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www.seag ig .org
A S I A P A C I F I CGlaucoma Guidelines
With the support of the Asian-Oceanic Glaucoma Society
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Copyright 20032004 SEAGIG, Sydney.
All rights reserved. No part of this publication may be reproduced, stored in a retrievalsystem or transmitted in any form or any means electronic, mechanical, photocopying,recording or otherwise without the prior permission of SEAGIG.
DISCLAIMER
These guidelines for clinical practice are based on the best available evidence at thetime of development. They are not intended to serve as standards of medical care.The use of these recommendations is the decision of each clinician, who is ultimatelyresponsible for the management of his/her patient. The South East Asia GlaucomaInterest Group (SEAGIG) and the Asian-Oceanic Glaucoma Society (AOGS), together withthe contributors, reviewers, sponsor and publisher, disclaim responsibility and liabilityfor any injury, adverse medical or legal effects resulting directly or indirectly from theuse of these Guidelines. All clinical diagnoses, procedures and drug regimens/doses mustbe independently verified. All products mentioned in this publication should be used inaccordance with the manufacturers instructions or prescribing information.
ISBN 0-9751692-0-3
Printed in Singapore
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A S I A P A C IGlaucoma Guide
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Foreword
By increasing awareness and knowledge of glaucoma aPacific region, these Guidelines aim to reduce glaucomdisability and to provide a rational basis for glaucoma
The establishment of best-practice methodologies thro
Pacific region represents a unique challenge, given ourservice systems and wide range of available resources. need, the South East Asia Glaucoma Interest Group (SEsupport of the Asian-Oceanic Glaucoma Society (AOGS)Asia Pacific Glaucoma Guidelines Working Party to devGlaucoma Guidelines for the Asia Pacific region.
The members of the Working Party collaborated duringmeetings to compile information and recommendationcomprehensive ophthalmologists, general healthcare aprofessionals, as well as healthcare policy makers to deglaucoma management to their communities. An extenCommittee assessed the results and made significant cothe final manuscript.
As these Guidelines rely on direct medical experience apossible, on published evidence, they are as up-to-dateThe Asia Pacific Glaucoma Guidelines Working Party is providing updates to the Guidelines on a regular basis.
Critical to the development of the Asia Pacific Glaucombeen the support of the AOGS, and a generous educatthen Pharmacia Corporation (now Pfizer Inc.). This sponthe Working Party to meet and to produce, publish andGuidelines.
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Members of the Working Party
Haruki Abe (Japan)
Manuel Agulto (Philippines)
Paul Chew (Singapore)
Paul Foster (UK)
Ivan Goldberg (Australia), Chair
Paul Healey (Australia)
Prin RojanaPongpun (Thailand)
Hidenobu Tanihara (Japan)
Ravi Thomas (India)
Ningli Wang (China)
Contributors
Gus Guzzard (UK)
Ching Lin Ho (Singapore)
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Ropilah Abdul Rahman (Malaysia)
Edi Affandi (Indonesia)
Harish Agarwal (India)
P Juhani Airaksinen (Finland)
Mario V Aquino (Philippines)
Makoto Araie (Japan)
Gomathy Arumugam (Malaysia)
Stephen Best (New Zealand)
Anne MV Brooks (Australia)
G Chandra Sekhar (India)
Guy DMellow (Australia)
Ataya Euswas (Thailand)
Seng Kheong Fang (Malaysia)
Adrian Farinelli (Australia)
Stuart Graham (Australia)
John Grigg (Australia)
Amod Gupta (India)
Ralph A Higgins (Australia)
Roger A Hitchings (UK)
Young J Hong (Korea)
Siu Ping Hui (Hong Kong)Por T Hung (Taiwan)
Changwon Kee (Korea)
Patricia M Khu (Philippines)
Don Minckler (U
Anthony CB Mo
William Morgan
Vinay Nangia (In
Stephen A Obstb
Francis Oen (Sing
Julian Rait (Aust
Rengappa Rama
Robert Ritch (US
Ngamkae Ruang
Julian Sack (Aust
Steve Seah (Sing
Ramanjit Sihota
Ikke Sumantri (In
Hem K Tewari (I
John Thygesen (
Aung Tin (Singa
Wasee Tulwatan
Anja Tuulonen (
Lingam Vijaya (I
Prateep Vyas (InTsing-Hong Wan
Robert N Weinre
Hon Tym Wong
Members of the Review Committee
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ACKNOWLEDGEMENT
This work was made possible by an unrestricted educationPfizer Inc.
