206- Comer - Glau Case Challenges [Read-Only] Comer - Glau Case Challenges [Read...Glaucoma Case Challenges George W. Comer, OD, ... To check for post-dilated IOP spikes & to have

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Glaucoma Case Challenges

George W. Comer, OD, MBA SCCO at M.B. Ketchum University

DisclosuresGeorge Comer, OD, MBA

SCCO at M.B. Ketchum University

Research funding from TopconResearch funding from OptovueResearch funding from Heidelberg Instruments

SCCO

MT 11/4/2015Followed for diabetic ret, AMD. Does he have glaucoma too?

• 59 A (Japanese) m • C/o of blurred vision distance, constant. No

fluctuation from day to day. • POHx: Being followed by OMD for diabetic

ret and AMD x 3, last exam 4 or 5 months ago there – no diabetic ret, took ret photos. Cryo OS x 2 in 2005 for diabetic ret?

• PMHx: DM since 1999 Ha1c: 7.9, last FBS: 180, hypercholesterolemia, thyroid disease

SCCO

MT 11/4/2015• Meds: Crestor, Lotrel, Lansoprazole

Metformin, Novolog, Synthroid• CT: Dist: Ortho Near: 18 ILXT• Manifest: OD: -9.25 -1.00 x 162 20/20

OS: -7.75 -0.75 x 120 20/30++ PH no improvement

• NCT: 22, 21, 22/20, 22, 24 1:50 • BP: 140/80 1:55 Pulse: 69• Color vision: HRR Plates OD: 6/6 OS: 6/6• VF screening: see FDT printout• SLE: 1+ NSC OU, mild ant cortical vacuoles

SCCO

MT 11/4/2015FDT C20-5 screening

SCCO

FDT Interpretation Considerationsfor MT OD

• 2nd eye tested often has misses – “2nd eye artifact”

– Strategy: Give the pt a brief (seconds) rest & test again

– But this (OD) is the first tested eye! • If head is positioned too high the upper row

of test points is not visible to patient. Hard to see this on FDT because you cannot see the pt’s eye during the test. Easy to see on Matrix video eye monitor. Retest if this is a possibility.

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SCCO

Why Run the Screening VF Again?

• Screening is very rapid way to confirm or rule out VF loss, much more rapid than a threshold test.

• Screening is much easier to interpret than threshold VFs

• Screening has much better specificity than threshold VFs

If not sure then quickly rescreen the VF. If true VF loss is likely then look at ONH, RNFL for correlating damage. Structural damage usually precedes VF loss. SCCO

MT 11/20/2015 OD ONH photosAnalyze inf rim carefully

Note inf peripapillary atrophy

SCCO

MT 11/4/2015• C/D: OD: .7 x .7 shallow broad inf notch

OS: .6 x .6 round cup• Few dot hemes OU• RPE mottling OU; possible CSME OS Assessment:• Glau suspect • Mild NPDR with possible CSME OS • Mild NSC & ant cortical changes OU• Myopia, astigmatism, presbyopia

SCCO

MT 11/4/2015

Plan: • Advised glau work-up: HFA 24-2, OCT

(92133), CCT, Pascal DCT, gonio • Macular OCT (92134) OS to assess

possibility of CSME• Report to PCP • Monitor cats • Spec Rx

SCCO

MT 11/20/2015 Glau EvalIOPs:• NCT: 16, 17, 18/ 19, 20,18 11:15 am predilated

• GAT: 16/16 12:05 postdilated• DCT: 19.4/22.2 12:10 postdilated (Q: 1 OU) CCT (Reichert IOPac): OD: 597µ OS: 605µ HFA 24-2: • OD: 8 point cluster - sup arcuate scotoma• OS: Mild gen depression, no focal VF loss Avanti OCT: see printouts Gonio: Open to CBB 360° OU, minimal TM pig

SCCO

Tonometry & CCT ConsiderationsWhy 3 different tonometers?• Why do NCT?

Does “not mess” with the cornea. We prefer it for IOPs prior to imaging (OCT, photos, HRT etc)

• Why do GAT post-dilated? To check for post-dilated IOP spikes & to have GAT for medico-legal purposes

• Why do Pascal DCT? Due to thick CCT. Important: Thick CCT does not necessarily mean false high IOP on applanation tonometers

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SCCO

MT 11/20/2015HFA 24-2

ODDoes this correlate to the FDT VF?Should this 24-2 be repeated? Does it correlate to the clinical ONH/RNFL evaluation?

SCCO

MT 11/20/2015OCT OU

OD RNFL: Abnormal (p<1%) sup temp, infnasal. Borderline inftemp sectorOD GCC: Large area of p<5% inferior OD: OD>OSOS: Normal RNFL & GCC

SCCO

MT 11/20/2015HRT OU

OD MRA: All ONH sectors abnormal (p<0.1%) except temp. OD Large cup with significant asymmetry OD>OS though asymmetric ONHsOS MRA: Borderline (p<5%) both inf nasal sectors

SCCO

Imaging Issues • Is imaging necessary for the diagnosis in

this case?No

• What is the value of imaging in this case? Assists your clinical eval in structural assessmentFor tracking for progression

• Could a patient have glaucoma yet have normal imaging?

With spectral domain imaging and ganglion cell imaging it is unlikely but could happen.

SCCO

MT 11/20/2015 CCT/IOP Considerations

• CCT is “high” in both eyes. Yet Pascal DCT reads higher than GAT or NCT, particularly in OS? Why does DCT read higher in a thick cornea?! What is the value of “adjusted IOP”?

SCCO

MT 11/20/2015 Decisions • Does MT have glau? • What evidence for glau? What evidence

against glau dx? • If glau what target IOP? • Would you initiate treatment on one eye or

both?• If glau what initial med(s)? • Would you consider a combo such as

Cosopt, Combigan or Simbrinza?

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SCCO

MT Diagnostic Considerations

Does MT have glau? What evidence for glau?

