Glaucoma/OHT in the Community eCare Ipswich Suspect … · 2019-03-22 · Glaucoma/OHT in the Community Suspect Investigation & Stable Management eCare Ipswich 20-03-2019 Christian

Glaucoma/OHT in the Community

Suspect Investigation &

Stable Management

eCare Ipswich

20-03-2019

Christian Dutton

Education & Compliance Lead OptometristBSc(Hons.) MScClinOpt FCOptom Prof.Cert.Glauc

Mr. Simon Hardman-Lea

Lead Consultant OphthalmologistMA (Oxon.) FRCS FRCOphth

Overview

Assessing Risk in Glaucoma

• Statistics

• Definitions

• Clinical Investigations• Discs / RNFL / Fields• IOP / CCT• A/C

• Treatment Philosophy• Target Pressure

• Treatment• Treatment Algorithm• Glaucoma Medications• Patient Information

• Review• Progression• Recall

Glaucoma Cases & Telemedicine

• Clinical case studies

• Clinical protocols

• Telemedicine

• Tips from the telemedicine consultants

• Validation & MCQ’s

Overview


• Statistics

• Definitions








• Telemedicine



• Second leading cause of blindness worldwide (10% of UK blindness)

• 50% is still undetected

• 2010 - 60.5 million people (OAG and ACG) – 500,000 in England• Blind: 4.5 million OAG, 4 million ACG

• 2020 - 79.6 million• Blind: 6 million OAG, 5 million ACG

• 75% OAG

• 60% are women (make up 55% of OAG and 70% of ACG)

• 50% are Asian (85% of ACG)

Statistics

HES:

• 30% of all outpatient follow-ups (over 1 million appts)

• 15% of all new assessments

Statistics

Overview


• Statistics

• Definitions








• Telemedicine



Definitions

OHT

• IOP ≥ 22mmHg

• Open angle

• Normal fields

• Normal discs

• ~10% of individuals with IOPs between 22-30mmHg develop POAG over 5 yrs

COAG suspect

• Open angle

• Suspicious fields

• Suspicious discs

• POAG suspect if IOP ≥ 22mmHg

• NTG suspect if IOP <22mmHg

Definitions

Glaucoma

• Group of diseases

• Acquired progressive optic neuropathy

• Progressive loss of visual function if• Undetected

• Untreated

• Undertreated

Definitions

Definitions

CLASSIFICATION

• Appearance of the aqueous drainage pathway at the TM• Open-angle glaucoma

• Normal clinical appearance

• Aqueous outflow may be restricted

• Angle closure glaucoma• Access to the TM is physically obstructed

• Mechanisms that push the iris forward from behind

• Mechanisms that pull it forward

PRIMARY ANGLE CLOSURE• Primary angle closure suspect (PACS)

• Contact between peripheral iris and posterior TM possible • IOP, discs and visual fields are normal

• Primary Angle Closure (PAC)• Obstruction of the TM by the peripheral iris has occurred• Raised IOP (appositional PAC) and/or peripheral anterior synechiae (synaechial PAC)• Disc and fields are normal

• Primary Angle Closure Glaucoma (PACG)• PAC with damage to the optic nerve and visual field change.• Damage caused by:

• Episodes of severe IOP elevation (so IOP might be normal or raised on presentation)• Long-term elevated IOP

Definitions

Overview


• Statistics

• Definitions








• Telemedicine



Specific to the eye

• Raised IOP• 15.5mmHg (SD 2.5mmHg) 10-21

• Refractive error• > –8D ocular connective tissue disorder

• Hypermetropic small ‘crowded’ ACs

• Thin CCT

Risk factors

Systemic

• Age• Increased TM resistance to outflow

• Family history• First-degree relatives = 10x risk

• Vascular disease• Poor optic nerve head blood flow (NTG)

• Migraine, Raynaud’s, Diabetes

• Obstructive sleep apnoea (?diurnal IOP variation)

Risk factors

Racial

• POAG• Afro- Caribbean and West African

• PAC/PACG• Far-East Asian and Inuit

Risk factors

Secondary

• Steroid

• PDS

• PXF

• Uveitis

• Iris neovascularisation from retinal ischaemia (e.g. CRVO)

Risk factors

Structure vs function

• Structure (physical measurable pathology e.g. cell loss)

• Function (field and VA)

• Combining structural & functional tests improves diagnostic accuracy

• Can get structural or functional defects first• Rarely both at the same time

Clinical Investigations

Optic disc• Vertical disc diameter

• 1.5mm small, 2.1mm large• Helps in C:D interpretation• 66D 1:1 (1/mag x graticule)

