Assist. Prof. Damrong Wiwatwongwana, MD Division of Glaucoma & Oculoplastics Chiang Mai University

Transcription

1 Assist. Prof. Damrong Wiwatwongwana, MD Division of Glaucoma & Oculoplastics Chiang Mai University

2 I Have no Financial Interest 2

3 Background

4 Etiology and Prevalence of Glaucoma Elevated intraocular pressure (IOP) is considered an important risk factor for the development of glaucoma 1,2 Glaucoma is the second leading cause of blindness worldwide 3,4 ~75% of cases will be primary open-angle glaucoma (POAG) 1 The worldwide prevalence of glaucoma is expected to rise over the next 10 years Baudouin C. Acta Ophthalmol 2008;86(7): Infeld DA, O'Shea JG. Postgrad Med J 1998;74(878): Resnikoff S, et al. Bull World Health Organ 2004;82(11): Quigley HA, Broman AT. Br J Ophthalmol 2006;90(3):

5 Primary open angle glaucoma (POAG) is the most prevalent type of glaucoma in the United States and affects about 2% of individuals over age 40 1 American Academy of Ophthalmology Glaucoma Panel. Preferred Practice Pattern Guidelines. Primary Open-Angle Glaucoma. San Francisco, CA: American Academy of Ophthalmology; Available at: 2 Alward WLM. Glaucoma: the requisites in ophthalmology. Krachmer JH (Ed.). St. Louis: Mosby, 2000:

6 Primary Open-Angle Glaucoma: Prevalence by Age, Race and Gender 1.Prevalence of POAG is higher in African Americans than Caucasians and increases with age: 1 1.Trend towards higher prevalence of POAG in females: 2 1. Sommer A. Curr Opin Ophthalmol. 1996;7(2): Friedman DS, et al. Arch Ophthalmol 2004;122(4): BDOS, Barbados Eye Study; BDES, Beaver Dam Eye Study; BES, Baltimore Eye Survey; BMES, Blue Mountain Eye Study; KEP, Kongwa Eye Project; MVIP, Melbourne Vision Impairment Project; PVER, Proyecto Vision Evaluation Research; RS, Rotterdam Study 4

7 7 Glaucoma is a chronic, progressive optic neuropathy characterized by thinning of the neuroretinal rim of the optic disc Resulting characteristic appearance of the optic nerve head called cupping, and a corresponding loss of visual field Kwon YH, Fingert JH, Kuehn MH, Alward WLM. Primary open-angle glaucoma. N Engl J Med Mar 12; 360:

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9 9 Importantly, the early symptoms of glaucoma can be quite subtle, and >50% are not aware! Early recognition is important because the prognosis can be good if patients are diagnosed and treated appropriately early on in the disease process but if left untreated it can progress to irreversible blindness

10 10 *High IOP Advanced age Family history African race Thin corneas Pseudo exfoliation Myopia Low ocular perfusion pressure? Sleep apnea? The only risk factor that is treatable is high IOP, and all current therapies for POAG are aimed at decreasing IOP

11 Evidence based glaucoma therapy The treatment goal is to maintain the patient s quality of life by preserving visual function help delay significant functional impairment.

12 IOP - Lowering therapy in Glaucoma Glaucoma is a chronic and asymptomatic disease IOP Lowering therapy can delay and limit progression - Six pivotal trials have demonstrated efficacy of IOP- Lowering: CGS, EMGT, CNGTS, AGIS, CGTS, OHTS Chauhan et al. Arch Ophthalmol2008;126: Heijl et al. Arch Ophthalmol2002;120: CNTG Group. Am J Ophthalmol 1998;126: AGIS Am J Ophthalmol2000;130: Lichter et al.ophthalmology 2001;108: Kass et al. Arch Ophthalmol2002;120:701-13

