ACTIVITY DISCLAIMER. Glaucoma DISCLOSURE. Learning Objectives. Audience Engagement System Step 1 Step 2 Step 3. Jeffrey SooHoo, MD. Jeffrey SooHoo, MD

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1 Glaucoma Jeffrey SooHoo, MD ACTIVITY DISCLAIMER The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented here. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP. DISCLOSURE Jeffrey SooHoo, MD It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose. Assistant Professor, Department of Ophthalmology, University of Colorado School of Medicine, Aurora. Dr. SooHoo is a graduate of Loyola University Chicago s Stritch School of Medicine, Illinois. He completed his residency in the department of ophthalmology at the University of Colorado School of Medicine, Aurora. Dr. SooHoo is board certified in ophthalmology and is fellowship trained in glaucoma and cataracts. His research interests include novel medical and surgical treatments for glaucoma. The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. Learning Objectives 1. Identify patients at risk of developing open-angle glaucoma for complete ophthalmologic examination. Audience Engagement System Step 1 Step 2 Step 3 2. Evaluate patients presenting with symptoms consistent with acute narrow-angle glaucoma for emergent treatment or referral to an ophthalmologist. 3. Establish a patient-centered approach for follow-up care for patients receiving glaucoma treatment, emphasizing patient adherence.. 1

2 Poll Question True or false: All patients with glaucoma have elevated intraocular pressure? Poll Question True or false: All patients with glaucoma have elevated intraocular pressure? Glaucoma by the Numbers Second leading cause of blindness worldwide (cataract #1) Leading cause of irreversible blindness worldwide Over 60 million patients with glaucoma worldwide Over 8 million people blind from glaucoma worldwide Over 3 million Americans have glaucoma, but only ½ of them know it 10 million physician visits in the US for glaucoma each year Costs the US government $1.5 billion annually Social Security benefits, lost income tax revenue, health care costs Glaucoma Key Facts There is no cure Anyone can get glaucoma There are usually no symptoms There are many different treatment options If caught early and treated blindness may be prevented What is Glaucoma? A progressive optic neuropathy characterized by distinct changes in the retinal nerve fiber layer and optic nerve head associated with visual field loss Many different forms Causes slow loss of optic nerve fibers Loss of peripheral vision initially Can progress to total vision loss Classified in part by anterior chamber angle anatomy: Open Angle Closed Angle Intraocular pressure (IOP) is not part of the definition Introduction Glaucoma Definition: an optic neuropathy with characteristic optic nerve head and nerve fiber layer changes Ganglion cell death PROGRESSION Retinal nerve fiber layer changes Optic nerve head changes Visual field changes 2

3 Anatomy of the Eye The Angle : Drains of the eye Angle closure vs. open angle glaucoma Open Angle Glaucoma Angle Closure Glaucoma Optic nerve changes 3

4 How does glaucoma affect vision? Poll Question True or false: if properly treated, glaucoma can be cured. Poll Question True or false: if properly treated, glaucoma can be cured. Symptoms Open angle glaucoma and chronic angle closure glaucoma Usually none Once a patient notices vision loss it s likely very advanced glaucoma already Acute angle closure glaucoma Hazy or blurred vision Halos around lights Severe eye pain and headache Red eye Nausea and vomiting Sudden vision loss Risk Factors Race African-Americans: 3x greater risk than Caucasians Hispanics Asians and Native Americans: increased risk of angle closure glaucoma due to eye anatomy Age: Older than 60 = 6x greater risk Family history of glaucoma 4-9x greater risk if first degree relative with glaucoma Current or past steroid use Eye injury or trauma Nearsightedness / Myopia Thinner corneas Increased IOP The only modifiable risk factor for glaucoma What about eye pressure? Intraocular pressure (IOP) Significant risk factor for developing glaucoma Only modifiable risk factor Not all forms of glaucoma have high IOP Basis for nearly all treatments Lower is better (think of a golf score) Normal IOP is mm Hg 4