• C:D ratio• ≥0.7, 0.2 difference, progression

• Rim contour • Diffuse narrowing / localized notching / both• Loss from inner edge of rim, especially ST/IT


Optic disc

• Haemorrhage(s)• 2-5x more common in NTG than POAG

• Associated with rapid progression, notches and B PPA

• Usually in RNFL (IT/ST)

• Frequency increases then decreases

• Often self-resolve within 2/12


Optic disc• Vascular changes (due to structural NRR loss)

• Baring of circumlinear vessels• Bayonetting (advanced disease)• ‘Fly-over’ vessels - lose contact with the previously underlying NRR• Nasalisation of central vessels

• PPA• Beta Zone (next to disc margin)

• RPE atrophy since choriocapillaris closed (absolute scotoma)

• Risk factor for progression• Extent proportional to disc and field damage• Precedes disc haemorrhage in 80% of cases


Progression - optic disc

• Structural qualitative changes (photos, clinical notes)• Vessel changes

• Notching

• Haemorrhages

• Enlarging PPA

• Quantitative changes• C:D progression

• OCT progression analysis (disc map volumetric data)


RNFL (axons of retinal ganglion cells)• Identify pre-perimetric damage

• Qualitative (red free photo)• Initially small slit/groove bundle defects• Coalesce to form large wedge defects• Later =diffuse loss

• Quantitative• OCT disc map (circumpapillary RNFL thickness)• OCT GCC map (segmentation algorithm)

• Over 50% of all RGC’s are in macula



Progression - RNFL (axons of retinal ganglion cells)

• Qualitative changes (red free photo)• Enlarging defects compared with previous photos

• Quantitative changes• OCT disc and macular map

• Progression analysis or subjective assessment


Visual Fields

• Diagnosis and monitor progression

• Main functional measurement

• Standard automated perimetry (central thresholding)• Gold standard

• Not optimal for early detection but good for monitoring

• Time consuming/tiresome so use intelligent algorithms


Visual Fields• Reliability

• Variability is normal in glaucoma• Patient performance• Fixation losses• Fatigue• Learning effects• Changes in pupil size• Improper refractive correction• True physiological variability• Artefacts (ptosis, spectacle/lens rim)



Reliability indices

• Fixation losses• Poor blindspot plotting• Field loss close to fixation

• False positives• Trigger happy• Under 20%

• False negatives• Inattentive• Common in glaucoma

Patient information

Test information

Reliability indices

Raw sensitivity

Gray scale (raw-interpolated)

Glaucoma hemifield test

Global indices

Total deviation plot

Total deviation probability plot

Pattern deviation plot

Pattern deviation probability plot

Gaze tracker

Clinical InvestigationsPatient information

Test information

Reliability indices

Raw sensitivity



Global indices





Gaze tracker

Total deviation plot• Age-matched norms

• Uncorrected rx• Cataract• Small pupils

Pattern deviation plot• Correct for diffuse loss• Highlight specific loss/patterns

p-values• % of normals who would return

a value equal or worse• p<0.05 = 1 in 20• p<0.01 = 1 in 100

GHT (vertical asymmetry)• “Outside normal limits” ≥1zoneP<0.01• “Borderline” anything between• “Within normal limits”

Clinical InvestigationsPatient information

Test information

Reliability indices

Raw sensitivity



Global indices





Gaze tracker

Global indicesMathematical evaluations of the visual field

Mean deviation (MD) index (-)• Reflects diffuse change• Weighted average of all the points

in the total deviation plot

Pattern SD (PSD) index (+)• Reflects variability across field• Higher = focal loss

(p) of the result being normal

Hodapp classificationEarly COAG MD > -6 dB.Moderate COAG -6 dB to -12 dB

Visual fields (RNFL bundle defects)

• Paracentral• Deep, close to fixation, especially in NTG

• Follow RNFL distribution and abruptly stop at horizontal midline

• Arcuate• Coalition of a group of smaller defects, more extensive than paracentral,

respect horiz midline

• Nasal step• Due to sensitivity difference above and below horizontal midline

• Normal patients may have shallow small steps (over 5 degrees is significant)

• Depth (deep = more likely to be real)

• Clustering (more than 2 abnormal points likely to be significant)


Progression - Fields• Clinical judgement

• Subjective observation of sequential VF results

• Defect classification systems• e.g AGIS scoring system

• Trend analyses• e.g. Linear regression

• Event analyses• e.g. Glaucoma change probability, Glaucoma progression analysis


Progression - Fields• Clinical judgement

• Subjective observation of sequential VF results

• Defect classification systems• e.g AGIS scoring system

• Trend analyses• e.g. Linear regression

• Event analyses• e.g. Glaucoma change probability, Glaucoma progression analysis

• Will the visual field last until the end of this patient’s

lifetime at this rate?