Sup arcuate - both FDT and HFA 24-2 ODClin ONH eval: shallow inf rim loss ODHRT: Sup and inf rim loss to p<0.1% ODOCT: Sup and inf RNFL loss to p<1% OD

All of the above correlate. Always check the ONH/RNFL clinicallyStructural damage plus correlating VF loss –compelling! SCCO

MT Management Issues

• If glau what type (POAG vs 2º glaucoma)? Need SLE and gonioscopy to differentiate.

• If glaucoma what target IOP? Stage the glaucoma then set target IOPFor stage consider all findings, particularly the VFs – moderate glaucoma by ICD 10 staging

• What target IOP?For initial 1st line med try to achieve 25 to 35% reduction

SCCO

MT 11/20/2015

Assessment:• Early POAG OD with VF loss sup• Mild NPDR & possible CSME OS • Mild NSC & ant cortical changes OU Plan: • Initiate topical med OD; f/u in 4 to 6 weeks

– Med to start? Start OD or OU??– Any topical glau meds contraindicated? – F/U in 4 to 6 weeks. Sooner?

• Macular OCT (92134) OS at f/u exam SCCO

MT Initiating Glaucoma Meds

What first line med? PG unless contraindicated or not allowed by insurance (name brand PG)

One eye trial in OD? Treat OD only? Or treat OU?

When it first f/u exam? At 4 to 6 weeks

SCCO

SELECTING THE INITIAL GLAUCOMA MEDICATION

• Target IOP & IOP lowering effect of various options

• Ease of use• Current systemic meds• Potential ocular and/or systemic

side effects• Specific

contraindication/considerations• Cost of med(s) SCCO

MT 1/20/2016

• 1st follow-up on glau med, Trav Z 1 gt OD hs• No dryness, little redness – “not bad”, no

other problems• Compliance reported as only 1 missed drop

every couple of weeks due to going to sleep while watching TV & forgetting the med

• GAT: 13/14 11:10 am

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SCCO

Management Considerations

How did Trav Z lower IOP in OS when it is used for OD only? What does equal IOP, though only OD is treated, suggest?

Must consider the possibility of diurnal IOP variation OU (Trav actually did not lower it in OD) or asymmetric IOP variation

What is the appropriate management at this point?

Continue the Trav Z and follow up again SCCO

MT 2/27/2016

• Still taking Trav Z OD only. Last instillation was bedtime last night, 11:30 pm. No redness, dry eye or other problems.

• GAT: 13/18 12:15 pm • What is management now?

SCCO

WT 7/12/13Glaucoma suspect? Glaucoma? Something else?

• 73 y/o Hispanic male, retired • Referred as glaucoma suspect by PCP – large

C/Ds• PEHx: Prior OMD followed from 6/2010 to 8/2012

labeled him glau suspect due to large C/Ds but IOPs always <15. Normal HFA 24-2 VF. CCT: OD: 493 OS: 505 12/21/2010 Cat extraction with PC IOL OS 7/10/2012

• FEHx: Does not know FEHx• PMHx: Elevated cholesterol Current meds:

Lovastatin 40 mg/day• Allergies: none SCCO

WT 7/12/2013

• NCT: 12, 10, 15/ 10, 15, 13 1:22 pm • SLE: 2+ NSC, 2+ ant cortical OD, PC IOL

OS – clear, centered with capsulotomy. Angles ¼ OD and 1 OS.

• ONH: large ONH OU with large shallow C/Ds of about .75 x .75 OU

• No apparent RNFL defects, no Drance heme. 360º PPA OS, possible pallor OS

SCCO

WT 7/12/2013

• VF: HFA 24-2 OU – OD: Questionable reliability- increased fix

losses. No VF loss– OS: Possible sup paracentral scotoma

• HRT: See slide• RTVue OCT: see slide • Gonio after dilation:

OD: open to CBB inf with 2+ TM pig, open to TM in all other angles OS: open to CBB in all angles with 2+ TM pig

SCCO

WT HFA 24-2 OU 7/12/13

•

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SCCO

WT7-12-13

HRTOUReport

SCCO

ColorWT7-12-13

RTVueOCT

SCCO

WT 7/12/2013 Management Assessment:• 2+ NSC, 2+ ACC OD – BCVA: 20/30 • Glau suspect based on large C/Ds, very

suspicious HRT & RTVue. But low IOPs and good VFs

Management: • Get records from OMD who saw him 2010

to 2012 – progression? • Re-evaluate IOPs in 3 months • Re-evaluate VFs, imaging in 6 months

SCCO

WT 10/10/2013

• GAT: 13 / 11 10:29 am • SLE: unchanged• ONH: no apparent change ; no Drance

heme• Old records show diagnosis of glau

suspect based on large C/Ds but no VF loss; no imaging

Management• Re-evaluate for progression in VFs, ONH,

RNFL or GCC in 3 months

SCCO

WT 12-21-2010 HFA VFs from Prior Eye Doctor

SCCO

WT 1/10/2014• No change in history• Pre-dilation NCT: 11, 13, 12/12, 13, 12 10:43

am• Post dilation GAT: 11 / 11 11:45 am • SLE: unchanged• ONH: no apparent change ; no Drance heme• VFs: HFA 24-2

– OD: Poor foveal threshold but no glau VF loss– OS: Poor foveal threshold; possible sup

paracentral scotoma – 2 point cluster– Suspect more VF loss – get FDT or Matrix

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SCCO

WT 1/10/2014

• HRT: see slide Baseline scan. Very suspicious but consider possibility of a false positive due to large ONH size.

• Cirrus OCT: see slide Baseline scan. Highly suspicious – inf arcuate RNFL loss with corresponding inf GCA loss OU

Need 3 scans for progression detection on either HRT or OCT

SCCO

Color WT HFA 24-2 OU 1/10/2014OS: possible sup paracentral scotoma

•

SCCO

WT1/10/14

HRTOUReport

SCCO

WT1-10-2014

RTVueOCT

SCCO

WT1/10/14

CirrusOCTONH & RNFL

SCCO

WT1/10/14

CirrusOCTGCA

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SCCO

WT 1/10/2014 Management

Assessment: • Mild NSC OD• Glaucoma suspect OU with very suspicious

structural findings (C/D, HRT, RNFL and GCA on Cirrus) but little to no VF loss OS only and normal VF. IOPs < 15 on all exams at UEC.

