas turn out to be thick (610) Should he have been treated? Should we stop? 1

2 So What Do You Think? OD OS Case: It just isn t clear 24 YOBF CC: Blurred vision OS Happens twice a year since age 7 BVA 20/15 OD, 20/20 OS PERRL (-) RAPD CF: FTFC OD, OS Medical history unremarkable Case: It just isn t clear Conjunctiva clear OU Cornea: steamy edema, KP s A/C deep IOP: 21 mm Hg OD, 70 mm Hg OS 2

3 So, What are your thoughts? MANAGEMENT This Patient In Office: Pred Forte, Timoptic 0.5%, Alphagan, Trusopt (i gt. each, separated by 5 min) After 30 min: IOP 50 mm Hg; edema completely gone! Now everything is perfect. Can I go now? Repeat regimen: After 30 min: IOP 35 mm Hg Send patient home with Pred Forte Q2H; Alphagan TID F/U 24 Hrs: IOP 10 mm Hg Threshold fields, GDx: Normal OD, OS Points to Ponder Is GCC a truly benign disease? Is GCC a real diagnosis or a variant of uveitic glaucoma? Is GCC an herpetic variant? Bad Prognosis? 78 YOWF Average IOP (1 yr x5); 22 mm OD, 20 mm OS CCT: 517 OD, 527 OS PXE material OU Gonio open OU with moderate pigment 3

4 Bad Prognosis? PXE glaucoma diagnosed Considerations: Mild field loss Older age Lower initial baseline IOP PXE Can this patient be monitored or should she be treated? Bad Prognosis? Pt answers the question- declines treatment Bad experience with treatment suggested by doctors in past more afraid of treatment than glaucoma Wants to see change or other conclusive proof of need for treatment. However, everything says she will do poorly Peak IOP: 34 mm Hg OD, 37 mm Hg OS Any Final thoughts? All Glaucoma is Not Created Equal 71 YOF Diagnosed POAG OU treated with Travatan Z will good response (IOP drops to 18 from 28) CCT: 579, 583 Transfers care for convenience Angles open- no evidence of secondary glaucoma All Glaucoma is Not Created Equal 2012: 20/30 OD, 20/400 OS SLT OU x2 Meds: Lumigan, Combigan, Azopt Hx: Used oral CAI 3x/day- hands and feet hurt too much to continue Used pilocarpine- motion sickness IOP- 22 mm OD and 38 mm OS Now What? Now what? 4

5 All Glaucoma is Not Created Equal Visit 2/14 Not seeing OS since 9/13 20/50 OD, LP OS IOP 36 mm OD, 30 mm OS Now What? Declines surgery again and again All Glaucoma is Not Created Equal N/S until 2/15 Did request med refills throughout, however Using Combigan only- ran out of Azopt and Travatan 20/60 OD, NLP OS IOP 46 mm OD and 72 mm OS Refill all meds Declines surgery again All Glaucoma is Not Created Equal Visit 6/15 Using meds regularly, but was confused when to use Travatan so didn t use it in past week Vision unchanged IOP: 40 mm OD and 53 mm OS New views on surgery Any Final thoughts? Clinical Pearl You can only call a glaucoma patient well controlled in retrospect Some patients progress slowly without treatment and some progress rapidly, even with treatment You don t know who is who until you follow up over time Asymmetric Progression? 76 YOWM- 2008; now 83; US citizen, lives/works Brazil BPH, hypercholesteremia, aortic stenosis Crestor, Flomax, Levitra 20/20 OD, OS Peak IOP 25 mm OD, 20 mm OS CCT 618 OU PERRL (-) RAPD; gonio/sle normal Dx ed POAG OS; OHTN OD vs early POAG Travatan OU Occasionally used DuoTrav mm Hg OU 5

6 /2015 6

7 Asymmetric Progression? Treated IOP mid teens Marked field progression OS only Meds changed throughout BP 114/70; 46 BPM Travatan Z/ Simbrinza IOP 12 mm Hg OU Why asymmetric (rapid) marked progression OS? What else to look for? Next step? Now What Do You make of This? 63 YOWF- OHTN OU Treated previously with timolol 0.5% OD only Complained of fatigue with med use Timolol stopped Followed without treatment Q6 mos 6 mos then becomes 18 mos Resident wants to repeat fields and OCT Now What Do You make of This? Now What? Is Non-Compliance Always Bad? 68 YOF- OHTN Would fields or OCT show what was wrong? 7

8 Treat or Observe? 2012 CCT: 605; 604 IOP: Low 30s consistently Is Non-Compliance Always Bad? Treatment advocated- pt declines; agrees to close observation 3 mos f/u scheduled- returns 3 years later Best management now? Any Final thoughts? Help! The Diagnostic Imaging Doesn t Agree with My Diagnosis! 56 YOM- Glaucoma suspect since

9 Is It Only Glaucoma? Is this person really a glaucoma suspect? 53 YOBF- No complaints BVA 20/20 OD, OS Perrl (+) RAPD OS IOP 30 mm Hg OD and 32 mm Hg OS Unilateral sectorial disc pallor with minimal rim damage Color vision testing normal SLE normal OU Anterior chamber angles open gonioscopically. Is this glaucoma or something else like a tumor? Unilateral disc pallor? Glaucoma, something else, or both? Neuroimage or not? 9

10 Not All Omas are Glaucoma; other things cause cupping Pituitary adenoma Craniopharyngioma Meningioma Glioma Metastatic carcinoma Ischemioma Anterior ischemic optic neuropathy (AION)/ Retinal infarcts Retinaloma Congenitaloma Coincidentaloma Misdiagnosoma Back to the patient Rim minimally notched Disc pallor Unilateral damage No disc hemorrhage/ parapapillary atrophy Age over 50 Arcuate defect- glaucomatous Risk factor- IOP 30s Acuity and color normal But the last doctor said that I had glaucoma 57 YOBF: Diagnosed POAG OU in 2008 based upon disc appearance and abnormal GDx Treated with Travatan z Seen by multiple doctors glaucoma by history Good IOP- CPM Poor compliance can lead to blindness Visual fields- dense superior and inferior arcuate defects Do not use fields for this patient Diagnostic GDx reviewed normal 10

11 But the last doctor said that I had glaucoma Treated IOP 14 mm Hg OU Fields, discs, imaging normal OU Stop meds IOP rises to 17 mm Hg OD and 18 mm Hg OS New diagnosis: normal Misdiagnosoma 11