IOP

• Errors• Lids, misaligned, meniscus width, prolonged contact

• Short term changes• Diurnal range (3-6 normal, glaucoma 13) • Increase if accommodating, blinking, squeezing, raised

intrathoracic pressure (strain, hold breath, tight collar)

• Other factors• Corneal thickness (thin = underestimate)• Curvature (flat = underestimate)• Elasticity (stiff = overestimate)• Hydration


CCT

• Normal distribution 540 ±30 μm (mean +/- SD)

• Thin CCT (less than 555μm) risk factor for:• Development of POAG

• Progression of POAG

• Visual field progression

• CCT can influence accuracy of IOP measurement• No verified algorithm to apply

• Ehler: 1mmHg correction for every 15 μm


Anterior Eye

• Cornea• Epi oedema, posterior embryotoxin, KP

• A/C• Trauma, uveitic, pigmentary, lens related• Cells, flare, pigment, protein, lens particles

• Iris• Atrophy (diffuse, sector), deposits, pupil margin, TI, neovasc

• Lens• PXF, glaucomflecken (anterior subcaps), phacodonesis (zonular

weakness in PXF – wobbly iris), phacomorphic, phacolytic


Anterior Chamber Depth

• Limbal Depth• Van Herick

• 600, narrow, bright beam, nasal & temporal• AC:cornea - record as % and equivalent VH• <25% occludable

• A-S OCT• Qualitative image, quantitative analysis possible

• Gonioscopy• Raised IOP requiring treatment (open angle vs angle closure)• Patients at risk of acute angle closure (VH <25%)


Anterior Chamber Depth

• Central Depth• Smith technique

• Illumination at 600, beam horizontal and short

• Cornea in focus temporally

• Move nasally until the beam just touches nasal pupil margin

• Increase beam height until images touch

• Multiply result by 1.4 (gives central A/C depth in mm)

• <1.8 shallow, >2.5 deep


Overview


• Statistics

• Definitions








• Telemedicine



• 4 Principles

• IOP is the only modifiable risk factor

• Reduction in IOP reduces the rate of damage

• Damage occurs at the presenting IOP

• Treatment should reduce IOP to a ‘target pressure’

Treatment Philosophy

• Estimated upper limit

• To slow progression to maintain vision-related quality of life

• For the expected lifetime of the patient• MD <-14dB visual impairment• MD <-22dB statutory blindness

• 20-35% (5-7 mmHg)

• Set by consultant• Rate of progression, risk factors (e.g. CCT)• TargetIOP.com

Target Pressure

OHT/Suspected POAG (IOP 24 or more)

• Are they at risk of future visual impairment?

• Consider: IOP, CCT, FH, life expectancy

• Old CG85 - categories which might be at risk

• Not at risk• No treatment

• Regular EE

Treatment

OHT/Suspected POAG (IOP 24 or more)

• At risk of visual impairment in lifetime• Generic PGA (e.g. latanoprost od nocte R&L)

• If non-tol:• Another generic PGA / Beta Blocker / Non-generic PGA/other class of drug

• If preservative allergy• Consider preservative free (e.g. monoprost) if significant OSD and

• High risk of COAG conversion

• If ineffective• Different therapeutic class or combination

Treatment

COAG

• Generic PGA (e.g. latanoprost od nocte R&L)• If non-tol

• Try different therapeutic class

• If preservative allergy• Consider preservative free if significant OSD

• If ineffective:• Discuss adherence

• Check eye drop instillation technique

• Try different therapeutic class or combo

• Surgery if 2 classes don’t work

Treatment

Overview


• Statistics

• Definitions








• Telemedicine



• Start with 1 drug

• Show how to put in

• If IOP not at target • Change if IOP reduced 2 or less

• Add second drug if IOP reduced more than 2

• Generally treat both eyes (give px choice)• Less confusing

• Cosmetic balance with PGA

• Avoid • Beta Blocker if asthma, heart disease, poor

circulation

• PGA in pregnancy

Treatment Algorithm & Considerations

• Prostaglandin analogues (latanoprost)• Prostamide (bimatoprost)

