Disclosures. MT 11/4/2015 Followed for diabetic ret, AMD. Does he have glaucoma too? Glaucoma Case Challenges. George Comer, OD, MBA

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1 Disclosures George Comer, OD, MBA at M.B. Ketchum University Glaucoma Case Challenges Research funding from Topcon Research funding from Optovue Research funding from Heidelberg Instruments George W. Comer, OD, MBA at M.B. Ketchum University MT 11/4/2015 Followed for diabetic ret, AMD. Does he have glaucoma too? 59 A (Japanese) m C/o of blurred vision distance, constant. No fluctuation from day to day. POHx: Being followed by OMD for diabetic ret and AMD x 3, last exam 4 or 5 months ago there no diabetic ret, took ret photos. Cryo OS x 2 in 2005 for diabetic ret? PMHx: DM since 1999 Ha1c: 7.9, last FBS: 180, hypercholesterolemia, thyroid disease MT 11/4/2015 Meds: Crestor, Lotrel, Lansoprazole Metformin, Novolog, Synthroid CT: Dist: Ortho Near: 18 ILXT Manifest: OD: x /20 OS: x /30++ PH no improvement NCT: 22, 21, 22/20, 22, 24 1:50 BP: 140/80 1:55 Pulse: 69 Color vision: HRR Plates OD: 6/6 OS: 6/6 VF screening: see FDT printout SLE: 1+ NSC OU, mild ant cortical vacuoles MT 11/4/2015 FDT C20-5 screening FDT Interpretation Considerations for MT OD 2 nd eye tested often has misses 2 nd eye artifact Strategy: Give the pt a brief (seconds) rest & test again But this (OD) is the first tested eye! If head is positioned too high the upper row of test points is not visible to patient. Hard to see this on FDT because you cannot see the pt s eye during the test. Easy to see on Matrix video eye monitor. Retest if this is a possibility. 1

2 Why Run the Screening VF Again? Screening is very rapid way to confirm or rule out VF loss, much more rapid than a threshold test. Screening is much easier to interpret than threshold VFs Screening has much better specificity than threshold VFs If not sure then quickly rescreen the VF. If true VF loss is likely then look at ONH, RNFL for correlating damage. Structural damage usually precedes VF loss. MT 11/20/2015 OD ONH photos Analyze inf rim carefully Note inf peripapillary atrophy MT 11/4/2015 C/D: OD:.7 x.7 shallow broad inf notch OS:.6 x.6 round cup Few dot hemes OU RPE mottling OU; possible CSME OS Glau suspect Mild NPDR with possible CSME OS Mild NSC & ant cortical changes OU Myopia, astigmatism, presbyopia MT 11/4/2015 Plan: Advised glau work-up: HFA 24-2, OCT (92133), CCT, Pascal DCT, gonio Macular OCT (92134) OS to assess possibility of CSME Report to PCP Monitor cats Spec Rx MT 11/20/2015 Glau Eval IOPs: NCT: 16, 17, 18/ 19, 20,18 11:15 am predilated GAT: 16/16 12:05 postdilated DCT: 19.4/ :10 postdilated (Q: 1 OU) CCT (Reichert IOPac): OD: 597µ OS: 605µ HFA 24-2: OD: 8 point cluster - sup arcuate scotoma OS: Mild gen depression, no focal VF loss Avanti OCT: see printouts Gonio: Open to CBB 360 OU, minimal TM pig Tonometry & CCT Considerations Why 3 different tonometers? Why do NCT? Does not mess with the cornea. We prefer it for IOPs prior to imaging (OCT, photos, HRT etc) Why do GAT post-dilated? To check for post-dilated IOP spikes & to have GAT for medico-legal purposes Why do Pascal DCT? Due to thick CCT. Important: Thick CCT does not necessarily mean false high IOP on applanation tonometers 2

3 MT 11/20/2015 HFA 24-2 OD Does this correlate to the FDT VF? Should this 24-2 be repeated? Does it correlate to the clinical ONH/RNFL evaluation? MT 11/20/2015 OCT OU OD RNFL: Abnormal (p<1%) sup temp, inf nasal. Borderline inf temp sector OD GCC: Large area of p<5% inferior OD: OD>OS OS: Normal RNFL & GCC MT 11/20/2015 HRT OU OD MRA: All ONH sectors abnormal (p<0.1%) except temp. OD Large cup with significant asymmetry OD>OS though asymmetric ONHs OS MRA: Borderline (p<5%) both inf nasal sectors Imaging Issues Is imaging necessary for the diagnosis in this case? No What is the value of imaging in this case? Assists your clinical eval in structural assessment For tracking for progression Could a patient have glaucoma yet have normal imaging? With spectral domain imaging and ganglion cell imaging it is unlikely but could happen. MT 11/20/2015 CCT/IOP Considerations CCT is high in both eyes. Yet Pascal DCT reads higher than GAT or NCT, particularly in OS? Why does DCT read higher in a thick cornea?! What is the value of adjusted IOP? MT 11/20/2015 Decisions Does MT have glau? What evidence for glau? What evidence against glau dx? If glau what target IOP? Would you initiate treatment on one eye or both? If glau what initial med(s)? Would you consider a combo such as Cosopt, Combigan or Simbrinza? 3

