Glaucoma Pearls and Grand Rounds Vision Expo East 2016

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1 Glaucoma Pearls and Grand Rounds Vision Expo East 2016 Murray Fingeret, Ben Gaddie, Richard Madonna Disclosures Murray Fingeret - Consultant Alcon, Allergan, Bausch & Lomb, Carl Zeiss Meditec, Dyopsys, Heidelberg Engineering, Reichert, Topcon Ben Gaddie Consultant: Glaukos, Allergan, Alcon, Bausch and Lomb, Zeiss, Marco, Sucampo Richard Madonna Consultant Alcon, Allergan, Carl Zeiss Meditec Agenda Ben Gaddie Is it Glaucoma or Glaucoma Suspect? Murray Fingeret Artifact in OCT Testing Richard Madonna The Glaucoma Treatment Algorithm Is It Glaucoma? Glaucoma Suspect to Glaucoma Patient Ben Gaddie, Co-Chairman, Vision Expos Gaddie Eye Centers Louisville, KY ibgaddie@me.com Disclosures Consultant: Glaukos, Allergan, Alcon, Bausch and Lomb, Zeiss, Marco, Sucampo Advisory Board: Allergan, Alcon, Bausch, Optovue, Zeiss, NicOx Employment: None Why Aren t More s Managing or at Least Diagnosing Glaucoma? 1. Lack of confidence in diagnosis 2. Lack of confidence in treatment 3. Lack of current glaucoma diagnostic devices 4. Concerns over malpractice 5. Lack of glaucoma authority in some states 6. Not sure whether they have it or not*** 1

2 Why Do We Work Up Patients For Glaucoma? Ocular Hypertension Suspicious Discs CCT and OHTS Among those who developed POAG Mean CCT was microns Among those who didn t. Mean CCT was microns Risk of developing POAG is inversely correlated with CCT Those pts with CCT < 555 microns 3 X greater risk Blacks in this study had average 23.5 mic thinner OHTS Calculators Why CCT-based IOP correction is flawed Ocular Response Analyzer (ORA) Corneal Resistance to bending is not dependant thickness, but on material properties Normal CH values Summary of published results Authors Ave CH Kirwan, O Keefe (Ireland) 10.8 ± 1.5 Shah et al. (UK) 10.7 ± 2.0 Ortiz (Spain) 10.8 ± 1.5 Hager et al. (Germany) 10.6 ± 2.3 Touboul et al (France) Lam et al. (China) 10.9 Fontes, et al (Brazil) ± 1.82 Ehongo (Belgium) 10.9 ± 1.3 Gonzalez-Meijome (Portugal) 11.4 ± 1.5 Kamiya (Japan) 10.2 ± 1.3 Carbonaro (UK) ± 1.24 Montard (France) ± 1.6 Kida et al (USA adults) 10.4 ± 1.1 Kida et al (USA Young Adults 20-26) 11.8 ± 1.6 Song (Chinese Children) 10.7 ± 1.6 Lim et al (Singaporean Children) 11.8 ± 1.55 Kirwan, O Keefe 2008 (Irish Children) 12.5 ±

3 New Active Level I CPT Code for Corneal Hysteresis (CH) New CPT Code Replaces previous Level III 0181T Bilateral code (like pachymetry) Suggest limiting to once per doctor per patient or no more than once per year Looking for Preponderance of Evidence to Make the Diagnosis Take IOP, Visual Field, Imaging, ONH Structure Looking for 2 or 3 of 4 to solidify the diagnosis Is there a structure/function relationship? If not, where is the outlier? Theoretically, function can change before structure (or at least detectable change) Why Do We Work Up Patients For Glaucoma? Ocular Hypertension Optic Disc Size Size of cup varies with size of disc Large discs have large cups in healthy eyes Suspicious Discs Small Average Identify small and large optic discs Small discs: avg vertical diameter <1.5 mm Large discs: avg vertical diameter >2.2 mm Large 3

4 Looking at Disc Asymmetry By Disc Size Parapapillary Atrophy Beta zone Width of beta zone inversely correlates with rim width at same area Larger beta zone thinner rim Progression of beta zone associated with progressive glaucoma Thin rim Larger zone 4

5 Extended Focal B Zone Sharp inferior focal notch Optic Disc Hemorrhage Normally disappears after 2-6 months Best Method to Detect ONH Hemorrhages is Inspection of Disc Photographs Budenz Ophthalmology 2006 Putting it All Together: Structure and Function 5

