Glaucoma/OHT in the Community Suspect Investigation & Stable Management

Transcription

1 Glaucoma/OHT in the Community Suspect Investigation & Stable Management Provider Training BHR Wilts Stable patients available from 28 th Jan Christian Dutton Clinical Optometrist BSc(Hons.) MScClinOpt FCOptom Prof.Cert.Glauc

2 Overview Assessing Risk in Glaucoma Statistics Definitions Clinical Investigations Discs / RNFL / Fields IOP / CCT A/C Treatment Philosophy Target Pressure Treatment Treatment Algorithm Glaucoma Medications Patient Information Review Progression Recall Glaucoma Cases & Telemedicine Clinical case studies Clinical protocols Telemedicine Tips from the telemedicine consultants Cataract post-operative assessment

3 Statistics Second leading cause of blindness worldwide (10% of UK blindness) 50% is still undetected million people (OAG and ACG) 500,000 in England Blind: 4.5 million OAG, 4 million ACG million Blind: 6 million OAG, 5 million ACG 75% OAG 60% are women (make up 55% of OAG and 70% of ACG) 50% are Asian (85% of ACG)

4 Statistics HES: 30% of all outpatient follow-ups (over 1 million appts) 15% of all new assessments

5 Definitions OHT IOP 22mmHg Open angle Normal fields Normal discs ~10% of individuals with IOPs between 22-30mmHg develop POAG over 5 yrs

6 Definitions COAG suspect Open angle Suspicious fields Suspicious discs POAG suspect if IOP 22mmHg NTG suspect if IOP <22mmHg

7 Definitions Glaucoma Group of diseases Acquired progressive optic neuropathy Progressive loss of visual function if Undetected Untreated Undertreated

8 CLASSIFICATION Appearance of the aqueous drainage pathway at the TM Open-angle glaucoma Normal clinical appearance Aqueous outflow may be restricted Angle closure glaucoma Access to the TM is physically obstructed Mechanisms that push the iris forward from behind Mechanisms that pull it forward Definitions

9 Definitions PRIMARY ANGLE CLOSURE Primary angle closure suspect (PACS) Contact between peripheral iris and posterior TM possible IOP, discs and visual fields are normal Primary Angle Closure (PAC) Obstruction of the TM by the peripheral iris has occurred Raised IOP (appositional PAC) and/or peripheral anterior synechiae (synaechial PAC) Disc and fields are normal Primary Angle Closure Glaucoma (PACG) PAC with damage to the optic nerve and visual field change. Damage caused by: Episodes of severe IOP elevation (so IOP might be normal or raised on presentation) Long-term elevated IOP

10 Risk factors Specific to the eye Raised IOP 15.5mmHg (SD 2.5mmHg) Refractive error > 8D ocular connective tissue disorder Hypermetropic small crowded ACs Thin CCT

11 Risk factors Systemic Age Increased TM resistance to outflow Family history First-degree relatives = 10x risk Vascular disease Poor optic nerve head blood flow (NTG) Migraine, Raynaud s, Diabetes Obstructive sleep apnoea (?diurnal IOP variation)

12 Risk factors Racial POAG Afro- Caribbean and West African PAC/PACG Far-East Asian and Inuit

13 Risk factors Secondary Steroid PDS PXF Uveitis Iris neovascularisation from retinal ischaemia (e.g. CRVO)

14 Clinical Investigations Structure vs function Structure (physical measurable pathology e.g. cell loss) Function (field and VA) Combining structural & functional tests improves diagnostic accuracy Can get structural or functional defects first Rarely both at the same time

15 Optic disc Vertical disc diameter 1.5mm small, 2.1mm large Helps in C:D interpretation 66D 1:1 (1/mag x graticule) C:D ratio 0.7, 0.2 difference, progression Rim contour Diffuse narrowing / localized notching / both Loss from inner edge of rim, especially ST/IT Clinical Investigations

16 Clinical Investigations Optic disc Haemorrhage(s) 2-5x more common in NTG than POAG Associated with rapid progression, notches and B PPA Usually in RNFL (IT/ST) Frequency increases then decreases Often self-resolve within 2/12

17 Clinical Investigations Optic disc Vascular changes (due to structural NRR loss) Baring of circumlinear vessels Bayonetting (advanced disease) Fly-over vessels - lose contact with the previously underlying NRR Nasalisation of central vessels PPA Beta Zone (next to disc margin) RPE atrophy since choriocapillaris closed (absolute scotoma) Risk factor for progression Extent proportional to disc and field damage Precedes disc haemorrhage in 80% of cases