4 MT Diagnostic Considerations Does MT have glau? What evidence for glau? Sup arcuate - both FDT and HFA 24-2 OD Clin ONH eval: shallow inf rim loss OD HRT: Sup and inf rim loss to p<0.1% OD OCT: Sup and inf RNFL loss to p<1% OD All of the above correlate. Always check the ONH/RNFL clinically Structural damage plus correlating VF loss compelling! MT Management Issues If glau what type (POAG vs 2º glaucoma)? Need SLE and gonioscopy to differentiate. If glaucoma what target IOP? Stage the glaucoma then set target IOP For stage consider all findings, particularly the VFs moderate glaucoma by ICD 10 staging What target IOP? For initial 1 st line med try to achieve 25 to 35% reduction MT 11/20/2015 Early POAG OD with VF loss sup Mild NPDR & possible CSME OS Mild NSC & ant cortical changes OU Plan: Initiate topical med OD; f/u in 4 to 6 weeks Med to start? Start OD or OU?? Any topical glau meds contraindicated? F/U in 4 to 6 weeks. Sooner? Macular OCT (92134) OS at f/u exam MT Initiating Glaucoma Meds What first line med? PG unless contraindicated or not allowed by insurance (name brand PG) One eye trial in OD? Treat OD only? Or treat OU? When it first f/u exam? At 4 to 6 weeks SELECTING THE INITIAL GLAUCOMA MEDICATION Target IOP & IOP lowering effect of various options Ease of use Current systemic meds Potential ocular and/or systemic side effects Specific contraindication/considerations Cost of med(s) MT 1/20/ st follow-up on glau med, Trav Z 1 gt OD hs No dryness, little redness not bad, no other problems Compliance reported as only 1 missed drop every couple of weeks due to going to sleep while watching TV & forgetting the med GAT: 13/14 11:10 am 4

5 Management Considerations How did Trav Z lower IOP in OS when it is used for OD only? What does equal IOP, though only OD is treated, suggest? Must consider the possibility of diurnal IOP variation OU (Trav actually did not lower it in OD) or asymmetric IOP variation What is the appropriate management at this point? Continue the Trav Z and follow up again MT 2/27/2016 Still taking Trav Z OD only. Last instillation was bedtime last night, 11:30 pm. No redness, dry eye or other problems. GAT: 13/18 12:15 pm What is management now? WT 7/12/13 Glaucoma suspect? Glaucoma? Something else? 73 y/o Hispanic male, retired Referred as glaucoma suspect by PCP large C/Ds PEHx: Prior OMD followed from 6/2010 to 8/2012 labeled him glau suspect due to large C/Ds but IOPs always <15. Normal HFA 24-2 VF. CCT: OD: 493 OS: /21/2010 Cat extraction with PC IOL OS 7/10/2012 FEHx: Does not know FEHx PMHx: Elevated cholesterol Current meds: Lovastatin 40 mg/day Allergies: none WT 7/12/2013 NCT: 12, 10, 15/ 10, 15, 13 1:22 pm SLE: 2+ NSC, 2+ ant cortical OD, PC IOL OS clear, centered with capsulotomy. Angles ¼ OD and 1 OS. ONH: large ONH OU with large shallow C/Ds of about.75 x.75 OU No apparent RNFL defects, no Drance heme. 360º PPA OS, possible pallor OS WT 7/12/2013 WT HFA 24-2 OU 7/12/13 VF: HFA 24-2 OU OD: Questionable reliability- increased fix losses. No VF loss OS: Possible sup paracentral scotoma HRT: See slide RTVue OCT: see slide Gonio after dilation: OD: open to CBB inf with 2+ TM pig, open to TM in all other angles OS: open to CBB in all angles with 2+ TM pig 5

6 WT HRT OU Report Color WT RTVue OCT WT 7/12/2013 Management 2+ NSC, 2+ ACC OD BCVA: 20/30 Glau suspect based on large C/Ds, very suspicious HRT & RTVue. But low IOPs and good VFs Management: Get records from OMD who saw him 2010 to 2012 progression? Re-evaluate IOPs in 3 months Re-evaluate VFs, imaging in 6 months WT 10/10/2013 GAT: 13 / 11 10:29 am SLE: unchanged ONH: no apparent change ; no Drance heme Old records show diagnosis of glau suspect based on large C/Ds but no VF loss; no imaging Management Re-evaluate for progression in VFs, ONH, RNFL or GCC in 3 months WT HFA VFs from Prior Eye Doctor WT 1/10/2014 No change in history Pre-dilation NCT: 11, 13, 12/12, 13, 12 10:43 am Post dilation GAT: 11 / 11 11:45 am SLE: unchanged ONH: no apparent change ; no Drance heme VFs: HFA 24-2 OD: Poor foveal threshold but no glau VF loss OS: Poor foveal threshold; possible sup paracentral scotoma 2 point cluster Suspect more VF loss get FDT or Matrix 6

7 WT 1/10/2014 HRT: see slide Baseline scan. Very suspicious but consider possibility of a false positive due to large ONH size. Color WT HFA 24-2 OU 1/10/2014 OS: possible sup paracentral scotoma Cirrus OCT: see slide Baseline scan. Highly suspicious inf arcuate RNFL loss with corresponding inf GCA loss OU Need 3 scans for progression detection on either HRT or OCT WT 1/10/14 HRT OU Report WT RTVue OCT WT 1/10/14 Cirrus OCT ONH & RNFL WT 1/10/14 Cirrus OCT GCA 7