The Asia Pacific Glaucoma Guidelines Working Party wouldespecially for their support:
Bruno ArcoMargarita JimenezAnders Lundqvist
Ian Saunders
MediTech Media Asia Pacific (Project Manager
Hooi Ping CheeM Paguio
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Contents
Foreword
Acknowledgement
Introduction
Epidemiology of Glaucoma in Asia
Section 1
1.1 Patient Assessment
1.2 Treatment Categories and Targets
Section 2
2.1 Initiation of Treatment
2.2 Medical Treatment
2.3 Laser Treatment
2.4 Surgery
Section 3
3.1 Follow-up
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List of Appendices
Appendix
1 How to test calibration of a Goldmann t
2 Tonometry mires
3a Gonioscopy
3b Goniogram/gonioscopic chart
3c Corneal wedge diagram
4 How to optimize patient
performance in subjective perimetry
5 Secondary glaucomas principles of man
6 Angle closure mechanisms
7a Argon laser trabeculoplasty
7b Contact transscleral diode laser
8 Glaucomatous optic neuropathy
9 Field progression print-outs
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Introduction
In 1996, with the support of the American Glaucoma SoAcademy of Ophthalmology produced its Preferred PraPrimary Open-Angle Glaucoma,1 followed four years latand two additional volumes on Primary Angle Closure3
Angle Glaucoma Suspect.4 These guidelines identify cha
components of quality eye care commensurate with prand resources this translates into guidance for state-of practice, which should be helpful in the care of mostthan any particular individual. Where data permits, thefirmly evidence-based; otherwise they rely on consensusthe European Glaucoma Society published its Terminolofor Glaucoma in 1998,5 with the aim of improving the
understanding of this disease in addition to providing ato the diagnosis and management of glaucoma. This yehas been released.6 These projects have set out to compscientific literature, and involved input from many glauThe resulting publications have proven useful for, and tcomprehensive ophthalmologists around the world. Theuseful in communications with allied eye healthcare pro
as governmental agencies and non-governmental organ
Over the past 20 years, increasing epidemiological data Asia Pacific region has highlighted the varying prevalenrates, diagnostic types and behavior of different glaucoencountered by the ophthalmological community. Withthis information, the need for similar guidelines relevannow be met. Such guidelines must be sensitive to the w
human, structural and equipment resources available thregion, as well as the ethnic diversity of our communitiapplicable in one country or location may not be in ano
These Guidelines have been developed during a time of
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In the development of these Guidelines, we have tried t
evidence, and to stratify the recommendations accordinThis has allowed us to clarify and to append to these Guareas for further research. It is hoped this will facilitate omutually supportive ophthalmic community.
How widespread is the problem? What are the risk factodiffer from elsewhere? The section on Epidemiology trie
questions. How do we take a focused history, perform aexamination? What additional tests might we consider feither in the presence or absence of glaucoma? What is developing glaucoma? What is the degree of damage ifalready present? What is the risk of glaucoma progressinAssessment tackles these, both for initiation of therapy
The Treatment Categories and Targets section helps us tindividual patient, therapeutic goals to severity of glaucglaucoma has been divided into medical, laser and surgidetection is considered from both population screening points of view.
These guidelines have been developed in an easy-to-reabenefit of comprehensive ophthalmologists, other eye c
our healthcare colleagues. The format answers questionwhen?, how? and for whom?. We strongly recommeexamines the entire Guidelines before applying informasection to the care of an individual patient.
As with all treatment guidelines, this publication is not aautomated care. By adapting the guidelines with respec
individual needs, the socio-economic environment and mavailable, as well as your own experience, we hope the excellent care will be achieved.
Ivan Goldberg
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References
1 American Academy of Ophthalmology. Preferred Practice PatterGlaucoma, 1996.
2 American Academy of Ophthalmology. Preferred Practice PatterGlaucoma, 2000.
3 American Academy of Ophthalmology. Preferred Practice PatteClosure, 2000.
4 American Academy of Ophthalmology. Preferred Practice PatterGlaucoma Suspect, 2000.
5 European Glaucoma Society. Terminology and Guidelines for GlDogma.
6 European Glaucoma Society. Terminology and Guidelines for Gl2003, Italy: Dogma.
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Epidemio
Epidemiology of Glaucoma in Asia
Glaucomatous optic neuropathy (GON) is most prevaleAfrican origin, and least prevalent in full-blooded AustAsian populations have rates intermediate between thEuropean- and African-derived peoples suffer predomiopen angle glaucoma (POAG), whereas rates of primar
glaucoma (PACG) are higher among East Asians than inAlthough a direct and exact comparison of POAG rateslikely has a similar prevalence in Asian and European phigher rate of GON in those of Chinese extraction is prto the excess of PACG.2 Rates on the Indian subcontinebetween studies, although these differences are probaIn absolute terms, there are large numbers of people s
and POAG in India. Preliminary data suggests that prevless in Southeast Asian populations than in the ChineseEuropeans.
Incidence rates of symptomatic acute angle closure (givpersons/year for the population aged 30 years and oveEurope (Finland)3 to 15.5 in Chinese Singaporeans.4 Mapeople in Singapore have lower rates than Chinese Sin6.3, respectively).5
Population surveys in Mongolia found glaucoma to be of blindness in adults (cataract being the cause of 36%Among Chinese Singaporeans, 60% of adult blindness glaucoma.7 Cautious extrapolation of these data sugge1.7 million people in China suffer blindness caused by g
responsible for the vast majority (91%) of these cases.2
glaucoma is the most common cause of uniocular blind
Glaucoma is the leading cause of registered, permanenHong Kong (23%).8 In Japan, diabetic retinopathy (18%
Incidence ofsymptomatic,acute angleclosure
Glaucomablindness
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Although angle closure is associated with a hyperme
cases do occur in myopes. A shallow anterior chamberecognized to be a factor that predisposes toward andepth of the anterior chamber reduces with age andin women than in men.21,22 There may also be an assomyopia and POAG.23 In India, pseudoexfoliation was cases of POAG.24
References:
1. Royal Australian and New Zealand College of OphthalmoloTrachoma and Eye Health Program, Chapter 8, pp. 82100,
2. Foster PJ, Johnson GJ. Glaucoma in China: how big is the p2001;85:12771282.
3. Teikari J, Raivio I, Nurminen M. Incidence of acute glaucom1982. Graefe's Arch Clin Exp Ophthalmol 1987;225:357360
4. Seah SKL, Foster PJ, Chew PT, et al. Incidence of acute primglaucoma in Singapore. An Island-Wide Survey.Arch Ophth1997;115:14361440.