18 Clinical Investigations Progression - optic disc Structural qualitative changes (photos, clinical notes) Vessel changes Notching Haemorrhages Enlarging PPA Quantitative changes C:D progression OCT progression analysis (disc map volumetric data)

19 Clinical Investigations

20 RNFL (axons of retinal ganglion cells) Identify pre-perimetric damage Qualitative (red free photo) Initially small slit/groove bundle defects Coalesce to form large wedge defects Later =diffuse loss Quantitative OCT disc map (circumpapillary RNFL thickness) OCT GCC map (segmentation algorithm) Over 50% of all RGC s are in macula Clinical Investigations

21 Clinical Investigations Progression - RNFL (axons of retinal ganglion cells) Qualitative changes (red free photo) Enlarging defects compared with previous photos Quantitative changes OCT disc and macular map Progression analysis or subjective assessment

22 Clinical Investigations Visual Fields Diagnosis and monitor progression Main functional measurement Standard automated perimetry (central thresholding) Gold standard Not optimal for early detection but good for monitoring Time consuming/tiresome so use intelligent algorithms

23 Visual Fields Reliability Variability is normal in glaucoma Patient performance Fixation losses Fatigue Learning effects Changes in pupil size Improper refractive correction True physiological variability Artefacts (ptosis, spectacle/lens rim) Clinical Investigations

24 Patient information Test information Reliability indices Raw sensitivity Gray scale (raw-interpolated) Glaucoma hemifield test Global indices Total deviation plot Clinical Investigations Reliability indices Fixation losses Poor blindspot plotting Field loss close to fixation False positives Trigger happy Under 20% False negatives Inattentive Common in glaucoma Total deviation probability plot Pattern deviation plot Pattern deviation probability plot Gaze tracker

25 Patient information Test information Reliability indices Raw sensitivity Gray scale (raw-interpolated) Glaucoma hemifield test Clinical Investigations Total deviation plot Age-matched norms Uncorrected rx Cataract Small pupils Pattern deviation plot Correct for diffuse loss Highlight specific loss/patterns Global indices Total deviation plot Total deviation probability plot Pattern deviation plot Pattern deviation probability plot Gaze tracker p-values % of normals who would return a value equal or worse p<0.05 = 1 in 20 p<0.01 = 1 in 100 GHT (vertical asymmetry) Outside normal limits 1zoneP<0.01 Borderline anything between Within normal limits

26 Patient information Test information Reliability indices Raw sensitivity Gray scale (raw-interpolated) Glaucoma hemifield test Global indices Total deviation plot Total deviation probability plot Pattern deviation plot Pattern deviation probability plot Gaze tracker Clinical Investigations Global indices Mathematical evaluations of the visual field Mean deviation (MD) index (-) Reflects diffuse change Weighted average of all the points in the total deviation plot Pattern SD (PSD) index (+) Reflects variability across field Higher = focal loss (p) of the result being normal Hodapp classification Early COAG MD > -6 db. Moderate COAG -6 db to -12 db

27 Clinical Investigations Visual fields (RNFL bundle defects) Paracentral Deep, close to fixation, especially in NTG Follow RNFL distribution and abruptly stop at horizontal midline Arcuate Coalition of a group of smaller defects, more extensive than paracentral, respect horiz midline Nasal step Due to sensitivity difference above and below horizontal midline Normal patients may have shallow small steps (over 5 degrees is significant) Depth (deep = more likely to be real) Clustering (more than 2 abnormal points likely to be significant)

28 Clinical Investigations Progression - Fields Clinical judgement Subjective observation of sequential VF results Defect classification systems e.g AGIS scoring system Trend analyses e.g. Linear regression Event analyses e.g. Glaucoma change probability, Glaucoma progression analysis

29 Clinical Investigations Progression - Fields Clinical judgement Subjective observation of sequential VF results Defect classification systems e.g AGIS scoring system Trend analyses e.g. Linear regression Event analyses e.g. Glaucoma change probability, Glaucoma progression analysis Will the visual field last until the end of this patient s lifetime at this rate?

