Medical Treatment Algorithms (M)

Question 1

What two tests should be performed at every visit for every suspect or glaucoma patient?

Answer 1

1. IOP

2. ONH evaluation

Question 2

What are the times you would not consider prostaglandins as an initial therapy?

Answer 2

1. inflammatory glaucoma
2. history of recurrent uveitis or CME
3. acute angle closure or any other IOP emergencies
4. monocular therapy because noticeable difference btw eyes (iris and lashes)

Question 3

What is the recommended schedule for low risk suspects of longstanding suspects?

Answer 3

annual exam with periodic fundus photo or NFL measurement

Question 4

When are surgical methods required for the treatment of glaucoma?

Answer 4

1. initial Tx for severe cases with advanced vision loss
2. when maximal medical therapy (MMT) does not impede progression
3. inability to take topical hypotensives
4. most congenital forms of glaucoma
5. poor compliance with drug therapy

Question 5

What is the recommended schedule for a patient that has been diagnosed with glaucoma and is being treated with drops?

Answer 5

1. comprehensive exam with DFE and fundus photo
2. Glc visit 1: VF, OCT, IOP, ONH eval
3. Glc visit 2: IOP, ONH eval, repeat gonio as necessary

Question 6

What are the important factors that go into selecting glaucoma medications?

Answer 6

1. efficacy
2. safety profile
3. tolerability
4. patient acceptance

Question 7

Should medications be switched or added first when target pressure has not been met?

Answer 7

switched

Question 8

What are the best additive medications?

Answer 8

PG’s and CAI’s b/c 24hr control

Question 9

What is the recommended schedule for an initial glaucoma suspect and higher risk suspects?

Answer 9

1. annual exam with IOP, DFE, fundus photo

2. within 6 months return for OCT, VF, IOP, gonio, and pach

Question 10

At what percentage risk on the risk calculator must you treat the patient?

Answer 10

20%

Question 11

When is the best time to take beta blockers for glaucoma? Why?

Answer 11

QD in am only because can lower blood pressure and impair optic nerve perfusion

Question 12

What is the target pressure reduction amount for a patient with an IOP of 20mmHg and mild damage? 1. Moderate damage? 2. Advanced damage? 3

Answer 12

1. 25%
2. 35%
3. 45%

Question 13

When should a topical beta blocker not be used?

Answer 13

1. any pulmonary condition
2. pregnant or nursing mothers
3. patients on cardiac glycosides
4. congestive heart disease
5. pulse rate below 60

Question 14

According to the OD at the Baltimore VA, what is the proper pressure reduction for treatment of ocular hypertension with no damage? 1. Mild to moderate damage? 2. Moderate to severe damage? 3

Answer 14

1. 25% reduction
2. IOP below 18mmHg at all times
3. IOP below 15 at all times

Question 15

At what pressure do you treat ocular hypertension even if there is no damage or family history, etc?

Answer 15

30mmHg

Question 16

What do monocular trials on medications do?

Answer 16

1. factor out diurnal IOP fluctuations to determine true effect of med
2. determine ocular SE’s of meds

Question 17

What are good methods to check your patients compliance with drop usage?

Answer 17

1. have them demonstrate installation in office
2. have them explain how and when use them
3. have them bring in their bottles to each appt
4. monitor patient refills

Question 18

What is the absolute minimum IOP reduction required once treatment is determined to be necessary?

Answer 18

25%

Question 19

What did the AGIS study determine about IOP reduction?

Answer 19

significant benefit in minimizing progression in advanced glaucoma if IOP below 18 at every visit

Question 20

What are the reasons to switch prostaglandins (and what to)?

Answer 20

1. redness exists (to Xalatan or Zioptan)

2. target pressure not reached (to Lumigan)

Question 21

What are the ocular hypotensives that are effective nocturnally?

Answer 21

1. prostaglandins

2. carbonic anhydrase inhibitors

Question 22

What are the two key goals of IOP reduction?

Answer 22

1. adequate % dec in IOP

2. maintain consistent and regular IOP

Question 23

What is the target pressure reduction amount for a patient with an IOP of 40mmHg and mild damage? 1. Moderate damage? 2. Advanced damage? 3

Answer 23

1. 40%
2. 50%
3. 60%

Question 24

When should CAI’s not be taken?

Answer 24

1. Fuch’s dystrophy

2. advanced glaucoma

Question 25

What is the concept that is when the patient is maxed out on the meds/mechanisms of action that can effectively lower IOP? 1. How many meds is considered this? 2

Answer 25

1. maximal medical therapy (MMT)

2. 3 meds (usually in two bottles)

Question 26

How long should you wait until a pressure check after initiating therapy?

Answer 26

30 days

Question 27

What are the factors that should be consider to lower the initial target pressure even further than recommended on the chart?

Answer 27

1. longer life expectancy at time of Dx

2. High rate/risk of progression (Pseudoexfoliation, disc hemes, Beta zone PPA)

Question 28

What is the target pressure reduction amount for a patient with an IOP of 30mmHg and mild damage? 1. Moderate damage? 2. Advanced damage? 3

Answer 28

1. 30%
2. 40%
3. 50%

Question 29

What is the relative effectiveness of combination agents? 1. Why are they useful? 2

Answer 29

1. less effective

2. better compliance

Question 30

What type of hypotensive has the greatest effect on maintaining the flattest diurnal curve, including for nocturnal control?

Answer 30

prostaglandins

Question 31

What are the factors that go into the glaucoma risk estimator?

Answer 31

1. age
2. untreated IOP
3. central corneal thickness
4. vertical cup to disc ratio
5. pattern std. dev./crossed loss variance