Glaucoma GrdRds Done Wrong-1 hr- '15 ho€¦ · Glaucoma Grand Rounds: What Was Done Wrong? COPE #45911-GL Robert E. Prouty, O.D., FAAO Specialty Eye Care Parker, Co [email protected]

7/21/2015

1

Glaucoma Grand Rounds:What Was Done Wrong?

COPE #45911-GL

Robert E. Prouty, O.D., FAAO

Specialty Eye Care

Parker, Co

[email protected]

Disclosures

• Financial disclosures:• Speakers Bureaus/Consultant:

�Alcon�Allergan�Optovue�Zeiss-Meditec�VSP�B&L�Ivantis

• I have no personal financial interests in any of these companies

Case 1

L Duvall

• 60yo WF presents for a glaucoma update and assess of vision on referral from her Neuro-Ophthalmologist

• MHx: DM, HTN, Thyroid• Her case starts in Oct. 2000 • Here is her story…..

L Duvall - 2000

• 49yo WF presents for evaluate “I don’t see well out of my right eye”

• MHx: DM, HTN, Thyroid• OHx: KCN?• VA: 20/70 OD 20/60 OS• Pupils, EOMs & Ant Seg normal

• EyeSys: Shown• IOP: 14 OU• M: -6.25 -3.75 X094

-9.25 -2.50 X 095

• DFE: Mac clear, Lacquer cracks noted without NVM, peripheral lattice noted C/D ratio 0.15 OU with tipping

L Duvall - 2000

7/21/2015

2

L Duvall - 2000

• Diagnosis? • Dx: Degenerative Myopia

KCN with irregular astigmatism

• Plan: RGP fit & monitor

L Duvall - 2002

• 51yo WF presents for evaluate “Vision has decreased”

• MHx: DM, HTN, Thyroid• OHx: KCN (Dx 2000)• VA: 20/70 OD 20/60 OS• Pupils, EOMs & Ant Seg normal

L Duvall - 2002

• OrbScan: Shown• IOP: 16 OD / 19 OS• DFE: C/D ratio 0.15 OU with tipping, mac with pig changes, Lacquer cracks noted without CNVM, peripheral lattice noted with asymptomatic-atrophic superior hole

• VF: Shown

L Duvall - 2002

• OrbScan: Shown• IOP: 16 OD / 19 OS• DFE: C/D ratio 0.15 OU with tipping, mac with pig changes, Lacquer cracks noted without CNVM, peripheral lattice noted with asymptomatic-atrophic superior hole

• VF: Shown

L Duvall - 2002

• Diagnosis?• Dx: Degenerative Myopia

KCN with irregular astigmatism

Bitemp hemi

• Plan: Order MRI (Results shown)

7/21/2015

3

L Duvall - 2003

• VA (p/op): 20/60 OU• F/up VF: shown • Why is VA reduced?– KCN?

– Optic atrophy s/p pit surgery?

– Degenerative myopia?

– Glaucoma?

– All of the above?

L Duvall - 2010

• Patient appears stable for 7 years

April 2010:

• CC: recheck of vision, notes loss of peripheral VF and OD now turns inward

• VA: 20/70 OU• + APD OD• Tapp: 15/17

• SLE:– Trace NS otherwise WNL

• DFE: C/D 0.2 OU with noted pallor OD>OS, mac with pig changes & periphery clear

• VF: shown

L Duvall – April 2010

• Diagnosis?• Management?• Pachy:– 471 OD

– 465 OS

• Are IOPs reliable?– I added Brimonidine 0.2% bid OU

L Duvall – April 2010

Change Analysis L Duvall – April 2010

• Diagnosis?• Management?– I added Brimonidine 0.2% bid OU

7/21/2015

4

L Duvall – April 2011

• VA: 20/80- OU• VF recheck: shown

• Diagnosis?• Management?

L Duvall – April 2011

• Is this glaucoma?– Repeat MRI shows no regrowth of Pituitary macroadenoma

• Diagnosis?• Management?

Case 2

Dorothy T

• 79 yo WF presents for a glaucoma update• MHx: HTN, Thyroid• OHx: Cat surgery OU Spring 2000 • VA: 20/30 OU• Pupils, EOMs & VF grossly normal • Here is her story…..