30 Clinical Investigations IOP Errors Lids, misaligned, meniscus width, prolonged contact Short term changes Diurnal range (3-6 normal, glaucoma 13) Increase if accommodating, blinking, squeezing, raised intrathoracic pressure (strain, hold breath, tight collar) Other factors Corneal thickness (thin = underestimate) Curvature (flat = underestimate) Elasticity (stiff = overestimate) Hydration

31 Clinical Investigations CCT Normal distribution 540 ±30 μm (mean +/- SD) Thin CCT (less than 555μm) risk factor for: Development of POAG Progression of POAG Visual field progression CCT can influence accuracy of IOP measurement No verified algorithm to apply Ehler: 1mmHg correction for every 15 μm

32 Clinical Investigations Anterior Eye Cornea Epi oedema, posterior embryotoxin, KP A/C Trauma, uveitic, pigmentary, lens related Cells, flare, pigment, protein, lens particles Iris Atrophy (diffuse, sector), deposits, pupil margin, TI, neovasc Lens PXF, glaucomflecken (anterior subcaps), phacodonesis (zonular weakness in PXF wobbly iris), phacomorphic, phacolytic

33 Clinical Investigations Anterior Chamber Depth Limbal Depth Van Herick 60 0, narrow, bright beam, nasal & temporal AC:cornea - record as % and equivalent VH <25% occludable A-S OCT Qualitative image, quantitative analysis possible Gonioscopy Raised IOP requiring treatment (open angle vs angle closure) Patients at risk of acute angle closure (VH <25%)

34 Clinical Investigations Anterior Chamber Depth Central Depth Smith technique Illumination at 60 0, beam horizontal and short Cornea in focus temporally Move nasally until the beam just touches nasal pupil margin Increase beam height until images touch Multiply result by 1.4 (gives central A/C depth in mm) <1.8 shallow, >2.5 deep

35 Treatment Philosophy 4 Principles IOP is the only modifiable risk factor Reduction in IOP reduces the rate of damage Damage occurs at the presenting IOP Treatment should reduce IOP to a target pressure

36 Target Pressure Estimated upper limit To slow progression to maintain vision-related quality of life For the expected lifetime of the patient MD <-14dB visual impairment MD <-22dB statutory blindness 20-35% (5-7 mmhg) Set by consultant Rate of progression, risk factors (e.g. CCT) TargetIOP.com

37 Treatment OHT/Suspected POAG (IOP 24 or more) Are they at risk of future visual impairment? Consider: IOP, CCT, FH, life expectancy Old CG85 - categories which might be at risk Not at risk No treatment Regular EE

38 Treatment OHT/Suspected POAG (IOP 24 or more) At risk of visual impairment in lifetime Generic PGA (e.g. latanoprost od nocte R&L) If non-tol: Another generic PGA / Beta Blocker / Non-generic PGA/other class of drug If preservative allergy Consider preservative free (e.g. monoprost) if significant OSD and High risk of COAG conversion If ineffective Different therapeutic class or combination

39 Treatment COAG Generic PGA (e.g. latanoprost od nocte R&L) If non-tol Try different therapeutic class If preservative allergy Consider preservative free if significant OSD If ineffective: Discuss adherence Check eye drop instillation technique Try different therapeutic class or combo Surgery if 2 classes don t work

40 Start with 1 drug Show how to put in If IOP not at target Change if IOP reduced 2 or less Add second drug if IOP reduced more than 2 Generally treat both eyes (give px choice) Less confusing Cosmetic balance with PGA Avoid Beta Blocker if asthma, heart disease, poor circulation PGA in pregnancy Treatment Algorithm & Considerations

41 Glaucoma Medications Prostaglandin analogues Prostamide Beta blockers Sympathomimetics Carbonic Anhydrase Inhibitors Miotics Combination products (latanoprost) (bimatoprost) (timolol) (brimonidine) (brinzolamide) (pilocarpine) (above plus timolol)

42 Glaucoma Medications Prostaglandin analogues Action: increase (uveoscleral) aqueous outflow Examples: Gutt Latanoprost 50microgram/ml OD nocte (Branded = Xalatan) Monopost (PF) Travoprost (Travatan), Tafluprost (Saflutan) Avoid: Aphake, pseudophake, A/C implant Severe asthma Herpetic diease Induces labour

43 Glaucoma Medications Prostamide Action: increase (uveoscleral) aqueous outflow Examples: Gutt Bimatoprost 100microgram/ml (0.01%) OD (Lumigan) Gutt Bimatoprost 300microgram/ml (0.03%) (PF) (Lumigan) Avoid: Aphake, pseudophake, A/C implant Severe asthma Renal disease