8 WT 1/10/2014 Management WT 1/17/2014 Mild NSC OD Glaucoma suspect OU with very suspicious structural findings (C/D, HRT, RNFL and GCA on Cirrus) but little to no VF loss OS only and normal VF. IOPs < 15 on all exams at UEC. Probable optic atrophy inf ONH OS Management: RTC in 1 week for serial tonometry, reclined IOPs, ONH/RNFL photos, CCT, FDT screening NCT: 13, 13, 13/12, 12, 12 8:13 am Tonpen sitting: 13/10 9:00 am Tonopen reclined: 14/11 9:10 am Pascal DCT: 16/15 9:15 am NCT: 21, 20, 18 / 12,12, 12 12:00 pm NCT: 12, 12, 14 / 10, 11, 12 2:05 pm NCT: 12, 13, 12 / 10, 12, 11 4:15 pm Color WT ONH 50º Color OU WT ONH 50º Red Free OU WT ONH 30º Color OU WT 1/17/2014 Matrix N 30-5 Screening 8

9 WT 1/17/2014 CCT (IOPac): OD: 502 OS: 508 SLE: unchanged ONH: no apparent change ; no Drance heme VFs: Matrix N 30-5 screening VF OD: Sup arcuate with dense nasal step OS: Incomplete sup arcuate with incomplete dense nasal step ONH/RNFL photos see slides WT 1/17/2014 Management OA OS inf ONH old AION? IOPs low teens but in mid-teens OU with Pascal DCT and spiked in OD only at noon No IOP change when reclined Deep sup nasal step OU on Matrix VFs Plan: Rule out systemic causes of OA OS - Westegren ESR, CRP, VDRL, FTA ABS, ANA, CT Initiate Trav Z OU hs and RTC in 1 month Might cat extraction be an option for WT OD? IOP Lowering with Phaco Generally accepted that phaco lowers IOP Greater IOP-lowering for higher pre-surgical IOPs and possibly greater for narrower presurgical angles Duration of IOP-lowering is not well defined OHTS showed a very slow IOP increase postop, about 0.05 mmhg/month Large study on normal and oc hypertensives showed no significant change over 4.5 years post-op Mansberger SL et al. OHTS Group. Ophthalmology 119: , 2012 Poley BJ, Lindstrom RL et al. J Cataract Refract Surg 34: , IOP-LOWERING EFFECT OF PHACO Two factors: Initial IOP effect, Duration Initial IOP-lowering was proportional to pre-op IOP greater at higher IOPs Poley BJ, Lindstrom RL et al. J Cataract Refract Surg 34: , IOP-lowering appears to last well out to at least 3 years post-op; much longer in Poley s study Mansberger SL et al. OHTS Group. Ophthalmology 119: , 2012 WT KEY POINTS RNFL loss & VF loss are not specific to glaucoma; ONH changes are Always consider the possibility of a nonglaucomatous cause Evaluate the ONH rim tissue for pallor to find and differentiate non-glaucomatous from glaucomatous Try to correlate ONH changes to the RNFL loss &/or VF loss LR 5/15/13 IOPs Gone Wild!!! 56 y/o Hf, realtor ECC patient since 9/2003 PEHx: On glau meds since 8/1984; Pilo then T1/2 Started on Travatan OU in 2001; switched to Lumigan 0.3% in mid 2012 FEHx: Strong FHx of glaucoma on father s side: paternal grandfather, father, aunt (father s sister) & others PMHx: Asthma rather severe in childhood Current meds: 0.1% Alphagan P OU q12h x 9 days (switched from Lumigan) Allergies: sulfa meds, erythromycin 9

10 LR 5/15/13 Recent glaucoma meds as of 5/2013: Lumigan 0.3% - fair IOP control (low 20s) but not available in US as of 1/1/2013 so d/ced in 12/2012 Lumigan 0.1% - d/ced 4/1/2013 due to inadequate IOP control (low to mid 20s) Travatan Z d/ced 5/6/2013 due to inadequate IOP control (mid 20s) Alphagan 1 gt OU q12h started 5/6/2013 LR 5/15/13, continued Complains of prolonged (1+ hour) blur after instillation of Alphagan both morning and night (q12h schedule). NCT: 26, 26, 28 / 28, 28, 28 at 2:47 PM Last Alphagan at 7:30 am (7+ hours ago) LR 5/15/2013 Questions Based on the history what meds are contraindicated? Which prostaglandins (PG) have we not yet used and are they worth a try? If we are trying to maintain a one med/one drop/day schedule what are the options? Which med class(es) have we not yet tried and are they worth a try? SWITCHING FROM ONE PG TO ANOTHER PG? Can it work? Yes, sometimes Why? Individual variations in PG receptors Most common switch is Xalatan or Travatan to Lumigan Would adding a PG to a PG work? No, IOP may rise, probably will not fall. PGs should be used once/day. C/Ds: OD:.4 rd LR - Other Info OS:.4 rd No clinically apparent RNFL loss Pachymetry: Reichert IOPac OD: 539 µ OS: 541 µ Pascal DCT tonometry on 5/6/13: OD: 24.5 mmhg, OPA 1.8, Q=3 OS: 22.5 mmhg, OPA 1.8, Q=3 (GAT: 24/24 on 5/6/13) Gonio: CBB, 1+ TM pig, flat angle approach in all quadrants BP: 118/84, pulse 70 LR HFA GPA OU GPA 4/2004 to 4/2013 Normal 24-2 OU 10

