Pharmacologic Management of Glaucoma Flashcards
What are the four steps of glaucoma treatment?
- Determine the type of glaucoma
- Determine the severity of glaucoma
- Apply the evidence
- Initiate treatment
What must be present in order for you to code for glaucoma?
RNFL abnormalities AND Reliable VF defects
Describe the stages of glaucoma.
Mild: Definite disc or RNFL abnormalities but normal perimetry findings.
Moderate: Definite disc or RNFL abnormalities AND glaucomatous VF abnormality in ONE hemifield NOT within 5 degrees of fixation
Severe: Definitie optic disc or RNFL abnormalities AND glaucomatous VF abnormality in BOTH hemifields AND/OR loss within 5 degrees of fixation in at least one hemifield
Indeterminate: Definite optic disc or RNFL abnormalities but an inability of the patient to perform VF testing, unreliable tests or VF not performed yet
When can you consider a VF to be reliable?
3 fields ran within 4 months that are similar are required to be considered reliable?
Can an OCT and Fundus photo be billed at the same time?
No
What do you do after you determine the type and stage of glaucoma a patient has?
Document your findings of nerve structure and function
Determine IOP target pressure
Initiate pharmacological/surgical treatment
Monitor changes and ask about side effects of meds!
EDUCATE YOUR PATIENT and encourage their involvement in the treatment process!
What are some variables to consider when setting your IOP target pressure? (6)
More advanced glaucoma requires lower target presure
What stage?
What are the baseline IOPs?
What is patient age?
Do they have additional risks? FHx, Race, etc
Rate of progression?
Explain the evidence found in the OHTS. How does this impact your treatment goals?
OHTS: Ocular Hypertension Treatment Study
Most patients with elevated IOP did not progress in 5 years
20% reduction of IOP (and less than 24mmHg) resulted in a 50% reduction in risk to develop POAG
What this means:
If you choose to treat ocular hypertension, you should shoot for a target IOP that is both below 24mmHg and a 20% reduction of IOP from their baseline
Ex: Pre-treatment IOP: 30mmHg -> Try and get below 24mmHg (just so happens to be 20% reduction too)
Explain the evidence found in the EMGTS.
EMGTS: Early Manifest Glaucoma Trial
Patients with newly diagnosed POAG had an average of 50% reduction in risk of progression of their glaucoma if IOP was reduced by ~25%.
What should be your target pressure of a patient with each stage of glaucoma?
Mild Stage: 25% dec from baseline and IOP <25
Moderate Stage: 30-35% dec from baseline and IOP <18
Severe Stage: IOP in low teens (10-12)
Explain the evidence found in CIGTS and AIGS:
CIGTS: Collaborative Initial Glaucoma Treatment Study
AIGS: Advanced Glaucoma Intervention Study
For mild stage glaucoma, when IOP was aggressively treated and was reduced by 30%, there was no VF progression in 7 years!
For moderate stage glaucoma, CIGTS found the same for mild (above). AIGS found that consistently low IOP slowed the progression of VF loss.
IOP at 12mmHg had NO progression in VF over 14 years
IOP in mid-upper teens had 2.5dB defect
IOP of 20 had 3.5dB defect
Explain the evidence of CNTGS.
CNTGS: Collaborative Normal Tension Glaucoma Study
30% reduction in IOP and IOP between 12-14mmHg is required to slow progression of VF loss
Which is harder to treat? POAG or Normal Tension Glaucoma? Why?
Normal Tension Glaucoma is harder to treat because the IOP is already normal/low. It is harder to decrease IOP from 16 to 11 than 50 to 14
If a patient is compliant with their PGA treatment, but IOP is not lowering at least 25%, what should you do next?
Try another PGA before switching to another drug
What is the maximum medical therapy for glaucoma? (number of drugs)
3 drugs. If you cannot get/keep IOP low enough after using 3 drugs, refer for surgery (Selective Laser Trabeculoplasty)
