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The Essentials for Paraoptometric Personnel in Understanding Medical Optometry. Jeff D. Miller, O.D. Stillwater, Oklahoma [email protected] Baby Boomers. Approximately 80 Million 7,918 people turn 60 each day in 2006 That’s 330/hour

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The essentials for paraoptometric personnel in understanding medical optometry

The Essentials for Paraoptometric Personnel in Understanding Medical Optometry

Jeff D. Miller, O.D.

Stillwater, Oklahoma

[email protected]


Baby boomers
Baby Boomers

  • Approximately 80 Million

  • 7,918 people turn 60 each day in 2006

  • That’s 330/hour

  • Every day until 2014, 10,000 Americans turn 50

  • 1/8 Americans are 65 or older


Health of americans
Health of Americans

  • Diabetes –epidemic in children

  • HTN – steep rise

  • CVD – linked w/HTN

  • Obesity – 15% in 1980 - 33% in 2004

  • Obesity doubles the risk of vision loss AMD, Glaucoma, Cataracts, Diabetes


Ocular disease today
Ocular Disease -TODAY

  • Diabetic Retinopathy is the leading cause of blindness ages 25-74

  • AMD is the most common cause of blindness in Americans 60 and older

  • Cataracts are the leading cause of blindness in the world


Ocular disease today1
Ocular Disease-TODAY

  • Glaucoma – 2.2 million cases diagnosed, 2 million undiagnosed

  • 1 Million blind, 2.4 million visually impaired (2/3 are female)

  • By far the most common ocular disorder:

    “Ocular Surface Disease” or OSD


Ocular disease estimates in the year 2020
Ocular Disease Estimates In The Year 2020

  • NEI Eye Prevention Research Group

  • Diabetic Retinopathy – 50% increase

  • AMD – 70% increase

  • Glaucoma – 3.36 million – 53% increase

  • Legal Blindness – 70% increase

  • In 2036 all today’s numbers will double


Remember of the eye diseases we are covering today they represent
REMEMBER- OF THE EYE DISEASES WE ARE COVERING TODAY THEY REPRESENT:

A. THE LEADING CAUSE OF BLINDNESS IN THE USA

AGES 25-74.

B. THE LEADING CAUSE OF CENTRAL VISION LOSS IN

PATIENTS OVER 60

C. THE SECOND LEADING CAUSE OF PREVENTABLE

BLINDNESS IN THE USA (CATARACTS ARE FIRST)

AND THERE IS NO WAY TO TELL YOU HAVE THEM BASED ON THE WAY YOU FEEL! THEY ARE ONLY DETECTABLE THROUGH AN EYE HEALTH EVALUATION


Glaucoma
GLAUCOMA REPRESENT:

  • Glaucoma is a group of diseases that can damage the eye’s optic nerve and result in irreversible vision loss and blindness.

  • Glaucoma is multifactorial – it is not a single disease process. Rather it is a large group of disorders.

  • The term glaucoma should only be used in reference to the entire group of disorders, just as the term cancer is used to encompass many clinical entities with certain common denominators.


Glaucoma1
GLAUCOMA REPRESENT:

  • The common denominator in glaucoma is optic nerve damage/death which derives from various risk factors.

  • Glaucoma is the leading cause of preventable blindness in the US.

  • There are several forms of glaucoma, the most common is Primary Open Angle Glaucoma or POAG.


Forms of glaucoma
Forms of Glaucoma REPRESENT:

  • POAG, Primary Open Angle Glaucoma

  • LTG or NTG, Low Tension or Normotensive Glaucoma

  • Angle Closure Glaucoma

  • Congenital Glaucoma

  • Secondary Glaucoma’s – Pigmentary Glaucoma, Neovascular Glaucoma, and Inflammatory or Uveitic Glaucoma, Angle Recession Glaucoma


Risk factors for glaucoma
Risk Factors for Glaucoma REPRESENT:

  • Intraocular Pressure, IOP

  • Genetics - Family History

  • Age (increases after 40yrs and 60 yrs)

  • Race (African American, Hispanics)

  • Gender (men or women?)