5. Wong TY, Foster PJ, Seah SKL, et al. Rates of hospital admisclosure glaucoma among Chinese, Malays, and Indians in Si2000;84:990992.
6. Baasanhu J, Johnson GJ, Burendei G, et al. Prevalence and cvisual impairment in Mongolia: a survey of populations ageWorld Health Organization 1994;72:771776.
7. Foster PJ, Oen FT, Machin DS, et al. The prevalence of glauc
of Singapore. A cross-sectional population survey in TanjonOphthalmol2000;118:11051111.
8. Hong Kong Hospital Authority Statistical Report 20012002permanent blindness in hospital authority ophthalmology thttp://www.ha.org.hk (accessed 27 Sept 2003).
9 Tso MOM Naumann GO Zhang S Editorial Studies of the
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Epidemio
14. Wensor MD, McCarty CA, Stanislavsky YL, et al. The prevalenc
Melbourne Visual Impariment Project. Ophthalmology1998;115. Mitchell P, Smith W, Attebo W, et al. Prevalence of open-angl
The Blue Mountains Eye Study. Ophthalmology1996;103:1661
16. Shiose Y, Kitazawa Y, Tsukuhara S, et al. Epidemiology of glaunationwide glaucoma survey.Jpn J Ophthalmol1991;35:1331
17. Leske MC, Connell AM, Wu SY, et al. Risk factors for open angBarbados Eye Study.Arch Ophthalmol1995;113(7):91824.
18. McNaught AI, Allen JG, Healey DL, et al. Accuracy and implicafamily history of glaucoma: experience from the Glaucoma InTasmania.Arch Ophthalmol2000;118(7):900904.
19. Foster PJ, Machin D, Wong TY, et al. Determinants of intraocuassociation with glaucomatous optic neuropathy in Chinese STanjong Pagar Study. Invest Ophthalmol Vis Sci2003;44(9):388
20. Trnquist R. Shallow anterior chamber in acute angle-closurestudy.Acta Ophthalmol1953;31(Suppl. 39):174.
21. Okabe I, Taniguchi T, Yamamtoo T, et al.. Age-related changechamber width.J Glaucoma 1992;1:100107.
22. Foster PJ, Alsbirk PH, Baasanhu J, et al. Anterior chamber depVariation with age, sex and method of measurement.Am J O1997;124:5360.
23. Mitchell P, Hourihan F, Sandbach J, et al. The relationship betwmyopia. The Blue Mountains Eye Study. Ophthalmology1999;
24. Krishnadas R, Nirmalan PK, Ramakrishnan R, et al. Pseudoexfopopulation of southern India: the Aravind Comprehensive EyeOphthalmol2003;135:8307.
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Section 1
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1.1 Patient Assessment
The purpose of this section is to describe the initial assein whom glaucoma is suspected, from the perspective othe developed and developing worlds. Inevitably, somemore relevance to one or other setting, however, time a patient is seldom wasted. The initial consultation lays
for successful management of the patient.
Assessment of a child with suspected glaucoma raises squestions. Such a child should be referred urgently to a
The aims during the initial assessment are:
to determine whether or not glaucoma is present, o(i.e., assess risk factors)
to exclude or confirm alternative diagnosis
to identify the underlying mechanism of damage, sochoice of management
to begin planning a strategy of management
to identify suitable forms of treatment, and to excluinappropriate.
Understand the natural history of the glaucomas in youassessment can be divided into two phases:
1. History
2. Examination/investigations
Key points:
Most glaucomas, including angle closure glaucoma (asymptomatic until advanced
Why assess?
What toassess?
History
A i P ifi Gl G id li
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Past medical history
Consider:Factors that will affect life expectancy and compliancExclude past hemodynamic crises (postpartum hemorabdominal aneurysm, severe trauma) that may causecupping that mimics glaucoma but is not progressive
Specific predisposing diseases are summarized in Tab
Table 1.1: Factors to consider when taking a medicalwith suspected glaucoma
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Visual symptoms of glaucoma Visual blurring and discomfort:
This may be due to angle closure, Posner-Schlosyndrome or pigment dispersion
Glare and colored rings around lights from corne This needs to be differentiated from migraine
Poor light/dark adaptation
Difficulty tracking fast-moving objects (e.g., golf
Respiratory Asthma and other chronic obstruc
diseases associated with hyperresand/or reduced lung capacity willtopical -blockers
Cardiovascular Cardiac arrhythmias, e.g., heart the use of topical blockers or
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Endocrine Diabetes increasingly prevalentwith open angle and neovascular
Thyroid eye disease
Pituitary tumors
Central Previous cerebrovascular accidentnervous system injury/pituitary lesions (field loss)
Early dementia affects complianand insight into the disease
Musculo- Arthritis (osteo-, rheumatoid) maskeletal the ability to administer eye drop
Urogenital Urinary stones may limit systemicanhydrase inhibitors (CAIs)
Ocular trauma Angle recession, lens dislocation, damage
Pregnancy and Present or possible, renders all inlactation potentially hazardous
Medication
Use of any current medication needs to be considerecertain specific past medications, including:
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Social history
Consider:
How regularly can the patient attend?
