Treatmnet And Managment Overview

Question 1

Factors to consider when developing treatment and management plan

Answer 1

1. Making an accurate clinical diagnosis
2. Assessing the stage of disease
3. Assessing the risk factors for disease progression
4. Understanding the patients access to health care and related factors
5. Considering the patients lifestyle, health status, and life expectancy
6. Implementing a treatment strategy on the bases of these factors and other considerations

Question 2

Treatment and management goals

Answer 2

Determine a target IOP to minimize the progression of glaucomatous optic neuropathy

Communicate well with patient, especially in the age of the internet

Question 3

A few things about the major glaucoma studies

Answer 3

NHI sponsored
Large scale randomized clinical trials
Subjects had various forms and stages of POAG or glaucoma suspect

Question 4

Objective of OHTS

Answer 4

Evaluated the safety and efficacy of topical ocular hypotensive medications or preventing the onset of the POAG in subjects with no initial glaucomatous damage and IOP between 24 and 32mmHg

Question 5

Results of OHTS

Answer 5

• topical hypotensice medication can delay the onset of POAG in patients with elevated IOP
• not all patients with OHTN require treatment
• race was not significant risk factors
• glaucoma risk factors: older age, large CD, early VFL, thin CCT, elevated IOP

Question 6

Objective of EMGT

Answer 6

Assessed treatment vs observation in patients with early glaucoma

Question 7

Results of EMGT

Answer 7

• progression less frequent and occurred later in treated patients
• glaucoma progression predictors: elevated IOP, older age, bilaterality, exfoliation, disc heme, relatively thin CCT
• new predictors: lower systolic perfusion pressure, lower systolic pressure, Hx of cardiovascular disease: suggesting vascular role in glaucoma progression

Question 8

CIGTS objective

Answer 8

Eval the efficacy and safety of surgery versus medical treatment in patitns iwth newly diagnosed, early glaucoma

Question 9

Results of CIGTS

Answer 9

• similar to two previous studies
• pateitns who receive glaucoma Dx may have symptoms not matching clinical testing: need to discuss with pateitn to reduce worries and unessecary concerns about blindness and improving their quality of life

Question 10

AGIS objective

Answer 10

Ivensitgates two surgical sequences with patients with advanced glaucoma

Question 11

Results of AGIS

Answer 11

• initially ALT dielays progression of glaucoma more effectively in black patients than in white patients (Small correlation)
• consistent, low IOPs with minimal IOP variations with reduced progression of VF in patitns with advanced glaucoma (retrospective eval of study)

Question 12

Using the studies in practice

Answer 12

Utilize the studies to help with the management and treatment plans but recognize that these are guidelines
-not every pateitn fits within the starts of each study
0remember the long term goal of reducing vision loss. Keep in mind as you monitor target IOPs: this can be a moving target

Question 13

Things to do for a glaucoma exam that aren’t normal in other exams

Answer 13

Pachymetry 
Gonio
Fundus photo (optic nerve heard)
VF
OCT

Question 14

Exam for preexisting glaucoma patient

Answer 14

• are they complying with topical meds? What are they taking, how often do they take it, when was their last dose, about how often do they miss a dose?
• tonometery
• slit lamp
• posterior seg

Gonio
Fundus photo
VF
OCT
Patient education

Question 15

Decision to make for treatment and management plan for glaucoma patients

Answer 15

• when to initiate treatment
• what will be first line of treatment
• how often is follow up
• when do change the treatment
• when to refer/move on to surgical interventions

Question 16

When to initiate treatment

Answer 16

• treat if glaucomatous optic neuropathy (hopefully before VF loss)
• if not glaucomatous findings, but elevated IOPS, consider risk factors

Question 17

What’s treatment to start on

Answer 17

Determine target IOP
- goal is 20-30% reduction in IOP
-mild damage (rim thinning without VF loss): middle to high teens as target IOP
-moderate damage (cupping with early field loss): low to middle teens for target IOP
Severe damage (extensive cupping and VF loss): high single digits to low teens for target IOP
-these are just guidelines

Question 18

Target IOP for mild damage

Answer 18

Mid to high teens

Question 19

target IOP for moderate damage

Answer 19

Low to middle teens

Question 20

Severe damage target IOP

Answer 20

High single digits to low teens for target IOP

Question 21

Starting a treatment, determining target IOP: risk factors to consider

Answer 21

POAG: thin corneas, older age, family Hx, AA, myopia

ACG: Asian, hyperopia

NTG: vascular factors; ocular ischemia

Question 22

SLT/ALT

Answer 22

• MOA: increasing aqueous outflow
• cost effective (no monthly drop)
• no change in quality of life (less daily meds)
• does it provide enough IOP reduction

Question 23

Topical medications

Answer 23

-MOA: enhancing outflow, reducing aqueous production, or both

Question 24

The catch with SLT/ALT

Answer 24

Sometimes it doesnt lower the pressure and we have to let the patients know that. There is still a chance they need to be put on drops after wards

Question 25

Topical medications considerations

Answer 25

Uniocular trial: ther may be an IOP reduction seen in untreated eye

Question 26

Topical meds uniocualr

Answer 26

There may be an IOP reduction seen in untreated eye

Question 27

How often to follow up?

Answer 27

• inital start of topical meds: F/U in 1 month IOP check
• once they have a stable/target IOP: F/U 3-4 months IOP check with DFE, OCT, HVF, gonio

Based on severity of glaucoma, consider DFE, OCT, HVF, gonio every year to every 3-6 months

Question 28

When to change treatment?

Answer 28

• when IOP reduction is not enough to reduce risk of glaucoma progression
• when reach target IOP, but see progressing glaucomatous optic nerve damage and/or VF loss

Question 29

When to refer/move on to surgical intervention

Answer 29

• when you need a second opinion

- when topical and SLT/ALT is not working

Question 30

Patient education when treating for glaucoma

Answer 30

• explain the disease and the status of their condition
• explain why you chose your treatment plan
• explain what management plan will be like (follow ups)
• answer any and all questions
• provide the patient with informational pamphlets
• check on refill amounts, create medication log/calendar