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GP Powerpoint No 2
GP Powerpoint No 2
- A Charitable Trust
Glaucoma New Zealand
Aims to
A Christchurch CASE :
A 81 yr old man is referred by his GP for urgent
cataract surgery for his very poor vision.
CATARACT
• The patient will present to you when the visual
disability reaches the threshold for that person
to complain about their vision.
• “Screening” for cataract is not required.
• Visual acuity with a pinhole is near normal for
early to modest cataract (and refractive errors)
• Vision can be restored by surgery at any stage
in the development of cataract from a clear
lens to one that has been dense for years.
Cataract and glaucoma compared
GLAUCOMA
• The patient will complain of visual problems
only at a late stage in glaucoma development.
• The sight lost cannot be restored (this century!)
• The cupped optic disc is at high risk for sudden
loss of vision from a retinal vein occlusion,
which adds insult to the injury !
• Early treatment is effective in preventing
progression in glaucoma damage.
(Level 1 evidence: multiple double blind trials)
Glaucoma in General Practice
THREE considerations for today:
• Detecting glaucoma : symptomatic and
asymptomatic patients.
• Assessment of “Glaucoma Risk Factors” :
determines appropriate monitoring and may
indicate pre-glaucoma intervention. (reviewed)
• Evaluation of health and life-style issues that
may accelerate damage to the cupped and
compromised optic disc in those with glaucoma.
Detecting Glaucoma
and
Ophthalmoscopy
• Direct viewing is most convenient for you.
Indirect viewing uses a slit lamp microscope.
• Documentation of the optic disc:
Draw the disc and its cup
Assess the vertical ratio of the cup diameter to
the disc diameter. Record as a decimal eg 0.3
Optic disc scanning : a technical assessment
GDx, OCT, HRT machines. They will become
widely used in the next few years.
Optic Disc Parameters to check
GENERALISED LOSS
• Assess the cup / disc ratio esp. vertically.
• Assess the thickness of the rim to the cup.
• A normal cup is oval horizontally.
• The glaucomatous cup is often oval vertically.
• The mean c /d ratio is 0.3 with a wide range !
• Your index of suspicion will be enhanced if you see a
large c / d ratio. (As in the patient described.)
• Asymmetry in the c / d ratio between eyes is very
significant. (< 0.2 difference in 98 %)
The Neuro-retinal rim / nerve fibres
LOCALISED LOSS
• Look for localised notches in the rim.
• Focal loss is often inferiorly, then superiorly.
• Record as the c / d ratio in that meridian
eg. c/d 0.9 at 5 o’clock
PALE DISCS
• Glaucomatous discs may look pale as the cup
deepens and enlarges. BUT..
• True pallor of the rim ( the remaining nerve fibres) is
optic atrophy NOT glaucoma.
Typical cortical cataract shadows in the red reflex.
Expect good Pin hole acuity here or consider dual pathology
Fundus photo of the same eye. Blurred view from cataract but optic disc
visible : healthy disc with cup / disc ratio of 0.3
The optic disc in glaucoma
Department of Ophthalmology
The University of Auckland
Private Bag 92019
Auckland
Tel 09 373 8779
Fax 09 373 7947
www.glaucoma.org.nz
Email: info@glaucoma.org.nz