Can the patient afford and comply with treatment?
How will having glaucoma affect the patients life/wand treatment)?
Family history
Consider:
What is the disease type and course in the family? (S
Examination requires appropriate equipment, sufficieexamination techniques and accurate and reliable re
While resources vary widely across our region, there acceptable standard of equipment and training.
Minimal acceptable resources for examination
A slit lamp with indirect lens between 6090D an
ophthalmoscope
An automated perimeter
A gonioscope that allows indentation gonioscop
A Goldmann-style applanation tonometer (or ToMaklakov tonometers are not generally accepta
When the patient cannot get to a slit lamp
Portable hand held slit lamp may be very useful
In the absence of a portable slit lamp a jeweler
Examination/Investigations
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How toperform
Goldmanntonometry?
Intraocular pressure (IOP) is the only modifiable risk fac
Goldmann-style Applanation Tonometry (GAT). (Tonopenot available).
Every visit.
Ensure tonometer is calibrated (seeAppendix 1: Howof a Goldmann tonometer).
The prism tip must be disinfected and then disinfect
The eyelashes must be kept out of the way (avoid pr
The cornea must be anesthetized.
The tip must touch the central cornea gently with th
through the slit lamp eyepiece just prior to the tip m(tip: look for the white split ring that will fluoresce wtouches the cornea).
Adjust the gauge until the split tear meniscus just to
Factors associated with IOP
Table 1.2: Factors affecting measured IOP
Circadian cycle The IOP follows a circadian cycle, ofthe morning and a trough in the evdiurnal variation is 36 mmHg
Central corneal Thicker corneas are associated with
thickness IOP measurements, thinner corneas depressed IOP measurements: apply13 mmHg/40 deviation from 525
Blood pressure IOP is positively associated with systti l l t li
When?
How toperformGoldmanntonometry?
Why?
What?
Slit lampexamination
tonometry
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Table 1.3: Measurement errors associated with GAT8
IOP reading artificially low Insufficient fluo
IOP reading artificially high Excessive fluore
Eyelid pressure blepharospasm
Digital pressurelids apart
Obese patient
Patient straininchin/forehead r
Patient breath-
Patient wearingaround neck (ecollar +/- tie for
Hair lying acrosdistorting mires
Lens-corneal ap
Technical difficulties (interpret Corneal abnormresults with caution) graft, edema)
Marked cornea
Small palpebral
N t
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Anterior chamber:
pigment on corneal endothelium (pigment dispersio
peripheral anterior chamber depth (van Herick techn
central anterior chamber depth
evidence of inflammation (e.g., keratic precipitates).
Iris:
mid-dilated poorly reactive (post angle closure attac
isolated zones of patch atrophy or spiraling
rubeosis
synechiae
configuration in relation to lens pseudoexfoliation material on pupil edge pigment deposit on anterior surface transillumination defect.
Lens:
pseudoexfoliation material
lens thickness and opacity
phacodonesis
glaukomflecken.
(SeeAppendix 3a: Gonioscopy)
Detect angle closure, occludable and secondary glauco
Angle width and characteristics (see below).
Initially for all.
Regularly for angle closure patients
Why?
What to lookfor?
When?
Gonioscopy
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Place lens gently on eye while looking through slit
doing tonometry) no gel needed with Zeiss-type Look through the upper mirror (inferior angle) as
stop pushing when you can see the iris.
Move slit lamp beam inferiorly (avoid pupil) to exa
Then turn beam 90 degrees and move on axis.
Move to nasal side (temporal angle) then to temp
Record findings on goniogram.(seeAppendix 3b: Goniogram/Gonioscopic chart)
Tip: If you cannot find the angle structures, use a bright wide slat low magnification. Once you have found the angle structuredown, shorten and narrow the slit and look for the change in irYou may need to wait a minute or so.
Figure 1.4: Gonioscopy flow diagram
Scleral spur visible?
YES
Grade: Record findings
NO
Do indentation gonioscopyAny synechiae?
YES
Grade: Record findingsN
IOP r
YESGrade: Record findings
Open angle
PAC (synechiae)
PAC (apposition)
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Defines glaucoma.
Disc size.
Neuroretinal rim.
Disc hemorrhage.
Nerve fiber layer defect.
Peripapillary atrophy (PPA).
Vascular pattern.
Every visit.
Consider:
Non-glaucomatous optic neuropathies. Differentiate anoptic neuropathy (AION) from glaucoma especially giBoth cause pale cupped disc and field loss.
Slit lamp.
Very thin, bright beam for disc measurement.
Dimmer beam for clearer/artificial lenses.
Indirect slit lamp lens (6090D).
Stereoscopic view (best when dilated recommende
Red-free (green) illumination may help assessment o
Direct ophthalmoscopy or slit lamp view through unlens if pupil small and not able to be dilated.
Figure 1.5: Disc examination flowchart
Why?
What to look
for?
When?
How toperform discexamination?
Optic nerve
head andretinalnerve fiberlayer
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Table 1.6: Normal vertical cupdisc ratios for vertical
Disc diameter Mean cupdisc ratio1.0 0.261.2 0.331.4 0.391.6 0.451.8 0.502.0 0.55
Disc recording
Draw optic disc (large), rim, key vessels that definesigns.
Draw notches, shelving, loss to rimclock hours.