13 How Often Does Glaucoma Progress? Study N Follow-up % Progression Clinic-based Tx No Tx OHTS patients 5 y 4.4% 9.5% EGPS patients 5 y 13.4% 14.1% DIGS patients 7 y N/A 25% EMGT patients 6 y 45% 62% CNTGS eyes 7 y 12% 35% CIGTS patients 5 y 10.7%-13.5% N/A AGIS eyes 8-13 y 28.1%-32.5% N/A Population-based St. Lucia patients 10 y N/A 52%-73% 1. Kass et al. Arch Ophthalmol. 2002; 2. Miglior et al. Ophthalmology. 2005; 3. Medeiros et al. Arch Ophthalmol. 2005; 4. Heijl et al. Arch Ophthalmol. 2002; 5. Collaborative Normal-Tension Glaucoma Study Group. Am J Ophthalmol. 1998; 6. Lichter et al. Ophthalmology. 2001; 7. AGIS Investigators. Am J Ophthalmol. 2002; 8. Wilson et al. Am J Ophthalmol

14 However - Lifelong treatment is required to prevent disease progression - Patients must take their medication(s) daily as directed

15 15 Alward WLM. A new angle on ocular development. Science. 2003;299: Anatomy TM Outflow Uveoscleral Outflow

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18 18 Histology Glaucomatous: Normal:

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22 Symptom POAG is generally asymptomatic until late in the course of the disease. The primary symptom is loss of VF, but there is usually such a gradual decrease in peripheral vision that it may not be noticeable to the patient until the vision loss is advanced. Furthermore, studies have shown that up to half of the retinal ganglion cells may be lost before there are signs of visual field loss on exam 1 Alward WLM. Glaucoma: the requisites in ophthalmology. Krachmer JH (Ed.). St. Louis: Mosby, 2000: Weinreb RN, Khaw PT. Primary open-angle glaucoma. Lancet. 2004;363:

23 23 Tonometry Applanation Schiotz

24 Goldmann applanation tonometer 24

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26 26 Optic Disc Exam slit lamp+ 78 D / indirect ophthalmoscopy (DFE) is useful for diagnosing early glaucoma since optic disc changes occur before loss of visual field is noticeable.

27 27 Direct ophthalmoscopy is somewhat more difficult due to the lack of a stereoscopic view but can still be used to look for characteristic changes The key findings on examination of the optic nerve head include: Large cup to disc ratio Progressive cupping Vertical cupping Asymmetric optic nerve head cupping Notching of the neuroretinal rim Disc hemorrhage

28 FIVE RULES (THE 5 RS ) FOR ASSESSMENT OF THE OPTIC DISC IN GLAUCOMA 1. Observe the scleral Ring to identify the limits of the optic disc and its size.

29 OPTIC DISC SIZE Measurement of optic disc size with biomicroscopy Volk lens Measure length of slit beam Correction factors Volk 60D x 1.0 Volk 78D x 1.1 Volk 90D x 1.3 Average vertical diameter: 1.8 mm Average horizontal diameter: 1.7 mm

30 OPTIC DISC SIZE Size of cup varies with size of disc Large discs have large cups in healthy eyes 1.4 mm 1.9 mm 2.4 mm Small Average Large Identify small and large optic discs Small discs: Average vertical diameter < 1.5 mm Large discs: Average vertical diameter > 2.2 mm

31 OPTIC DISC SIZE BY HRT 3 Size of cup varies with size of disc Large discs have large cups in healthy eyes 1.6 mm 2.3 mm 3.77 mm Small Average Large Identify small and large optic discs Small discs: Average vertical diameter < 1.5 mm Large discs: Average vertical diameter > 2.2 mm Note: Normative database does not account for ethnicity.

32 FIVE RULES FOR ASSESSMENT OF THE OPTIC DISC IN GLAUCOMA 1. Observe the scleral Ring to identify the limits of the optic disc and its size. 2. Identify the size of the Rim.

33 ISNT RULE N S I T Rim width Distance between border of disc and position of blood vessel bending ISNT rule Inferior > Superior > Nasal > Temporal

34 FIVE RULES FOR ASSESSMENT OF THE OPTIC DISC IN GLAUCOMA 1. Observe the scleral Ring to identify the limits of the optic disc and its size. 2. Identify the size of the Rim. 3. Examine the Retinal nerve fiber layer (RNFL).