44 Glaucoma Medications Beta-blockers Action: Reduce aqueous production Examples: Gutt Timolol 0.25% / 0.5% bd (or LA mane) available unit dose (PF) Timolol 1mg/g gel mane (Tiopex) Levobunolol (Betagan), Betaxolol (Betoptic) Avoid: Heart probs (reduce HR) Asthma/COPD (bronchoconstriction) Worsen vasc disease ACE inhib, anti arythmias (amiodarone), calcium channel blocker (verapamil), parasympathomimetic (pilo), sympathomimetic (adrenaline) very rare in clinical practice

45 Glaucoma Medications Sympathomimetics Action: Reduce aqueous production and increase outflow Examples: Gutt Brimonidine 0.2% bd (Alphagan) Apraclonidine (Iopidine) Avoid: Heart/vascular disease (smooth muscle/vaso constriction, heart works harder and incr. BP) MAOI s (phenelzine, isocarboxazid) Tricyclic antidepressants (amitryptilline, doxepin) Alpha stimulation also: Eyelid retraction, mydriasis, increase outflow

46 Carbonic anhydrase inhibitors Action: reduce aqueous production Glaucoma Medications Examples: Gutt Brinzolamide 10mg/ml bd (Azopt) Dorzolamide 2% bd/tds (Trusopt) PO 250mg Acetazolamide take two tablets up to max QDS Avoid: Sulphonamide allergy e.g. trimethoprim (since it is a sulphonamide derivative) Electrolyte imbalance/renal disease Pregnancy

47 Glaucoma Medications Miotics Action: increase aqueous outflow Examples: Gutt Pilocarpine 1%, 2% max qds Avoid: Heart problems (reduce HR) Asthma/COPD (bronchoconstriction) Peptic ulcer (increase secretions) Anterior uveitis, secondary glaucoma

48 Glaucoma Medications Latanoprost 50micrograms & timolol 5mg/ml Travoprost 40 micrograms & timolol 5mg/ml eye drops Bimatoprost 0.03% & timolol 0.5% eye drops (also Ganfort PF available) Brimonidine 0.2% & timolol 0.5% eye drops Brinzolamide 10mg & timolol 5mg/ml eye drops Dorzolamide 2% & timolol 0.5% eye drops Brinzolamide 10mg/ml & Brimonidine 2mg/ml eye drops Xalacom DuoTrav Ganfort Combigan Azarga Cosopt Simbrinza