• Probable optic atrophy inf ONH OSManagement: • RTC in 1 week for serial tonometry, reclined

IOPs, ONH/RNFL photos, CCT, FDT screening SCCO

WT 1/17/2014

• NCT: 13, 13, 13/12, 12, 12 8:13 am• Tonpen sitting: 13/10 9:00 am• Tonopen reclined: 14/11 9:10 am• Pascal DCT: 16/15 9:15 am • NCT: 21, 20, 18 / 12,12, 12 12:00 pm • NCT: 12, 12, 14 / 10, 11, 12 2:05 pm • NCT: 12, 13, 12 / 10, 12, 11 4:15 pm

SCCO

Color WT ONH 50º Color OU

SCCO

WT ONH 50º Red Free OU

SCCO

WT ONH 30º Color OU

SCCO

WT1/17/2014

Matrix N 30-5 Screening

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SCCO

WT 1/17/2014

• CCT (IOPac): OD: 502 OS: 508• SLE: unchanged• ONH: no apparent change ; no Drance heme• VFs: Matrix N 30-5 screening VF

– OD: Sup arcuate with dense nasal step– OS: Incomplete sup arcuate with incomplete

dense nasal step• ONH/RNFL photos – see slides

SCCO

WT 1/17/2014 ManagementAssessment: • OA OS inf ONH – old AION? • IOPs low teens but in mid-teens OU with

Pascal DCT and spiked in OD only at noon• No IOP change when reclined• Deep sup nasal step OU on Matrix VFsPlan: • Rule out systemic causes of OA OS -

Westegren ESR, CRP, VDRL, FTA ABS, ANA, CT

• Initiate Trav Z OU hs and RTC in 1 month

SCCO

Might cat extraction be an option for WT OD?IOP Lowering with Phaco

• Generally accepted that phaco lowers IOP• Greater IOP-lowering for higher pre-surgical

IOPs and possibly greater for narrower pre-surgical angles

• Duration of IOP-lowering is not well defined OHTS showed a very slow IOP increase post-op, about 0.05 mmHg/monthLarge study on normal and oc hypertensives showed no significant change over 4.5 years post-op

Mansberger SL et al. OHTS Group. Ophthalmology 119:1826-31, 2012Poley BJ, Lindstrom RL et al. J Cataract Refract Surg 34:735-742, 2008. SCCO

IOP-LOWERING EFFECT OF PHACOTwo factors: Initial IOP effect, Duration

Initial IOP-lowering was proportional to pre-op IOP – greater at higher IOPsPoley BJ, Lindstrom RL et al. J Cataract Refract Surg 34:735-742, 2008.

IOP-lowering appears to last well out to at least 3 years post-op; much longer in Poley’s studyMansberger SL et al. OHTS Group. Ophthalmology 119:1826-31, 2012

SCCO

WT KEY POINTS• RNFL loss & VF loss are not specific to

glaucoma; ONH changes are • Always consider the possibility of a non-

glaucomatous cause • Evaluate the ONH rim tissue for pallor to

find and differentiate non-glaucomatous from glaucomatous

• Try to correlate ONH changes to the RNFL loss &/or VF loss

SCCO

LR 5/15/13IOPs Gone Wild!!!

• 56 y/o Hf, realtor• ECC patient since 9/2003• PEHx: On glau meds since 8/1984; Pilo then T1/2• Started on Travatan OU in 2001; switched to

Lumigan 0.3% in mid 2012• FEHx: Strong FHx of glaucoma on father’s side:

paternal grandfather, father, aunt (father’s sister) & others

• PMHx: Asthma – “rather severe” in childhood• Current meds: 0.1% Alphagan P OU q12h x 9

days (switched from Lumigan) • Allergies: sulfa meds, erythromycin

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SCCO

LR 5/15/13• Recent glaucoma meds as of 5/2013:

– Lumigan 0.3% - fair IOP control (low 20s) but not available in US as of 1/1/2013 so d/ced in 12/2012

– Lumigan 0.1% - d/ced 4/1/2013 due to inadequate IOP control (low to mid 20s)

– Travatan Z – d/ced 5/6/2013 due to inadequate IOP control (mid 20s)

– Alphagan – 1 gt OU q12h started 5/6/2013

SCCO

LR 5/15/13, continued• Complains of prolonged (1+ hour) blur

after instillation of Alphagan – both morning and night (q12h schedule).

• NCT: 26, 26, 28 / 28, 28, 28 at 2:47 PM

• Last Alphagan at 7:30 am (7+ hours ago)

SCCO

LR 5/15/2013 Questions• Based on the history what meds are

contraindicated?• Which prostaglandins (PG) have we not

yet used and are they worth a try? • If we are trying to maintain a one

med/one drop/day schedule what are the options?

• Which med class(es) have we not yet tried and are they worth a try?

SCCO

SWITCHING FROM ONE PG TO ANOTHER PG?

• Can it work? Yes, sometimes • Why? Individual variations in PG

receptors• Most common switch is Xalatan or

Travatan to Lumigan• Would adding a PG to a PG work? No,

IOP may rise, probably will not fall. PGs should be used once/day.