11 LR HRT OU Report LR 4/1/13 RTVue GCC scan Symmetry Printout OD: Normal RNFL. Inf GCC loss OS: Normal RNFL. Sup GCC loss. Note respect of GCC loss for temp raphe LR 4/1/13 RTVue GCC Change Printout OD LR 4/1/13 RTVue GCC Change Printout OS LR Summary to 5/15/2013 IOPs variable and not well controlled recently on multiple PGs and Alphagan as monotherapy Pascal = GAT IOPs VF very stable OU OD: HRT change sup & inf with inf GCC loss on OCT OS: HRT repeatable x3 sup progression with corresponding sup GCC loss on OCT showing possible progression LR Management Options Change to q8h schedule of Alphagan Note that last IOPs on Alphagan were at 7 hours after instillation Switch to an alternative PG Substitute a combo med for Alphagan Re-initiate Lumigan or Travatan and add a med to it. What add-on med? SLT Cat extraction- phaco but no cataracts MIG but no cataracts More invasive options but much more risk Trabeculectomy or valve/stent Ahmed valve etc 11

12 COMBO MEDS Fixed combination meds Cosopt (2% dorzolamide + 0.5% timolol) Combigan (0.2% brimonidine + 0.5% timolol) Simbrinza (0.2% brimonidine + 2% brinzolamide) COMBO MEDS Potential advantages Less drop adminstrations/day better compliance? Two meds/one bottle Less bottles to buy lower cost? One co-pay instead of two. Less bottles to keep track of Less exposure to preservatives COMBO MEDS Fixed combination meds containing a beta blocker Cosopt (2% dorzolamide + 0.5% timolol) Combigan (0.2% brimonidine + 0.5% timolol) CAUTIONS WITH COMBOS Assure that both of the two components are effective, only then Rx the combo Do not assume that each component works Watch the dosage frequency carefully Rx no more often than the component with the lowest dosage frequency Cosopt: Timolol can be used BID and Trusopt can be used TID but Rx Cosopt for no more often than BID Combigan: No more often than BID due to the timolol. Simbrinza: FDA- approved for TID LR Pt Ed 5/15/2013 Patient desires to stay on a one med qd schedule Note med hx sulfa allergies and asthma Advised SLT + 1or 2 meds is best option however pt wishes to avoid the cost of laser Advised that 2 meds is possible option but our best monotherapy meds (PGs) have not controlled IOPs well will likely need more invasive option, SLT LR 6/5/2013 Burning/stinging with Rescula has lessened but worse than any other med she has used NCT: 24, 23, 25/ 25, 24, 26 2:10 pm Last Rescula at 7:30 am IOP control is not improved; stinging and burning not subsiding. Need to switch meds. Management: Sustitute dorzolamide 1 gt q12h x 3 days then q8h with lid closure/punctal occlusion try to minimize metallic taste. D/C if any allergic side effects in eye or rash. 12

13 LR 7/9/2013 Retinal consult for atrophic holes Has had HA on & off feels that it is like the HA she used to get with high IOPs many years ago NCT: 33, 31, 33/ 34, 34, 35 1:21 pm Last dorzolamide at about 7:30 am today No treatment necessary for ret holes Need IOPs down; see Dr. Comer soon and consider SLT to control IOPs How to Minimize Systemic Absorption & Systemic Side Effects Punctal occlusion Hold eyes closed for at least 3 minutes after instillation, longer is better Instill at bed time prolonged closed eye condition! LR 8/2/2013 Follow-up for glaucoma; was out of country on vacation for last 2 weeks Much more HAs than she was having at retinal consult feels that it is like the HA I used to get with high IOPs many years ago, in 1980s NCT: 41, 42, 40/ 51, 50, 45 10:57 am Last dorzolamide at about 7:00 am SLE: corneal clear, no KPs, no cell in AC Gonio: Open to CBB 360 OU, 1+ TM pig View of fundus clear, no Drance hemes or change apparent BIG IOPs! NOW WHAT? Given the prior findings including gonio what is the most likely cause of these high IOPs? What other condition should be ruled out? Hint: younger patients typically with intermittent high IOPs and often NO symptoms at all!? What is the management of these big IOPs? If you use topicals what can you do to speed and enhance the absorption of the drops? STRATEGY FOR SIGNIFICANTLY ELEVATED IOPs Determine the cause: Rule out angle closure gonio Rule out iritis and trabeculitis (HZV) Rule out steroid response Rule out secondary glaucomas such as pigmentary and pseudoexfoliation Consider wildly variable IOPs in POAG very common! STRATEGY FOR SIGNIFICANTLY ELEVATED IOPs Slit lamp for secondary glau and inflammatory signs Gonioscopy view all angles carefully Tonometry with GAT touch the cornea! 1 gt Alphagan followed by prolonged lid closure do not blink. Repeat in 15 to 20 minutes 1 gt timolol, prolonged lid closure Check IOPs at 1 hour. Re-instill Alphagan. 13

