How Strongly Do You Feel That This Patient Has Glaucoma? % % % % %

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1 My Favorite Cases Anthony B. Litwak, OD, FAAO VA Medical Center Baltimore, Maryland Dr. Litwak is a speaker and on advisory boards for Alcon and Zeiss Meditek CASE CR 35 yohf Neg PMH +FOH mother and grandmother with glaucoma VA 20/20 OD, 20/20 OS SL unremarkable TA OD, OS CCT 554/561 Gonio: 4+ open OU, s PAS or angle recess How Strongly Do You Feel That This Patient Has Glaucoma? % % % % % How Strongly Do You Feel This Patient is at Risk for Becoming Visually Impaired from Glaucoma? 1. No risk 2. Very little risk 3. Low risk 4. Moderate risk 5. High risk Should we treat or observe? 1. Does the patient have nerve damage? If yes then in most cases TREAT If no, then access risk factors to determine the benefits of treatment vs observation Level of IOP CCT Age FOH Race POAG Endpoints by Central Corneal Thickness and Baseline IOP (mmhg) in Observation Group* Decided to treat Based on elevated IOP Strong family history Hispanic race Young age

2 Follow up Pt started on timolol.5% bid ou IOP range OD OS What should you do? How Strongly Now Do You Feel This Patient is at Risk for Becoming Visually Impaired from Glaucoma? 1. No risk 2. Very little risk 3. Low risk 4. Moderate risk 5. High risk Glaucoma as the Disease Progresses Visual Field changes occur late in the disease What should you do now? Reset TP < 15 OU Added travatan qhs ou Changed timolol to cosopt bid ou IOP 12, 15, 17 OD 13, 14, 17 OS What should we do? Add Alphagan? ALT/SLT? Would you filter? 30-2 vs 10-2 Testing Points CASE RR 65 yobm transferring care to VA c/o reduced VA in OS Glaucoma suspect, OU on med IOP s meds: OD 16-22, OS CCT: 570/560 CD ratio.3/.3 Started Latanoprost QHS OU, set tentative TP < 18 OU (4/2013) Past Medical History Closed fracture of clavicle Panic disorder Male erectile disorder h/o Nasopharyngeal Carcinoma VA & current specs BVA cc OD 20/25 OS 20/40-2 MR OD x113 OS x85 ADD +2.50

3 Neuro-ocular exam EOM: full and smooth, OU CVF: FTFC, OU PERRL ( )APD, OU Amsler Grid Test OD cl OS Pt reports fog superior temporal to fixation Slip Lamp Cornea: cl OU Conjunctiva: white and quiet OU AC: D + Q OU Iris: No NVI OU Tonometry IOP OD 18 OS 18 Time 1:30pm Gonioscopy : 3+ open OU with 1+ pigment in TM OU DFE VF Review (5/2013) Did you expect to see this? Diagnosis? Plan? Oct: ONH (6/2013) OCT: onh, GCC (6/2013) Oct: Macula od (6/2013) Oct: macula OS (6/2013) Diagnosis? Is this glaucoma? Is this a retina problem? Is this a neurological problem? Is this a pituitary tumor? Is this something else? Case RB 76 yobm +PMH HTN, DM, s/p R CVA -POH VA 20/20 OU EOM full PERRLA APD CF left superior quad SL unremarkable OU TA 24 OD 22 OS Does this patient have glaucoma?

4 69 yowm PMH HTN, Arthritis Ocular Problem List: 1. h/o Allergic Conjunctivitis OU - Prior history of severe allergies and eczema; 2. h/o Chronic Recurrent Anterior Uveitis OD>OS - Lab test Review : (-) Lyme, TB, RPR, ACE (+), ANA, elevated ESR (arthritis) - AC deep and quiet OU 02/05/15 - (+)photophobia; longstanding 3. Dry Eye Syndrome OU 4. Pseudophakia OU 3/2015 Cc: bilateral blurred vision and pain and redness in both eyes x 3 days VA 20/60 OD 20/200 OS EOM full CF FTFC PERRLA APD SL Conj 2+ hyperemia OU Cornea cl OU AC 2+ cell/flare OU Iris No NVI OU TA 14/ Diagnosis Management Treatment CME Topical NSAID Treatment Uveitis Cycloplegia Topical Steroids 65 yowm Problem List: 1) Stage 4 macular hole OD - s/p unsuccessful repair (PPV, FGE, ILM peel, 10% C3F8 OD (9/10)) 2) Stage 1b macular hole OS VA 6ft OD 20/30 OS Management??? Patient s vision dropped from 20/30 to 20/60 in left eye over last 6 months

5 Treatment options??? Patient s vision dropped from 20/30 to 20/60 in left eye over last 6 months Patient given option Jetra injection. Performed 6/11/14 1 week f/u Pt reports improvement of vision in left eye VA 20/40 OS VA 20/30 OS JETREA (ocriplasmin) Intravitreal Injection, 2.5 mg/ml, is a proteolytic enzyme indicated for the treatment of symptomatic vitreomacular adhesion. VMA resolution occurred in 26.5% of Jetrea patients vs 10.1% in vehicle injection patients A decrease of 3 lines of best-corrected visual acuity (BCVA) was experienced by 5.6% of patients treated with JETREA and 3.2% of patients treated with vehicle in the controlled trials. Intraocular inflammation occurred in 7.1% of patients injected with JETREA vs 3.7% of patients injected with vehicle