35 RNFL RED-FREE PHOTOGRAPHS Bright striations

36 LOCALIZED RNFL LOSS Localized RNFL defect Wedge-shaped dark area

37 FIVE RULES FOR ASSESSMENT OF THE OPTIC DISC IN GLAUCOMA 1. Observe the scleral Ring to identify the limits of the optic disc and its size. 2. Identify the size of the Rim. 3. Examine the RNFL. 4. Examine the Region of parapapillary atrophy.

38 Alpha zone Hypopigmented and hyperpigmented areas Present in normal as well as in glaucomatous eyes Beta zone Atrophy of the retinal pigment epithelium (RPE) and choriocapillaris PARAPAPILLARY ATROPHY Large choroidal vessels become visible More common in glaucomatous eyes β α

39 PARAPAPILLARY ATROPHY Thin rim Beta zone Width of beta zone inversely correlates with rim width at same area Larger β zone

40 FIVE RULES FOR ASSESSMENT OF THE OPTIC DISC IN GLAUCOMA 1. Observe the scleral Ring to identify the limits of the optic disc and its size. 2. Identify the size of the Rim. 3. Examine the RNFL. 4. Examine the Region of parapapillary atrophy. 5. Look for Retinal and optic disc hemorrhages.

41 OPTIC DISC HEMORRHAGE Normally disappears after 1 to 3 months

42 OPTIC DISC HEMORRHAGE Detection of disc hemorrhages requires careful optic disc examination

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44 44 Goldmann perimeter Glaucoma visual fields

45 Humphrey automated perimetry 45

46 Visual fields in glaucoma Early Late 46

47 47 Optic nerve signs of glaucoma progression Increasing C:D ratio Development of disk pallor Disc hemorrhage (60% will show progression of visual field damage) Vessel displacement Increased visibility of lamina cribosa

48 STRUCTURAL FEATURES INDICATIVE OF GLAUCOMA PROGRESSION Increased excavation of optic cup Displacement of blood vessels Change in neuroretinal rim width Focal narrowing (notching) Diffuse narrowing Change in RNFL appearance Focal thinning (new or expansion of existing defect) Diffuse thinning Increase in beta zone parapapillary atrophy Splinter hemorrhage

49 OCT measures the reflection of light from different structures in the eye

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51 51 Congenital glaucoma Symptoms Blepharospasm Photophobia Epiphora Poor vision Signs Elevated IOP Buphthalmos Haab s striae Corneal clouding Glaucomatous cupping Field loss

52 Buphthalmos and cloudy corneas 52

53 53 Buphthalmos, glaucomatous cupping, and cloudy cornea OD Normal OS Haab s striae

54 54 Treatment Surgery Medication while waiting

55 ACUTE ANGLE CLOSURE GLAUCOMA : DEFINITION AND EPIDEMIOLOGY

56 OVERVIEW Quigley HA, Broman A. The number of persons with glaucoma worldwide in 2010 and Br J Ophthalmol 2006; 90:

57 OVERVIEW Angle-Closure accounts for 50% of all glaucoma blindness worldwide. Foster PJ, Johnson GJ. Glaucoma in China: how big is the problem? Br J Ophthalmol 2001; 85:

58 OVERVIEW With glaucoma blindness, PACG is a major priority for efforts to prevent blindness. Foster PJ. The epidemiology of primary angle closure and associated glaucomatous optic neuropathhy Seminars in Ophthalmology 2002, Vol. 17, No. 2, pp

59 OVERVIEW Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and Br J Ophthalmol 2006;90:262-7.

60 POAG VS PACG

61 DEFINITION

62 DISEASE DEFINITION The presence of iridotrabecular contact (ITC) caused by multiple mechanisms. Noncompressed gonioscopy