SCCO

LR - Other Info• C/Ds: OD: .4 rd OS: .4 rd• No clinically apparent RNFL loss • Pachymetry: Reichert IOPac

OD: 539 µ OS: 541 µ • Pascal DCT tonometry on 5/6/13:

OD: 24.5 mmHg, OPA 1.8, Q=3OS: 22.5 mmHg, OPA 1.8, Q=3

(GAT: 24/24 on 5/6/13)• Gonio: CBB, 1+ TM pig, flat angle

approach in all quadrants• BP: 118/84, pulse 70

SCCO

LR HFA GPAOU

GPA4/2004 to

4/2013

Normal24-2 OU

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SCCO

LR4-1-2013

HRTOUReport

SCCO

LR4/1/13

RTVueGCC scan

SymmetryPrintoutOD: Normal RNFL. InfGCC loss

OS: Normal RNFL. Sup GCC loss. Note respect of GCC loss for temp raphe

SCCO

LR4/1/13

RTVueGCC Change Printout OD

SCCO

LR4/1/13

RTVueGCC Change Printout OS

SCCO

LR – Summary to 5/15/2013• IOPs variable and not well controlled recently

on multiple PGs and Alphagan as monotherapy• Pascal = GAT IOPs• VF very stable OU• OD: HRT change sup & inf with inf GCC loss

on OCT • OS: HRT repeatable x3 sup progression with

corresponding sup GCC loss on OCT showing possible progression

SCCO

LR – Management Options• Change to q8h schedule of Alphagan

Note that last IOPs on Alphagan were at 7 hours after instillation

• Switch to an alternative PG• Substitute a combo med for Alphagan• Re-initiate Lumigan or Travatan and add a

med to it. What add-on med? • SLT • Cat extraction- phaco – but no cataracts• MIG – but no cataracts• More invasive options – but much more risk

– Trabeculectomy or valve/stent – Ahmed valve etc

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SCCO

COMBO MEDS“Fixed combination meds”

• Cosopt (2% dorzolamide + 0.5% timolol)

• Combigan (0.2% brimonidine + 0.5% timolol)

• Simbrinza (0.2% brimonidine + 2% brinzolamide)

SCCO

COMBO MEDSPotential advantages

• Less drop adminstrations/day –better compliance?

• Two meds/one bottle – Less bottles to buy – lower cost?

One co-pay instead of two. – Less bottles to keep track of

• Less exposure to preservatives

SCCO

COMBO MEDSFixed combination meds containing a beta blocker

• Cosopt (2% dorzolamide + 0.5% timolol)

• Combigan (0.2% brimonidine + 0.5% timolol)

SCCO

CAUTIONS WITH COMBOS• Assure that both of the two components are

effective, only then Rx the comboDo not assume that each component works

• Watch the dosage frequency carefullyRx no more often than the component with the lowest dosage frequencyCosopt: Timolol can be used BID and Trusopt can be used TID but Rx Cosopt for no more often than BIDCombigan: No more often than BID due to the timolol.Simbrinza: FDA- approved for TID

SCCO

LR Pt Ed 5/15/2013• Patient desires to stay on a one med qd

schedule • Note med hx – sulfa allergies and asthma• Advised SLT + 1or 2 meds is best option –

however pt wishes to avoid the cost of laser

• Advised that 2 meds is possible option but our best monotherapy meds (PGs) have not controlled IOPs well – will likely need more invasive option, SLT

SCCO

LR 6/5/2013• Burning/stinging with Rescula has lessened

but worse than any other med she has used • NCT: 24, 23, 25/ 25, 24, 26 2:10 pm

Last Rescula at 7:30 am • Assessment: IOP control is not improved;

stinging and burning not subsiding. Need to switch meds.

• Management: Sustitute dorzolamide 1 gt q12h x 3 days then q8h with lid closure/punctal occlusion – try to minimize metallic taste. D/C if any allergic side effects in eye or rash.

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SCCO

LR 7/9/2013

• Retinal consult for atrophic holes • Has had HA on & off – feels that it is like the HA

she used to get with high IOPs many years ago• NCT: 33, 31, 33/ 34, 34, 35 1:21 pm

– Last dorzolamide at about 7:30 am today

• No treatment necessary for ret holes • Need IOPs down; see Dr. Comer soon and

consider SLT to control IOPs SCCO

How to Minimize Systemic Absorption & Systemic Side Effects

• Punctal occlusion• Hold eyes closed for at least 3

minutes after instillation, longer is better

• Instill at bed time – prolonged closed eye condition!

SCCO

LR 8/2/2013 • Follow-up for glaucoma; was out of country

on vacation for last 2 weeks• Much more HAs than she was having at retinal

consult – feels that it is like “the HA I used to get with high IOPs many years ago, in 1980s”

• NCT: 41, 42, 40/ 51, 50, 45 10:57 am – Last dorzolamide at about 7:00 am

• SLE: corneal clear, no KPs, no cell in AC• Gonio: Open to CBB 360 OU, 1+ TM pig• View of fundus clear, no Drance hemes or

change apparent SCCO

BIG IOPs! NOW WHAT? • Given the prior findings including gonio

what is the most likely cause of these high IOPs?

• What other condition should be ruled out? Hint: younger patients typically with intermittent high IOPs and often NO symptoms at all!?

• What is the management of these big IOPs?• If you use topicals what can you do to speed

and enhance the absorption of the drops?

SCCO

STRATEGY FOR SIGNIFICANTLY ELEVATED IOPs

Determine the cause:• Rule out angle closure – gonio• Rule out iritis and trabeculitis (HZV) • Rule out steroid response • Rule out secondary glaucomas such as

pigmentary and pseudoexfoliation • Consider wildly variable IOPs in POAG

– very common! SCCO

STRATEGY FOR SIGNIFICANTLY ELEVATED IOPs

• Slit lamp – for secondary glau and inflammatory signs

• Gonioscopy – view all angles carefully• Tonometry with GAT – touch the cornea!• 1 gt Alphagan followed by prolonged lid

closure – do not blink. Repeat in 15 to 20 minutes

• 1 gt timolol, prolonged lid closure • Check IOPs at 1 hour. Re-instill Alphagan.

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SCCO

Other Considerations

• Steroids - if significant cell in AC. This can happen in angle closure.

• Oral agents (Diamox) if very high IOP to speed IOP reduction

• Pilo if angle closure & IOPs are <50 mmHg

SCCO

LR 8/2/2013 Acute IOP Control

• Alphagan 1 gt OU at 11:15, 11:30, 11:45 • Timolol 1 gt OU at 12:30 • Advised to RTC in 1-1/2 hours (after

lunch) to recheck IOPs• GAT: 24/ 26 2:00 pm

Pt reports that HA is much better though not completely gone. Vision is blurry though clear cornea and media; pt feels that Alphagan causing the blur.

