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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