14 Other Considerations Steroids - if significant cell in AC. This can happen in angle closure. Oral agents (Diamox) if very high IOP to speed IOP reduction Pilo if angle closure & IOPs are <50 mmhg LR 8/2/2013 Acute IOP Control Alphagan 1 gt OU at 11:15, 11:30, 11:45 Timolol 1 gt OU at 12:30 Advised to RTC in 1-1/2 hours (after lunch) to recheck IOPs GAT: 24/ 26 2:00 pm Pt reports that HA is much better though not completely gone. Vision is blurry though clear cornea and media; pt feels that Alphagan causing the blur. LR 8/2/2013 Management Advised that SLT + med is best option; cannot keep IOPs down with any single med; may not be possible with 2 meds Pt wants to try 2 meds before going to SLT Initiated Lumigan 1 gt OU hs + Timolol 1gt qam Advised of significant potential for exacerbation of childhood asthma d/c immediately if any shortness of breath, wheezing, congestion in chest etc Advised that prolonged lid closure/punctal HOW OFTEN ARE ADD-ON MEDS REQUIRED? OHTS ~ 45% required two or more meds CIGTS ~ 75% required two or more meds Lichter PR. Ophthalmology, 108, , Kass MA and OHTS Study Group. Arch Ophthalmol 128(3):701-13, occlusion is necessary RTC in 1 week ADD-ON MEDS OPTIONS When 1 st line med was a PG Beta blockers Alphagan (brimondine) Alphagan P 0.1% or Alphagan P 0.15% Brimonidine 0.2% Topical CAIs Trusopt (dorzolamide) Azopt (brinzolamide) Rescula WHAT IS THE BEST ADD-ON MED (ADDED to PROSTAGLANDIN)? Most common add-on is beta blocker Best is probably topical CAI Why? Almost equal IOP-lowering to beta blockers & alpha-2 agonist at peak, trough and in between Better night time IOP lowering than either beta blockers or alpha-2 agonists Side effects not significant e.g. taste disturbance Tanna AP et al. Arch Ophthalmol 128:825-33, 2010 Liu JH et al. Ophthalmology July 20, 2010 epub ahead of print Liu JH et al. Ophthalmology 116:449-54,

15 LR 8/16/2013 No HAs at all; no shortness of breath or other respiratory symptoms suggestive of beta blocker side effect Reports 100% compliance & holds lids closed for at least 5 minutes NCT: 20,22,24/19,19,23 11:01 am No change in ant segment or ONH/RNFL Advised that IOPs are lower but still not <20, the target IOP. Will likely need laser; 2 meds probably not adequate Discussed potential side effects RTC in if any HAs or in 3 mos to monitor LR 12/13/2013 No HAs though mild HA today, thinks it might be sinus; did not take a decongestant to avoid any effect on glau f/u exam No shortness of breath or other respiratory symptoms no apparent beta blocker side effect Reports strict compliance & holds eyes closed at least 5 minutes NCT: 19, 20, 20/ 18,19,18 11:05 am No apparent change in ant segment or ONH/RNFL - no Drance heme, no RNFL defect LR IOPs 5/2010 to 12/2013 LR 12/13/2013 HFA 24-2: No VF loss and no progression on GPA VFI trend is flat with no progressing points HRT: see slides RTVue: see slides Management: Advised that IOPs are a little higher than desirable; strict compliance is necessary Continue Lumigan hs + Timolol qam Call if any HAs at all; IOPs can be highly variable in glaucoma LR HRT OU Report LR HRT TCA OD 15

16 LR HRT TCA OS LR 12/13/13 RTVue GCC Symmetry Printout Repeatable in inner wall of sup cup OS probable earliest sign of progression LR 12/13/13 RTVue GCC Change Printout OD LR 12/13/13 RTVue GCC Change Printout OS LR 12/13/2013 Management Advised that IOPs are a little higher than desirable; strict compliance is necessary IOPs can be highly variable in glaucoma so in long run we must assure that there is no further damage since we don t know the IOPs at all times Call if any HAs at all; it MAY mean IOP spiking variable IOPs alone may damage the ONH Continue Lumigan hs + Timolol qam but strongly recommend SLT Need every 3 month f/u LR What did we learn? Previously well-controlled IOPs can go off! We really don t know what is going on with a patient s IOPs the vast majority of the time! Be prepared for wild IOP spikes very common in glaucoma. The more IOPs you have the better. Be prepared to manage those wild IOP spikes Be prepared for pts progressing but you have not found high IOP (in the office) We really need home IOPs or better yet, around-the-clock IOP monitoring 16

17 IOP Disaster Kit GAT and gonio Alphagan or brimonidine very rapid Timolol or another topical beta blocker (Istalol etc) Pilo 1 or 2% Pred Forte (or prednisolone actetate) Diamox 250 mg tablets Hypertonic saline to clear edematous cornea LR /16/2014: Still on Lumigan pm, Timolol1/4 in am. No breathing problems, HAs or other side effects. GAT: 21/21 11:25 am DCT: 24.8/24 12:30 pm HRT: Probable progression in sup rim OD; likely progression in sup rim OS Advised SLT; pt prefers to defer it until late the year if possible. F/U in 4 months. 9/10/2014: No problems. No HAs. GAT: 24/25 11:28 am No apparent clinical change. Scheduled OS for SLT for 12/2014 LR 12/2/2014 SLT SLT Issues No breathing problems, HAs or other SEs Same meds: Lumigan hs OU; Timolol ¼ qam OU GAT: 23/23 11:17 am SLT performed: 103 spots at 0.8 mj over entire 360 of TM OS F/U in 1 week; continue with current meds Should the glaucoma meds be changed prior to the SLT? What IOP-lowering effect would we typically get from SLT? How quickly does the IOP respond to the SLT? What is the strategy in the case that the IOP does not significantly respond to the SLT? LR 2015 Uneventful post-op course However, IOPs did not significantly respond to the 12/2014 SLT OS 4/8/2015: No side effects or HAs Same meds: Lumigan OU hs; Timolol ¼ OU qam GAT: 21/23 11:30 A: Inadequate response to SLT OS Progressing glau OS on HRT, clin exam Consider repeat SLT with higher power or consider Pilo 1%. Pt opted to try Pilo OU tid LR 5/13/2015 Blurred distance vision OU right after each instillation of Pilo The mid-day instillation caused more blur problems so recently went from tid to bid In last week has noticed increasing asthmalike symptoms GAT: 21/21 12:15 pm Last Pilo at 7:15 am A: Pulmonary side effect d/c pilo Little, if any, IOP lowering at 5 hours after instillation of Pilo D/C pilo; continue other meds 17

