OPEN ANGLE GLAUCOMA

Frank J. Weinstock, MD, FACS

Professor of Ophthalmology-
NEOUCOM
Canton, Ohio
USA
 TYPES OF GLAUCOMA

 PRIMARY CHRONIC SIMPLE OPEN ANGLE

 ANGLE CLOSURE- NARROW ANGLE
 SECONDARY
 TRAUMATIC
 PRIMARY CHRONIC SIMPLE
OPEN ANGLE GLAUCOMA
 SERIES OF CONDITIONS
 OPTIC NERVE AND VISUAL FIELD LOSS
SECONDARY TO ELEVATED
INTRAOCULAR PRESSURE OR POOR
NUTRITION TO OPTIC NERVE
 ETIOLOGY- NOT TRULY KNOWN
 VARIANTS

 TRAUMATIC
 SECONDARY
 LOW TENSION
 OPEN ANGLE GLAUCOMA
 US- 2.2 MILLION (3.4 MILLION BY 2020)
 175000 IN US BLIND (10% OF BLINDNESS)
 BLACKS-HISPANICS (30% OF BLINDNESS)
 1 IN 1000 OVER 40 YR OLD- BLIND
 OVER 75 YEARS- 2.7/1000 BLIND (6.7/1000
VISUALLY IMPAIRED)
SOPHISTICATED OFFICE EQUIPMENT
AUTOMATIC PERIMETER (VISUAL FIELD TESTING)
 COMPLIANCE
 SCREENING $60/SCREENING AND
$1000/CASE DISCOVERED
 (SCREEN HIGH RISK-RELATIVES-AFRICAN
AMERICANS-HISPANICS-)
 25-40% OF PTS. TAKING Rx TO STORE-
DON’T PICK IT UP
 60% PICKING UP Rx D/C XALATAN DURING
YR AND 76% WITH OTHER MEDS
 DIAGNOSIS
 OPTIC NERVE FIBER EVALUATION
(OPHTHALMOCSCOPE)
 VISUAL FIELD EVALUATION- OFFICE
 OPTIC NERVE IMAGING AND ANALYSIS-
OFFICE
 MEASUREMENT OF INTRAOCULAR
PRESSURE (PORTABLE)
 MEASUREMENT OF CORNEAL THICKNESS
 GENETIC PREDISPOSITION ????
 SCREENING
 OPTIC NERVE EVALUATION-
OPHTHALMOLOSCOPE
 INTRAOCULAR PRESSURE (IOP)
MEASUREMENT- APPLANATION
TYPE TONOMETER
 IOP HAS DIURNAL VARIATION
 GOALS OF SCREENING
 EDUCATION
 DETECTION OF GLAUCOMA (NOT
PROVEN)
 TESTS NOT SPECIFIC OR SENSITIVE
SCREENING- NO VALUE IF:
NOT ABLE TO REFER FOR DEFINITIVE
DIAGNOSIS, TREATMENT AND
FOLLOWUP
 SCREENING
 CHOOSE HIGH RISK GROUPS E.G.
HISPANICS, BLACKS (OVER AGE 40,
WHITES (OVER 65 YEARS OLD), HISTORY
OF EYE TRAUMA; DIABETICS;
 FAMILY HISTORY OF GLAUCOMA
 DIABETICS
 PATIENTS WITH SEVERE MYOPIA
INTRAOCULAR PRESSURE
 VERY EASY TO DO- PORTABLE
INSTRUMENTS
 POOR SENSITIVITY AND SPECIFICITY
 NORMAL- 20 mmHg OR LESS
 MEASURED BY: APPLANATION
TONOMETER- NOT PRACTICAL
 FINGER PALPATION- INACCURATE

APPLANATION TONOMETRY
 SCHIOTZ TONOMETER
ADVANTAGES:
INEXPENSIVE
PORTABLE
EASY TO USE
READILY AVAILABLE
DISADVANTAGES:
NOT THE MOST
ACCURATE
REQUIRES TOPICAL
ANESTHETIC
 OPHTHALMOSCOPY
 EASY; QUICK
 REQUIRES OPHTHALMOSCOPE- AVAILABLE
 REQUIRES EXPERT AT OPHTHALMOSCOPY
 PICKS UP DEFINITIVE GLAUCOMA ( A LATE
STAGE)- MAY BE TOO LATE TO HAVE MUCH
BENEFIT
 INTER-OBSERVER VARIABILITY
 NORMAL C:D RATIO- 0.3 OR LESS THAN 0.2
DIFFERENCE
 (STEREO VIEWS ARE BEST (NOT PRACTICAL)
E-11 Normal and Cupped Disc

NORMAL CUPPED DISC

ENLARGED CUP
PERIPHERAL VISUAL FIELD TESTING
 PICKS UP LATER GLAUCOMA
 REQUIRES EXPENSIVE EQUIPMENT-
DIFFICULT TO PERFORM- NOT PRACTICAL
FOR SCREENING
 OPTIC NERVE ANALYSIS- PICKS UP
PROBLEMS EARLIER (REQUIRES
EXPENSIVE EQUIPMENT AND
TECHNNICAL SUPPORT)- NOT PRACTICAL
FOR SCREENING
 REFERRAL
 SET CRITERIA FOR EACH SCREENING
 E.G PRESSURE OVER 20 MM hG
 INDIVIDUALS WITH SUSPICIOUS DISCS
(LARGE CUPS)
 OPTIC NERVE- HEMORRHAGES; LARGE
CUP:DISC RATIO (OVER 0.4) OR
ASYMMETRY OF CUPS (HORIZONTAL AND
VERTICAL CUP:DISC RATIO)- 0.3
DIFFERENCE
 BEST SCREENING

 COMPREHENSIVE EYE EXAM IN

OFFICE SETTING- BY SPECIALIST
ADDITIONAL SCREENING BENEFITS
 POSSIBLY MORE IMPORTANT THAN
DIAGNOSING GLAUCOMA
 EDUCATION OF NEED FOR EYE CARE
 OPHTHALMOSCOPIC EXAM WILL PICK UP:
 CATARACTS
 CORNEAL SCARS

 RETINAL DISEASE- DIABETES, HYPERTENSION,

TUMORS
 TREATMENT OF GLAUCOMA
 MEDICATIONS- MANY NEW MEDICATIONS-
POTENTIAL SIDE-EFFECTS
 ONCE A DAY DOSAGE- BEST COMPLIANCE
 TREAT EARLIER
 LASER OR SURGERY- EARLIER ????- BEING
EVALUATED
 WHICH FIRST? – BEING EVALUATED
 NEW PROCEDURES
 GOAL- < 20mmHg. (LOWER IN MANY SITUATIONS)
 SUMMARY
 GLAUCOMA SCREENING
 QUESTIONNABLE BENEFIT FOR PREVENTING
BLINDNESS
 WILL PICK UP A NUMBER OF CASES GLAUCOMA
AND OTHER EYE CONDITIONS
 CONCENTRATE ON HIGH-RISK GROUPS
 EASY TO DO
 MARKED EDUCATIONAL AND PUBLIC RELATIONS
BENEFIT