  • Diabetes Mellitus

  • Cardiovascular Disorders

  • Obstructive Sleep Apnea


Glaucoma diagnosis
Glaucoma Diagnosis REPRESENT:

  • Traditionally: IOP, optic nerve changes, visual field defect – treat or monitor.

  • Risk factors are better known today and play a large role in treatment initiation.

  • Today’s technology also allows much earlier diagnosis and treatment initiation through various tests/technology:IOP, stereoscopic optic nerve evaluation, optic nerve topography, nerve fiber layer analysis with scanning lasers and OCT, central corneal thickness, gonioscopy, Visante OCT, blood flow analysis, and visual fields.


Diagnosis
Diagnosis REPRESENT:

  • IOP – “normal” 10-22mmHg

  • Remember LTG or NTG, IOP appears

    in the normal range

  • ONH evaluation –characteristic changes

  • CCT - central corneal thickness obtained via pachymetry - normal is 555 microns

  • Gonioscopy – evaluates where the aqueous fluid drains

  • Nerve Fiber layer Analysis: GDx VCC, HRT II and III, OCT (i.e.Stratus,Cirrus)

  • Visual Fields


ONH EVALUATION REPRESENT:

Normal Healthy Optic Nerve




SUSPICIOUS ONH REPRESENT:


GLAUCOMATOUS REPRESENT:




EMGTS-patients with exfoliation or recurrent disc hemorrhage may have worse prognosis and need greater tx and closer observation.

CNTGS-”strongly predictive of disease progression”

OHTS-detection of disc hemorrhages-84% were detected only by photos 16% by exam and photos. Increased risk of glaucoma development found however, 86.7% w/disc hem have not converted to glaucoma.


Grading cup to disc ratio may have worse prognosis and need greater tx and closer observation.


Optic nerve head analysis

Key parameters are Horizontal Integrated Rim Volume* and Cup/Disc ratios

Yellow line on composite diagram indicates individual radial scan selected and displayed

Fundus image for verification of scan placement

Optic Nerve Head Analysis

Disc edge is determined by the end of the RPE -shown by blue marker

*Comparison of three optical coherence tomography scanning areas for detection of glaucomatous damage. Wollstein G, Ishikawa H, Wang J, Beaton SA, Schuman JS. Am J Ophthalmol. 2005 Jan;139(1):39-43


xxx Cup/Disc ratios


Cct central corneal thickness
CCT-Central Corneal Thickness Cup/Disc ratios

  • Ultrasound Pachymetry (sound waves)

  • Visante OCT Pachymetry (light waves)

  • Ocular Hypertensive Treatment Study

    OHTS – CCT can suggest/determine risk

    >588 microns (low risk)

    =555-588 microns (mod. risk)

    <555 microns (high risk)


Gonioscopy
Gonioscopy Cup/Disc ratios


Virtual gonioscopy
Virtual Gonioscopy Cup/Disc ratios



Retinal nerve fiber layer
Retinal Nerve Fiber Layer Cup/Disc ratios


GDx VCC Printout Cup/Disc ratios

Glaucoma

Normal

Fundus Image

Parameters

Thickness Map

Deviation Map

TSNIT Graph

Comparisons of each scan to the Normative Database allows accurate and rapid interpretation in one exam


Correlation of the Deviation Map and Thickness Map with Visual Field Pattern Deviation

is shown below

These are examples from normal to advanced glaucoma

  • A normal eye with normal thickness and deviation maps and normal visual field

  • An eye with focal Retinal Nerve Fiber Layer loss prior to visual field loss

  • A moderate glaucoma eye with superior RNFL loss and inferior visual field loss

  • An advanced glaucoma eye with advanced RNFL and visual field loss


Cirrus™HD-OCT Visual Field Pattern Deviation

Stratus OCT™


Glaucoma rnfl thickness analysis
Glaucoma – RNFL Thickness Analysis Visual Field Pattern Deviation

An OU analysis example (2)


Visual fields
VISUAL FIELDS Visual Field Pattern Deviation

  • Helps to confirm a definitive diagnosis of glaucoma.