49 First choice Last choice S/E Avoid Rx Prostaglandin Analogues Latanoprost Xalatan 0.005% nocte Pres-free option = Monopost Tafluprost Saflutan 15mg/ml nocte Available in unpreserved form only Aphake, A/C implant, severe asthma, herpetic disease, induces labour. Prostamide (Bimatoprost): aphake, pseudophake, A/C implant, severe asthma, renal disease Carbonic Anhydrase Generics Generic PF multidose = Eysano Travoprost Travatan 0.004% nocte Generic Travatan does NOT contain BAK Generic Travoprost DOES contain BAK Bimatoprost Lumigan 0.01% nocte Preserved = 0.01% or 0.03% Unpreserved = 0.03% only Generics (0.03% only) PF unit dose = Lumigan UD PF multidose = Eyreida Brinzolamide Azopt 1% bd/tds Dorzolamide Trusopt 2% bd/tds Unit dose Pres-free multi-dose (Eydelto ) Generic Sulphonamide allergy e.g. trimethoprim (since it is a sulphonamide derivative) Watch for skin rash, electrolyte imbalance/renal disease, pregnancy Gutt Latanoprost 50microgram/ml (also Gutt Brinzolamide 10mg/ml bd PF) od Gutt Dorzolamide 2% bd/tds Gutt Travoprost 40microgram/ml od PO 250mg Acetazolamide take Gutt Tafluprost 15microgram/ml (PF) od two tablets up to max QDS Gutt Bimatoprost 100microgram/ml Generic 0.25 & 0.5% Unit dose Levobunolol Betagan 0.5% bd Unit dose Generic Betaxolol Betoptic 0.5% bd Betoptic-S 0.25% bd Generic Unit dose (0.25% only) Beta-Blockers Timolol (gel and guttae) Timoptol 0.25/0.50% bd Tiopex 1mg/g gel mane Reduce HR, Bronchoconstrict Heart probs, asthma/copd, worsen vascular disease. ACE inhib, anti arythmias (amiodarone), calcium channel blocker (verapamil), parasympathomimetic (pilo), sympathomimetic (adrenaline) very rare Gutt Timolol 0.25% / 0.5% bd (also 0.1% LA pres free od) Gutt Levobunolol 0.5% od / bd Brimonidine (Generics include Brymont ) Generic Apraclonidine Adrenergics Alphagan 0.2% bd Iopidine 0.5/1% tds NB cost of unit dose: 1% available only in unit dose 0.5% available only in multi dose Smooth muscle/vaso constriction (heart works harder and increases BP). Alpha stimulation also: Eyelid retraction, mydriasis, increase outflow Heart/vascular disease. MAOI s (phenelzine, isocarboxazid), tricyclic antidepressants (amitryptilline, doxepin) Gutt Brimonidine 0.2% bd Pilocarpine Miotics Generic Pilocarpine 1/2/4% qds Unit dose (2% only) Reduce HR, bronchoconstriction, increase secretions, headaches Heart probs, Asthma/COPD, peptic ulcer, anterior uveitis, secondary glaucoma Gutt Pilocarpine 1%, 2% max qds Duotrav Xalacom Ganfort Taptiqom Travoprost 0.4mg/ml / Timolol 5mg/ml - mane - branded only Latanoprost 0.05mg/ml / Timolol 5mg/ml - mane - branded, Bimatoprost 0.3mg/ml / Timolol 5mg/ml - mane - branded only Tafluprost 0.015mg/ml / Timolol 5mg/ml - mane - branded only Cosopt / Tidomat / Eylamdo Combigan Azarga Simbrinza Dorzolamide 20mg/ml / Timolol 5mg/ml - bd - branded multi/ unit dose, generic Brimonidine 2mg/ml / Timolol 5mg/ml - bd - branded only Brinzolamide 10mg/ml / Timolol 5mg/ml - bd - branded only Brinzolamide 10mg/ml / Brimonidine 2mg/ml - bd/tds - branded only

50 Patient Information The disease Symptomless but irreversible loss What the treatment does How to instil drops Side-effects (& what to do) How to get repeat rx Sources of info/support Importance of regular review

51 Review Usually in 4-8 weeks Verify medication Check compliance and understanding Assess possible side-effects ( tolerance ) Check logistics for repeat prescriptions Check effectiveness of treatment Answer any unresolved queries Tolerating well, self-reported compliance good, has repeat rx from GP. See in x/12 (high presenting IOP/suspicious disc) with fields

52 Recall Treated OHT/suspected COAG Discharge if OHT not requiring treatment or COAG suspect no longer suspect No conversion to COAG: 18-24/12 (12-18/24 for COAG suspect) Conversion to COAG uncertain: 1-4/12 (and review treatment plan) if IOP not controlled Else 6-12/12 Conversion: see COAG section COAG No progression: 1-4/12 (and review treatment plan) if IOP not controlled Else 6-12/12 if high risk or 12-18/24 if low risk Progression/uncertain: 1-2/12 (and review treatment plan) if IOP not controlled Else 2-6/12

53 Female, Caucasian, Age 68 July 12 - Optom referral C:D asymmetry and?field defect IOP 20/18 C:D 0.5/0.4 Fields?mildly enlarged blind spot Sept 12 - Community glaucoma service IOP 28/26 C:D 0.5/0.4 Fields normal R&L CCT 573/584 A/C Deep Impression OHT, no treatment indicated, review 6/12 Case 1 OHT (stable, untreated)

54 Case 1 OHT (stable, untreated) Jan 18 (5.5 years later) 6/12 reviews initially Then annual review IOP 24/23 CD 0.55/0.45 Fields Normal R&L

