10/3/2018. Case: 63 year old white female 6/11/2012 visit. Glaucoma Update for the Primary Care OD CHRISTOPHER WOLFE, OD, FAAO, DIPL ABO

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1 DISCLOSURE STATEMENT Ihave no direct financial or proprietary interest in any companies, products or services mentioned in this presentation. GLAUCOMA UPDATE FOR THE PRIMARY CARE OD Please silence all mobile devices Glaucoma Update for the Primary Care OD CHRISTOPHER WOLFE, OD, FAAO, DIPL ABO At the conclusion of this course, please properly dispose of your trash as you leave this room 1 2 To: Text: christopherw667 To participate in audience polling: 6/11/2012 visit New patient CHIEF COMPLAINT: Blurry vision at distance and near ONSET: last 2 3 months SIGNS/SYMPTOMS: glasses do not seem clear PHx: Simvastatin, HCTZ, Metoprolol, Synthroid. No ocular medications, RK, Lasik OU. No history of trauma or ocular injuries. FHx: unremarkable SHx: Patient is currently a non smoker REVIEW OF SYSTEMS: No reported disorders or current medical treatment of: Constitutional, Cranial / Facial, Endocrine, Gastrointestinal, Gentitourinary, Hematologic / Lymphatic, Immunologic, Integumentary / Skin, Musculoskeletal, Neurologic, Psychiatric, Respiratory (14) 3 New: /11/2012 visit Fields: FTFC CT: distance and near Tonometry: 20/24 Adnexa: clear OU Eyelids: clear EOM: F&S ONH: 0.55 OD, inferior notch 0.75 OS, order photo to evaluate and monitor Posterior Seg (DFE): Unremarkable OU DISPOSITION: This patient's mood is pleasant and sociable. ORIENTATION: Patient is fully alert to time, place, and person. Recent and remote memory is fully intact. SPECIAL TESTING: Retinal Photography: Bilateral: CPT I&R Retinal camera. The defect exists in the disk. Defect is consistent with glaucoma. Plan: Follow for trend analysis as directed and treatment as indicated in plan. 1. Glaucoma suspect 2. Cataracts 3. Corneal scars Treatment: 1. Monitor IOP, gonio, pach, 30 2 and ONH OCT in 1 week, request prior records today 2. New spec Rx 6/11/2012 visit Examination: 14, MDM: Moderate , 92015,

2 7/30/2012 visit Est patient CHIEF COMPLAINT: Pt here for a glaucoma evaluation ONSET: exam 1 month ago SIGNS/SYMPTOMS: no pain or pressure REVIEW OF SYSTEMS: PHx: Simvastatin, HCTZ, Metoprolol, Synthroid. No ocular medications, RK, Lasik OU. No history of trauma or ocular injuries. 7/30/2012 visit Tonometry: 20/25 Adnexa: clear OU Eyelids: clear ONH: 0.55 OD, inferior notch 0.75 OS, order gonio, pachs, ONH OCT and 30 2 to evaluate and monitor Posterior Seg: Unremarkable OU DISPOSITION: This patient's mood is pleasant and sociable. ORIENTATION: Patient is fully alert to time, place, and person. Recent and remote memory is fully intact. SPECIAL TESTING: Gonio OU: CPT CB 360, trace pigment, flat Pach OU: CPT /521 ONH OCT: CPT Diffuse RNFL deviation from NDB OU with inferior wedge defect OS VF OU: CPT mild superior nasal step OD, severe superior nasal step 1. Primary Open Angle Glaucoma Moderate Stage 2. Cataracts stable 3. Corneal scars stable Treatment: 1. Monitor IOP, 30 2 and ONH OCT in 1 week, ed pt that we will initiate treatment at that time 2. Monitor Established: Examination: 10, MDM: Moderate 8 7/30/2012 visit 7/30/2012 visit , 92133, 92020, 76514, /10/2012 visit Est patient CHIEF COMPLAINT: Pt here for a glaucoma evaluation ONSET: exam 2 months ago SIGNS/SYMPTOMS: no pain or pressure REVIEW OF SYSTEMS: PHx: Simvastatin, HCTZ, Metoprolol, Synthroid. No ocular medications, RK, Lasik OU. No history of trauma or ocular injuries. 8/10/2012 visit Tonometry: 21/25 Adnexa: clear OU Eyelids: clear ONH: 0.55 OD, inferior notch 0.75 OS, order ONH OCT and 30 2 to evaluate and monitor Posterior Seg: Unremarkable OU DISPOSITION: This patient's mood is pleasant and sociable. ORIENTATION: Patient is fully alert to time, place, and person. Recent and remote memory is fully intact. SPECIAL TESTING: ONH OCT: CPT Diffuse RNFL deviation from NDB OU with inferior wedge defect OS VF OU: CPT possible superior nasal step OD, severe superior nasal step w/in 1. Primary Open Angle Glaucoma Moderate Stage/Severe Stage stable 2. Cataracts stable 3. Corneal scars stable Treatment: 1. Initiate Lumigan 0.01% OU QHS, Monitor IOP 4 week 2. Monitor New: Examination: 10, MDM: Low 12 2