• Beta blockers (timolol)

• Sympathomimetics (brimonidine)

• Carbonic Anhydrase Inhibitors (brinzolamide)

• Miotics (pilocarpine)

• Combination products (above plus timolol)

Glaucoma Medications

Prostaglandin analogues

• Action: increase (uveoscleral) aqueous outflow

• Examples:• Gutt Latanoprost 50microgram/ml OD nocte (Branded = Xalatan)• Monopost (PF)• Travoprost (Travatan), Tafluprost (Saflutan)

• Avoid:• Aphake, pseudophake, A/C implant• Severe asthma• Herpetic diease• Induces labour


Prostamide

• Action: increase (uveoscleral) aqueous outflow

• Examples:• Gutt Bimatoprost 100microgram/ml (0.01%) OD (Lumigan)• Gutt Bimatoprost 300microgram/ml (0.03%) (PF) (Lumigan)

• Avoid: • Aphake, pseudophake, A/C implant• Severe asthma• Renal disease



Beta-blockers

• Action: Reduce aqueous production

• Examples:

• Gutt Timolol 0.25% / 0.5% bd (or LA mane) – available unit dose

(PF)

• Timolol 1mg/g gel mane (Tiopex)

• Levobunolol (Betagan), Betaxolol (Betoptic)

• Avoid:

• Heart probs (reduce HR)

• Asthma/COPD (bronchoconstriction)

• Worsen vasc disease

• ACE inhib, anti arythmias (amiodarone), calcium channel blocker

(verapamil), parasympathomimetic (pilo), sympathomimetic

(adrenaline) – very rare in clinical practice

Sympathomimetics

• Action: Reduce aqueous production and increase outflow

• Examples:• Gutt Brimonidine 0.2% bd (Alphagan)• Apraclonidine (Iopidine)

• Avoid: • Heart/vascular disease (smooth muscle/vaso constriction,

heart works harder and incr. BP)• MAOI’s (phenelzine, isocarboxazid)• Tricyclic antidepressants (amitryptilline, doxepin)• Alpha stimulation also: Eyelid retraction, mydriasis, increase

outflow


Carbonic anhydrase inhibitors

• Action: reduce aqueous production

• Examples:

• Gutt Brinzolamide 10mg/ml bd (Azopt)

• Dorzolamide 2% bd/tds (Trusopt)

• PO 250mg Acetazolamide take two tablets up to max QDS

• Avoid:

• Sulphonamide allergy e.g. trimethoprim (since it is a sulphonamide derivative)

• Electrolyte imbalance/renal disease

• Pregnancy


Miotics

• Action: increase aqueous outflow

• Examples:

• Gutt Pilocarpine 1%, 2% max qds

• Avoid:

• Heart problems (reduce HR)

• Asthma/COPD (bronchoconstriction)

• Peptic ulcer (increase secretions)

• Anterior uveitis, secondary glaucoma


• Latanoprost 50micrograms & timolol 5mg/ml Xalacom

• Travoprost 40 micrograms & timolol 5mg/ml eye drops DuoTrav

• Bimatoprost 0.03% & timolol 0.5% eye drops Ganfort(also Ganfort PF available)

• Brimonidine 0.2% & timolol 0.5% eye drops Combigan

• Brinzolamide 10mg & timolol 5mg/ml eye drops Azarga

• Dorzolamide 2% & timolol 0.5% eye drops Cosopt

• Brinzolamide 10mg/ml & Brimonidine 2mg/ml eye drops Simbrinza


Miotics

Pilocarpine

Generic

Pilocarpine 1/2/4% qds

Unit dose (2% only)

S/E

Reduce HR, bronchoconstriction,

increase secretions, headaches

Avo

id

Heart probs, Asthma/COPD,

peptic ulcer, anterior uveitis,

secondary glaucoma

Rx

Gutt Pilocarpine 1%, 2% max qds

Reduce HR, Bronchoconstrict

Heart probs, asthma/COPD, worsen vascular

disease. ACE inhib, anti arythmias

(amiodarone), calcium channel blocker

(verapamil), parasympathomimetic (pilo),

sympathomimetic (adrenaline) – very rare

Travoprost 0.4mg/ml / Timolol 5mg/ml - mane - branded only

Latanoprost 0.05mg/ml / Timolol 5mg/ml - mane - branded,

generic

Taptiqom®

Cosopt®

/ Tidomat® / Eylamdo

®

Simbrinza®

Aphake, A/C implant, severe asthma,

herpetic disease, induces labour.