  • Determines the degree of vision loss associated with glaucoma.

  • Helps to monitor the progression of the disease and determine treatment strategies and if the medications and/or surgeries are working.


Treatment

Treatment – ultimate goal is to lower IOP by reducing Visual Field Pattern Deviation

the production of the fluid in the eye or increasing the

outflow of the fluid (Aqueous)

Medical Treatment

Topical Glaucoma Drops

Various Classes: reduce aqueous production or

increase aqueous outflow

Neuro-protection (now and future)

Blood flow enhancers (future)

Timoptic, Betimol, Betagan, Betoptis S, Azopt, Trusopt Travatan, TravatanZ, Lumigan, Xalatan, Alphagan, Alphagan-P, Cosopt, Combigan, Pilocarpine

What about oral meds ? (Diamox, Neptazane)

Treatment


Surgical treatment
Surgical Visual Field Pattern DeviationTreatment

  • Laser treatment: The laser treats the tissue that the aqueous fluid drains through such that it opens or “cleans” it out increasing drainage ALT - Argon Laser Trabeculoplasty

    SLT - Selective Laser Trabeculoplasty

  • Other Lasers

  • Trabeculectomy - creates drainage canal

  • Glaucoma valve – creates drainage canal


Glaucoma management
Glaucoma Management Visual Field Pattern Deviation

  • Once diagnosed patients should be monitored on a quarterly basis for IOP and yearly (at minimum) for changes in VF, optic nerve, nerve fiber layer damage and gonioscopy.

  • The more advanced the more often VF, and other testing should be performed.

  • Glaucoma suspects should be monitored yearly or on a 6 month basis depending on their findings and other health issues.


GLAUCOMA Visual Field Pattern Deviation

QUESTIONS ?


Macular degeneration
MACULAR DEGENERATION Visual Field Pattern Deviation

  • Leading cause of severe irreversible central vision loss and legal blindness in individuals 60 and older in the US.

  • Predominantly Caucasian (Hispanics on the rise)

  • Approximately 30% of those over 75 have early AMD

  • 23% of the remainder of those will develop it with

    in five years

  • By 2020 the incidence is estimated to rise by 70%

  • By 2036 all today’s numbers will double (Baby Boomers)


Macular degeneration two forms
Macular Degeneration- Two Forms Visual Field Pattern Deviation

  • Non-neovascular, dry or atrophic

    macular degeneration

  • Neovascular, wet or exudative

    macular degeneration


Dry or atrophic macular degeneration amd
Dry or Atrophic Visual Field Pattern DeviationMacular Degeneration-AMD

  • The retina is 10 layers thick. The last layer is called the RPE - Retinal Pigment Epithelium

  • The RPE is responsible for providing nourishment to the retinal visual cells and maintains the retinal environment

  • If the RPE is sick or damaged the retina degenerates

  • AMD is characterized by abnormalities in the retinal pigment epithelium (RPE) with drusen formation

  • Drusen are tiny white or yellow accumulations in Bruch’s membrane, a membrane between the final layer of the retina (RPE) and its blood supply in the choriocapillaris.


Wet or exudative macular degeneration
Wet or Exudative Visual Field Pattern DeviationMacular Degeneration

  • The wet form of AMD is defined by the appearance of “new” blood vessel growth, neovascularization, originating in the layer below the retina called the choricapillaris.