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7 Looking for Preponderance of Evidence to Make the Diagnosis Take IOP, Visual Field, Imaging, ONH Structure Looking for 2 or 3 of 4 to solidify the diagnosis Is there a structure/function relationship? If not, where is the outlier? Theoretically, function can change before structure (or at least detectable change) Clinically, Which Factors Are Contributory? Nerve hemorrhage Elevated IOP Optic nerve asymmetry > 20% Rim thinning Family history (brother, mother, etc) confirmable African-Americans, Hisapnic/latino Thin pachs with elevated IOP 7

8 Example Case 64 YOWF History of glaucoma: Mother and Sister Baseline averaged IOP 26 and 27 Pach 545 and 535 CH 9.0 and 8.6 8

9 Does this meet the treatment requirement? IOP + Optic Nerve + OCT + VF + CH + CCT Borderline No brainer Treat 9

10 Name: DOB: ID: Technician: Gender: Adams, Carl 10/30/ Operator, Cirrus Male Exam Date: 12/4/ /4/2013 Gaddie Eye Centers Exam Time: 10:54 AM 10:52 AM Serial Number: Signal Strength: 9/10 9/10 ONH and RNFL OU Analysis:Optic Disc Cube 200x200 RNFL Thickness Map RNFL Deviation Map Disc Center(-0.03,-0.15)mm Extracted Horizontal Tomogram Extracted Vertical Tomogram RNFL Circular Tomogram Comments RNFL Quadrants RNFL Clock Hours Neuro-retinal Rim Thickness RNFL Thickness Doctor's Signature RNFL Thickness Map RNFL Deviation Map Disc Center(0.06,0.06)mm Extracted Horizontal Tomogram Extracted Vertical Tomogram RNFL Circular Tomogram CIRRUS SW Ver: Copyright 2012 Carl Zeiss Meditec, Inc All Rights Reserved Page 1 of 1 Name: DOB: ID: Technician: Gender: Adams, Carl 10/30/ Operator, Cirrus Male Exam Date: 12/4/ /4/2013 Gaddie Eye Centers Exam Time: 10:53 AM 10:51 AM Serial Number: Signal Strength: 9/10 9/10 Ganglion Cell OU Analysis: Macular Cube 512x128 Deviation Map Comments Thickness Map Horizontal B-Scan Sectors Sectors Thickness Map Fovea: 250, 64 Fovea: 262, 64 Doctor's Signature Horizontal B-Scan Deviation Map CIRRUS SW Ver: Copyright 2012 Carl Zeiss Meditec, Inc All Rights Reserved Page 1 of 1 Name: DOB: ID: Technician: Gender: Adams, Carl 10/30/ Operator, Cirrus Male Exam Date: 12/4/ /4/2014 Gaddie Eye Centers Exam Time: 11:52 AM 11:54 AM Serial Number: Signal Strength: 8/10 9/10 ONH and RNFL OU Analysis:Optic Disc Cube 200x200 Disc Center(-0.06,-0.15)mm Extracted Horizontal Tomogram Extracted Vertical Tomogram RNFL Circular Tomogram Comments RNFL Thickness Map RNFL Deviation Map RNFL Quadrants RNFL Clock Hours Neuro-retinal Rim Thickness RNFL Thickness Doctor's Signature RNFL Thickness Map RNFL Deviation Map Disc Center(0.03,0.06)mm Extracted Horizontal Tomogram Extracted Vertical Tomogram RNFL Circular Tomogram CIRRUS SW Ver: Copyright 2012 Carl Zeiss Meditec, Inc All Rights Reserved Page 1 of 1 Name: DOB: ID: Technician: Gender: Adams, Carl 10/30/ Operator, Cirrus Male Exam Date: 12/4/ /4/2014 Gaddie Eye Centers Exam Time: 11:50 AM 11:53 AM Serial Number: Signal Strength: 9/10 8/10 Ganglion Cell OU Analysis: Macular Cube 512x128 Deviation Map Comments Thickness Map Horizontal B-Scan Sectors Sectors Thickness Map Fovea: 247, 64 Fovea: 261, 64 Doctor's Signature Horizontal B-Scan Deviation Map CIRRUS SW Ver: Copyright 2012 Carl Zeiss Meditec, Inc All Rights Reserved Page 1 of 1 2/11/ YO WF Followed since 2008 with IOP in mid 20 s Pach=555 OU Only finding was mild inferior GCC loss CH=9.5 and OCT s 2 years later. Is this glaucoma? Would a 10-2 pick this up better? Remember the asymmetric CH > Should she be treated IOP now 24 and 26 And what should target IOP be? 10