SCCO

LR 8/2/2013 Management• Advised that SLT + med is best option;

cannot keep IOPs down with any single med; may not be possible with 2 meds

• Pt wants to try 2 meds before going to SLT• Initiated Lumigan 1 gt OU hs + Timolol 1gt

qAM• Advised of significant potential for

exacerbation of childhood asthma – d/c immediately if any shortness of breath, wheezing, congestion in chest etc

• Advised that prolonged lid closure/punctalocclusion is necessary RTC in 1 week SCCO

HOW OFTEN ARE ADD-ON MEDS REQUIRED?

• OHTS ~ 45% required two or more meds

• CIGTS ~ 75% required two or more meds

Lichter PR. Ophthalmology, 108, 1943-53, 2001. Kass MA and OHTS Study Group. Arch Ophthalmol 128(3):701-13, 2010.

SCCO

ADD-ON MEDS – OPTIONSWhen 1st line med was a PG

• Beta blockers• Alphagan (brimondine)

– Alphagan P 0.1% or Alphagan P 0.15%

– Brimonidine 0.2% • Topical CAIs

– Trusopt (dorzolamide) – Azopt (brinzolamide)

• ResculaSCCO

WHAT IS THE BEST ADD-ON MED (ADDED to PROSTAGLANDIN)?

• Most common add-on is beta blocker• Best is probably topical CAI • Why?

– Almost equal IOP-lowering to beta blockers & alpha-2 agonist at peak, trough and in between

– Better night time IOP lowering than either beta blockers or alpha-2 agonists

– Side effects not significant e.g. taste disturbance

Tanna AP et al. Arch Ophthalmol 128:825-33, 2010Liu JH et al. Ophthalmology July 20, 2010 epub ahead of print Liu JH et al. Ophthalmology 116:449-54, 2010.

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SCCO

LR 8/16/2013• No HAs at all; no shortness of breath or

other respiratory symptoms suggestive of beta blocker side effect

• Reports “100%” compliance & holds lids closed for at least 5 minutes

• NCT: 20,22,24/19,19,23 11:01 am • No change in ant segment or ONH/RNFL • Advised that IOPs are lower but still not <20,

the target IOP. Will likely need laser; 2 meds probably not adequate

• Discussed potential side effects • RTC in if any HAs or in 3 mos to monitor SCCO

LR 12/13/2013• No HAs though mild HA today, thinks it

might be sinus; did not take a decongestant to avoid any effect on glau f/u exam

• No shortness of breath or other respiratory symptoms – no apparent beta blocker side effect

• Reports strict compliance & holds eyes closed at least 5 minutes

• NCT: 19, 20, 20/ 18,19,18 11:05 am • No apparent change in ant segment or

ONH/RNFL - no Drance heme, no RNFL defect

SCCO

LR IOPs 5/2010 to 12/2013

SCCO

LR 12/13/2013• HFA 24-2: No VF loss and no progression

on GPA – VFI trend is flat with no progressing points

• HRT: see slides • RTVue: see slides• Management:

– Advised that IOPs are a little higher than desirable; strict compliance is necessary

– Continue Lumigan hs + Timolol qAM– Call if any HAs at all; IOPs can be highly

variable in glaucoma

SCCO

LR12-13-2013

HRTOUReport

SCCO

LR12-13-2013

HRTTCAOD

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SCCO

LR12-13-2013

HRTTCA OSRepeatable in inner wall of sup cup OS –probable earliest sign of progression SCCO

LR12/13/13

RTVueGCC

SymmetryPrintout

SCCO

LR12/13/13

RTVueGCC Change Printout OD

SCCO

LR12/13/13

RTVueGCC Change Printout OS

SCCO

LR 12/13/2013 Management • Advised that IOPs are a little higher than

desirable; strict compliance is necessary • IOPs can be highly variable in glaucoma so

in long run we must assure that there is no further damage since we don’t know the IOPs at all times

• Call if any HAs at all; it MAY mean IOP spiking – variable IOPs alone may damage the ONH

• Continue Lumigan hs + Timolol qAM but strongly recommend SLT

• Need every 3 month f/u SCCO

LR What did we learn? • Previously well-controlled IOPs can “go off”! • We really don’t know what is going on with a

patient’s IOPs the vast majority of the time!• Be prepared for wild IOP spikes – very

common in glaucoma. The more IOPs you have the better.

• Be prepared to manage those wild IOP spikes

• Be prepared for pts progressing but you have not found high IOP (in the office)

• We really need home IOPs or better yet, around-the-clock IOP monitoring

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SCCO

“IOP Disaster” Kit • GAT and gonio• Alphagan or brimonidine – very rapid• Timolol or another topical beta blocker

(Istalol etc) • Pilo 1 or 2% • Pred Forte (or prednisolone actetate)• Diamox 250 mg tablets• Hypertonic saline to clear edematous

cornea

SCCO

LR 20144/16/2014: Still on Lumigan pm, Timolol1/4 in am. No breathing problems, HAs or other side effects. GAT: 21/21 11:25 am DCT: 24.8/24 12:30 pm HRT: Probable progression in sup rim OD; likely progression in sup rim OS Advised SLT; pt prefers to defer it until late the year if possible. F/U in 4 months. 9/10/2014: No problems. No HAs. GAT: 24/25 11:28 am No apparent clinical change. Scheduled OS for SLT for 12/2014

SCCO

LR 12/2/2014 SLT • No breathing problems, HAs or other SEs • Same meds: Lumigan hs OU; Timolol ¼

qam OU• GAT: 23/23 11:17 am • SLT performed: 103 spots at 0.8 mj over

entire 360 of TM OS

• F/U in 1 week; continue with current meds

SCCO

SLT Issues

• Should the glaucoma meds be changed prior to the SLT?

• What IOP-lowering effect would we typically get from SLT?

• How quickly does the IOP respond to the SLT?

• What is the strategy in the case that the IOP does not significantly respond to the SLT?