  • These new blood vessels are abnormal and leak fluid and blood into the subretinal space causing disruption of the RPE with subsequent fibrosis and scarring

  • The damage to the RPE is irreversible


Macula Visual Field Pattern Deviation


### Visual Field Pattern Deviation


RNFL Visual Field Pattern Deviation

RGC

Rods & Cones

Retinal Anatomy

RPE


Cirrus HD-OCT Healthy Macula Visual Field Pattern Deviation

NFL

ILM

GCL

IPL

INL

OPL

ONL

ELM

IS

IS/OS

OS

RPE

Choroid

NFL: Nerve Fiber Layer OPL: Outer Plexiform Layer IS/OS: Junction of inner and outer

ILM: Inner Limiting Membrane ONL: Outer Nuclear Layer photoreceptor segments

GCL: Ganglion Cell Layer ELM: External limiting membrane OS: Photoreceptor Outer Segment

IPL: Inner Plexiform Layer IS: Photoreceptor Inner Segment RPE: Retinal Pigment Epithelium

INL: Inner Nuclear Layer


Diagnosis1
DIAGNOSIS Visual Field Pattern Deviation

  • Primarily observation

  • Patients must be seen yearly for eye health exams

  • Retinal evaluation with various lenses and photographic devices

  • OCT/HRT scans (Stratus,Cirrus,HRT-II,III)

  • Fluorescein Angiography (RSFA)

  • Macular pigment optical density


DRUSEN Visual Field Pattern Deviation


Drusen and RPE Changes Visual Field Pattern Deviation


Drusen and RPE Changes Visual Field Pattern Deviation


SOFT DRUSEN Visual Field Pattern Deviation


FLOURESCEIN ANGIOGRAPHY- RSFA Visual Field Pattern Deviation


xx Visual Field Pattern Deviation


DRUSEN Visual Field Pattern Deviation


DRUSEN WITH PROGRESSIVE Visual Field Pattern Deviation

RPE DISRUPTION/DROPOUT


RSFA OF DRUSEN AND Visual Field Pattern Deviation

RPE CHANGES


EXUDATIVE OR WET Visual Field Pattern Deviation

MACULAR DEGENERATION


WET AMD Visual Field Pattern Deviation


RSFA OF WET Visual Field Pattern Deviation

MACULAR DEGENERATION


WET OR EXUDATIVE Visual Field Pattern Deviation

MACULAR DEGENERATION


EXTENSIVE WET Visual Field Pattern Deviation

MACULAR DEGENERATION


Macular pigment
Macular Pigment Visual Field Pattern Deviation


Risk factors
RISK FACTORS Visual Field Pattern Deviation

Diets high in antioxidants and lutein have been shown to have a positive effect on controlling the formation and advancement of dry AMD

  • Age

  • Smoking

  • Family History

  • Exposure to UV (sunlight)

  • Females

  • Caucasian

  • Hyperopia

  • HTN

  • Diabetes

  • Cardiovascular Risk Factors

  • High Fat Intake

  • Diets with foods that have a high glycemic index, refined sugars starchy foods “the white stuff”


Atrophic and exudative macular degeneration patient education
Atrophic and Exudative Visual Field Pattern DeviationMacular DegenerationPatient Education

  • The leading cause of blindness in people over 60

  • To avoid: don’t smoke, UV protection, diet high in lutein/antioxidants

  • Carrots vs. broccoli, peas and spinach

  • Dry accounts for 90%, Wet 10%

  • “New abnormal blood vessels” – CNV membranes, grow at a rate of 20 microns/day

  • Wet AMD patients prompted to seek exam when membranes are on avg. 3300 microns


Lutein concentration mcg 100g

Kale 39,550 Visual Field Pattern Deviation

Turnip Gr. 12,825

Spinach 12,198

Mustard Gr. 9,900

Collard Gr. 8,932

Green Peas 2,477

Brussel Sprouts 1,819

Broccoli 1,403

Yellow corn 764

Asparagus 710

Green Beans 640

Artichokes 464

Red Cabbage 329

Tomatoes 123

White Onion 5

Lutein Concentrationmcg/100g


Injections for exudative amd
Injections for Exudative AMD Visual Field Pattern Deviation

  • Block Vascular Endothelial Growth Factor – Anti-VEGF drugs stop the growth of neovascularization in and beneath the retina restoring vision in many cases. Prior to 2005 these drugs were not available and most with wet macular degeneration lost significant vision if laser treatment was not an option.