11 Name: ID: DOB: Gender: Technician: Howard, Thomas CZMI /5/1945 Male Operator, Cirrus Deviation Map Comments Thickness Map Horizontal B-Scan Exam Date: 3/23/2015 3/23/2015 CZMI Exam Time: 10:54 AM 10:56 AM Serial Number: Signal Strength: 10/10 10/10 Sectors Sectors Thickness Map Fovea: 258, 67 Fovea: 272, 70 Doctor's Signature Horizontal B-Scan Deviation Map CIRRUS SW Ver: Copyright 2012 Carl Zeiss Meditec, Inc All Rights Reserved Page 1 of 1 Name: DOB: ID: Technician: Gender: Howard, Thomas 11/5/1945 CZMI Operator, Cirrus Male Exam Date: 3/23/2015 3/23/2015 CZMI Exam Time: 10:54 AM 10:55 AM Serial Number: Signal Strength: 10/10 9/10 ONH and RNFL OU Analysis:Optic Disc Cube 200x200 Disc Center(0.03,0.06)mm Extracted Horizontal Tomogram Extracted Vertical Tomogram RNFL Circular Tomogram Comments RNFL Thickness Map RNFL Deviation Map Neuro-retinal Rim Thickness RNFL Thickness RNFL Quadrants RNFL Clock Hours Doctor's Signature RNFL Thickness Map RNFL Deviation Map Disc Center(0.12,0.06)mm Extracted Horizontal Tomogram Extracted Vertical Tomogram RNFL Circular Tomogram CIRRUS SW Ver: Copyright 2012 Carl Zeiss Meditec, Inc All Rights Reserved Page 1 of 1 2/11/2016 Ganglion Cell OU Analysis: Macular Cube 512x YO BM History of suspect ONH cupping Baseline IOP 18 and 17 Gonio=D40R with 2+ PTM (open to CB) Pach=545 and 535 CH=9.8 and 7.5 Was started on PGA 12/2013 IOP now 13 Is that low enough? What is the goal of treatment Clinically, Which Factors Are Contributory? At least 30% reduction Can one medicine do this?? Monitor to see if 30% is enough Is there progression at 6 mos, 1 year?? How do we tell if there is progression? Visual Field IOP drift OCT Nerve hemorrhage Elevated IOP Optic nerve asymmetry > 20% Rim thinning Family history (brother, mother, etc) confirmable African-Americans, Hisapnic/latino Thin pachs with elevated IOP 11

12 Decision Fatigue How does it impact your consistency on starting treatment in ocular hypertension? Artifacts in OCT Testing Murray Fingeret, Artifacts in Evaluating OCT Printouts OCT evaluation have become a part of the examination for individuals with glaucoma and retinal disease Each OCT image/printout needs to be carefully analyzed Some may not be of sufficient quality and should be evaluated with caution Need to identify those with reduced quality because they can mislead the clinician into an erroneous finding There are different reasons why an OCT image may not of adequate quality Images may be identified as abnormal and glaucomatous when it is an artifact or poor quality image that is the cause of the problem What Do You Look For When You Evaluate a Scan Quality score Illumination Focus OK Image centered Any signs of eye movement Segmentation accuracy B Scan Centration What Do You Look For When You Evaluate a Scan RNFL Thickness Map Hot colors present? Any areas in yellow or red? What areas? Do they correlate to other sections of printout? RNFL Deviation Map Any areas flagged? Is so, yellow or red? How large? Location of area flagged 12

13 What Do You Look For When You Evaluate a Scan RNFL Thickness Curve (TSNIT) Areas flagged Focal loss even if not flagged Important part of printout Sector and quadrant map Any areas flagged? Yellow or red? Least important area Need significant damage before it is flagged Parameters Which ones flagged? One eye or both? Yellow or red? How many? Any gray areas? Neuroretinal Rim Thickness Curve Compare and Any irregular dips in curve? Any areas in yellow or red? What Do You Look For When You Evaluate a Scan Quality score Illumination Focus OK Image centered Any signs of eye movement Segmentation accuracy B Scan Centration What Do You Look For When You Evaluate a Scan RNFL map RNFL quadrants RNFL sectors Comparison b/w eyes Asymmetry b/w eyes What Do You Look For When You Evaluate a Scan Quality score Illumination Focus OK Image centered Any signs of eye movement Segmentation accuracy B Scan Centration What Do You Look For When You Evaluate a Scan RNFL Thickness Map Hot colors present? Any areas in yellow or red? What areas? Do they correlate to other sections of printout? RNFL Deviation Map Any areas flagged? Is so, yellow or red? How large? Location of area flagged Analyzing the OCT Errors in data acquisition may be operator error or patient related Media opacity Cataracts, Vitreous floater High myopia Operator misalignment and errors in technique Out of focus or scan too high Blink and eye movement Software analysis difficulties Segmentation algorithm failure Any of these confound interpretation Some errors in technique avoidable Scan too high Out of focus Some unavoidable errors Epiretinal membrane Cataract Important to recognize when artifacts are present no matter the cause to make proper analysis Also when comparing test to test, random variability occurs in 5% of cases 13