SCCO

LR 2015 • Uneventful post-op course • However, IOPs did not significantly respond

to the 12/2014 SLT OS • 4/8/2015: No side effects or HAs • Same meds: Lumigan OU hs; Timolol ¼ OU

qam• GAT: 21/23 11:30 • A: Inadequate response to SLT OS

– Progressing glau OS on HRT, clin exam• Consider repeat SLT with higher power or

consider Pilo 1%. Pt opted to try Pilo OU tid SCCO

LR 5/13/2015 • Blurred distance vision OU right after each

instillation of Pilo• The mid-day instillation caused more blur

problems so recently went from tid to bid • In last week has noticed increasing asthma-

like symptoms • GAT: 21/21 12:15 pm Last Pilo at 7:15 am • A: Pulmonary side effect – d/c pilo

– Little, if any, IOP lowering at 5 hours after instillation of Pilo

• D/C pilo; continue other meds

18

SCCO

LR 8/12/2015 • No side effects since d/c Pilo. No HAs • Same meds: Lumigan OU hs, Timolol ¼ OU

qam• GAT: 27/29 11:20 am • HRT: further progression likely OS sup rim• RTVue suggests RNFL & GCC progression

OS not OD • Clin exam suggests probable sup rim loss

OU• A: IOPs not adequately controlled • What should be done to lower IOPs? SCCO

LR 10/20/2015 SLT • No breathing problems, HAs or other SEs • Same meds: Lumigan hs OU; Timolol ¼

qam OU• NCT: 23, 24, 25/24, 21, 23 11:30 am • SLT performed: 105 spots at 1.1 mj over

entire 360 of TM OS

• F/U in 1 week; continue with current meds

SCCO

LR IOPS since 10/20/2015 SLT OS

• 10/28/2015: GAT 22/22 11:24 am • 12/17/2015: NCT: 23, 23, 25/20, 21, 21 4:30

GAT: 25/22 4:30 pm • 1/27/2016: NCT: 24, 24/ 25, 25 11:25 am

GAT: 25/25 11:30 am

SCCO

LR IOPs 5/2010 to 1/2016

SCCO

LR – Management Options Now• Change to q8h schedule of Alphagan• Switch to an alternative PG• Substitute a combo med for Alphagan• Re-initiate Lumigan or Travatan and add a

med to it. What add-on med? • SLT • Hang on and wait for the new glau meds:

ROCK inhibitors, Trabdenoson etc• Cat extraction- phaco – but no cataracts• MIG – but no cataracts• More invasive options – but much more risk

– Trabeculectomy or valve/stent – Ahmed valve etc SCCO

JPKeratoconus, unrepairable

total RD OD & now glaucoma in OS, the one

good eye??•

19

SCCO

JP 6/3/2008 • 71 y/o wm• PEHx: Long term RGP wearer for

keratoconus; followed by our CL Service since 5/2006. RD OD, 3 unsuccessful attempts at repair; OD is LP with no light projection

• FEHx: Negative• PMHx: HBP, hypercholesterolemia,

psoriasis, occasional kidney stones

SCCO

JP 6/3/2008 Flashes of light in OS started this morning upon arising. Very concerned due to prior RD in OD with bad outcome. Followed by retinal specialist but could not get appointment there today. • VAs: OD: LP without projection all

quadrantsOS: 20/25+ with RGP

GAT: 4/12 4:50 pm

•

SCCO

JP 6/3/2008

GAT: 4/12 4:50 pm HFA C 40 VF screening: No misses OSDFE:

OD: Dislocated PC IOL, nearly total RDOS: PVD without ret breaks, C/D: .3 x.3

SCCO

JP 6/3/2008 Assessment:

– Acute symptomatic incomplete PVD without ret breaks or RD OS

– Old RD in OD with poor outcome on multiple repair attempts

– Keratoconus OUPlan:

– Re-evaluate with DFE in 1 month or sooner if symptoms increase

– Continue f/us with ret specialist; recommend protective (PCB or Trivex) spectacles over CLs

– Schedule CL f/u

SCCO

JP 2/7/2011• CL f/u, 1st since 2008; last saw ret spec 6 mos

ago• VAs: OD: LP without projection

–OS: 20/25+ with RGP CLGAT: 14/20 5:55 pmUndilated ophthalmoscopy:OD: No view, no red reflexOS: Fleeting views of ONH, C/D: ~ .6 x .6,

larger than records show .3 x .3 in 2008!! Confrontation fields: OS normalRecommend dilated exam

• SCCO

JP 2/14/2011 DFE visitNCT: 4,5,6 / 8,7,8 2:15 pm GAT: 6/10 2:20 pm HFA C 40 VF screening: Single isolated miss inf nasal OSDFE:

OD: No view, no red reflex, much pig in vit

OS: Small ONH, C/D: .6 x .6Recommended glau eval due to apparent cup change (recorded not photos) from 2008 to 2011, variable IOPs OS, monocular status

20

SCCO

JPOS

HFA C40 screening2-14-2011

Is a single isolated miss on the edge of the VF significant? Not likely

Single isolated miss

SCCO

JP 2/18/2011 Glau eval visit• NCT: 6,5,6 / 9,8,8 10:35 am GAT: 7/9 11:30 am• HFA 24-2: Inf paracentral scotoma (5 point

cluster at p<0.5%) • Gonio: Open to CBB, minimal TM pig, no

signs of 2º glau• HRT: Good quality, all sectors normal• RTVue OCT: Sup RNFL loss, GCC shows

substantial sup and inf GCC loss• DFE: OD: unchanged

– OS: Small ONH, C/D: .7v x .6h sup notch

SCCO

JPOS HRT

2-18-2011

Small ONH –common cause of false negative on HRT and on clinical ONH evaluation!

MRA shows normal in all ONH sectors except nasal.

SCCO

JPOS

RTVue OCT2-18-2011

Sup RNFL loss to p<1%Sup and inf GCC loss that respects the temporal horizontal raphe

GCC loss respects temp raphe’

SCCO

JPOS HFA 24-2

2-18-2011

First threshold VF.Good reliability.

Inf paracentral scotoma

SCCO

JP 2/18/2011 Glau eval visit• Assessment:

– Probable early POAG based on clin ONH eval, VF possible progression over past 3 years (relative to 2008 C40 screening), RTVue RNFL and GCC results.

