NTG? 8/26/14. Cases in Normal Tension Glaucoma Management: PointCounterpoint Discussion. JL Photos

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1 8/26/14 Cases in Normal Tension Glaucoma Management: PointCounterpoint Discussion NTG? BRETT J. KING, OD, FAAO VICTOR MALINOVSKY, OD, FAAO INDIANA UNIVERSITY SCHOOL OF OPTOMETRY JL: 69 YO CAUCASIAN FEMALE JL JL Photos Referred for Glaucoma Eval History of LASIK OU BCVA: 20/20 OD, OS IOP: 18, 16 mmhg Pachs: 532, 529 Gonio and Lens: Unremarkable JL Photos JL OCT 1

2 JL VF JL VF JL JL Initial IOP s mid to high teens? Disc Heme OS Intact Rims and NFL OU No Defects ON HVF Thoughts? Serial Tonometry High 25 and 24 Low 16 and 15 Treat or Monitor? What s in a Number Continuum Since the IOP among subjects without glaucoma had a mean of 15 mm Hg to 16 mm Hg and an SD of 2.5 mm Hg, less than 2% of the general population was expected to have an IOP greater than 21 or 22 mm Hg (the ū ± 2 SD). It was assumed that those who did either had POAG or were bound to develop it; because they were uncommon in the general population, they were unlikely to be normal. Uncommon had become abnormal. Sommer A. Ocular hypertension and normal-tension glaucoma: time for banishment and burial. Arch Ophthalmol. 2011;129(6): POAG and NTG represent a continuum of openangle glaucomas At one end of spectrum IOP may be the predominant risk factor Other end IOP-independent factors take increasing importance Shields, B. Normal-tension glaucoma: is it different from primary open-angle glaucoma. Current Opinion in Ophthalmology 2008,19:

3 Pressure-Independent Factors Ocular Hemodynamics and Glaucoma Low perfusion pressure Low blood pressure Low cerebrospinal fluid pressure Situationally elevated IOP Systemic vascular dysregulation syndrome Hayreh has shown loss of capillary perfusion in mulitple IVFA studies Autoregulation/dysregulation of retinal blood flow has been demonstrated in multiple studies including Harris and Feke. Initially demonstrated in NTGL More recently confirmed in POAG as well Mroczkowska et al. recently published on POAG vs NTGL a vascular perspective Authours conclude both have hemodynamic concerns and appear to be a continuum of the same disease Vascular Raynaud s Risk Factors Migraine Blood transfusion Raynaud s Nocturnal hypotension *Sleep apnea Raynaud s Vasospasm and Glaucoma 3

4 Nocturnal Hypotension Vascular Dysregulation Reduction in Sympathetic Activity Decreased Heart Rate Decreased Cardiac Input Peripheral Resistance Sympathetic Dysfunction Further drop in nocturnal BP Over dippers Absent non-dippers Meyer et al, took this one step forward and reported patients with normal-tension glaucoma demonstrated a significantly greater drop in nocturnal BP compared to a healthy population. This they believed lead to greater progression of glaucoma damage. Vasoconstriction Arterial and Venous Dilations Tipping Point Case 2 REJ is a 57 yo caucasian male No significant history IOP 17 OD 16 OS Pachs 495 and 501 See images Case 2 Case 2 External exam ONH OD 4

5 Case 2 Case 2 GDx ONH OS Case 2 HVF Case 3 Longstanding treated NTG patient Note inferior temporal rim thinning OD with obvious inferior temporal rim notch defect noted with +78 D lens examination. Treated with.1 % Alphagan P bid-od TIOPs for the last 5 yrs. Pretreatment IOPs were around 17. No treatment for OS Note: Stereo photos, VFs & SD-OCT NFL layer 5

6 HVFs: OD 24-2 Note: Deep, superior paracentral scotoma HVFs: GPA Note: No real progression for 5yrs. HVF: 24-2 GPA WNL OS Note: Paracentral defect not as dense as white on white perimetry SD-OCT NFL measurement OD shows loss of RNFL (long arrow) Inf. temp compared to the normative database as well as loss compared to measurement of the left eye (short arrow) Most recent SD- OCT No real change Note: NFL wedge defect (white arrow) 6

7 Posterior pole retinal thickness measurement Posterior pole retinal thickness measurement Note that the next slide demonstrates a loss of retinal thickness inferior temporally (red arrows). This loss is clearly depicted as an arcuate shaped black area on the OD-OS asymmetry analysis as well as the hemisphere asymmetry analysis of the right eye. Comments This patient has been treated with Alphagan P for the last 5 yrs. and has shown no real progression. Is this due to IOP lowering, possible neuroprotective properties of Alphagan P or a non progressing NTG patient?? Normal Tension Treatment Study Why was the study done? First hypothesis: IOP independent Second hypothesis: IOP is an active participant in the disease Normal Tension Treatment Study Normal Tension Treatment Study 230 patients from 24 centers Evidence of glaucomatous cupping Median IOP 20mmHg or less 1 Eye randomized: Followed without treatment Treated with goal 30% reduction in IOP Aggressive 30% reduction IOP was shown beneficial 65% of non-treated eyes did not progress Balance treatment benefits to risk of adverse events 7