3 8/10/2012 visit 8/30/2012 visit Est patient CHIEF COMPLAINT: Pt here for a glaucoma evaluation ONSET: 2012 SIGNS/SYMPTOMS: no pain or pressure, good med adherence, eyes are more red and burn REVIEW OF SYSTEMS: PHx: Simvastatin, HCTZ, Metoprolol, Synthroid. Lumigan 0.01% OU QHS, RK, Lasik OU. No history of trauma or ocular injuries , 92133, Established: /30/2012 visit Tonometry: 15/17 Adnexa: clear OU Eyelids: clear Conjunctiva: 1+ injection DISPOSITION: This patient's mood is pleasant and sociable. ORIENTATION: Patient is fully alert to time, place, and person. Recent and remote memory is fully intact. 1. Primary Open Angle Glaucoma Moderate Stage/Severe Stage responding to topical treatment with mild local SE 2. Cataracts stable 3. Corneal scars stable Treatment: 1. Continue Lumigan 0.01% 7:00, w/ Systane Ultra OU at bedtime. Monitor IOP 8 weeks 2. Monitor 12/3/2012 visit Est patient CHIEF COMPLAINT: Pt here for a glaucoma evaluation ONSET: 2012 SIGNS/SYMPTOMS: no pain or pressure, good med adherence, no SE PHx: Simvastatin, HCTZ, Metoprolol, Synthroid. Lumigan 0.01% OU QHS, RK, Lasik OU. No history of trauma or ocular injuries. REVIEW OF SYSTEMS: Examination: 10, MDM: Low Established: /3/2012 visit Tonometry: 16/18 ONH: 0.55 OD, inferior notch 0.75 OS DISPOSITION: This patient's mood is pleasant and sociable. ORIENTATION: Patient is fully alert to time, place, and person. Recent and remote memory is fully intact. SPECIAL TESTING: ONH OCT: CPT Diffuse RNFL deviation from NDB OU with inferior wedge defect OS VF OU: CPT possible superior nasal step OD, severe superior nasal step 1. Primary Open Angle Glaucoma Moderate Stage/Severe Stage responding to topical treatment 2. Cataracts stable 3. Corneal scars stable Treatment: 1. Continue Lumigan 0.01% 7:00, w/ Systane Ultra OU at bedtime. Monitor IOP 4 months with ONH OCT 2. Monitor 5/24/2013 visit Est patient CHIEF COMPLAINT: Pt here for a glaucoma evaluation ONSET: exam 11 months ago SIGNS/SYMPTOMS: no pain or pressure, pt notices that vision fluctuates during the day REVIEW OF SYSTEMS: PHx: Simvastatin, HCTZ, Metoprolol, Synthroid. Lumigan 0.01% OU QHS, RK, Lasik OU. No history of trauma or ocular injuries. SHx: Patient is currently a non smoker Examination: 8, MDM: Low 99213, 92133, Established:

4 5/24/2013 visit Tonometry: 15/16 Adnexa: reduced TBUT Eyelids: 1+ MGD ONH: 0.55 OD, inferior notch 0.75 OS, order ONH OCT to evaluate and monitor Posterior Seg: Unremarkable OU DISPOSITION: This patient's mood is pleasant and sociable. ORIENTATION: Patient is fully alert to time, place, and person. Recent and remote memory is fully intact. SPECIAL TESTING: ONH OCT: CPT Diffuse RNFL deviation from NDB OU with inferior wedge defect OS, GPA confirms stability 1. Primary Open Angle Glaucoma Moderate Stage/Severe Stage responding to topical treatment - stable 2. Cataracts - stable 3. Corneal scars stable 4. Ocular surface dysfunction - worse Treatment 1. Continue Lumigan 0.01% 7:00, Monitor IOP 4 months with DFE and Monitor 4. Initiate Refresh Optive Advance OU QID, Hot compresses OU QD, Ocusoft OU QD 5/24/2013 visit Examination: 10, MDM: Moderate 99214, Summary of Care Glaucoma (1 year) Date Service(s) Price(s) Based on 2017 Medicare NV 6/11/ , 92015, $168.50, $50, $ /30/ , 92133, 92020, 76514, $110.51, $38.84, $27.77, $15,71, $ /10/ , 92133, $88.32, $38.84, $ /30/ $ /3/ , 92133, $75.18, $38.84, $ /24/ , $110.51, $38.84 Definitions and Risk Total Care: $ Elevated IOP Myopia Thinner central corneal thickness Older age African race or Latino/Hispanic ethnicity Lower systolic and diastolic blood pressure Disc hemorrhage Larger cup to disc ratio Family history Type 2 diabetes mellitus Visual field loss Risk Factors Prevalence Prevalence Glaucoma Prevalence Age African American Latino Caucasion

5 Central Corneal Thickness and Glaucoma Risk Corneal Hysteresis 40% 35% 30% 25% Impact of CCT and CD Ratio and IOP CH 20% 15% 10% 5% 0% IOP > Vertical C/D 0.3 <10 Increased Risk >10 Reduced Risk CCT < 555 CCT > Anterior Segment Findings: TIDs, Krukenberg s Spindle Anterior Segment Findings: Sampolisi s Line, Scheie s Line Anterior Segment Findings: Angle Recession, Amyloid Deposits, Pigment Balls Angle Closure: Iris Bombe, Narrow Angle Pre/Post Op