Dorothy T – 2003 to OMD

• SLE: WNL OU with stable pseudophakia• Gonio: 4+ with CBB visible 360° OU

• Pachy: 573 OD / 568 OS• IOP: 20/18 OD/OS• DFE: Mac, Vessels, periphery clear

C/D ratio O.5V-0.7H OD / 0.7 OS

+ ISNT OD / ? ISNT OS

Dorothy T - 2003

7/21/2015

5

Dorothy T - 2003

• ALT done OS • Patient lost to f/up…..

Dorothy T – 2007 Re-presents!

• SLE: WNL OU with stable pseudophakia• IOP: 12/10 OD/OS• DFE: Mac, Vessels, periphery clear

C/D ratio O.8 OD / 0.8 OS

- ISNT OD / - ISNT OS

Dorothy T

What do you want to do now?What do you want to do now?

Dorothy T – 2007

• Stratus OCT & GDx stable with no ONHindications of decline!

Dorothy T – 2009

• SLE: WNL OU with stable pseudophakia• IOP: 18/17 OD/OS• DFE: Mac shows:

– OD ERM changes

– OS soft Drusen changes

– Vessels, periphery clear

C/D ratio O.8 OD / 0.8 OS

Dorothy T – 2009

• What do you want to do now?• Stratus OCT stable with no progressive ONH indications of decline!

• VF:

7/21/2015

6

Dorothy T

Dorothy T – 2009

• What do you want to do now?• SLT done OD

Dorothy T – 2010

• SLE: WNL OU with stable pseudophakia• IOP: 14/16 OD/OS• DFE: Mac shows:

– OD ERM changes

– OS soft Drusen changes

– Vessels, periphery clear

C/D ratio O.8 OD / 0.8 OS

Dorothy T – 2010

• What do you want to do now?

• OCT stable?

Dorothy T – 2010

• What do you want to do now?

• VF stable?

7/21/2015

7

Dorothy T – 2010

• What was done wrong?

• Is the VF declining OD?

SLT 9/09 ALT 9/03

Case 3

Paul

• 63 yo WM presents for a glaucoma eval in Nov 2001

• MHx: HTN using Zestril & Terazosin• OHx: Unremarkable• VA: 20/30- OU• Pupils, EOMs & VF grossly normal

Paul

• SLE: WNL with 1+ NS• IOP: 23/22 OD/OS• DFE: Mac, Vessels, periphery clear– ONH are shown

7/21/2015

8

Paul

• GDx: Shown• VF: Shown

Paul

• Any other testing or questions?– Pachymetry

• 636/606

Paul

• Diagnosis?– Glaucoma

– Oc HTN secondary to incr CCT

– Lid related VF depression

– Learning effect VF

• Management?

Paul

• The patient was seen yearly with IOP remaining at ~ 23-24 OU and unchanged ONHs, VF or GDx

• On 9/23/04 Tapp was 29 OD/27 OS

Paul

• GDx: Shown• OCT: Shown

Paul

• VF: Shown

7/21/2015

9

Paul

• Are you getting nervous about the negative sloped GPA OS?

• 86% of visual field abnormalities notreplicated on retesting!– Keltner JL, Johnson CA et al. OHTS; Arch Ophthalmol. 2000; 118: 1187-1194

Visual field & OCT results show poor correlation in advanced RNFL loss

• A retrospective study of patients with early to advanced glaucoma showed a wide variation in mean deviation in patients with advanced retinal nerve fiber layer loss when comparing visual field sensitivity with retinal nerve fiber layer thickness.

• Jessica Neuville, OD, presented at AAOpt 2010, a study that suggests the OCT is moderately correlated to visual function in early loss, but is a poor predictor of visual function at advanced levels of RNFL loss

Paul

• Any other testing or assessment?

• Diagnosis now?• Management now?

Paul

• The patient was seen yearly with IOP remaining at ~ 27-28 OU and unchanged ONHs, VF, GDx or OCT

• On 2/14/06 Tapp was 29 OD/26 OS

Paul

• GDx: Shown• OCT: Shown

Paul

• VF: Shown

7/21/2015

10

Paul

• Diagnosis now?• Management now?

