DIS - Glaucoma Management I - Week 7 Flashcards
What number of signs is needed for a definitive diagnosis of glaucomatous optic neuropathy? List them.
3 signs:
ON (NNR) loss
RNFL (mGCC) loss
VF defects
What is the likely diagnosis for a VF defect with no other cause? What about a VF defect in combination with either ON or RNFL loss?
Both likely open angle glaucoma
What is the likely diagnosis for ON and RNFL loss but normal VF?
Likely pre-perimetric open angle glaucoma
What is the first step in the treatment loop of glaucoma? Explain for open angle glaucoma and low tension glaucoma.
Setting a target IOP
OAG: -25% / 18mmHg
LTG: -30% / 12mmHg
What is the most common intervention to reach target IOP for glaucoma?
gtt PGA noce
What is the next step after prescribing a drug for glaucoma? What should be kept in mind?
Monitoring response to the Rx
-review in a month
Keep in mind the patient’s adherence to the Rx
-dont assume they will follow Rx instructions
What time period after initiating glaucoma treatment should you refer to a specialist for surgical consult?
4/12
What are the NHMRC first choice drugs for treating glaucoma? List four options, including drug name, brand name, and concentration.
Latanoprost (Xalatan) 0.005%
Travoprost (Travatan) 0.004%
Bimatoprost (Lumigan) 0.03%
Salfutan (Tafluprost) 0.0015%
What are the NHMRC second choice drugs for treating glaucoma? List seven combination options, including drug name, brand name, and concentration.
Travaprost (0.004%) + Timolol (0.5%)
-DuoTrav
Latanoprost (0.005%) + Timolol (0.5%)
-Xalacom
Bimatoprost (0.03%) + Timolol (0.5%)
-Ganfort
Brimonidine (0.2%) + Timolol (0.5%)
-Combigan
Dorzolamide (2%) + Timolol (0.5%)
-Cosopt
Brinzolamide (1%) + Timolol (0.5%)
-Azagra
Brinzolamide (1%) + Brimonidine (0.2%)
-Simbrinza
What drug combination is good for low tension glaucoma?
Brinzolamide (1%) + Brimonidine (0.2%)
-Simbrinza
What is the NHMRC third drug of choice for glaucoma?
Pilocarpine (1%, 2%, 4%)
According to the NHMRC, when is surgery recommended in glaucoma?
Only if drugs do not stabilise IOP to the target set
What percentage of pateitns do not comply with drug use instructions after 1 month? What about after a year?
1 month - 20%
1 year - 65%
What is a solution to people who cannot instil drops (2) due to physical/psychological limitations?
Drop aid or assistant
What is a solution to people who have unacceptable side effects from eyedrops (2)?
Alter drug
Surgery referral
Should you always treat glaucoma if the diagnosis is established?
Yes
Are PGAs on their own generally adequate for glaucoma?
Yes, long term in 70% of cases
Briefly summarise glaucom management by optometrists (5).
Establish diagnosis, initiate treatment
Obtain a baseline - VF/OCT/photo
Monitor 0/12, 1/12, 3/12, then 4/12 for 8 VF tests, then 6/12 or 12/12
Consider need for neuro-protection
Refer at 4/12 to specialist for surgical options
Define target IOP. Does it change with age?
IOP that affords no loss of ganglion cells beyond ageing, for a particular patient
What is the target IOP generally and where does this figure come from?
Can change with age
Initial target is -25%, derived from clinical trials
-can be adjusted
Typical target: -25% or 18mmHg, whichever is less
What percentage of treated glaucoma cases progress in two years? what does this suggest of the Rx?
20% progress
-Rx slows progression, doesnt cure
How much change in relative visual field scores can you expect after the first 24 months of treatment? Explain in terms of <14, <18, and >18mmHg IOP.
Little change in the first 24 months
IOP <14 - doesnt progress
IOP <18 - slow progression over 8 years, max loss over 20 years
IOP >18 - max loss in 15 years
What is the maximum daily variation seen in most normal eyes? How does this relate to setting a target IOP?
4mmHg - 20% in eyes of 20mmHg
-20% is beyond normal physiological IOP variation (is therapeutic)
What are the target IOPs for the following:
OAG (starting)
-early
-moderate
-advanced
Advanced
Progressing
Include both percentage and mmHg.
OAG (starting) (-25% / ≤18mmHg)
-early (-20% / ≤18mmHg)
-moderate (-25% / ≤18mmHg)
-HR OAG (-30% / ≤14mmHg)
Advanced (-30% / ≤14mmHg)
Progressing (add -20% / ≤14mmHg)
By how much can target IOP be adjusted if the patient is stabled?
Max 4mmHg
What is moderate and severe threat to fixation defined as on VF, and what constitutes advanced glaucoma?
Defined by dB at 4 central 24-2 points
15-25dB - moderate
Severe if 1 point has 0 to 15dB
-this is considered advanced glaucoma
Are PGA effects fully expressed in low tension glaucoma?
Not
Within what time period is IOP reduction evident for glaucoma drugs and which is the quickest?
All within a week - PGAs quickest (80% of effect within a week)
How long do PGAs need to have the full therapeutic effect?
3-4 months
Do glaucoma combination drugs give more or less than the full effect of each component?
Less
Can the maximum effect of a glaucoma drug only be achieved from independent drug application?
Yes
What IOP change would prompt a drug change? What should you do if you need only a small change (2mmHg)? What about a large change?
If IOP change is <5mmHg on review
Change to combination drug if small change required
Add independent combo for large change
Can a third drug be added to a glaucoma therapy?
Yes, but contact an ophthalmologist first
What percentage of glaucoma patients need one, two, and three drugs?
One - 69%
Two - 28%
Three - 3%