5 Types of Glaucoma Types of Glaucoma Types of Glaucoma POAG Characteristics Primary open-angle (POAG) Angle-closure (acute or chronic AACG/CACG) Congenital Childhood Secondary Most common type of glaucoma Bilateral but not always symmetric Characteristic optic nerve and visual field damage Adult onset Open, normal-appearing anterior chamber angles Absence of secondary causes POAG: higher risk in African-Americans Blindness = 3-4 times more common Age > 70 = 10% prevalence (2% for Caucasians > 70) POAG occurs at an earlier age POAG more advanced when discovered POAG: Elevated IOP High IOP doesn t always correlate with optic nerve damage IOP is related to POAG prevalence, regardless of race IOP: Population Distribution Primary Open-Angle Glaucoma POAG: Other risks factors Factor Relative Risk Age (per decade >40) 2 African-American vs. Caucasian 4 Family history (1 relative) 2-4 Myopia Decreased corneal thickness 3 5

6 Introduction POAG: Prevalence in relation to screening IOP POAG: prevalence by age and sex POAG: Prevalence by age, race, sex Recommended Frequency of Eye Exams Age No Risk Factors Risk Factors At least once during interval Every 3-5 years At least twice during interval Every 2-4 years Every 2-4 years Every 2-4 years 65 + Every 1-2 years Every 1-2 years Types of Glaucoma Secondary Glaucomas Angle Closure Glaucoma: Who is at risk? Trauma Uveitis Chronic steroid use Diabetic retinopathy Ocular vascular occlusion Elderly Hyperopic patients Positive family history of angle closure Females Eskimo/Inuit Asians 6

7 Angle-Closure Glaucoma Angle-Closure Glaucoma Acute Angle Closure Glaucoma Severe ocular pain, redness Blurred vision Halos around lights Headache Nausea and vomiting Angle-Closure Glaucoma Acute Angle Closure Glaucoma Mid-dilated pupil Conjunctival injection Cloudy cornea Acute Angle Closure Glaucoma Manage medically with IOP-lowering drops, hyperosmotics Definitive therapy usually with laser or surgical iridotomy/iridectomy Angle-Closure Glaucoma Acute Angle Closure Glaucoma Requires evaluation of the fellow eye, usually prophylactic iridotomy Requires long-term follow up of both eyes May benefit from cataract surgery How do we test for glaucoma? 1. Intraocular pressure measurement 2. Evaluation of optic nerve 3. Evaluate drainage angle of the eye (gonioscopy) 4. Visual field testing 5. Corneal thickness measurement (pachymetry) 7

8 Testing IOP Testing IOP Evaluation of the Optic Nerve Primary Open-Angle Glaucoma Increased size of the cup Thinning of disc rim Progressive loss of neural rim tissue Disc hemorrhages Loss of nerve fibers Imaging and Ancillary Tests in Glaucoma Optic nerve photos Optical coherence tomography (OCT) Automated visual field Ideal Imaging Modality Differentiate between normal and glaucomatous eyes Detect glaucomatous changes before functional vision loss (pre-perimetric) Reliably detect progression of disease Other ideal features Fast, easy, applicable to all patients 8

9 Matched Flicker Advantages Easy to perform Direct anatomic comparisons Optic Nerve Photos Disadvantages Subjective and variable interpretation Not as helpful early on in disease detection No normative database to compare Difficulty delineating nerve rim on 2-D photos Hassle to keep track of non-digitized photos Cannot quantify RNFL thickness Optical Coherence Tomography (OCT) Non-invasive imaging modality Useful for a variety of ophthalmic conditions Retina Optic Nerve Anterior Chamber 9

10 GPA Glaucoma Progression Analysis Visual Field Testing Automated Generally takes ~ 5 minutes/eye Can take longer in older patients or patients with poor vision Dependent on subjective patient responses Putting it all together L R 10

11 Glaucoma Mid-Point Q&A How do we treat glaucoma? 1. Decrease eye pressure (IOP) - How much is enough? - Can it get too low? Poll Question The preferred treatment for glaucoma is: A. Eye drops B. Laser surgery C. Cataract surgery D. Other surgery Poll Question The preferred treatment for glaucoma is: A. Eye drops B. Laser surgery C. Cataract surgery D. Other surgery How do we treat glaucoma? Medications to lower IOP Many to choose from Prostaglandin analogues B-blockers Alpha2- agonists Carbonic anhydrase inhibitors Muscarinic agonists Side effects Burning, stinging redness Change eye color, eyelash growth Fatigue, breathing problems, hypotension 11