  • Lucentis $1500 to $ 2500 per injection

  • Avastin $70 to $400 per injection


Amd cataracts and carbohydrate consumption
AMD/Cataracts and Visual Field Pattern DeviationCarbohydrate Consumption

  • Carbohydrates – high glycemic index

  • American Journal of Clinical Nutrition – followed 1036 women over 10 years. Carbohydrate intake directly correlated to incidence of early AMD.

  • Dietary glycemic index was also linked with higher incidence of cataracts.


Amd cataracts and carbohydrate consumption1
AMD/Cataracts and Visual Field Pattern DeviationCarbohydrate Consumption

  • Annals of Internal Medicine – Study demonstrated women with early AMD were twice as likely to suffer a stroke vs. those who didn’t have AMD.

  • This finding was noted after factoring out smokers, Diabetics, and HTN patients.


MACULAR Visual Field Pattern Deviation

DEGENERATION

QUESTIONS ?


Diabetic eye disease
DIABETIC EYE DISEASE Visual Field Pattern Deviation

  • DIABETES IS THE LEADING CAUSE OF NEW BLINDNESS IN THE US AGES 25-74.

  • Accounts for 5800 new cases a year of legal blindness.

  • Approximately 25% of diabetics have some degree of retinopathy.

  • A significant increased risk of cataracts and glaucoma is seen in patients with both Type I and Type II diabetes.

  • At minimum, a diabetic should be seen yearly for a full eye health exam.


Diabetic eye disease1
DIABETIC EYE DISEASE Visual Field Pattern Deviation

  • The prevalence of retinopathy increases with the duration of diabetes and in those with uncontrolled blood sugar.

  • Patients are usually spared of diabetic retinopathy for

    3-5 years following the onset of the disease.

  • Diabetic retinopathy is broadly classified as nonproliferative and proliferative diabetic retinopathy – NPDR, PDR.

  • NPDR – bleeding and exudates (by-products) present in the retina

  • PDR – the growth of “new and abnormal” blood vessels or neovascularization


Diabetic eye disease2
DIABETIC EYE DISEASE Visual Field Pattern Deviation

  • Macular Edema – diabetic cystoid macular edema (DCME) can occur in any stage of retinopathy and results in decreased visual acuity.

  • Retinal treatment other than diet, oral meds and insulin is considered when patients have NPDR with clinically significant DCME to avoid permanent vision loss and progression to PDR


Treatment1
TREATMENT Visual Field Pattern Deviation

  • Control of blood sugar is always paramount; daily evaluation as well as regular Hemaglobin A1C.

  • Laser Treatment:

    Macular Grid - for Diabetic Cystoid Macular Edema (DCME)

    Pan-Retinal Laser Photocoagulation –

    or “PRP” to prevent or treat PDR which is characterized by the growth and extension of new blood vessels in the retina and vitreous.


NONPROLIFERATIVE DIABETIC RETINOPATHY - NPDR Visual Field Pattern Deviation


NPDR Visual Field Pattern Deviation


NPDR Visual Field Pattern Deviation


NPDR Visual Field Pattern Deviation



PROLIFERATIVE DIABETIC RETINOPATHY COTTON WOOL SPOTS (CWS)





PAN-RETINAL PHOTOCOAGULATION NEOVASCULARIZATION ELSEWHERE

“PRP”


RETINAL FIBROSIS NEOVASCULARIZATION ELSEWHERE


RETINAL FIBROSIS NEOVASCULARIZATION ELSEWHERE



RETINAL DETACHMENT NEOVASCULARIZATION ELSEWHERE


Patient management
PATIENT MANAGEMENT NEOVASCULARIZATION ELSEWHERE

  • Diabetics should be examined yearly at minimum.

  • Visit schedule should be adjusted when patients are suspect for progression of retinopathy and or Diabetic Cystoid Macular Edema (DCME).

  • Photodocumentation, IOP checks, retinal imaging (OCT, HRT), and gonioscopy should all be considered based on the patients clinical presentation.

  • Education should include other ocular complications; glaucoma and cataracts.


DIABETIC EYE DISEASE NEOVASCULARIZATION ELSEWHERE

QUESTIONS ?


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