8 Normal Tension Treatment Study Does it effect Tx Decisions? Risk Factors Migraine Female > Male Disc Hemorrhage Vascular Health Genetics? Zeitz et al: bimatoprost to latanoprost to dorzolamide Quaranta et al: Timolol, brimonidine, dorzolamide, and latanoprost Cantor looked at ocular hemodynamics and Trabeculectomy What About CAI s Low-Pressure Glaucoma Treatment Study CAI s have demonstrated improved hemodynamics in glaucoma patients May have some value when faced with a progressing patient despite low to sub-teen IOP Randomized pts to brimonidine to timolol and monitored for progression Conclude patients on brimonidine has less progression at similar IOP levels compared to those on timolol Brimonidine neuroprotective? Does timolol increase risk? One concern of study: significantly more patients dropped out of brimonidine arm as compared to timolol arm. Are the results skewed? JL Photos Would You Start Treatment? Case 4 8

9 64 year old male Patient presents for a NTG work up based on ONH notching in the OD and corresponding VF defect. Past ocular history is significant for a previous vascular accident in OD 6 years ago. Medical history is significant for cardiovascular disease and heart attack X 7 y/o. No visual complaints at this time. Objective Tests BCVA: OD 20/20, OS 20/20 Pupils: Perrla ( APD) Slit Lamp examination: no secondary signs and open angles Ta: 17mmHg in both eyes at 8:00AM Pachymetry : 625 microns OU ONH, HVFs, & SD-OCT- refer to slides HVF 24-2 Note: Dense superior centrocecal defect HVF 24-2 WNL 9

10 SD-OCT Note- deep inferior temporal NFL/ retinal defect (red circle) Note: Large inferior retinal thinning area (red circle) Line scan over retinal thinning area Explanation: refer to next slide Diagnosis-OD NTG with corresponding VF defects and inferior temporal NFL defect vs Optic neuropathy secondary to BRAO Combined disease??? comment Management Based on the SD-OCT line scans, it was felt that the patient may have suffered from a previous inferior BRAO and now has develop secondary retrograde optic neuropathy with a NFL layer defect. The appearance of SD-OCT line scan is consistent with the loss of retinal tissue from a BRAO. No treatment at this time with follow-up HVF and SD- OCT every 6-12 months for a few years to determine any progression. If no progression, then our tentative diagnosis of previous BRAO would be confirmed. 10

11 25 year old Asian Female patient Case 5 Presents to our clinic for a second opinion with a history of normal tension glaucoma with Lumigan treatment in each eye for the last year. No family history of glaucoma. Medical history is significant for a diagnosis of Myasthenia Gravis with no treatment at this time. No previous records at this initial visit. Objective testing Objective testing BCVA: OD 20/20 OS 20/20 Pupils: 1+ APD OS Slit lamp: open angles and no signs of secondary glaucoma. Ta: OD 15, OS 14 at 10:00 AM Pachymetry: OD 579, OS D Optic nerve appearance: OD.7/.7 ISNT rule normal, OS.7/.7 with superior & nasal rim thinner, no obvious Drance Hemes, pallor, PPA, pits, or coloboma noted; ONH size slightly larger than normal HRT, SD-OCT & HVF- see slides HRT Note: Superior & Nasal rim flagged in OS and parapapillary NFL thinner (black circle) : OD suspect nasally SD-OCT Note: OS significant nasal & superior NFL thinned, suspect inferior 11

12 Posterior pole retinal thickness OS: Atypical pattern of retinal thinning extending from the ONH superiorly and inferiorly, hemisphere asymmetry plot reveals greater deviation superiorly Hemisphere asymmetry plot reveals questionable superior retinal thinning in OD Note: For explanation refer to next slide OD WNL OS: 24-2 HVF Real defect? No trial lens used OS: 30-2 HVF 60-4 HVF?? Do we keep? Need OD? 12

13 Diagnosis and Management NTG vs Atypical optic neuropathy OS Continue treatment or refer for additional testing Patient was referred to glaucoma specialist for second opinion 2 weeks later at follow up, patient presents with copies of previous exams: IOPs (normal), VFs (No change), CAT scan & MRI results (normal findings) MRI and CT Results 6/21/2007 CT Head with and without contrast and orbits 6/28/2007 MRI of Brain with and without contrast 12/19/ MRI of brain & orbit 6/23/2011 MRI of brain & orbit with and without contrast All results normal! 2007 Previous HVF 2008 Previous HVF Exam with Glaucoma specialist 24-2 HVF Most recent Ø Specialist described visual field defect OS as somewhat variable over the years but relatively consistent. Ø Believes that patient is stable and he is not convinced at this time there is a progressive optic neuropathy. Ø Not able to determine cause of asymmetry but could possibly be a congenital optic nerve anomaly. Ø Recommend to discontinue Lumigan with IOP check in 1 month, if pressures remain as they were, he suggested following patient with visual fields every 6-12 months. 13

