Final - Tx Kinzer

Question 1

Factors when developing management plan

Answer 1

Accurate dx
Stage of disease
Risk factors for progression
Access to health care
Lifestyle, health, life expectancy

Question 2

Tx and management goals

Answer 2

Target IOP to minimize progression

Communicate

Question 3

Studies: Ocular HTN Treatment Study (OHTS)

Answer 3

Topical HTN meds can delay onset of POAG in pts with elev IOP

Not all pts with OHTN require tx

Race not a significant risk factor

Risk factors: age, large C/D, early VF loss, thin CCT, elev IOP

Question 4

Studies: Early Manifest Glaucoma Trial (EMGT)

Answer 4

Progression less frequent & occurred later in tx pts

Progression predictors: elev IOP, bilateraility, exfoliation, disc hemorr, thin CCT

New predictors: low systolic perfusion pressure, low systolic BP, hx of CVD (sugg vascular role in glauc progression)

Question 5

Studies: Collaberative Initial Glaucoma Tx Study (CIGTS)

Answer 5

Pts who rec’v glauc dx may have symptoms not matching clinical testing -> need to discuss w/ pt to reduce worry & unnecc concerns

Question 6

Studies: Advanced Glaucoma Intervention Study (AGIS)

Answer 6

Initial ALT delays progression of glauc more effectively in black pts than white (small correllation)

Consistent low IOPs w/ minimal variation is assoc with reduced progression of VF loss in pts with advanced glauc (retrospective eval of study)

Question 7

Newly dx pt exam

Answer 7

Pachymetry
Gonio (unless already dilated)
Fundus photos
VFs
OCT

Question 8

Pre-existing glaucoma pt exam

Answer 8

Compliance w/ meds (case hx)
Tonometry
SLE
Post seg
Gonio
Fundus photo
VFs
OCT

Question 9

When to initial tx

Answer 9

Tx if they have glaucomatous optic neuropathy

If no glaucomatous findings but elev IOPs, consider risk factors

Question 10

What tx to start on

-goal IOPs

Answer 10

Goal 20-30% IOP reduction

Mild damage: middle-high teens as target IOP
(E.g. rim thinning w/o VF loss)

Moderate: low-middle teens
(E.g. cupping with early VF loss)

Severe: high single digits to low teens
(E.g. extensive cupping & VF loss)

Question 11

What tx to start on

-risk factors to consider

Answer 11

POAG: thin cornea, age, fam hx, black, myopic

Angle-Closure: Asian, hyperopia

NTG: vascular factors, ocular ischemia

Question 12

What tx to start on

-initial tx type

Answer 12

Consider sx for childhood or acute angle-closure

Question 13

What tx to start on

-SLT/ALT

Answer 13

MOA: incr aqueous outflow

Cost-effective (no monthly gtts)

No change in quality of life (less dailiy meds)

Does it provide enough IOP reduction?

Question 14

What tx to start on

-topical meds

Answer 14

MOA: enhance aqueous outflow, reduce production, or both

Can consider monocular trial - may be an IOP reduction seen in untreated eye

Question 15

How often is F/U

Answer 15

Initial start of topical meds: 1 month IOP check

Stable/target IOP: 3-4 months IOP check w/ DFE, OCT, HFV, gonio
-based on severity, consider every year to every 3-6 months

Question 16

When to change tx

Answer 16

When IOP reduction is not enough to reduce risk of progression

When reach target IOP but see progressing glaucomatous ONH damage and/or VF loss

Question 17

When to refer/move on to sx intervention

Answer 17

When you need a 2nd opinion

When topical and SLT/ALT is not working

Question 18

Tx and management plan

-no matter your course of tx, always

Answer 18

Educate - explain:

• the disease & their status
• why chose their tx plan
• what management plan will be (F/Us)
• answer all questions
• provide pamphlets
• check on refills & create medication log/calendar