55 Case 1 OHT (stable, untreated) Oct 18 ecare transfer IOP 26/25 C:D 0.6/0.5 Fields Normal R&L Impression: Stable OHT Plan: No treatment indicated Review 12/12 Name: ID: DOB: Age: 68 Exam date: 21/11/18 Gender: Female Eye: Both Comments: Name: ID: DOB: Age: 68 Exam date: 21/11/18 Gender: Female Eye: Both Comments: R 21/11/18 10:04:14 3D 6x6 mm NFL signification DISC BOTH EYES NFL thickness NFL thickness 21/11/18 10:04:42 NFL signification 3D 6x6 mm L R 21/11/18 10:03:54 3D 7x7 mm NFL+GCL+IPL thickness RETINA BOTH EYES GANGLION NFL+GCL+IPL signification NFL+GCL+IPL signification 21/11/18 10:04:57 3D 7x7 mm NFL+GCL+IPL thickness L % µm µm % µm % % µm NFL+GCL+IPL deviation NFL+GCL+IPL deviation Ring diameter 2.40 mm. Ring thickness 0.40 mm. Ring diameter 2.40 mm. Ring thickness 0.40 mm. % % % % S - I Hemisphere asymmetry R - L Asymmetry L - R Asymmetry S - I Hemisphere asymmetry Version: SOCT Copernicus REVO Device SN: /11 Print date: 21/11/18 OPTOPOL Technology Sp. z o.o. µm I - S µm Version: SOCT Copernicus REVO Device SN: /11 Print date: 21/11/18 OPTOPOL Technology Sp. z o.o µm I - S µm

56 Male, Caucasian, 33 Oct 17 - High street optometry -?glaucoma IOP 22/23 (NCT) Discs 0.3/0.45 Fields Full R&L Nov 17 Community glaucoma service IOP 21/21 (GAT) Discs 0.4 tilted/0.5 tilted Fields Normal R&L CCT 558/550 A/C Deep Glaucoma suspect, no treatment indicated Case 2 OHT (stable, untreated)

57 Case 2 OHT (stable, untreated) Dec 18 - ecare IOP 23/24 (GAT) Discs 0.5/0.6 (tilt) Fields Full R&L Impression: Borderline OHT Plan: No treatment Monitor OCT Recall 1 year

58 Male, Caucasian, Age 64 Case 3 OHT (stable, treated) Jan 17 Community ophthalmology service (Optom referral for raised IOP) IOP 22/29 C:D 0.1/0.1 Fields Full R&L CCT 570/570 A/C Deep, no PDS/PXF Impression - LE OHT, commence latanoprost OD LE only, review 6/52 (initially) Nov 17 - Community glaucoma service IOP 20/20 C:D 0.1/0.1 Fields Full R&L Impression LE treated OHT, continue LE latanoprost, review 12/12

59 Case 3 OHT (UNstable, treated) Nov 18 ecare transfer IOP 27/20 C:D 0.1/0.1 Fields Full R&L A/C VH3/VH4 Impression: LE treated OHT RE OHT Plan: Continue latanoprost LE nocte Commence latanoprost RE nocte Target IOP 20 R&L Review 3/12

60 Female, Afrocarribean, Age 62 Case 4 Glaucoma suspect (stable, untreated) Jan 16 Optom referral for suspicious discs and fields IOP 23/24 C:D 0.6/0.5 Fields Early loss R&L Apr 16 - Community glaucoma service IOP 24/24 C:D 0.65/0.5 Fields RE early paracentral loss, LE full CCT 599/595 A/C Wide open angles Impression RE glaucoma suspect, LE OHT Plan No treatment indicated; Review 6/12

61 Jul 15 Optom referral for increasing IOP and?progressive cupping IOP 25/19 C:D? Fields? Aug 15 - Community glaucoma service IOP 28/25 C:D 0.6/0.4 Fields CCT 589/591 A/C Male, Caucasian, Age 70?early loss, unreliable Wide open angles Impression bilateral glaucoma suspect Plan commence latanoprost OD nocte R&L; Review 2/12 Case 5 Glaucoma suspect (unstable, treated)

62 Nov 18 Transfer to ecare IOP 28/16 C:D 0.7/0.4 Fields Impression RE?mild loss, LE unreliable but?early loss RE glaucoma suspect, inadequate control (but compliant) LE glaucoma suspect, well controlled Plan RE continue latanoprost o.d. nocte, add brinzolamide b.d. LE continue latanoprost o.d. nocte Target IOP R19 L 17 Review 2/12 (IOP) Case 5 Glaucoma suspect (unstable, treated)

63 Oct 16 optometrist referral for suspicious discs & field defect IOP 22/21 C:D 0.7/0.7 Fields Arcuate defect L>R (repeatable) Nov 16 community glaucoma clinic IOP 21/21 C:D 0.8/0.8 Fields Plan: Bilateral superior and inferior arcuate loss R>L Commence latanoprost o.d. nocte R&L Review 2/12 Male, Caucasian, Age 67 Case 6 Glaucoma (stable, treated)