Record whether nerve fiber layer is visible and assedefects.
Record vertical cupdisc ratio in the narrowest parrecording the rimdisc ratio at key parts of the rim
Record disc hemorrhages, baring of circumlinear bvessels bayoneting.
Tip: Disc margin is INSIDE the peripapillary scleral ring of ElschnAppropriate lens magnification correction: Superfield 1.5x, 90D
Disc size
Disc size is extremely variable, large discs have laeven though the area of the neuroretinal rim is
a large cupdisc ratio may not necessarily be patConversely, pathological rim loss can be missed iespecially if generalized.
Disc size can also be measured by using the smadirect ophthalmoscope This spot size can be use
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The most reliable way to detect glaucomatous optic nemay be with serial optic nerve head photographs.
Repeated scanning laser imaging is a promising approat l
The neuroretinal rim
The rim is more important than the cup. The cup defedge of the rim where most signs of glaucoma appe
The cardinal feature of glaucomatous optic neuropatissue from the inner edge of the rim.
Features that should raise suspicion that glaucomatoalready occurred include:12
notching of the rim (especially to the disc margin)
hemorrhage crossing the rim
undercutting of the rim
asymmetry of rim width between the eyes in the aasymmetry of disc size
an abnormally thin rim in one or two sectors
An approximate rule is that a vertical cupdisc ratio rim to the disc margin anywhere outside the temporsuggests glaucoma. This rule may not apply if the dislarge or very tilted.
ISNT rule
Normally, the thickest to thinnest parts of the neuroreoptic disc are Inferior Superior Nasal Temporal (ISNT).from this may help to detect glaucomatous damage.
Optic discphotographyand imaging
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Table 1.7: Optic disc/NFL assessment
Defines state of optic nerve function.
Defines visual impairment.
Automated perimetry.
When glaucoma is suspected on examination.
It is very important to understand the correct proced
visual field testing. Users should read and be familiarmanual.
Qualitative Quantitative
Direct ophthalmoscopy Disc photogrdigitalization
Slit lamp indirect ophthalmoscopyStereo disc p
Disc photograph optic disc an
Simultaneous stereophotography Confocal laseophthalmosc
Nerve fiber layer photography(red-free fundus photography) Laser polarim
Optical CoheTomography
Why?
What?
When?
How?
Tips for better visual fields (see Appendix 4: How
Visual fieldexamination
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Characteristics of glaucomatous visual field defect
Asymmetrical across horizontal midline.*
Located in mid-periphery* (525 degrees from fixati
Reproducible.
Not attributable to other pathology.
Clustered in neighboring test points (localized).
Defect should correlate with the appearance of the neighborhood.
*early/moderate cases
References:
1. Drance SM. The visual field of low tension glaucoma and shoc
neuropathy.Arch Ophthalmol1977;95:13591361.2. Drance SM. Some factors in the production of low tension gla
1972;56:229242.
3. Drance SM, Sweeney VP, Morgan RW, et al. Studies of factors production of low tension glaucoma.Arch Ophthalmol1973;8
4. Drance SM. Some studies of the relationships of haemodynamin open angle glaucoma, Trans Ophthalmol Soc UK1968;88:63
5. Rochtchina E, Mitchell P, Wang JJ. Relationship between age the Blue Mountains Eye Study. Clin Experiment Ophthalmol2
6. Foster PJ, Machin D, Wong TY , et al. Determinants of intraocassociation with glaucomatous optic neuropathy in Chinese STanjong Pagar Study. Invest Ophthalmol Vis Sci2003;44:3885
7 L JS L SH O m BS t l R l ti hi b t i t l
Other tests of optic nerve function
Short wave length automated perimetry (blue on
Frequency doubling perimetry
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Treatmen
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1.2 Treatment Categories and Targets
Tailor treatment to severity of glaucoma, depending onrisk factors.
Group 1: Glaucoma with high risk of progressive v
Definite glaucomatous optic neuropathy (GON) with co
field (VF) loss (moderate to advanced).
Includes moderate to advanced normal pressure glau
Group 2: Glaucoma with moderate risk of visual losuspect with high risk of visual loss
Mild GON with correlating early VF loss.
Mild to moderate NPG.2
Ocular hypertension 30 mmHg with suspicious disc.
Primary angle closure with high intraocular pressureanterior synechiae (PAS).
Angle neovascularization.
Group 3: Glaucoma suspect at moderate risk of vis Glaucoma-like disc appearance without detectable V
Fellow of eye with established GON (exclude secondglaucomas).4
Ocular hypertension with suspicious disc.3
Group 4: Glaucoma suspect with low risk of visualMore important:
ocular hypertension3,4
older age3,4
l d bl l ( iti ll l d ith t PAS
Why?
Whatare the
categories?
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Less important:
steroid responder, steroid users myopia, peripapillary atrophy (PPA)
diabetes mellitus
uveitis
systemic hypertension.
Multiple risk factors (RFs)
The presence of multiple RFs proportionally increasesmay elevate a patient to Group 3.
Each visit.
Modifiable mechanisms for RFs.
To maintain functional vision throughout the patientminimal effect on quality of life.
Goal of intervention is risk factor reduction (RFR
IOP.
Angle control.
T f di i di /f (di b
Other risk factors
Genetic risk factors: family history ethnicity
Vascular risk factors: hypertension reduced perfusion pressure
nocturnal hypotension
Myopia
Diabetes m
Vasospasm migraine Raynaud
Sleep apne
When?