Prostamide (Bimatoprost): aphake,

pseudophake, A/C implant, severe

asthma, renal disease

Gutt Latanoprost 50microgram/ml (also

PF) od

Gutt Travoprost 40microgram/ml od

Gutt Tafluprost 15microgram/ml (PF) od

Gutt Bimatoprost 100microgram/ml

Sulphonamide allergy e.g.

trimethoprim (since it is a

sulphonamide derivative)

Watch for skin rash, electrolyte

imbalance/renal disease,

pregnancy

Gutt Brinzolamide 10mg/ml bd

Gutt Dorzolamide 2% bd/tds

PO 250mg Acetazolamide take

two tablets up to max QDS

Duotrav®

Xalacom®

Ganfort® Bimatoprost 0.3mg/ml / Timolol 5mg/ml - mane - branded only

Tafluprost

Saflutan® 15mg/ml nocte

Available in unpreserved form only

Gutt Timolol 0.25% / 0.5% bd (also 0.1% LA pres

free od)

Gutt Levobunolol 0.5% od / bd

Gutt Brimonidine 0.2% bd

Heart/vascular disease. MAOI’s

(phenelzine, isocarboxazid),

tricyclic antidepressants

(amitryptilline, doxepin)

Smooth muscle/vaso constriction

(heart works harder and

increases BP). Alpha stimulation

also: Eyelid retraction, mydriasis,

increase outflow

First c

ho

ice

Last c

ho

ice

Prostaglandin Analogues Carbonic Anhydrase

Inhibitors

Bimatoprost Betaxolol

Betoptic®

0.5% bd

Betoptic-S®

0.25% bd Generic

Unit dose (0.25% only)

Lumigan® 0.01% nocte

Preserved = 0.01% or 0.03%

Unpreserved = 0.03% only

Generics (0.03% only)

PF unit dose = Lumigan UD®

PF multidose = Eyreida®

Generic

Travatan® does NOT contain BAK Generic

Travoprost DOES contain BAK

Unit dose

Pres-free multi-dose

(Eydelto® )

Generic

Unit dose

Generic

NB cost of unit dose:

1% available only in unit dose

0.5% available only in multi dose

Generics Generic PF multidose = Eysano®

Generic 0.25 & 0.5%

Unit dose

(Generics include ‘Brymont’) Generic

Travoprost

Travatan® 0.004% nocte

Dorzolamide

Trusopt® 2% bd/tds

Levobunolol

Betagan®

0.5% bd

Apraclonidine

Iopidine® 0.5/1% tds

Latanoprost

Xalatan® 0.005% nocte

Pres-free option = Monopost

Brinzolamide

Azopt® 1% bd/tds

Timolol (gel and guttae)

Timoptol®

0.25/0.50% bd

Tiopex® 1mg/g gel mane

Timoptol-LA® 0.25/0.5% mane

Brimonidine

Alphagan® 0.2% bd

Beta-Blockers Adrenergics

Dorzolamide 20mg/ml / Timolol 5mg/ml - bd - branded multi/ unit dose, generic

Brimonidine 2mg/ml / Timolol 5mg/ml - bd - branded only

Brinzolamide 10mg/ml / Timolol 5mg/ml - bd - branded only

Brinzolamide 10mg/ml / Brimonidine 2mg/ml - bd/tds - branded onlyTafluprost 0.015mg/ml / Timolol 5mg/ml - mane - branded only

Combigan®

Azarga®

• The disease• Symptomless but irreversible loss

• What the treatment does

• How to instil drops

• Side-effects (& what to do)

• How to get repeat rx

• Sources of info/support

• Importance of regular review

Patient Information

Overview


• Statistics

• Definitions








• Telemedicine



• Usually in 4-8 weeks

• Verify medication

• Check compliance and understanding

• Assess possible side-effects (‘tolerance’)

• Check logistics for repeat prescriptions

• Check effectiveness of treatment

• Answer any unresolved queries

Tolerating well, self-reported compliance good, has repeat rx from GP.See in x/12 (high presenting IOP/suspicious disc) with fields

Review

• Treated OHT/suspected COAG• Discharge if OHT not requiring treatment or COAG suspect no longer suspect

• No conversion to COAG:

• 18-24/12 (12-18/24 for COAG suspect)

• Conversion to COAG uncertain:

• 1-4/12 (and review treatment plan) if IOP not controlled

• Else 6-12/12

• Conversion: see COAG section

• COAG• No progression:


• Else 6-12/12 if high risk or 12-18/24 if low risk

• Progression/uncertain:


• Else 2-6/12

Recall

Overview


• Statistics

• Definitions








• Telemedicine



?Cause

• July’12 - Optom referral – C:D asymmetry and ?field defect

• IOP 20/18

• C:D 0.5/0.4

• Fields ?mildly enlarged blind spot

• Sept ‘12 - Community glaucoma service

• IOP 28/26

• C:D 0.5/0.4

• Fields normal R&L

• CCT 573/584

• A/C Deep

Impression – OHT, no treatment indicated, review 6/12

Case 1 – OHT (stable, untreated)

Female, Caucasian, Age 68

• Jan’18 (5.5 years later)

• 6/12 reviews initially

• Then annual review

• IOP 24/23

• CD 0.55/0.45

• Fields Normal R&L



Name:

ID:

DOB:

Age:

410630

68

Exam date:

Gender:

Eye: Both

21/11/18

Female

Comments:

Version: 8.0.2 SOCT Copernicus REVO Device SN: 1550974/11 OPTOPOL Technology Sp. z o.o.Print date: 21/11/18

LR21/11/18 10:04:42

3D 6x6 mm

21/11/18 10:04:14

3D 6x6 mm

DISC | BOTH EYES

NFL signification

%

NFL signification

%

NFL thickness

µm

NFL thickness

µm

Ring diameter 2.40 mm. Ring thickness 0.40 mm. Ring diameter 2.40 mm. Ring thickness 0.40 mm.

Name:

ID:

DOB:

Age:

410630

68

Exam date:

Gender:

Eye: Both

21/11/18

Female

Comments:

Version: 8.0.2 SOCT Copernicus REVO Device SN: 1550974/11 OPTOPOL Technology Sp. z o.o.Print date: 21/11/18

LR21/11/18 10:04:57

3D 7x7 mm

21/11/18 10:03:54

3D 7x7 mm

RETINA | BOTH EYES | GANGLION

NFL+GCL+IPL thickness

µm

NFL+GCL+IPL thickness

µm

NFL+GCL+IPL signification

%

NFL+GCL+IPL signification

%

NFL+GCL+IPL deviation

%

NFL+GCL+IPL deviation

%

S - I Hemisphere asymmetry

µm

I - S

S - I Hemisphere asymmetry

µm

I - S

R - L Asymmetry

µm

L - R Asymmetry

µm

% %

• Oct ’18 eCare transfer

• IOP 26/25

• C:D 0.6/0.5


• Impression:

• Stable OHT

• Plan:

• No treatment indicated

• Review 12/12

• Oct ’17 - High street optometry - ?glaucoma

• IOP 22/23 (NCT)

• Discs 0.3/0.45

• Fields Full R&L

• Nov ‘17 – Community glaucoma service

• IOP 21/21 (GAT)

• Discs 0.4 tilted/0.5 tilted


• CCT 558/550

• A/C Deep

Glaucoma suspect, no treatment indicated


Male, Caucasian, 33


• Dec ’18 - eCare

• IOP 23/24 (GAT)

• Discs 0.5/0.6 (tilt)

• Fields Full R&L

• Impression:• Borderline OHT

• Plan:• No treatment

• Monitor OCT

• Recall 1 year

• Jan’17 – Community ophthalmology service (Optom referral for raised IOP)

• IOP 22/29

• C:D 0.1/0.1

• Fields Full R&L

• CCT 570/570

• A/C Deep, no PDS/PXF

Impression - LE OHT, commence latanoprost OD LE only, review 6/52 (initially)

• Nov ‘17 - Community glaucoma service

• IOP 20/20

• C:D 0.1/0.1

• Fields Full R&L

Impression – LE treated OHT, continue LE latanoprost, review 12/12

Case 3 – OHT (stable, treated)

Male, Caucasian, Age 64

• Nov’18 – eCare transfer

• IOP 27/20

• C:D 0.1/0.1

• Fields Full R&L

• A/C VH3/VH4

• Impression:

• LE treated OHT

• RE OHT

• Plan:

• Continue latanoprost LE nocte

• Commence latanoprost RE nocte

• Target IOP 20 R&L

• Review 3/12

Case 3 – OHT (UNstable, treated)

• Jan ’16 – Optom referral for suspicious discs and fields

• IOP 23/24

• C:D 0.6/0.5

• Fields Early loss R&L

• Apr ‘16 - Community glaucoma service

• IOP 24/24

• C:D 0.65/0.5

• Fields RE early paracentral loss, LE full

• CCT 599/595

• A/C Wide open angles

Impression – RE glaucoma suspect, LE OHT

Plan – No treatment indicated; Review 6/12

Case 4 – Glaucoma suspect (stable, untreated)

Female, Afrocarribean, Age 62

• Jul ’15 – Optom referral for increasing IOP and ?progressive cupping

• IOP 25/19

• C:D ?