– IOPs appear very low – reassess IOPs • Management:

– Delay treatment until IOPs & CCTs are further evaluated; get CCT, Pascal DCT, reclined IOP, diurnal IOP

21

SCCO

JP 2-18-2011 Key Points

Don’t over-emphasize the importance of IOPs in glaudiagnosisSmall ONHs get small cups! Very difficult to detect glau damage in small ONHs Change in cupping is a great way to detect glaucoma but difficult without photos or imagingUse RNFL/GCC imaging for small ONHs but watch out for ONH hypoplasia which will also show RNFL & GCC defects Look at the pattern of GCC thinning; typically respects the temp horizontal raphe in early to moderate glaucoma.

Marshall B 133 SCCO

JP 3/4/2011 CCT, IOP eval visit

• CCT: OS: 420µ average of 8 on IOPac• NCT: OS: 5,7,8 10:20 am • GAT: OS: 9,7• Tonopen: OS: 9.8 sitting; 10.3 reclined after

15 minutes • Pascal DCT: OS: 21.7, 20.9 Q:1 OPA: 2.4 • Undilated ONH evaluation: unchanged, no

Drance hemes

SCCO

JP 3/4/2011 Issues to consider

• With CCT of 420µ what effect on IOPs mearsuredwith applanation tonometers is likely?

• Can “adjusted IOPs” help correct for this IOP error that is presumably due to CCT?

• What adjustment algorithm is most appropriate? • With 1 functional eye, early VF loss and moderate

ONH, RNFL and GCC damage what is the appropriate target IOP?

• Is initiation of a single med appropriate? • What initial med(s)? • What follow-up?

SCCO

JP 3/4/2011 ManagementAssessment: • Caution with applanation IOPs - may be

significantly false low• Initiate Trav Z 1 gt OS Plan:• Glau pt ed: no symptoms, VF loss has occurred

though he cannot tell, VF loss cannot be reversed, must prevent further loss, need to keep IOPs down with glau med every night, try not to miss drops

• F/U in 4 to 6 weeks with appt around 10:30 to 11:00 am

SCCO

JP 4/27/2011 1st F/U on Trav ZReports missing 1 drop each week, fell asleep. No problems with drops (redness, dryness etc) other than remembering it• GAT: OS: 9 11:35 am• Tonopen: OS: 7.8• Pascal DCT: OS: 15.4 Q:1 OPA: 2.1 • Undilated ONH evaluation: unchanged, no

Drance hemes Assessment: IOP down on DCT, not on GAT –probably good IOP reduction Management: Continue Trav Z; f/u in 3 mos

SCCO

JP 3/7/2012 2nd F/U Trav ZReports misses 1 drop about every 2 to 3 weeks. No problems with drops other than cost. High co-pay through HMO• NCT: OS: 8,6,7 11:45 am • GAT: OS: 10• Pascal DCT: OS: 14.3 Q:3 OPA: 2.0 • Dilated ONH evaluation: No apparent change• HFA: Denser, larger inf nasal step – possible

progression??• HRT: See images • RTVue OCT: See images

22

SCCO

JPOS HFA 24-2

3/7/2012

SCCO

JPOS HRT 3/7/2012

SCCO

JP 3/7/2012 ManagementAssessment:• Acceptable IOP reduction on DCT • However, possible progression in VF loss Management: • Change to latanoprost generic and re-

evaluate IOPs in 1 month to assure IOP control

• Get Reichert ORA reading (ORA on loan at that time) to double check Pascal DCT IOPs

• Encourage strict compliance to med scheduleSCCO

JP 4/20/2012 IOP F/UMissed “maybe 2 or 3 drops since last visit”. Latanoprost “much cheaper” but a little more stinging on instillation; eye dry sometimes since latanoprost started . • GAT: OS: 11 11:00 am • Pascal DCT: OS: 12.1 Q:2• Reichert ORA: 14.0 CH: 2.8 very low • Undilated ONH evaluation: No apparent change• HFA 24-2: Similar to 3/12/2012 – denser larger

VF defect in inf nasal VF – progression?

SCCO

JP 4/20/2012 Issues to consider

• Why might latanoprost have a greater dry eye symptoms than Trav Z?

• Should latanoprost have a similar IOP-lowering effect to Trav Z?

• Is there any benefit of getting readings from the Reichert ORA?

• What is the value, if any, of corneal hysteresis (CH) readings from the ORA?

• Given the low CH reading, one-eye status, possible VF progression & not great compliance should therapy be advanced?

SCCO

JP 4/20/2012 IOP F/UManagement considerations

• For further IOP control what is the best option?

• Why might SLT be a advisable in this case?

• If pt wishes to avoid SLT what is the best add-on med in this case?

• What is the typical effect of an additional med on compliance?

• Combo med? We need a PG combo in the US!!!

23

SCCO

JP 4/20/2012 IOP F/UAssessment: • Questionably acceptable IOP reduction on DCT, ORA

with latanoprost generic• Very low CH on ORA suggests increased likelihood

of progressionManagement: • Again encouraged strict compliance. Advised SLT

(in HMO) as best add-on to latanoprost – wants to avoid more eye surgery. Give sample: Azopt 1 gt OS q12h (upon awakening in am and after dinner)

• Use tear supplement for dry eye but not within 15 minutes of latanoprost or Azopt instillation

• F/U in 1 month to assess Azopt effect on IOP SCCO

JP 6/27/2012 IOP F/U

Missed “some drops of Azopt after dinner since, harder to remember it than at bedtime & on awakening”. No other problems with Azopt but “it real slow coming out of the bottle.” • GAT: OS: 9 12:30 pm • Pascal DCT: OS: 17 Q:2• Reichert ORA: 12.0 CH: 3.6 very low • Undilated ONH evaluation: No apparent change

SCCO

JP 6/27/2012 IOP F/U

Assessment: • Disparity between DCT and ORA – reason is

unclear • Compliance to Azopt fair, likely not as good as

reported; IOP control questionable Management • Recommend SLT; explain advantages &

emphasize that it is laser treatment, not surgical • Write script for dorzolamide 1 gt OS q12h• Reassess IOP control in 3 months

SCCO

JP 11/18/2012 Glau F/U

Reports same problem with forgetting the night instillation of dorzolamide sometimes. • GAT: OS: 15 1:17 pm • Pascal DCT: OS: 20.8 Q:3 OPA: 3.3 1:25 pm • Last latanoprost about 11:30 last night; last

dorzolamide at 7:00 am this morning• Dilated ONH evaluation: No apparent change• HFA: possible progression??• HRT TCA: possible progression in inner wall of sup

rim

SCCO

JPOS HFA 24-2 11/18/2012

SCCO

JPOS HFA GPA

11/18/2012

VFI trend is flat

Point by point analysis identifies 2 points progressed from baseline x 2 VFs

24

SCCO

JPOS HRT TCA 11/18/2012

SCCO

JP 11/18/2012 IOP F/UAssessment: • IOP is up on both DCT and GAT – unstable IOP control.