How?
Objective
Setting goals
Treatmen
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Stage of disease
Use the four treatment categories above.
Estimate rate of neural lossHigher more aggressive RFR.
Severity of RFsHigher or greater number more aggressive RFR.
Modifiers of goals Life expectancy.
Ability to attend follow-up.
Diseases that prevent accurate disc or field assessme
Goals of angle control Deepen peripheral angle closure (AC).
Iridotomy reduce pupil block.
Argon laser peripheral iridoplasty (ALPI) flatten pe
Lens extraction (LE) reduces pupil block, displaces i
Vitreous surgery.
IOP landmarks
Presenting (untreated) IOP.IOP in fellow normal eye in unilateral secondary glauco
Population mean and standard deviation IOP for norm
IOP control
Target IOP
Target IOP is based on the pressure reduction requ
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Goals (target IOPs) in Group 1
Target pressure reduction of at least 30%,
1,4,5
or closepressure (712 mmHg if achievable safely).47
Goals in Group 2Target pressure reduction of at least 20%.47
Goals in Group 3Monitor closely for change.Treat if risk(s) increase(s) with target pressure reduct
Group 4Monitor, no treatment.
Goals of treating predisposing diseasesPrevent onset of GON by proper management of dise
References:
1. The Collaborative Normal-Tension Glaucoma Intervention Steffectiveness of intraocular pressure reduction in the treatmglaucoma.Am J Ophthalmol1998;126:498505.
2. Tezel G, Siegmund KD, Trinkaus K, et al. Clinical factors assocglaucomatous optic disc damage in treated patients.Arch Op2001;119(6):813818.
3. Gordon MO, Beiser JA, James MS, et al. The ocular hypertenthat predict the onset of primary open-angle glaucoma.Arc2002;120:714720.
4. Leske MC, Heijl A, Hussein M, et al. Factors for glaucoma protreatment: the early manifest glaucoma trial Arch Ophthalm
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Section 2
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2.1 Initiation of Treatment
Glaucoma is a progressive optic neuropathy: if left untmay go blind.
Assess patients as a whole with the aim of preservationIntraocular pressure (IOP) is the only known causal risk one that can be manipulated effectively.2
Mechanisms that elevate IOP:
primary unknown cause
angle closure with or without glaucoma
secondary glaucomas (seeAppendix 5: Secondary glaof management).
In the presence or the likelihood of developing visual dinterfere with quality of life during the patients lifetim
Demonstrable functional and structural defect
Multiple mechanisms for angle closure (refer to Appclosure mechanisms)
Angle closure is caused by different sites of blockageoccur at multiple levels simultaneously and/or sequen
Site one: pupil block iris bomb appearance
Site two: anteriorly rotated ciliary processes that pforward and/or thick peripheral iris plateau iris c
Site three: lens induced forward displacement of tconfiguration
Site four: aqueous misdirection with accumulationvitreous pushing the entire lensiris diaphragm fo
Why shouldtreatmentbe initiated?
Whatshould betreated?
When totreat?
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Treat the mechanism(s)
IOP reduction: medication(s)
laser
surgery.
Correct the abnormal anatomy:
laser
surgery.
(Once any angle closure component has been appropmanagement is similar to open angle glaucoma).
Collaborate with colleague(s) to treat systemic proble
References:
1. Sommer A, Tielsch JM, Katz J, et al. Relationship between inprimary open angle glaucoma among white and black AmerSurvey.Arch Ophthalmol1991;109(8):10901095.
2. The AGIS Investigators. The advanced glaucoma interventionrelationship between control of intraocular pressure and visuAm J Ophthalmol2000; 130(4):429440.
How totreat?
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2.2 Medical Treatment
Effective for majority of patients.
Generally acceptable therapeutic index.
Mostly acceptable to patients.
Widely available.
Choice depends on mechanism of glaucoma as well as oto Patient Assessment). For angle closure, medical treatappropriate after peripheral iridotomy (PI).
Table 2.1: Efficacy, safety and dosing frequency of vari
Drug classDaily
Dosage Efficacy Loc
Adrenergicagonists
2x to 3x ++ to +++ ++
-blockers 1x to 2x +++ +
Carbonicanhydraseinhibitors
Topical
Systemic
2x to 3x
2x to 4x
++
++++
++
0
Cholinergics 3x to 4x +++ +++
Hyperosmoticagents
Statdose(s)
+++++ 0
Prostaglandinsand other lipid
Why?
What?