64 Nov 18 - ecare IOP 21/21 C:D 0.8/0.8 Fields CCT 528/521 A/C Bilateral superior and inferior arcuate loss R>L (unchanged) Wide open angles Case 6 Glaucoma (stable, treated)

65 Impression: Plan: Bilateral stable glaucoma R>L Continue latanoprost OD nocte R&L Review 12/12 Case 6 Glaucoma (stable, treated)

66 Female, Chinese, Age 48 Case 7 Narrow Angles Aug 18 optom referral for raised IOP with narrow angles IOP 25/24 Discs 0.35/0.35 Fields Abnormal & unreliable A/C VH2 Oct 18 - ecare IOP 27/26 Discs 0.2/0.2 Fields Abnormal & unreliable A/C VH1 R&L N&T

67 Impression Shallow A/C with raised IOP and field defect?pac Plan Case 7 Narrow Angles Refer to HES for angle assessment &?prophylactic treatment

68 Gonioscopy patients we treat if increased risk of acute angle closure and At risk of acute angle closure (V/H<2) Onward refer if gonioscopy not available Onward refer if raised IOP with angle closure Raised IOP requiring treatment Classify as open angle or angle closure?corporate clinic at first review after starting treatment Case 7 Narrow Angles

69 Glaucoma protocol

70 Glaucoma protocol (quick reference) NB this quick reference guide is not a substitute for the clinical protocol

71 Telemedicine Process Record sufficient notes & include images My feeling is I will ask for my consultant s opinion and if they agree we ll see you in xx months/report Send to telemed (ophthalmologist) Ophthalmologist Reviews clinical findings, images and proposal Provides their diagnostic impression and management plan Finalises any prescription requests Returns completed case to provider Provider Accept/reject telemed comments Retain = moves into retained silo in order of due date Refer = action onward referral within Evonnect (Evo) Generate letters GP NHS.net / ERS notification Referrer use Evonnect to view Patient print locally at your discretion Check daily (may be urgent) Optional/Mandatory Mandated Posterior OCT (naevus, AMD) Glaucoma Optional Prescription request Diagnostic uncertainty

72 The consultant s opinion was sought for confirmation and responded with the following comments the next day: Agreed, likely POAG. Request sent to GP for gutt. Latanoprost 0.005% nocte. Target IOP is 18 R&L. Suggest review in 3/12. The process of monitoring for change and proposing target pressures and treatments is robust and ultimately the consultant decides on the management plan. Telemedicine is a great opportunity to bridge the gap between optometry and ophthalmology and develop your skills within practice.

73 Telemedicine

74 If a patient requires a prescription Complete suggested medication box Send to telemedicine Accept when from telemed If consultant agrees/prescribes Do you want to view printing options? Prescription request to mailroom Dedicated request to GP (GMC no.) In addition to main report Prescription Requests

75 Tips from the Consultants Monitoring Stable, IOP within target IOP exceeds target VF or ONH progression despite 'adequate' IOP control Continue Monitoring Escalation of treatment algorithm Lowering of target IOP

76 Tips from the Consultants Treatment Algorithm Standard pathway Beta blocker intolerant pathway Preservative intolerance/ocular surface disease Low threshold for HES latanoprost Refer HES Monopost Multiple intolerances Ganfort latanoprost + brinzolamide Ganfort PF Secondary glaucoma/ntg Lumigan + cosopt Refer HES Lumigan PF + Cosopt PF Young/ advanced field changes/ etc HES referral Refer HES Others

77 Tips from the Consultants Monitoring Group 1. 4monthly for at least 12 months Glaucomatous visual field changes POAG, NTGs Group 2. 6 monthly for at least 12 months Glaucomatous disc changes, normal fields Gl. suspects Group 3. Annual Review OHT Suspected anomalous discs, glaucoma unlikely Stable group 1 and 2 patients

78 Tips from the Consultants What do we like to see on your records? A compact, targeted history A complete set of relevant observations Ideally with a conclusion In a perfect world, we should be able to go straight to your conclusion first, then scan back to make sure the details are correct Eg 63 year old lady, no risks for glaucoma, IOP 25 corrected, normal disc, OCT, field = glaucoma suspect. And a suggestion about follow up Plus any relevant patient related issues Eg prefers not to be treated at present/ worried about possible cancer

