Diagnosis, Treatment and Management of Glaucoma Desinee Drakulich O.D.

PARAS GUIDE TO GLAUCOMA

Diagnosis, Treatment and Management of Glaucoma

Desinee Drakulich O.D.

REVIEW What is Glaucoma?

A progressive optic neuropathy that damages retinal ganglion cells and other mechanisms in the visual pathway.

Retinal ganglion cells are very pressure sensitive and once damaged they do not regenerate.

REVIEW Eye Pressure- most people associate eye

pressure or Intraocular Pressure (IOP) with glaucoma.

Normal eye pressure is between 10 mmHg and 21 mmHg

Average is between 14 mmHg and 16 mmHg

Misconception is that the measured value is the pressure in the eye, it is actually the difference between the pressure in the eye and the atmospheric pressure.

Not all forms of glaucoma have IOPs > 21 mmHg

REVIEW Anatomy of the Eye

REVIEW Types of Glaucoma

Primary Open Angle GlaucomaAngle Closure GlaucomaLow Tension GlaucomaPigmentary GlaucomaExfoliative GlaucomaAcute GlaucomaCongenital GlaucomaSecondary Glaucoma

Traumatic Glaucoma

LOW TENSION GLAUCOMA Most difficult to diagnose Patient have IOPs in the normal range Thought to be caused by poor blood

flow to the optic nerve New research is answering some

questions In the past, diagnosis was made with

the appearance of visual field loss. With scanning laser technology normal

tension patients are often caught before visual field damage appears

PRIMARY OPEN ANGLE The most common form of glaucoma in

African Americans and Caucasians. Approximately 1% of Americans have

this form of glaucoma. Most common form in people over the

age of 50. Defined as increased intraocular

pressure inconsistent with a health optic nerve and consistent with an open angle of aqueous drainage.

HOW TO DETECT POAG Increased IOP > 21 mmHg Thin central corneal thickness > 555 um Peripapillary Atrophy Notching or thinning of the neuroretinal

rim Family History Large cup to disc ratio

ANGLE CLOSURE GLAUCOMA Affect about half a million people in the

US Tends to be inherited Affects Asians and hyperopes most

frequently Anterior chamber smaller than average Angle < 45 degrees Iris forced up against trabecular

meshwork causes complete closure or an acute glaucoma attack

Age can be a factor due to increasing size of the lens of the eye

HOW DO WE TREAT POAG Medication Drops Laser Treatments Surgery

HOW TO DETECT ACG

WHAT CAN OPTOMETRIST DO? Optometrist can detect and treatment

POAG in adults with drops. If pressure and vision loss can not be

controlled with drop referrals must be made to Ophthalmology for laser or surgical consideration.

CURRENT TYPES OF GLAUCOMA DROPS Cholinergics Beta Blockers Alpha Agonists Carbonic Anhydrase Inhibitors Prostaglandins

CHOLINERGICS Older method of treating glaucoma

rarely used anymore. Two major drugs: Pilocarpine and

Carbachol How do they work?

They constrict the pupil increasing drainage out of the trabecular meshwork in the angle of the eye.

Side effects included decrease vision in dim lighting and headaches

BETA BLOCKERS Also an older method of treating

Glaucoma however still commonly used today

Most commonly used drops are: Timolol, Betoptic and Betagan.

How do they work? Decrease the production of aqueous

Side effects include decreased heart rate, decreased pulse, fatigue and shortness of breath. Caution with people with Asthma or COPD and people currently taking Beta Blockers for BP control.

ALPHA AGONISTS Newer method of glaucoma treatment. Two different drops available: Iopidine

and Alphagan P How to they work? Both decreasing

aqueous production and increasing outflow of aqueous. Also considered a neuroprotective agent.

Side effects include fatigue, headache and dry mouth.

CARBONIC ANHYDRASE INHIBITORS Commonly used for patients who can’t

take Beta Blockers Two drops available and one oral

medication: Azopt, Trusopt and Diamox. Optometrists in NE can’t Rx Diamox.

How do they work? Decrease the production of aqueous.

Side effects include tingling or loss of strength of the hands and feet, upset stomach, mental fuzziness, memory problems, depression, kidney stones, and frequent urination.

COMBINATION DROPS Relatively new, good for patient who

drop want to do multiple drops per day. Two types of drops: Combigan and

Cosept Combigan is Alphagan and Timolol. Cosept is Trusopt and Timolol How to they work? Both increase

outflow and decrease production Side effects are the same as the

individual drugs.

PROSTAGLANDINS Newest method of treating glaucoma

considered the DOC of glaucoma medication.

Three major drops: Xalatan, Lumigan and Travatan

How do they work? Increase drainage of the aqueous via and uveal scleral pathway.

Side effects include iris pigment change, redness in eye, stinging and itching.

SO WHAT IS THE BEST DROP? Current studies from the Review of

Optometry March 2009 show that the DOC is still Xalatan.