Compliance to recommended f/us – not good, to meds probably fair.

• Possible progression on HRT (sup rim) and VF infarcuate OS

Management: • Again encouraged strict compliance. • Advised that IOPs are up and possible progression on

VFs• Advised SLT as better around-the-clock IOP control; in

HMO? Should consult the glau specialist in HMO for possible SLT. Will send all records to HMO.

• F/U in 1 month to re-assess IOP

SCCO

JP 3/10/2013 Glau F/U

Reports that glau specialist in HMO said he is overtreated. He got IOP of 9 with blue light instrument (GAT). Did an HFA VF but did not act like he had seen the records we sent.Reports missing “a couple of dorzolamide drops (night time) every week.”

• GAT: OS: 7 1:07 pm • Pascal DCT: OS: 13.6 Q:3 OPA: 4.8 • Undilated ONH evaluation: Questionable progression

in sup rim OS

SCCO

JP 3/10/2013 Glau F/UAssessment: • Unstable IOP control. Compliance questionable. • Probable progression – on clinical exam, on HRT (sup

rim) and VF inf arcuate OS Management: • Again encouraged strict compliance; advised that our

tests for progression show probable progression. • Advised that IOPs are OK today but are very dynamic.

Advised that it is best to keep the IOPs down at all times. SLT again advised to help achieve this; alternatively 3rd

med as a combo. • F/U in 3 months to re-assess IOP, stability & determine

whether to advance therapy

SCCO

JP 6/14/2013 Glau F/U

Reports missing “a couple of dorzolamide drops (night time) every week.” • GAT: OS: 7, 8 1:30 pm • Pascal DCT: out for repair• Undilated ONH evaluation: Probable progression

in sup rim OS • HRT: repeatable x3 progression in sup rim• HFA: VFI trend flat; progression at 2 points x 3 VFs

SCCO

JPOS HRT

6/14/2013

Repeatable progression in the sup temp rim

25

SCCO

JPOS HRT TCA

6/14/2013

Repeatable x 3 progression in the sup temp rim correlating to the infparacentral scotoma

SCCO

JPOS HFA GPA

6/14/13

VFI trend is flat but the point-to-point comparison (event analysis) suggests likely progression at 2 points over 3 consecutive VFs in the infarcuate region of VF

SCCO

JP 6/19/2013 Glau F/UAssessment: • GAT pressure is down but IOPs likely unstable • Likely progression – on clinical exam, on HRT

(sup rim) and VF inf arcuate OS Management: • Advised that progression has likely occurred;

need to try to lower & stabilize the IOPs more • Pt wants to avoid laser (SLT) if possible even if

he must take more meds• Substitute Simbrinza (gave samples) for

dorzolamide, same dose, but q6h dose schedule • F/U in 2 months to re-assess IOP, stability

SCCO

JP 2/5/2014 Glau F/UReports no problems with Simbrinza though cost is higher than any other drop he has tried. Same pattern on compliance: reports missing “a couple of Simbrinza drops (night time) every week.” GAT: OS: 6, 8 12:30 pm Pascal DCT: 12.6 Q: 3 OPA: 3.5Undilated ONH evaluation: Probable progression in sup rim OS HRT TCA: repeatable progression in sup rimHFA GPA: no progression in inf arcuate; flat VFI trend

SCCO

JPOS HFA GPA

6/14/2013

VFI trend is flat but the point-to-point comparison (event analysis) suggests likely progression at 2 points over 3 consective VFs in the infarcuate region of VF

SCCO

JPOS HFA GPA

2/5/2014

What happened to the progression in the inf arcuate region that was present on the 6/14/13 VF??Somehow the baseline VFs were deleted so that this VF is not being compared to the true baseline VFs!!!

26

SCCO

JPOS HRT TCA

2/5/2014

Same blotchy areas of progression in sup temp rim (inner wall of cup) as noted in past (repeatable progression)

SCCO

JP2/5/2014

OS Cirrus

ONH/RNFL Sup arcuate RNFL loss to p<1% due to glaucoma.

Mild (p<5%) inf arcuate loss as well

SCCO

JP2/5/2014

OS Cirrus GCC

Moderate GCA loss –note that most loss is sup and mostly respects the temporal horizontal raphe.

SCCO

JP2/5/2014OS GPA Page 1

See the Trend Analysis for Ave RNFL and Inf RNFL Thickness. Inf RNFL Thickness is statistically thinner on last 3 scans than on the baseline. The more scans and the tighter (less variable) the data the better the ability to detect small changes in RNFL.

SCCO

JP2/5/2014OS Cirrus

GPA Page 2

The data behind the trend lines. Note the infquadrant RNFL thickness on the last 3 visits. The more scans the better the ability to detect small changes.

Likely progression in inf RNFL

SCCO

JP 2/5/2014 Glau F/UAssessment: • GAT & DCT IOPS are down. Better control with

Simbrinza?? • Likely progression – on clinical exam, on HRT (sup rim)

and VF inf arcuate OS Management: • Advised that progression has likely occurred; need to try

to lower & stabilize the IOPs more • Pt wants to avoid laser (SLT) if possible• Continue Latanoprost qhs, Simbrinza q6h• F/U in 3 months to re-assess IOP, stability of VFs, HRT,

clinical ONH eval