Paul

• The patient was seen yearly with IOP remaining at ~ 27-28 OU and unchanged ONHs, VF, GDx or OCT

• On 2/13/07 Tapp was 38 OD/36 OS!

Paul

• GDx & OCT: Unchanged!• VF: Shown

Paul

• What do you want to do now?

Paul

• I elected to do a SWAP VF analysis:

Paul

• Short Wave Automated Perimetry VF Analysis:– “Blue-on-yellow perimetry deficits are an early indicator of glaucomatous damage and are predictive of impending glaucomatous visual field loss for standard White on white automated perimetry”• Arch Ophthalmol. 1993;111; no. 5:645-650

• FDT– “In the same way that SWAP may predict Achromatic Automated Perimetry (AAP) visual field loss, Frequency Doubling Perimetry may also detect field loss earlier than AAP “• Arch Ophthalmol. 2003;121:1705-1710

7/21/2015

11

Paul’s current status

Case 4

Joan

• 59 yo white female presents for evaluation of glaucoma with a “Superior BINASAL VF loss”!

• MHx: Negative • Meds: None • FHx: None• OHx: LASIK OU ’99 • VA: 20/20 OU• Pupils, EOMs & CVF WNL

Joan

• SLE:– Mild SPK OD – moderate SPK OS

– Lids, conj & iris clear

• Tapp: 11/12 OD/OS• Gonio: 4+ 360° OU• Peak flow: WNL• Pachy: 512/518 OD/OS

Joan

• DFE: – C/D 0.4 OU + ISNT (Shown)

– Mild macular pig changes

– Vessels & periphery clear

• Referring Doc’s VF: Shown

Joan

• What did the referring doc do wrong?• What is your diagnosis?– Glaucoma?

• Management?

7/21/2015

12

Joan

• Our GDx: Shown• Our OCT: Shown• Our repeat VF: Shown

Joan

• Diagnosis?• Management?

Joan

• I ordered a MRI: – Read is shown

Joan

• If the patient: – Cannot see 20/20 and you cannot explain it

– Has a recent significant VA decr

– Has sudden onset of diplopia

– Has a persistent/repeatable/reliable VF defect

– Has an APD

– Has unexplained EOM restrictions

Get a MRI!

Case 5

7/21/2015

13

CB

• 26 Y/O WF • CC: Referred with incr IOP and pain OD

OS WNL

• MHx: Neg• OHx: Episodes of “Corneal Edema”

� Managed with topical steroids

CB

• Meds: None• FHx: Neg for Glaucoma• VAsc: 20/25

20/20

• Pupils: no APD (slow OD)

CB

• EOM: FROM • Ext: WNL • Tapp: 42/15• SLE: Conj: 1+ inj OD

Cornea: Clear no KP’s OUAC: 4+ Deep with 1+-2+ fine cells OD

Micro-Hyphema OD (shown)

CB

• Gonio: open to CB OU • FDT: decr OD• Fundus: c/d 0.4/0.3 OD/OS, vitreous, vessels & periphery WNL

CB

• Differential diagnosis1. Uveitic Glaucoma

2. Angle closure

3. Open angle glaucoma

4. Glauocmatocyclitic crisis

CB

What was done wrong?

7/21/2015

14

Glaucomatocyclitic CrisisAKA Posner-Schlossman Syndrome

(PSS)

• Unilateral involvement• Recurrent attacks of mild cyclitis• Slight decrease in vision• Elevated IOP (30-40) – symptoms usually minimal

• Open angle

PS Syndrome

• Crisis has a duration from a few hours to weeks and optic nerve & VF are usually normal

• IOP and exam are normal between attacks• Age group: 20-50 yo• Usually unilateral (bilateral cases reported)• Etiology?

Uveitic Glaucoma Evaluation

• Thorough history and ROS• Careful slit lamp and fundus examination• Gonioscopy• Referral for laboratory and ancillary investigations

Pathogenesis

• Cellular and biochemical alterations– Inflammatory cells in aqueous (direct effect on TM cells or cause synechiae formation)

– Proteins (“aqueous sludging”)

– Prostaglandins??

