Fine Tuning Glaucoma Diagnosis and Management in

HaitiDaniel Laroche MD

Director of Glaucoma, St Lukes-Roosevelt Hospital, NY

President, Advanced Eyecare of New YorkAssistant Clinical Professor Ophthalmology

New York Eye and Ear InfirmaryNew York Medical College

Chair NMA Ophthalmology Section/AAO Task for on Haiti Disclosure: Speaker Bureau for Alcon, Allergan Merck

Thanks to the SHO and CNPC for the invitationand congratulations on your ongoing efforts

I worked at the University Eye Hospital

Persistent Structural damage to buildings that

need reconstruction

HUEH Faculty

Dr. Jean Claude Cadet- Chief Dr. Ritza Eugene Dr. Jean Claude Cadet Jr. Dr. Valery Cadet Visiting Professors

Ophthalmology Residents

Astrid St. DicRachel Aglae AmedeeRachel GauthierNathalie FrancoisReginald RejouisMyriam BeliardMarie Dieumane ChaperonMilon Osnel

3 ½ Days of seeing patients

May 13-16, 2012 60 glaucoma patients were presented Under went tonometry, gonioscopy, optic disc

examination, FDT VF Diagnosis were:

Open angle glaucoma,Angle closure glaucoma,Juvenile Open angle glaucomaTraumatic Glaucoma, Congenital Glaucoma, Physiologic cupping without glaucoma, Congenital glaucoma, Neovascular glaucoma

Haitian Ophthalmology Residents Learning Gonioscopy www.gonioscopy.org

Residents Used Perkin tonometry to check IOP There was a shortage of slit lamps

and goldman applanation tonometry available

Only one 3 mirror gonio lens present Residents were trained to use the

lens and also performed gonioscopy on each other

Residents learned importance of optic disc drawings and were evaluated

Each resident advised that they must invest in a four mirror lens to properly evaluate glaucoma

Resident Education Residents were given lectures on

gonioscopy, optic disc evaluation, Target IOP in treating glaucoma, glaucoma surgical video were reviewed on trabeculectomy, trabeculotomy, Ahmed valve.

14

Goldmann equation3

P0 = (F/C) + PvP0: IOP (mmHg)F: rate of aqueous formation (µL/min)C: facility of outflow (µL/min/mmHg)Pv: episcleral venous pressure (mmHg)R: resistance to outflow; is the inverse of C and may replace

C in rearrangements of the Goldmann equation

GAT

Applanation tonometry is currently the gold standard for measuring IOP, and GAT is the standard procedure.1

GAT assumes a constant CCT. However, variation in CCT can influence GAT reading.2

1. Tsai JC et al. In: Medical Management of Glaucoma. Professional Communications, Inc; 2003:15–37.2. Brandt JD et al. Ophthalmology. 2001;108:1779–1788.3. Web review of ophthalmology. Comprehensive review: glaucoma. Available at:

http://www.webeyemd.com/wro/wro_comp_glaucoma.htm. Accessed September 2, 2004.

Hans Goldmann

Goldmann Applanation TonometryReprinted with permission from AgingEye Times.

Must perform gonioscopy to r/o angle closure

AS-OCT iris light and dark

Indentation Gonioscopy Allows viewing

of angle structures when

there is appositional

Angle closure

Angle will not open if

Synechia is present

Pupillary Block/Indentation Gonioscopy

PAS

Treatment for Angle Closure is iridotomy and

sometimes with iridoplasty

Identify small and large optic discs• Small discs: avg vertical diameter < 1.5 mm• Large discs: avg vertical diameter > 2.2 mm

Average Large

• Size of cup varies with size of optic disc • Large optic discs have large cups in healthy

eyes

Small

1.4 1.9 2.4

Optic Disc Size

Rim width: Distance

between border of disc and position of blood vessel bending

S

N T

ISNT rule: Inferior > Superior > Nasal > Temporal

I

Look at the Neuroreintal rim: ISNT Rule

NotchingNotching

Localized Rim Thinning/Notching

Patterns of Glaucomatous Progression

Adapted from Tuulonen and Airaksinen. Am J Ophthalmol. 1991.