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Table 2.2: Mechanism of action of different drug clas
Mechanism of action Drug class
Reduction ofaqueous inflow
Adrenergic agonists
-blockers
N
Carbonic anhydrase
inhibitors
S
T
Increase in
Cholinergics
Increase trabecularoutflow
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ndications*
Commondrug
interactions
Localsideeffects
S
ystemicsideeffe
cts
mineoxidase
ortherapy
an2yearso
ld
CNSdepressan
ts
(alcohol,barbiturates,
opiates,sedatives,or
anesthetics),tricyclic
antidepressan
ts
Burning
,stinging,
blurring,
foreign-body
sensation,
itching,
hyperemia,
follicular
conjunctivitis
Oraldryness,
headache,
fatigue,
drowsiness
tely
ndicatedin
ialasthma,
obstructive
narydisease
,
ardia,
heart
used
uslyincardia
c
Systemic-blo
ckers,
calciumc
hann
el
blockers
Burning
,stinging,
photop
hobia,
itching,
tearing
,decreased
cornealsensitivity,
hyperemia,punctate
epithelialkeratopathy
Bronchospasm,
hypotension,
bradycardia,
heart
block,mask
hypoglycemia,
adverselyaffectslipid
profile(except
carteolol),
lossof
libido,
fatigue,
aggravationof
myastheniagravis,
depression,memory
impairment,reduced
exercisetolerance,
increasedfalls
intheelderly
y
Asfornon-sel
ective
Asfornon-selective
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ndications*
Common
drug
interactions
Localsideeffects
S
ystemicsideeffe
cts
ure,
ryedema,
ure
with
sion
NA
Headaches,
unpleasanttaste,
heartfailure,
pulmonaryedema,
death
y dicatedin
nceofactiv
e
atoryocular
ns,cystoid
edema
following
ted
arsurgery
Chronicpiloca
rpine
usemayreduce
efficacyofthe
se
agents
Blurred
vision,
burning,stinging,
conjunctival
hyperemia,
foreign
-body
sensation,
itching,
increased
iris/periorbitalskin
pigmen
tation,
lash
growth
,punctate
epithelialkeratopathy,
cystoid
macular
edema,reactivation
ofherp
eticinfection
Asfo
rindividualcomponents
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Choose the most appropriate medication
Greatest chance of reaching target. Best safety profiles.
Minimally inconvenient.
Affordable.
Start low and slow Minimal concentration.
Minimal frequency.
One-eyed therapeutic trial
Start treatment in the worse eye.
Check the IOP response after 24 weeks.
Assess side effects.
If acceptable and effective, make treatment bilate
If response inadequate to achieve target pressure: sw
Switch to different class of medication (switching wagonist class may be useful, but compliance and reneed to be considered).
Use the one-eyed therapeutic trial again.
Use more than one agent only if each has demonstrainsufficient to reach target
Apply this principle also to the fixed combinations
How?
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Teach the technique of drop instillation
Demonstrate the preferred method including punctaeyelid closure for at least 3 minutes (double DOT Technique, Dont Open Technique).
Ensure the patient can do it.
If two or more drops being instilled, wait at least 5 mbetween drops.
Provide educational material.
Suggested reading:
1. European Glaucoma Society. Treatment principles and optionGuidelines for Glaucoma, IInd edition, 2003, pp.3-13-45. Italy:
2. Ritch R, Shields MB, Krupin T. The Glaucomas Glaucoma TheEd, Missouri: Mosby.
3. Hoyng PFJ, van Beek LM. Pharmacological Therapy for Glauco2000;59:411434.
4. Goldberg I. Drugs for glaucoma.Australian Prescriber2002;25
5. Soltau JB, Zimmerman TJ. Changing paradigms in the medicaglaucoma. Survey of Ophthalmology2002;47(Suppl 1):S2S5.
6. Kass MA, the Ocular Hypertension Treatment Study Group. Thtreatment study. A randomized trial determines that topical omedication delays or prevents the onset of primary open-angOphthalmol2002;120:701713.
7. Frishman WH, Kowalski M, Nagnur S, et al. Cardiovascular contopical, oral, and intravenous drugs for the treatment of glau
hypertension: focus on beta-adrenergic blockade. Heart Dis 2
8. Schuman JS. Antiglaucoma medications: a review of safety anrelated to their use. Clin Ther2000 Feb;22(2):167208.
9. Susanna R Jr, Medeiros FA. The pros and cons of different promanagement of glaucoma Curr Opin Ophthalmol 2001;12(2):
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Figure 2.3: Medical Treatment Algorithm
Drug 1
Maximize compliance
Maxi
YES
Partial / side effeStop
Hold in reserve
Partial / side effe
Partial / side effeStop
Hold in reserve
Reaches target?Side effects none
/ tolerable?
Reaches target?Side effects none
/ tolerable?
Reaches target?Side effects none
/ tolerable?
Dr(if
Maxi
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2.3 Laser Treatment
Laser treatment for open angle glaucoma
Outflow enhancement: laser trabeculoplasty.
Inflow reduction: cyclophotocoagulation (usually for
Laser treatment for angle closure ( glaucoma) Pupillary block relief: laser iridotomy.
Modification of iris contour: laser iridoplasty (goniop
Inflow reduction: cyclophotocoagulation (usually for
Relatively effective. Relatively non-invasive.
Laser treatment to trabecular meshwork to increase ou
Medical therapy failure or inappropriate.
Adjunct to medical therapy.
Primary treatment if appropriate.
Pre-laser management
Explain the procedure.
To reduce post-treatment intraocular pressure (IOP) inflammation, consider 1% apraclonidine1 or 0.2% b24% pilocarpine and/or -blocker and/or steroid droprocedure.
Topical anesthesia.
When?
Why?
What?
Lasertrabeculoplasty
How?
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Placement of laser spots
Between pigmented and non-pigmented trabecular m(seeAppendix 7a: Argon laser trabeculoplasty).
Parameters
Power: 3001200 mw depending on the rSpot size: 50 m (for Argon), 75 m (for dioDuration: 0.1 sec (for Argon & diode), 3 ns f
Number of burns: 3050 spots evenly spaced over 18remaining 180 degrees sequentially, or at the same t
Complications
Temporary blurred vision.