14 Artifacts in Evaluating OCT Printouts Poor Quality Images Out of focus Reduced illumination Not properly illuminated Reduced signal strength (SS) Dry eye, small pupils, cataracts, other media opacities There is a relationship between signal strength and RNFL thickness Need to be careful when utilizing scans with reduced SS Need to know manufacturer s recommendations Carl Zeiss 7 or above Heidelberg 15 or above Optovue 30 or above Dry eye Poor image quality Same Eye after Tears Instilled Analyzing the OCT Poor Quality Images Signal strength is a proxy measurement of scan quality Scans of lower quality have more variability Underestimate RNFL thickness Want signal strength or quality index to meet manufacturer s recommendations Cirrus 7 or above Optovue 30 or above Heidelberg 15 or above Use with care any image in which quality scores are below manufacturer s recommendations Even if Quality score is acceptable, there still may be problems with image Multifocal intraocular lenses may affect OCT scan quality leading to reduced signal strength The Effect of Signal Strength 14

15 Impact of Signal Strength on RNFL Thickness Image Artifacts Blink cutting off image Scan too high or too low cutting off image Eye movement Large optic disc and / or PPA RNFL circle too small - encroaches on optic disc/ppa Floaters obscuring tissue underneath Pathologies such as epiretinal membrane or chorioretinal scar Blink Bad and Good Images OCT Artifact Due to Floater Vitreous floater Retake image Eye Movement 15

16 Analyzing the OCT B Scan Too High Inspect the B scans for correct position Inspect for segmentation errors Did the computer correctly locate the top and bottom of the different layers such as the RNFL Important for the B scan image to be of high quality and contrast Click on image to enlarge Segmentation errors are common Epiretinal membranes, vitreous detachments and poor image contrast can lead to segmentation errors One source of segmentation errors are epiretinal membranes B Scan Too High Can You Accurately Evaluate This Person For Glaucoma? - ERM 16

17 Another case - erm And Another Case Need To Look Very Carefully b/c ERM Lurk and Can Impact OCT Analysis 17

18 Vitreoretinal Traction Why Are there two images for the same date recipe for a problem Delete Bad Image Figure 1A Figure 1B Delete Bad Image GPA Analysis Uses First Image from Date 18

19 Artifacts in Evaluating OCT Printouts Segmentation Failure Algorithm failure Segmentation errors B scan segmentation inaccurate Disc margin error Throws off disc size Cup not properly outlined (material in cup throwing segmentation off) Can not over ride this with Cirrus 19

20 The Treatment Algorithm for Open-Angle Glaucoma Richard J. Madonna,, MA, FAAO SUNY State College of Optometry New York, NY The Treatment Algorithm for Open Angle Glaucoma Establish a Target Pressure a. Factors that affect establishing a target pressure b. RCTs c. Should be constantly assessed First-choice Therapy Risk-benefit ratio Efficacy Cost a. Decision b. Usually a PGA PGA efficacy PGA adverse reactions Which PGA? Brand vs generic? Ocular surface? Should we use a monocular trial? If not a PGA, then what? 1. SLT as first-choice therapy 2. Other topicals besides a PGA The Treatment Algorithm for Open Angle Glaucoma Adjunctive Therapy When should an adjunctive medicine be added? Treatment failure when should a treatment be considered a failure? Progression Factors affecting the choice of an adjunctive therapy Always: risk vs. benefit Topical medications beta-blockers alpha-agonists CAIs Fixed combinations when should they be employed? beta-blocker/cai beta-blocker/alpha agonist CAI/alpha agonist MIGS procedures Cataract surgery? Surgery When is surgery indicated? Which surgery? 20