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64 CLASSIFICATION AND CLINICAL CHARACTERISTICS OF ANGLE CLOSURE

65 Primary angle closure is generally bilateral. 90% of acute attacks are unilateral. Seah SK, Foster PJ, Chew PT, et al. Incidence of acute primary angle-closure glaucoma in Singapore. An island-wide survey. Arch Ophthalmol 1997;115: Friedman DS, Gazzard G, Foster P, et al. Ultrasonographic biomicroscopy, Scheimpflug photography, and novel provocative tests in contralateral eyes of Chinese patients initially seen with acute angle closure. Arch Ophthalmol 2003;121:

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67 67 Acute Angle Closure Crisis Symptoms Severe eye/headache pain Blurred vision Red eye Nausea and vomiting Halos around lights Intermittent eye ache at night Signs Red, teary eye Corneal edema Closed angle Shallow AC Mid-dilated, fixed pupil Glaucomflecken Iris atrophy AC inflammation

68 68 Angle anatomy Grade I Grade 0 Grade III Grade II

69 Anatomy of Angle Closure Glaucoma 69

70 Mid-dilated, fixed pupil 70

71 Medication 71

72 Treatment: Peripheral Iridotomy 72

73 Mx of AACC 73

74 74 Normal Tension Glaucoma (NPG, LTG, LPB, NTG) Similar to OAG but IOP always < 21 mmhg Higher prevalence of vasospastic disorders, blood dyscrasias, autoimmune diseases May be related to episodic hypotension, Cardiovascular disease A diagnosis of exclusion!!!

75 75 IOP lowering Hypotensive eye drop Incisional surgery Laser treatments

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77 Treatment 77

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85 Glaucoma Laser 85

86 Glaucoma specialists agree it's virtually impossible to monitor patients' compliance with glaucoma medications 86

87 Nordstrom BL, Friedman DS, Mozaffari E, et al. Persistence and adherence with topical glaucoma therapy. Am J Ophthalmol. 2005;140:

88 Absence of most of the ocular and systemic side effects 88

89 89 Direct at TM in OAG to improve aqueous outflow Argon laser trabeculoplasty Selective laser trabeculoplasty To modulate configulation of iris in ACG Peripheral laser iridotomy Laser iridoplasty

90 BhZnRlciB 90 ALT/SLT

91 91 LPI ;Treatment area Under upper eyelid at 11-1 O Clock Avoid bisect by the eyelid: diplopia and ghost images Iris crypts : thinner Inferior for SO in the eye

92 92 Complications IOP spikes 1/3 but decresed by using apraclonidine or brimonidine Iritis Transient Fail Ideal micron ( at least 50micron)

93 Diplopia Prismatic effect created by tear meniscus or upper eyelid Sunglasses Cosmetic contact lens 93

94 Bleeding Rare and self-limited Lens opacities Directly or indirectly: focal at iridotomy area Corneal injury Transient Glycerin can clear the cornea temporaarily Others Malig glaucoma, retinal burn, lens induced uveitis 94

95 Surgical iridectomy Unavailable laser equipment uncooperative patient eg. Children Failure by laser 95

96 96 Cyclodestruction one of the surgical modalities of management of glaucoma refractory to other means of surgical and medical treatment cyclocryotherapy, or by non-contact or contact trans-scleral cyclophotocoagulation by diode, or YAG lasers.

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99 Trabeculectomy 99

100 100 If surgery for glaucoma was 100% safe, it would be used in every patient. surgery for glaucoma should only be undertaken with proper attention to the risk/benefit ratio.

101 101 Trabeculectomy indication Uncontrolled IOP with medication /laser Intolerance to glaucoma medication Poor compliance Forgetfulness Insufficient monetary funds to cover cost of therapy

102 Gold standard Diverting aqueous humor into the subconjunctival space, forming a filtering bleb under the upper lid 102

103 103 Unfavourable outcome Hypotony Exuberant scaring Infection Undesirable bleb Tearing Burning Leaking stinging

104 Glaucoma Drainage Device

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106 Interesting case 106

107 107 Be aware of steroid induced glaucoma!

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110 Thank you 110

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