18 LR 8/12/2015 No side effects since d/c Pilo. No HAs Same meds: Lumigan OU hs, Timolol ¼ OU qam GAT: 27/29 11:20 am HRT: further progression likely OS sup rim RTVue suggests RNFL & GCC progression OS not OD Clin exam suggests probable sup rim loss OU A: IOPs not adequately controlled What should be done to lower IOPs? LR 10/20/2015 SLT No breathing problems, HAs or other SEs Same meds: Lumigan hs OU; Timolol ¼ qam OU NCT: 23, 24, 25/24, 21, 23 11:30 am SLT performed: 105 spots at 1.1 mj over entire 360 of TM OS F/U in 1 week; continue with current meds LR IOPS since 10/20/2015 SLT OS LR IOPs 5/2010 to 1/ /28/2015: GAT 22/22 11:24 am 12/17/2015: NCT: 23, 23, 25/20, 21, 21 4:30 GAT: 25/22 4:30 pm 1/27/2016: NCT: 24, 24/ 25, 25 11:25 am GAT: 25/25 11:30 am LR Management Options Now Change to q8h schedule of Alphagan Switch to an alternative PG Substitute a combo med for Alphagan Re-initiate Lumigan or Travatan and add a med to it. What add-on med? SLT Hang on and wait for the new glau meds: ROCK inhibitors, Trabdenoson etc Cat extraction- phaco but no cataracts MIG but no cataracts More invasive options but much more risk Trabeculectomy or valve/stent Ahmed valve etc Keratoconus, unrepairable total RD OD & now glaucoma in OS, the one good eye?? 18

19 6/3/ y/o wm PEHx: Long term RGP wearer for keratoconus; followed by our CL Service since 5/2006. RD OD, 3 unsuccessful attempts at repair; OD is LP with no light projection FEHx: Negative PMHx: HBP, hypercholesterolemia, psoriasis, occasional kidney stones 6/3/2008 Flashes of light in OS started this morning upon arising. Very concerned due to prior RD in OD with bad outcome. Followed by retinal specialist but could not get appointment there today. VAs: OD: LP without projection all quadrants OS: 20/25+ with RGP GAT: 4/12 4:50 pm 6/3/2008 GAT: 4/12 4:50 pm HFA C 40 VF screening: No misses OS DFE: OD: Dislocated PC IOL, nearly total RD OS: PVD without ret breaks, C/D:.3 x.3 6/3/2008 Acute symptomatic incomplete PVD without ret breaks or RD OS Old RD in OD with poor outcome on multiple repair attempts Keratoconus OU Plan: Re-evaluate with DFE in 1 month or sooner if symptoms increase Continue f/us with ret specialist; recommend protective (PCB or Trivex) spectacles over CLs Schedule CL f/u 2/7/2011 CL f/u, 1 st since 2008; last saw ret spec 6 mos ago VAs: OD: LP without projection OS: 20/25+ with RGP CL GAT: 14/20 5:55 pm Undilated ophthalmoscopy: OD: No view, no red reflex OS: Fleeting views of ONH, C/D: ~.6 x.6, larger than records show.3 x.3 in 2008!! Confrontation fields: OS normal Recommend dilated exam 2/14/2011 DFE visit NCT: 4,5,6 / 8,7,8 2:15 pm GAT: 6/10 2:20 pm HFA C 40 VF screening: Single isolated miss inf nasal OS DFE: OD: No view, no red reflex, much pig in vit OS: Small ONH, C/D:.6 x.6 Recommended glau eval due to apparent cup change (recorded not photos) from 2008 to 2011, variable IOPs OS, monocular status 19

20 OS HFA C40 screening Is a single isolated miss on the edge of the VF significant? Not likely Single isolated miss 2/18/2011 Glau eval visit NCT: 6,5,6 / 9,8,8 10:35 am GAT: 7/9 11:30 am HFA 24-2: Inf paracentral scotoma (5 point cluster at p<0.5%) Gonio: Open to CBB, minimal TM pig, no signs of 2º glau HRT: Good quality, all sectors normal RTVue OCT: Sup RNFL loss, GCC shows substantial sup and inf GCC loss DFE: OD: unchanged OS: Small ONH, C/D:.7v x.6h sup notch OS HRT Small ONH common cause of false negative on HRT and on clinical ONH evaluation! MRA shows normal in all ONH sectors except nasal. OS RTVue OCT Sup RNFL loss to p<1% Sup and inf GCC loss that respects the temporal horizontal raphe GCC loss respects temp raphe OS HFA First threshold VF. Good reliability. Inf paracentral scotoma 2/18/2011 Glau eval visit Probable early POAG based on clin ONH eval, VF possible progression over past 3 years (relative to 2008 C40 screening), RTVue RNFL and GCC results. IOPs appear very low reassess IOPs Management: Delay treatment until IOPs & CCTs are further evaluated; get CCT, Pascal DCT, reclined IOP, diurnal IOP 20