79 Tips from the Consultants How old is the patient How long for /when did it start Ever had it before One eye or both Anything makes it better / worse For vision when it s at its worst, what would you be able to see if you were looking at me. Any previous ophthalmic history**. (They won t tell you) If there are previous notes, check through them for eg highest IOP before treatment PLEASE DO NOT MANIPULATE THE HISTORY TO MATCH WHAT YOU THINK IS HAPPENING. History taking and reporting

80 Tips from the Consultants Avoid abbreviations Need to be understood by GP and other stakeholders Helpful to start with age, sex and highest IOP first Comment on the reliability of fields/oct Disc photos are essential, especially for tilted/anomalous discs If the fields/oct show progression review early e.g. 2/12 When prescribing, unless contraindicated consider: 1. Latanoprost 2. Ganfort (i.e. Bimatoprost with timolol) 3. Lumigan (bimatoprost) & cosopt (i.e. dorzolamide & timolol) or refer!

81 Tips from the Consultants Remember those poor GPs Their letter is taken straight from your notes They don t know our abbreviations So CRVO / LO / RD / ERM doesn t mean anything to them Beware your own pet abbreviations I keep reading ones I have no idea about! Remember to spell out RIGHT and LEFT Quite apart from confusion over LVA, it s frowned on medicolegally

82 Tips from the Consultants Remember We ll never get troubled if you say I really don t know what is going on here what do you think? However, you ll need to remember to take that statement out when the record comes back from telemed. If you are really concerned about a telemed decision, best to either Simon.Hardman-Lea@evolutio-uk.com or Harry.Roberts@evolutio-uk.com

83 evonnect record card If you were the consultant managing this patient would you be satisfied?

84 evonnect record card What disc problem PMH FOH V/H PDS/PXF GAT or NCT? CCT VA!! Field plot VDD Disc haemorrhage Disc/OCT images R/L/Both What treatment & how often Leaflets given If you were the consultant managing this patient would you be satisfied?

85 Cataract Post-op Cataract Post-Op Proforma Evolutio Care Innovations Limited Apr 2018 CATARACT POST-OP ASSESSMENT (4 weeks) Date of review PATIENT DETAILS: Title: First Name: Surname: Date of Birth: Address: Mobile Phone No.: GP Name & Address: NHS Number: Home Phone No.: Postcode: Postcode: CLINICAL DETAILS: Date of Procedure: Address: Consultant Name: Which eye was treated? Right Eye Left Eye IOP: R L Goldman Perkins icare NCT Pain No R L Both Unexplained reduced VA No R L Both A/C cells No R L Both Posterior synechiae No R L Both Vitreous activity No R L Both Incision not healing/abnormal No R L Both Reduced corneal clarity No R L Both Posterior capsular thickening No R L Both Intolerable refractive error No R L Both What is the refractive error and VA? Right: Left: Sph Cyl Axis VA Add Near VA Any additional relevant information? Patient is: Satisfied Dissatisfied Neither satisfied nor dissatisfied (tick one with supporting comments) Vision is: Improved No Change Worse Plan: Discharge Optometrist Review / Follow-up (specify timescale: ) Refer back to ophthalmologist for complication related to surgery* Refer to ophthalmologist for a condition unrelated to recent cataract surgery* * NB This form does NOT constitute a referral - a separate referral must be made with appropriate urgency CLINICIAN DETAILS: First Name: GOC: Practice Address: Address: Surname: Phone Number: Postcode: Evolutio Care Innovations Limited 2018 Page 1 of 1

86 Community post-op review at 4 weeks HES follow-up within 24hrs/1 week Phased, Queens initially HES send post-op patients to Evolutio via nhs.net Evolutio contact patient to arrange choice Lands in your accept/reject silo Cataract Post-op GOS test at same time Outcomes sent back to bhr-tr.outsourcing@nhs.net via evonnect Sign up for the pathway via affiliate@myecare.co.uk

87 Pathways/process (BH&R Specific) Cataract IFR request Sending a referral for funding approval IFR agreed cataract referral Funding approved so sending on for surgery Community Post-op assessment ( 30) Referral back to community for 4 week post op review Community post op satisfactory outcome Following post op assessment all is well?hes OMR Unsatisfactory outcome due to CMO Cataract Post-op