– Mediators (Cytokines and oxygen free radicals): tissue destruction ?

Mechanical Blockage

• The trabeculum may be mechanically blocked by serum components or precipitates on the TM

• Inflammatory cells and debris can become trapped in the juxtacanalicular meshwork and decrease outflow

Trabeculum Damage

• In severe chronic or repeated uveiticepisodes, permanent changes in the TM may result in loss or dysfunction of the TM cells, scarring of the meshwork or Schlemm’s canal, and obstruction of the trabeculum by a hyaline membrane

• The CB may also be damaged (fluctuations of IOP)

7/21/2015

15

Management

How would you treat this case?

Therapy for Uveitic Glaucoma

• Mydriatics/Cycloplegics:

– Prevent or break posterior synechiae (PS) and help relieve pain of ciliary spasm

• B-Blockers: past mainstay of Tx

• Adrenergics: Brimoniodine is becoming preferred

• CAIs: Topical or systemic

• Prostaglandins: ???

Therapy

• Miotics: Avoid!– may potentiate uveitis and also lead to Posterior Synechiae

• Hyperosmotics: i.e. Glycerine or Mannitolmay be indicated in the context of acute IOP rise (ACG)

PSS Treatment

• Standard Glaucoma Tx except no miotics• Depending on the iritis anti-inflammatories may or may not be used

– Consider NSAIDs for possible steroid responders

• No proof that interim treatment between attacks reduces risk of attacks

Case 6

CR

• 50 yo WF presents in Jan 2000 for C/D evaluation

• MHx: HTN, acephalgic migraines• Meds: Atenolol, BCP• FHx: COAG (Dad)• OHx: None • VAcc: 20/20 OD

20/20 OS

7/21/2015

16

CR

• OMD’s assessment in 2000:– Pupils & EOM’s: WNL

– SLE: Conj/cornea clear, Anterior segment clear

– Gonio: Open TM & CB 360°

– Tapp: 17/16 OD/OS

– BP: 120/80

CR

• DFE: c/d 0.6/0.65 OU, sloped margins temporally OU, Ø flame heme OU, Mac clear, crossings WNL, periphery clear

Jan ‘00

CR

• HVF Shown ’00:

CR• Diagnosis?1. LTG

2. Glaucoma suspect

3. POAG

4. Migrainous VF changes NOT glaucoma!

• Treatment/management?– OMD starts Alphagan bid OU

– IOP decreases ~ 18-19%

• Further management?

CR

• Patient goes from OMD to you after 2 yrs• MHx: HTN, acephalic migraines• Meds: Atenolol, BCP, Alphagan-P bid OU• FHx: COAG (Dad)• OHx: none • VAcc: 20/20 OD

20/20 OS

CR

• YOUR assessment:– Pupils & EOM’s: WNL

– SLE: Cornea clear, anterior segment clear

– Tapp: ranges over years from 10-14mm HG

• Refinement?• What med(s)?– Added Travatan qhs OD (Monoc trial)

– IOP decreased from 14 -10 mm HG OD while OS remained elevated at 20 mm HG

7/21/2015

17

CR

• HVF Shown ’03:

Do things look stable

to you?

CR

• Diagnosis?1. LTG

2. Still just a glaucoma suspect!

3. POAG

4. Migrainous VF changes but NOT glaucoma!

CR

• Over the next 3 yrs, her IOP ranges from 11-16mm Hg OU

• Various “Prosta-somethings” were tried with equivocal outcomes for each

• Further refinement?

CR

• GPA printout

CR

• Extensive discussion on MD slope and IOP diurnal flux in September ’04

What did I do wrong?

CR

• Patient changes insurance so sees another glaucoma specialist

• He recommends:– LASER PI OU due to narrow angles!

– MY repeat gonio indicates grade 1+ to 2+ 360º OU with 2+ to 3+ inferiorly OU

• What did I do wrong……………. I trusted another doc’s gonio!

7/21/2015

18

CR

• Take home lessons:– Repeat gonio every few years

– If large IOP flux:

•May be diurnal flux•May be chronic narrow angles•May be compliance•May be ? so get another opinion!