Type of progressionof disc abnormality

First glaucomatousoptic disc change

Disc cup enlargement

Disc cup enlargementwith local notching

Local notch

Pale neuroretinal rim;no change of configuration

Normal optic disc(left eye)

Diffuse enlargement:round-shaped

Diffuse enlargement:vertically oval

Broader local notch

Pale rim; no changeof configuration

13%

9%

56%

22%

OCT was taught available with Dr. Tavern

Localized Retinal Nerve fiber layer loss can be seen with red free light

on ophthalmoscopy

Event Analysis, Look for VF progression was taught although only FDT available at the clinic

Baseline Different from baseline?

Follow-up (years)

5

4

3

2

1

0

-10 1 2 3 4 5 7 86

100% of visits

75 - 99% of visits

50 - 74% of visits

0 - 49% of visits

Mea

n c

han

ge

in v

isu

al d

efec

t sc

ore

AGIS 7Sustained IOP reduction below 18

mmHg is correlated with stability of visual field

Percent of Visits with IOP Less Than 18 mmHg

AGIS Investigators, 2000, Am. J. Ophthalmol., 130, 429-440

MEAN IOP20.2 mmHg

16.9 mmHg

14.7 mmHg

12.3 mmHg

Medical Management vs Surgery

Both Stabilize Visual Fields

Collaborative Initial Glaucoma Treatment Study (CIGTS)

0

1

2

3

4

5

6

7

8

0 6 12 18 24 30 36 42 48 54 60

Medicine

Surgery

Time in Months

Vis

ual

Fie

ld S

core

Lichter et al, Ophthalmology, 2001 Nov: 108 (11) 1943-53

1- (reference IOP + VF score)/100 x Reference IOP =40% reduction

35%vs 48% IOP lowering

Ensuring Compliance With Antiglaucoma

Treatment Communication More than 40% of pts

being treated with glaucoma do not realize it can lead to blindnessGRF survey

Education Use the minimum number

of medications required to safely achieve the target IOP

QD and BID dosing offers best compliance regimens

Non-compliance can be as high as 50% for one med, 61% for two meds, 70% for multiple medsPatel, Spaeth: Compliance in patients taking eyedrops for glauocma:

Ophthalmic Surg 1995 26 ;3 ;233-236

Do not forget Laser and filtering surgery if medical

therapy fails or ptscannot obtain medications.

Dr. Eugene to perform Ahmed valve with corneal patch with resident watching

Haitian Ophthalmology 2nd year OphthalmologyResidents performing trabeculectomy

Glaucoma Surgery

3 Ahmed valves performed 13 Trabeculectomies 3 pediatric examination under

anesthesia 2 Trabeculotomy/Trabeculectomy

1st year residents watching 2nd year

ophthalmology Residents performing glaucoma

surgery

Congenital glaucoma with trabeculotomyunder general Anesthesia at theUniversity HospitalMain Operating RoomAble to be performed

Still a great need for sutures, instruments,Glaucoma valves and patches, and medicationsSpecial thanks to New World Medical, Alabama EyeBank, and Alcon. 1 tube inserter also donated

Glaucoma Challenges for developing World

Compliance Cost (Medicaitons per month vs

Trabeculectomy ) Lack of manpower Stigma associated with surgery Lack of glaucoma awareness Poor equipment maintenance Not enough visual rehabilitation

programs

Potential Action items for Glaucoma

Train a new generation of trainers in glaucoma subspecialty

Encourage sandwich fellowships with physicians in the US and Canada

Provide educational, training materials and resources from other countries and translate into French/Creole

Systematically link professional development with institution capacity development

Further develop and take advantage of online educational resources and link with HSO website

www.web-sho.org

Towards the future in Haiti

Important for eyecare providers and officials to ensure that glaucoma becomes a high priority along with cataracts as a treatable disease for blindness and to prevent blindness.

We need continued development, refinement and validation of clinical and educational programs

Thank you Keep up the great efforts You are not alone Many are thinking of you and willing to

work with you. I believe the private practice/public

practice with sliding scale payments will succeed.

Ongoing free eyecare by NGO’s undermines ophthalmology in Haiti

Must support the residency program that is the future of ophthalmology in Haiti.

Must support capacity in the ophthalmologists of HSO

WITH LIMITED RESOURCES AND SUPPLIES COLLABORATION IS ESSENTIAL