Glaucoma: one step forward?

Audrey Kaplan-Messas Director of glaucoma Unit Assaf Harofe Medical Center

What have we learnt in 10 years? (hebrew?) How does it impact our practice?

Glaucoma/ IOP?

Out of the definition but…

Target IOP ?

Appears 10 years ago,PPAAO % of baseline, or absolute value Target IOP= [baseline IOP x (1- baseline IOP/ 100)- Z-Y] Z= VF index 1-3, Y= QOL index 1-3 Jampel 1997

Ganglion cell loss Individual Target Pressure B Patient B Treatment gain Patient A No gain IOP Treated Untreated IOP IOP

Target IOP = Max Acceptable Lower is Better Higher Target IOP

Early Short High

Damage L ife Expectancy IOP at Which Damage Occurred

Advanced Long Low

Lower Target IOP

The above factors need to be considered as a whole in deciding the individual target pressure required © E.G.S

Lower is Better For Every Optic Nerve 45 40 35 30 25 20 15 10 5 0 0 5

Target IOP

Target pressure according to risk Target IOP range 10 15 20 25 30 Initial IOP When Damage Occurred 35 40 45 Decrease 20% 25% 30% 40% OHTS EMGT NTG 20% 25% 30% CIGTS > 35% 21 mm Hg

Diurnal Variations: Relative risk* of disease progression/5 years relative risk 6 5 4 3 2 5.76

1 0 1.00

diurnal IOP range 3.1 mm Hg diurnal IOP range 5.4 mm Hg * ratio between the incidence of a disease among individuals with a given risk factor to the incidence among those without it

Asrani S, et al. J Glaucoma.

2000;9:134-142

Nothing to do with cornea?

Not anymore…

Central corneal thickness as a risk factor for conversion and progression

baseline IOP (mmHg) >25.75

36% 13% >23.75 to < 25.75

12% 10% < 23.75

17% < 555 9% >555 to < 588 2% >588 central corneal thickness (microns) Gordon et al, Arch Ophthalmol , 2002 7% 6% * through 8 Nov 2001

Significant baseline predictive factors from multivariate proportional hazard models

age (decade) diabetes mellitus IOP (per mmHg) CCT (per 40 µM decrease) PSD (per 0.2 dB increase) horizontal C/D ratio (per 0.1 increase) 1.22 (1.01, 1.49) 0.37 (0.15, 0.90) 1.10 (1.04, 1.17) 1.71 (1.40, 2.09) 1.27 (1.06, 1.52) 1.27 (1.14, 1.40) vertical C/D ratio (per 0.1 increase) 0.0

Kass et al, Arch Ophthalmol , 2002 1.32 (1.19, 1.47) 1.0

2.0

3.0

4.0

5.0

hazard ratio (95% CI)

Normal Tension Glaucoma How many do we still miss?

Many glaucoma patients have IOP <22 mm Hg 80 60 number of POAG 40 patients 20 71 33 0 IOP >21 mm Hg IOP <22 mm Hg Beaver Dam Eye Study (N = 4926) Klein et al, 1992

I think it’s glaucoma and the VF is normal?

Pre-perimetric glaucoma Disc shows rim thinning and verticalisation of cup Sita Standard 24-2 is Normal

Pre-perimetric glaucoma Normal Visual Field



OCT

Glaucoma treatment a big step forward… from Bb-, diamox and Pilo

What is Rx achieving ?

medications laser techniques surgical approaches

with disease progression non-IOP factors IOP

age genetics BP diabetes sleep apnea lipids vasospasm

Goal of Antiglaucoma Rx Preserve visual function Insure acceptable Quality of Life Strategy: to find the right pathway between efficacy and side effects of Rx

Introducing … new anti-glaucoma agents 1870s 1920s 1950s 1970s 1990s 2000s miotics topical systemic CAIs adrenergics BBs PGs topical CAIs a-2 agonists Combi nations

Compliance / Non-Compliance Compliance:

“The extent to which the patient’s behaviour (drugs, diets, life-style changes) coincides with the clinical prescription.”

Sackett D, 1976 Non-Compliance:

“The intentional or accidental failure to comply with a physician’s express or implied directions in the self-administration of any treatment.”

Boyd JR et al, 1974

Laser Trabeculoplasty we can do it more!

Human TM: ALT 50 microns spot SLT 400microns spot

SLT in the glaucoma armamentarium

Still waiting for the big step forward in surgery?

CIGTS

M edical management and surgery both lower IOP

30 26 22 18 14 10 0 12 24 36 time (months) medicine surgery 48 60

Lichter et al, 2001

Larger area of MMC exposure

Trabeculectomy +MMC + RS Pre-operative IOP 26 mmHg on MTM.

Day 1: IOP 17 mmHg

Where does the aqueous go?

Tube

Lens extraction in PAC

Pre-Phaco/IOL Post-Phaco/IOL

In conclusion, 10 years later Realisation that the glaucomas Are different in their causation Probably channel into a final common intra cellular pathway of destruction Have a complex relationship with IOP

Treat glaucoma or …reduce the IOP IOP reduction is up to date THE approach to slow down GON We have new diagnosis too;ls, new definitions, new drugs, new lasers, new surgeries And we can look after our patients’ ON in respect of their QOL

Thank you