21 Key Points Don t over-emphasize the importance of IOPs in glau diagnosis Small ONHs get small cups! Very difficult to detect glau damage in small ONHs Change in cupping is a great way to detect glaucoma but difficult without photos or imaging Use RNFL/GCC imaging for small ONHs but watch out for ONH hypoplasia which will also show RNFL & GCC defects Look at the pattern of GCC thinning; typically respects the temp horizontal raphe in early to moderate glaucoma. 3/4/2011 CCT, IOP eval visit CCT: OS: 420µ average of 8 on IOPac NCT: OS: 5,7,8 10:20 am GAT: OS: 9,7 Tonopen: OS: 9.8 sitting; 10.3 reclined after 15 minutes Pascal DCT: OS: 21.7, 20.9 Q:1 OPA: 2.4 Undilated ONH evaluation: unchanged, no Drance hemes Marshall B 133 3/4/2011 Issues to consider With CCT of 420µ what effect on IOPs mearsured with applanation tonometers is likely? Can adjusted IOPs help correct for this IOP error that is presumably due to CCT? What adjustment algorithm is most appropriate? With 1 functional eye, early VF loss and moderate ONH, RNFL and GCC damage what is the appropriate target IOP? Is initiation of a single med appropriate? What initial med(s)? What follow-up? 3/4/2011 Management Caution with applanation IOPs - may be significantly false low Initiate Trav Z 1 gt OS Plan: Glau pt ed: no symptoms, VF loss has occurred though he cannot tell, VF loss cannot be reversed, must prevent further loss, need to keep IOPs down with glau med every night, try not to miss drops F/U in 4 to 6 weeks with appt around 10:30 to 11:00 am 4/27/ st F/U on Trav Z Reports missing 1 drop each week, fell asleep. No problems with drops (redness, dryness etc) other than remembering it GAT: OS: 9 11:35 am Tonopen: OS: 7.8 Pascal DCT: OS: 15.4 Q:1 OPA: 2.1 Undilated ONH evaluation: unchanged, no Drance hemes IOP down on DCT, not on GAT probably good IOP reduction Management: Continue Trav Z; f/u in 3 mos 3/7/ nd F/U Trav Z Reports misses 1 drop about every 2 to 3 weeks. No problems with drops other than cost. High co-pay through HMO NCT: OS: 8,6,7 11:45 am GAT: OS: 10 Pascal DCT: OS: 14.3 Q:3 OPA: 2.0 Dilated ONH evaluation: No apparent change HFA: Denser, larger inf nasal step possible progression?? HRT: See images RTVue OCT: See images 21

22 OS HFA /7/2012 OS HRT 3/7/2012 3/7/2012 Management Acceptable IOP reduction on DCT However, possible progression in VF loss Management: Change to latanoprost generic and reevaluate IOPs in 1 month to assure IOP control Get Reichert ORA reading (ORA on loan at that time) to double check Pascal DCT IOPs Encourage strict compliance to med schedule 4/20/2012 IOP F/U Missed maybe 2 or 3 drops since last visit. Latanoprost much cheaper but a little more stinging on instillation; eye dry sometimes since latanoprost started. GAT: OS: 11 11:00 am Pascal DCT: OS: 12.1 Q:2 Reichert ORA: 14.0 CH: 2.8 very low Undilated ONH evaluation: No apparent change HFA 24-2: Similar to 3/12/2012 denser larger VF defect in inf nasal VF progression? 4/20/2012 Issues to consider Why might latanoprost have a greater dry eye symptoms than Trav Z? Should latanoprost have a similar IOPlowering effect to Trav Z? Is there any benefit of getting readings from the Reichert ORA? What is the value, if any, of corneal hysteresis (CH) readings from the ORA? Given the low CH reading, one-eye status, possible VF progression & not great compliance should therapy be advanced? 4/20/2012 IOP F/U Management considerations For further IOP control what is the best option? Why might SLT be a advisable in this case? If pt wishes to avoid SLT what is the best add-on med in this case? What is the typical effect of an additional med on compliance? Combo med? We need a PG combo in the US!!! 22

23 4/20/2012 IOP F/U Questionably acceptable IOP reduction on DCT, ORA with latanoprost generic Very low CH on ORA suggests increased likelihood of progression Management: Again encouraged strict compliance. Advised SLT (in HMO) as best add-on to latanoprost wants to avoid more eye surgery. Give sample: Azopt 1 gt OS q12h (upon awakening in am and after dinner) Use tear supplement for dry eye but not within 15 minutes of latanoprost or Azopt instillation F/U in 1 month to assess Azopt effect on IOP 6/27/2012 IOP F/U Missed some drops of Azopt after dinner since, harder to remember it than at bedtime & on awakening. No other problems with Azopt but it real slow coming out of the bottle. GAT: OS: 9 12:30 pm Pascal DCT: OS: 17 Q:2 Reichert ORA: 12.0 CH: 3.6 very low Undilated ONH evaluation: No apparent change 6/27/2012 IOP F/U 11/18/2012 Glau F/U Disparity between DCT and ORA reason is unclear Compliance to Azopt fair, likely not as good as reported; IOP control questionable Management Recommend SLT; explain advantages & emphasize that it is laser treatment, not surgical Write script for dorzolamide 1 gt OS q12h Reassess IOP control in 3 months Reports same problem with forgetting the night instillation of dorzolamide sometimes. GAT: OS: 15 1:17 pm Pascal DCT: OS: 20.8 Q:3 OPA: 3.3 1:25 pm Last latanoprost about 11:30 last night; last dorzolamide at 7:00 am this morning Dilated ONH evaluation: No apparent change HFA: possible progression?? HRT TCA: possible progression in inner wall of sup rim OS HFA /18/2012 OS HFA GPA 11/18/2012 VFI trend is flat Point by point analysis identifies 2 points progressed from baseline x 2 VFs 23