• Fields ?

• Aug ‘15 - Community glaucoma service

• IOP 28/25

• C:D 0.6/0.4

• Fields ?early loss, unreliable

• CCT 589/591


Impression – bilateral glaucoma suspect

Plan – commence latanoprost OD nocte R&L; Review 2/12

Case 5 – Glaucoma suspect (unstable, treated)


• Nov ‘18 – Transfer to eCare

• IOP 28/16

• C:D 0.7/0.4

• Fields RE ?mild loss, LE unreliable but ?early loss

• Impression

• RE glaucoma suspect, inadequate control (but compliant)

• LE glaucoma suspect, well controlled

• Plan

• RE continue latanoprost o.d. nocte, add brinzolamide b.d.

• LE continue latanoprost o.d. nocte

• Target IOP R19 L 17

• Review 2/12 (IOP)

Case 5 – Glaucoma suspect (unstable, treated)

• Oct ’16 – optometrist referral for suspicious discs & field defect

• IOP 22/21

• C:D 0.7/0.7

• Fields Arcuate defect L>R (repeatable)

• Nov ‘16 – community glaucoma clinic

• IOP 21/21

• C:D 0.8/0.8

• Fields Bilateral superior and inferior arcuate loss R>L

• Plan:

• Commence latanoprost o.d. nocte R&L

• Review 2/12

Case 6 – Glaucoma(stable, treated)


• Nov ‘18 - eCare

• IOP 21/21

• C:D 0.8/0.8

• Fields Bilateral superior and inferior arcuate loss R>L (unchanged)

• CCT 528/521



Impression:

Bilateral stable glaucoma R>L

Plan:

Continue latanoprost OD nocte R&L

Review 12/12


• Aug ‘18 – optom referral for raised IOP with narrow angles

• IOP 25/24

• Discs 0.35/0.35

• Fields ‘Abnormal’ & unreliable

• A/C VH2

• Oct ‘18 - eCare

• IOP 27/26

• Discs 0.2/0.2

• Fields ‘Abnormal’ & unreliable

• A/C VH1 R&L N&T

Case 7 – Narrow AnglesFemale, Chinese, Age 48

• Impression

• Shallow A/C with raised IOP and field defect ?PAC

• Plan

• Refer to HES for angle assessment & ?prophylactic treatment

Case 7 – Narrow Angles

Gonioscopy if increased risk of acute angle closure and patients we treat

• At risk of acute angle closure (V/H<2)• Onward refer if gonioscopy not available

• Onward refer if raised IOP with angle closure

• Raised IOP requiring treatment• Classify as ‘open angle’ or ‘angle closure’

• ?corporate clinic at first review after starting treatment

Case 7 – Narrow Angles

Overview


• Statistics

• Definitions








• Telemedicine



Glaucoma protocol

Glaucoma protocol (quick reference)

NB – this quick reference guide is not a substitute for the clinical protocol

Overview


• Statistics

• Definitions








• Telemedicine



Telemedicine Process

• Record sufficient notes & include images

• My feeling is … I will ask for my consultant’s opinion and if they agree we’ll see you in xx months/report

• Send to telemed (ophthalmologist)

• Ophthalmologist• Reviews clinical findings, images and proposal

• Provides their diagnostic impression and management plan

• Finalises any prescription requests

• Returns completed case to provider

• Provider• Accept/reject telemed comments

• Retain = moves into retained silo in order of due date

• Refer = action onward referral within Evonnect (Evo)

• Generate letters

• GP – NHS.net / ERS notification

• Referrer – use Evonnect to view

• Patient – print locally at your discretion

• Check daily (may be urgent)

• Optional/Mandatory• Mandated

• Posterior OCT (naevus, AMD)

• Glaucoma

• Optional

• Prescription request

• Diagnostic uncertainty

““The consultant’s opinion was sought for confirmation and responded with the

following comments the next day:

Agreed, likely POAG.

Request sent to GP for

gutt. Latanoprost

0.005% nocte. Target

IOP is 18 R&L. Suggest

review in 3/12.”