14 Comment Is there a need to treat a 25 year old for the rest of her life for glaucoma if she really doesn t have it? Congenital optic nerve defects do exist! Case 6 KB: 62 YO CAUCASIAN MALE KB KB Patient Referred for Glaucoma Eval Decreased Mental Capacity Hx of Blepharospasm BCVA: 20/20 OD, OS Pupils = 1mm OD, OS IOP: 13, 14 mmhg Pachs: 511 and 502 Gonio: Moderate Depth Lens: 1-2+ NSC Difficult View Secondary to Small Pupils Post Dilation KB Photos KB OCT 14

15 KB VF KB VF Small Pupils Thin Pachs IOP max 14 KB Chronic Blepharospasm Pale ONH s Generalized Loss on OCT Enlarged Blind Spot with Generalized Constriction What s the Next Step? Treat or Monitor? Take home message Just because a case might look like NTG doesn t mean it is always glaucomatous optic neuropathy. Very important to integrate all of your findings and not just focus on one element of your exam. Once again, as the following two cases demonstrate, we have to be careful of our diagnosis of NTG and realize that a number of conditions can masquerade as NTG! CSF and Glaucoma Developing Technologies Checking IOP is a trans-corneal measurement and not a measurement of trans-lamina pressure CSF Model for both high and low IOP Low systemic blood pressure Low CSFP = abnormally high trans-lamina pressure differential Thin pach readings also indicate further potential for posterior flexing of the lamina 15

16 Enhanced Depth Imaging OCT of the Lamina Cribrosa Advanced Imaging ONH and RNFL Martus et al. compared 203 POAG pts with elevated IOP to 97 with NTG Thinner neuroretinal rim and wider-zone β PPA predictive for progression in POAG alone Presence of disc heme was the only predictive factor of progression in NTG Kim et al. studied macular RNFL in NTG dividing between those <15 and greater The greater the 15 group had localized defects closer to the center as compared to the less then group Putting imaging types together- 8 x 5 structural RNFL Montage on a 57 yo Male Volumetric AO-OCT image with OCT beam focus at RNFL (S2) - Focus at RNFL Vitreous side - Light source: Integral - Loca6on: 6 deg superior Horizontal Raphe Fovea * - Size: 3 x 3 degrees - Registra6on: Custom 300 µm OP Kocaoglu, B Cense, RS Jonnal, Q Wang, S Lee, W Gao, DT Miller Vision research 51 (16), Choroid side 16

17 8/26/14 Registering the AO- OCT image loca5ons on the wide field SLO image (S1) Cross sectional imaging of RNF bundles (S1, 3 Deg Nasal) Averaged C- scans obtained from the volumetric AO- OCT image - Focus at RNFL - Light source: Broadlighter - Loca6on: 3 degrees nasal 6 degrees superior 6 degrees Inferior - Size: 3 x 3 degrees - Registra6on: ImageJ 0 µm 13 µm 24 µm 18 9 µµm m µ m µm Oblique Averaged C- scan C- scan through RNFL Obtained extracted from t he from Volumetric the volumetric OCT image OCT image B- Scan extracted from the volumetric OCT image SLO image of 54 years old healthy male subject AO-OCT image locations on the wide field SLO image (S3) - interesting case Averaged C- scans obtained from the volumetric AO- OCT image - Focus at RNFL - Light source: Broadlighter - Loca6on: 3 degrees nasal 6 deg superior 4.5 deg superior 5 deg superior by 6, 7, 10.5 deg nasal - Size: 3 x 3 degrees - Registra6on: ImageJ Cross sectional imaging of RNF bundles (S3, 4.5 Deg Superior) Arcuate NFL defect 250 µm 31 µ22 m µm Oblique Averaged C- scan C- scan through RNFL Obtained extracted from t he from Volumetric the volumetric OCT image OCT image 30 µm B- Scan extracted from the volumetric OCT image SLO image of 62 years old male subject Commercial OCT vs UHR- AO- OCT OCT (S3) Commercial OCT : Conclusion Multiple Aspects to Consider in a Glaucoma Eval (Heidelberg Engineering Spectralis) Glaucoma is multi-factorial Balance treatment decisions and risk of progression Beware of Mimicking Disorders Multiple Visits are Valuable Pieces of the Puzzle Indiana UHR- AO- OCT : 122 µm 17