24 OS HRT TCA 11/18/ /18/2012 IOP F/U IOP is up on both DCT and GAT unstable IOP control. Compliance to recommended f/us not good, to meds probably fair. Possible progression on HRT (sup rim) and VF inf arcuate OS Management: Again encouraged strict compliance. Advised that IOPs are up and possible progression on VFs Advised SLT as better around-the-clock IOP control; in HMO? Should consult the glau specialist in HMO for possible SLT. Will send all records to HMO. F/U in 1 month to re-assess IOP 3/10/2013 Glau F/U Reports that glau specialist in HMO said he is overtreated. He got IOP of 9 with blue light instrument (GAT). Did an HFA VF but did not act like he had seen the records we sent. Reports missing a couple of dorzolamide drops (night time) every week. GAT: OS: 7 1:07 pm Pascal DCT: OS: 13.6 Q:3 OPA: 4.8 Undilated ONH evaluation: Questionable progression in sup rim OS 3/10/2013 Glau F/U Unstable IOP control. Compliance questionable. Probable progression on clinical exam, on HRT (sup rim) and VF inf arcuate OS Management: Again encouraged strict compliance; advised that our tests for progression show probable progression. Advised that IOPs are OK today but are very dynamic. Advised that it is best to keep the IOPs down at all times. SLT again advised to help achieve this; alternatively 3 rd med as a combo. F/U in 3 months to re-assess IOP, stability & determine whether to advance therapy 6/14/2013 Glau F/U Reports missing a couple of dorzolamide drops (night time) every week. GAT: OS: 7, 8 1:30 pm Pascal DCT: out for repair Undilated ONH evaluation: Probable progression in sup rim OS HRT: repeatable x3 progression in sup rim HFA: VFI trend flat; progression at 2 points x 3 VFs OS HRT 6/14/2013 Repeatable progression in the sup temp rim 24

25 OS HRT TCA 6/14/2013 OS HFA GPA 6/14/13 Repeatable x 3 progression in the sup temp rim correlating to the inf paracentral scotoma VFI trend is flat but the point-topoint comparison (event analysis) suggests likely progression at 2 points over 3 consecutive VFs in the inf arcuate region of VF 6/19/2013 Glau F/U GAT pressure is down but IOPs likely unstable Likely progression on clinical exam, on HRT (sup rim) and VF inf arcuate OS Management: Advised that progression has likely occurred; need to try to lower & stabilize the IOPs more Pt wants to avoid laser (SLT) if possible even if he must take more meds Substitute Simbrinza (gave samples) for dorzolamide, same dose, but q6h dose schedule F/U in 2 months to re-assess IOP, stability 2/5/2014 Glau F/U Reports no problems with Simbrinza though cost is higher than any other drop he has tried. Same pattern on compliance: reports missing a couple of Simbrinza drops (night time) every week. GAT: OS: 6, 8 12:30 pm Pascal DCT: 12.6 Q: 3 OPA: 3.5 Undilated ONH evaluation: Probable progression in sup rim OS HRT TCA: repeatable progression in sup rim HFA GPA: no progression in inf arcuate; flat VFI trend OS HFA GPA 6/14/2013 OS HFA GPA 2/5/2014 VFI trend is flat but the point-topoint comparison (event analysis) suggests likely progression at 2 points over 3 consective VFs in the inf arcuate region of VF What happened to the progression in the inf arcuate region that was present on the 6/14/13 VF?? Somehow the baseline VFs were deleted so that this VF is not being compared to the true baseline VFs!!! 25

26 OS HRT TCA 2/5/2014 Same blotchy areas of progression in sup temp rim (inner wall of cup) as noted in past (repeatable progression) 2/5/2014 OS Cirrus ONH/RNFL Sup arcuate RNFL loss to p<1% due to glaucoma. Mild (p<5%) inf arcuate loss as well 2/5/2014 OS Cirrus GCC Moderate GCA loss note that most loss is sup and mostly respects the temporal horizontal raphe. 2/5/2014 OS GPA Page 1 See the Trend Analysis for Ave RNFL and Inf RNFL Thickness. Inf RNFL Thickness is statistically thinner on last 3 scans than on the baseline. The more scans and the tighter (less variable) the data the better the ability to detect small changes in RNFL. 2/5/2014 OS Cirrus GPA Page 2 The data behind the trend lines. Note the inf quadrant RNFL thickness on the last 3 visits. The more scans the better the ability to detect small changes. Likely progression in inf RNFL 2/5/2014 Glau F/U GAT & DCT IOPS are down. Better control with Simbrinza?? Likely progression on clinical exam, on HRT (sup rim) and VF inf arcuate OS Management: Advised that progression has likely occurred; need to try to lower & stabilize the IOPs more Pt wants to avoid laser (SLT) if possible Continue Latanoprost qhs, Simbrinza q6h F/U in 3 months to re-assess IOP, stability of VFs, HRT, clinical ONH eval 26