The process of monitoring for change and proposing target pressures and treatments is robust and ultimately the consultant decides on the management plan. Telemedicine is a great opportunity to

bridge the gap between optometry and ophthalmology and develop your skills within practice.

Telemedicine

• If a patient requires a prescription• Complete ‘suggested medication’ box

• Send to telemedicine

• ‘Accept’ when ‘from telemed’• If consultant agrees/prescribes

• “Do you want to view printing options?”

• “Prescription request to mailroom”

• Dedicated request to GP (GMC no.)

• In addition to main report

Prescription Requests

Tips from the Consultants

Escalation of

treatment algorithm

IOP exceeds target

VF or ONH progression

despite 'adequate' IOP

control

Stable, IOP

within target

Continue

Monitoring

Monitoring

Lowering of

target IOP


Treatment Algorithm

Standard pathway

latanoprost

Ganfort

Lumigan + cosopt

HES referral

Beta blocker intolerant pathway

Refer HES

latanoprost + brinzolamide

Refer HES

Preservative intolerance/ocular

surface disease

Monopost

Ganfort PF

Lumigan PF + Cosopt PF

Refer HES

Low threshold for HES

Multiple intolerances

Secondary glaucoma/NTG

Young/ advanced field changes/ etc

Others


Monitoring

Group 1. 4monthly for

at least 12 months

Glaucomatous visual field changesPOAG, NTGs

Group 2. 6 monthly for at

least 12 months

Glaucomatous disc changes, normal fieldsGl. suspects

Group 3. Annual Review

OHTSuspected anomalous discs, glaucoma unlikelyStable group 1 and 2 patients


A compact, targeted history

A complete set of relevant observations

Ideally with a conclusion

In a perfect world, we should be able to go straight to your conclusion first, then scan back to make sure the

details are correct

Eg 63 year old lady, no risks for glaucoma, IOP 25 corrected, normal disc, OCT, field = glaucoma suspect.

And a suggestion about follow up

Plus any relevant patient related issues

Eg prefers not to be treated at present/ worried about possible cancer

What do we like to see on your records?


History taking and reportingHow old is the patient

How long for /when did it start

Ever had it before

One eye or both

Anything makes it better / worse

For vision – when it’s at its worst, what would you be able to see

if you were looking at me.

Any previous ophthalmic history**. (They won’t tell you)

If there are previous notes, check through them for

eg highest IOP before treatment

PLEASE DO NOT MANIPULATE THE HISTORY TO MATCH WHAT YOU THINK IS HAPPENING.


Avoid abbreviations

Need to be understood by GP and other stakeholders

Helpful to start with age, sex and highest IOP first

Comment on the reliability of fields/OCT

Disc photos are essential, especially for tilted/anomalous discs

If the fields/OCT show progression review early e.g. 2/12

When prescribing, unless contraindicated consider:

1. Latanoprost

2. Ganfort (i.e. Bimatoprost with timolol)

3. Lumigan (bimatoprost) & cosopt (i.e. dorzolamide & timolol) … or refer!


Their letter is taken straight from your notes

They don’t know our abbreviations

So CRVO / LO / RD / ERM doesn’t mean anything to them

Beware your own pet abbreviations – I keep reading ones I have no idea about!

Remember to spell out RIGHT and LEFT

Quite apart from confusion over LVA, it’s frowned on medico-legally

Remember those poor GPs


However, you’ll need to remember to take that statement out when the record comes back from telemed.

If you are really concerned about a telemed decision, best to

email either

[email protected] or

[email protected]

We’ll never get troubled if you say – “I really don’t know what is

going on here – what do you think?”

Remember

eVonnect record card

If you were the consultant managing this

patient would you be satisfied?

eVonnect record card

If you were the consultant managing this

patient would you be satisfied?

What disc problem

PMH FOH

VA!!

GAT or NCT? CCT

V/H

Field plot

Disc/OCT images

PDS/PXF

VDD Disc haemorrhage

R/L/Both

What treatment & how often

Leaflets given

Overview


• Statistics

• Definitions








• Telemedicine



• 12 MCQ’s

• Completed online• Eloomi training platform or Survey Monkey – link will be sent

• Minimum of 9/12 must be correctly answered to pass

Validation & MCQ’s

Thank you

Documents

Glaucoma/OHT in the Community eCare Ipswich Suspect … · 2019-03-22 · Glaucoma/OHT in the Community Suspect Investigation & Stable Management eCare Ipswich 20-03-2019 Christian