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GLAUCOMA UPDATE Managing The Glaucoma Suspect – When Do I Refer?. DR RAJIV SHAH EASTWOOD EYE SURGERY. Glaucoma. Glaucoma is the most common cause of irreversible blindness worldwide Often bilateral and mostly asymptomatic

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glaucoma update managing the glaucoma suspect when do i refer
GLAUCOMA UPDATEManaging The Glaucoma Suspect – When Do I Refer?



  • Glaucoma is the most common cause of irreversible blindness worldwide
  • Often bilateral and mostly asymptomatic
  • Early detection and intervention will reduce incidence of blindness and visual morbidity
  • Well established risk factors, clinical findings, investigations and treatments
glaucoma suspect
Glaucoma Suspect
  • Many people are labelled as Glaucoma Supects (GS)
  • Usually those with borderline IOP, family history or questionable disc/field changes
  • Aren’t enough eye doctors in the community to see them all
  • The optometrist is often the carer for the GS
  • Patients have faith in their healthcare providers and therefore we need to know how to manage and when to refer (this applies for all)
glaucoma suspects
Glaucoma Suspects
  • Is it acceptable to follow up GS with serial white on white fields?
  • Once a field defect is seen many nerve fibres have been lost (Klein et al.,IOVS 2004; 45:59-62)
  • Ideally, in the 21st century we need to aim to detect damage at preperimetric levels
  • Not always easy – compliance and cost issues, keeping up with technology
  • There are some simple and effective ways
who to screen
Who to screen?
  • Everyone?
  • Those with family history?
  • Raised pressure?
  • Those above 40?
  • All of the above

It doesn’t take a long time to look at a disc even through an undilated pupil

key questions
Key Questions
  • The optometrist is often the first port of call. Role as the eye GP?
  • Family history – blindness, laser/surgeries, eyedrops, glaucoma or ocular hypertension?
  • Isn’t always reliable
  • Disregard beyond two generations and beyond first cousins/ blood uncles and aunts
key questions8
Key Questions
  • Past ocular history?
    • Previous trauma
    • Previous LASIK / other laser surgery (PI/ALT), other incisional surgery and complications
    • Eyedrops
    • Refraction, amblyopia
key questions9
Key Questions
  • General Health
    • Asthma
    • Hypertension
    • Diabetes
    • Sleep Apnea
    • Migraine
    • Neurological problems (CVA, tumour) – can cause field defects
    • Medications – antidepressants, sulphonamides, steroids (inhaled, nasal, topical, systemic)
key questions10
Key Questions
  • Other risk factors
    • Age
    • Racial group
    • Consanguinity
    • Occupation
    • Driving
    • Cigarettes / alcohol
    • Living arrangements / carers
  • Aided and unaided VA
  • RAPD
  • CCT
  • IOP (Goldmann applanation). Diurnal?
  • AC depth (Van Herrick > ¼ cornea thickness). Gonioscopy ?
  • Iris heterochromia, PXF, PDS
  • Look for laser iridotomy, iridoplasty, PS, Glaukomflecken, cataract (phacomorphic)
  • DILATE (very, very small risk of AAC)
  • Central corneal thickness (CCT) measurements must be performed in all glaucoma suspects. Those with thinner corneas (<500 microns) have a greater risk of glaucoma development and progression (OHTS Study).
  • Which method?
    • NCT
    • Applanation
    • Tonopen
    • Percussion
  • Artifacts – lid pressure, breath holding, upgaze, lash, blepharospasm, too much fluorescein, astigmatism, corneal scar, nystagmus
  • At what level is treatment mandatory?
  • There are a large percentage (30% at least) of patients who have glaucoma with normal pressures (NPG). In some populations (Japan, Korea) NPG incidence is 2-3 times POAG.
  • The end organ damage is the same (disc cupping) but the natural history and prognosis may differ. There is a stronger association with vascular disorders ( migraine, nocturnal hypotension, Raynauds disease)
ocular hypertension
Ocular Hypertension
  • Ocular hypertension when IOP > 21mmHg
  • The most significant risk factor for glaucoma development
  • Different techniques/examiners can get differing IOP
  • OHTS looked at people with IOP 24-32
  • Probability of progression in the treated group (4.4%) was half that of observation group (9.5%) at 5 years
  • 90% didn’t progress at 5 years
  • Role of corneal thickness
does lowering iop help
Does lowering IOP help?
  • No evidence until late 1990’s
  • Early Manifest Glaucoma Trial (EMGT)
  • Compared immediate treatment v no or delayed treatment on newly diagnosed POAG patients
  • Treated group had less frequent and later progression at 6 years
  • High IOP risk of vascular occlusions
  • Disc size – must identify the limits of the disc
  • C/D
  • Notching? General rim thinning? ISNT rule
  • PPA?
  • Pallor? Colour?
  • Disc haem?
  • RNFL defects
  • Other disease – lid height, ARMD, DR, peripheral retina abnormalities, RP, Laser scars, disc drusen, tilted discs, disc pits
  • Alpha and beta
  • Alpha in most normals – hyper and hypopigmetation of RPE
  • Beta more in glaucomas – atrophy of RPE and choriocapillaris
  • Alpha more peripheral if both present
  • Extent of beta corresponds with extent of rim loss
  • Disc photography (stereo?) – simple, cheap and very effective. Give patient a copy!
  • Field (SAP, FDT, SWAP ) - subjective, time consuming, late diagnosis
  • OCT / HRT / GDx – expensive, useful for progression?
visual fields
Visual Fields
  • Patients hate fields (nearly as much as puff tonometry)
  • Many differing machines and strategies
  • Get familiar with your machine, its limitations and the artifacts that come up
  • Know how to do your own fields or delegate to someone trained in them
  • Explain and instruct the test to patients (will not see every spot, may be gaps)
visual fields27
Visual Fields
  • Don’t set the patient up and then leave, get coffee, make phone calls.
  • Quiet and dark room
  • Let patients know that they can stop and restart. Make sure they are comfortable
  • Let them know that all doesn’t depend on one field test (may need 3 or 4 before a pattern is identified. A learning effect will be seen)
  • If they are tired, sleepy, not well or anxious then do it another day
visual fields28
Visual Fields
  • Is it reliable? (correct patient, age, refraction, eye)
  • Test duration?
  • Is it reproducible?
  • Does it match the disc?
  • Does it look like glaucoma? Follow NFL pattern?
  • Make sure you are comparing tests of the same strategy (SITA Fast v Standard, 24-2 v 10-2 or 30-2)
  • Look for artifacts- lid, lens rim, pupil size, cataract
oct in glaucoma
OCT in Glaucoma
  • Most recent addition in disc and RNFL imaging
  • Many now using it to image the disc and RNFL
  • RNFL loss often precedes cupping
  • Will detect damage before SAP (or FDT- Brusini P, Eye 2007 Feb)
  • How useful is/will it be to detect change in the RNFL thickness ?
fast rnfl analysis
Fast RNFL Analysis

Three 3.4mm diameter circle scans in 1.92 secs allow all retinal nerve fibres to be imaged

Acquires 768 A-scans 3* 256 A-scans per circular scan