12 Topical medications Prostaglandin Analogues Lower IOP by either increasing outflow or decreasing aqueous production Have systemic absorption and systemic side effects i.e. beta-blockers Congestive heart failure Bronchospasm Bradycardia Prostaglandin Analogues: Side Effects Punctal Occlusion Conjunctival hyperemia Increased iris pigmentation Eyelash growth Periocular skin pigmentation Treatment of POAG Why does medical therapy fail? Target IOP not achieved Poor patient compliance IOP fluctuations Average Adherence in Studies of 17 Disease Conditions HIV 88% Arthritis 81% GI disorders 80% Cancer 79% Seizures/brain disorders 78% Genitourinary and STDs 77% Skin disorders 77% Cardiovascular diseases 77% ENT and mouth disorders 76% Blood disorders 76% OB-GYN 75% Infectious disease 74% Eye disorders 73% End stage renal disease 70% Pulmonary disease 69% Diabetes 68% Sleep disorders 66% DiMatteo. Medical Care. 2004;42(3):

13 Predictors of Nonadherence in Glaucoma Treatment Identified in Prior Research Cost of treatment Real or feared adverse events Not seeing benefits of treatment Poor doctor-patient relationship Physical limitations Cognitive dysfunction Other Possibilities Negative mood or depression Anxiety about treatment Lack of social support Low treatment motivation Forgetfulness Lack of perceived control Lack of knowledge Other treatment options Laser to lower IOP Laser trabeculoplasty (ALT or SLT) Quick, painless, performed in office Can lose effect over time May be repeated ~75% response Surgical treatments Surgery to lower IOP More risk but more reward Trabeculectomy bypass normal eye drainage system Tube shunt bypasss normal eye drainage system Minimally Invasive Glaucoma Surgery Risks of surgery Pain, bleeding, infection Blurred vision, activity restrictions Cataract Low IOP, high IOP Need for further surgery or repeat surgery 13

14 Trabeculectomy Glaucoma Drainage Devices Valved and non-valved devices Minimally Invasive Glaucoma Surgery (MIGS) Several newer procedures Endocyclophotocoagulation (ECP) istent Less risk, less reward Most target existing fluid drainage pathways Usually combined with cataract surgery istent First FDA approved MIGS device (June 2012) Trabecular micro-bypass stent Heparin-coated titanium 1mm long, 0.33mm high, 60ug, 120um bore Indication: Mild to moderate OAG and visually significant cataract istent Bypasses outflow resistance in the trabecular meshwork 14

15 ECP Endoscopic cyclophotocoagulation Only MIGS aimed at decreasing aqueous production 3-in-1 Endoscope Xenon light, video image, 810nm diode laser Ablation of ciliary epithileum ECP What s on the horizon? New laser/medications More effective Easier to use and tolerate Medications that can protect or improve the function of the optic nerve (not just lower eye pressure) Neuro-protective agents Neuro-potentiating agents New minimally invasive glaucoma surgery Drugs or therapies to regenerate the optic nerve Conclusion Glaucoma is a disease of the optic nerve It is a frequent cause of blindness worldwide There are usually no symptoms until very late Risk increases with age Early detection is key encourage screening for patients with risk factors If treated early vision loss can be prevented You can help! Ask about a family history of eye problems Encourage screening exams Ask if patients are taking eye drops for glaucoma Encourage compliance Ask about side effects Let the ophthalmologist/optometrist know of any possible systemic contraindications 15

16 Practice Recommendations Patients with acute eye pain and loss of vision should be referred for immediate evaluation by an ophthalmologist (SORT = C) Acute angle closure glaucoma is an ophthalmic emergency (SORT = C) Requires immediate IOP lowering Laser iridotomy is usually the definitive treatment Patients with a family history of glaucoma should have a complete screening eye exam (SORT = C) Thank you! jeffrey.soohoo@ucdenver.edu 16