6 RNFL Defects KP s: Stellate vs Typical Uveitic OCT: RNFL Nerve Fiber Layer Defect OCT: RNFL Nerve Fiber Layer Defect

7 Pre perimetric?: OCT: Ganglion Cell Complex Macular Disease Impact Pre perimetric?: 10 2 Review Sensitivity: The ability of a test to find those with the disease Specificity: The ability of a test to find those without the disease You will never have a test that is 100% sensitive and 100% specific As you increase one, the other one will decrease

8 Relationship between RNFL and Macular thickness VF Defects w/ Glaucoma R square: Range from 0 1. The closer to 1, the stronger the two variables are related Glaucoma Staging Mild Optic nerve abnormalities consistent with glaucoma NO visual field abnormalities on standard automated perimetry Abnormalities present only on short wave length automated perimetry or frequency doubling perimetry Moderate Optic nerve abnormalities consistent with glaucoma AND glaucomatous visual field abnormalities in ONE hemifield NOT within 5 degrees of fixation Advanced Optic nerve abnormalities consistent with glaucoma AND glaucomatous visual field abnormalities in BOTH hemifields AND/OR loss within 5 degrees of fixation in at least one hemifield Corneo scleral Outflow Uveo scleral Outflow Aqueous Production : PGA 2: SLT/NO 3: β blocker/cai 4: agonist Case

9 Case: 79 year old white female CC: sticky left eye FHx: glaucoma OcHx: cataract surgery w/ monofocal OU MHx: hypercholesterolemia (atorvastatin, asa) BVA: OD: x /20 OS: x /20 CT, pupils: unremarkable Confrontation: superior nasal restriction OD, normal OS Anterior Segment: PCIOL, 2+ MGD Case: 79 year old white female IOP: Posterior Segment: OD: beta atrophy, Inferior nerve notch with corresponding RNFL wedge defect OS: beta atrophy Case: 79 year old white female Case: 79 year old white female What Does the Literature Say? Comparison of glaucomatous progression between untreated patients with normal tension glaucoma and patients with therapeutically reduced intraocular pressures. Collaborative Normal Tension Glaucoma Study Group. Am J Ophthalmol Oct;126(4): patient eyes, 61 treatment group, 79 untreated controls. Twenty eight (35%) of the control eyes and 7 (12%) of the treated eyes reached end points (specifically defined criteria of glaucomatous optic disk progression or visual field loss). 53 9

10 What Does the Literature Say? Krupin T, et al. A randomized trial of brimonidine versus timolol in preserving visual function: results from the Low Pressure Glaucoma Treatment Study. Am J Ophthalmol Apr;151(4): brimonidine, 79 timolol Statistically fewer brimonidine treated patients (9, 9.1%) had visual field progression by pointwise linear regression than timolol treated patients (31, 39.2%, log rank 12.4, P=.001). Mean treated IOP was similar for brimonidine and timolol treated patients at all time points. 55 What Does the Literature Say? Poley BJ et al. Intraocular pressure reduction after phacoemulsification with intraocular lens implantation in glaucomatous and nonglaucomatous eyes: evaluation of a causal relationship between the natural lens and open angle glaucoma. J Cataract Refract Surg Nov;35(11): The study comprised 124 eyes. The final mean IOP reduction was 8.5 mm Hg (34%) in the 29 to 23 mm Hg group, 4.6 mm Hg (22%) in the 22 to 20 mm Hg group, 3.4 mm Hg (18%) in the 19 to 18 mm Hg group, and 1.1 mm Hg (10%) in the 17 to 15 mm Hg group. In the 14 to 5 mm Hg group, IOP increased by 1.7 mm Hg (15%). 57 What Does the Literature Say? Craven ER et al. Cataract surgery with trabecular micro bypass stent implantation in patients with mild to moderate open angle glaucoma and cataract: two year followup. J Cataract Refract Surg Aug;38(8): Overall, the mean IOP was stable between 12 months and 24 months (17.0 mm Hg ± 2.8 [SD] and 17.1 ± 2.9 mm Hg, respectively) in the stent group but increased (17.0 ± 3.1 mm Hg to 17.8 ± 3.3 mm Hg, respectively) in the control group. Ocular hypotensive medication need was statistically significantly lower in the stent group at 12 months; it was also lower at 24 months, although the difference was no longer statistically significant

11 Testing Regularity Financial Impact 61 Based on AOA Clinical Practice Guidelines and AAO Preferred Practice Patters 62 Financial Impact OHTN/Glaucoma suspect: $523 $623 Mild/early: $1223 $1480 Moderate: $ Advanced/Severe: $1552 $2511 Thank You! EyeCode Education Contact Information: website: Blog: These fees include medications, office visits, and testing and the range depends upon patient adherence to follow up and medication usage and Medicare vs actual physician fees