IOP spike with possible visual field loss.
Transient iritis.
Peripheral anterior synechiae if placement of burnpost-laser inflammation control is not effective.
Endothelial burns of treatment too anterior.
Chronic increase in IOP.
Post-laser management
Continue any current medical treatment.
Especially if IOP spike prevention treatment is not IOP at 16 hours after laser and again 2448 hours
Topical steroid qid for 414 days (consider omitting
Closer monitoring is suggested in certain cases
Advanced glaucoma with severe field loss.
One-eyed patient.
High pre laser IOP
Iridotomy
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Effective.
Relatively non-invasive.
Preferable to surgical iridectomy.
Laser treatment to connect the anterior and posterior cpupillary block.
Angle closure.
Angle closure glaucoma.
Occludable angle (absolute):
angle closure in the fellow eye confirmed family history of angle closure glaucoma
Occludable angle (relative):
need for repeated dilated examinations
poor access to regular ophthalmic care.
Pre-laser management
Explain the procedure.
Instill 2% or 4% pilocarpine .
To reduce post-treatment IOP spike/inflammation, co
1% apraclonidine1
or 0.2% brimonidine2
and/or -blocarbonic anhydrase inhibitor and/or steroid drops be
Topical anesthesia.
Topical glycerin, if the cornea is edematous.
Superior 1/3 of iris (beneath upper lids) desirable.
Laser: Nd-YAG.
Argon or krypton.
Why?
What?
When?
How?
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Complications
Temporary blurring of vision.
Laser parameters for Argon laser
Preparatory stretch burns:
Spot size 200500 m
Exposure time 0.20.5 sec
Power 200600 mW
Penetration laser burns:
Diameter 50 m
Exposure time 0.02 sec
Power 8001000 mW
For pale blue or hazel iris:
First step, to obtain a gas bubble:
Diameter 50 m
Exposure time 0.5 secPower 1500 mW
Second step, penetration through the gas bubble:
Diameter 50 m
Exposure time 0.05 sec
Power 1000 mW
For thick dark brown iris: (chipping technique)Diameter 50 m
Exposure time 0.010.02 sec
Power 15002500 mW
Choose and modify parameters depending on indiv
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Post-laser management
Particularly if IOP spike prevention treatment is not IOP at 16 hours after laser and again at 2448 hour
Topical steroid at least 46 times/day for 414 days dinflammation.
Verify the patency of the peripheral iridotomy (PI).
Repeat gonioscopy.
Pupillary dilatation to break posterior synechiae whe
Reasonably effective.
Relatively non-invasive.
Adjunct to peripheral iridotomy.
Laser treatment to contract the peripheral iris:
to flatten the peripheral iris
to widen the anterior chamber angle inlet.
Angle remains occludable following peripheral iridotom
Help break an attack of acute angle closure. Facilitate access to trabecular meshwork for laser tra
Minimize the risk of corneal endothelial damage du
Pre-laser management
Explain the procedure.
Instill 2% or 4% pilocarpine. To reduce post-treatment IOP spike/inflammation, co
1% apraclonidine1 or 0.2% brimonidine2 and/or -blocarbonic anhydrase inhibitor and/or steroid drops be
Topical anesthesia
Why?
Iridoplasty(gonioplasty)
When?
What?
How?
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Endpoint
Iris contraction with peripheral anterior chamber dvisible angle in line with the laser applications.
Complications
Mild iritis.
Corneal endothelial burns.
IOP spikes.
Peripheral anterior and/or posterior synechiae.
Post-operative treatment
If IOP spike prevention treatment is not available, 16 hours and then 2448 hours depending on the
Topical corticosteroids 46 times/day for 7 days or the post-laser inflammation.
Repeat gonioscopy to evaluate the anterior chambany other mechanism(s) of angle closure that mighintervention.
Pupillary dilatation to break posterior synechiae w
Preferable to cyclocryoablation or cyclodiathermy.
Laser parameters
Power: 200 to 400 mW according to theSpot size: 200500 mDuration: 0.20.5 secNumber of burns: 30 to 50 applications over 360 d
least 12 spot diameters betwee
Why?
Cyclophoto-coagulation
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Techniques
Transpupillary. Transscleral.
Endolaser.
Conservative, incremental applications avoiding 3 anpositions.
Non-contact transscleral Nd-YAG laser
Lasag Microruptor 2 using thermal mode.
Contact transscleral Nd-YAG laser
Continuous wave Nd-YAG laser with transscleral contac
Contact transscleral diode laser
Diode laser with transscleral contact probe (seeAppentransscleral diode laser).
Laser parameters
Power: 810 J and with maximum defocuposterior to the limbus
Number of burns: 32 over 360 degrees
Laser parameters
Power: 47 JDuration: 0.50.7 secNumber of burns: 3040 over 360 degreesLocation: 1.02.0 mm from limbus
Laser parameters
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Complications
Pain. Persistent inflammation.
Loss of visual acuity.4,5
Hypotony.6
Scleral thinning.7,8
Macular edema.
Retinal detachment.9
Aqueous misdirection syndrome.10
Phthisis.11
Sympathetic ophthalmia.12
Failure to control IOP multiple procedures may b
Post-operative management
Analgesia.
Continue any current treatment.
Check IOP after 2448 hours.
Topical corticosteroids 46 times/day for 14 days orpost-laser inflammation.
Cycloplegia 24 times/day for 714 days.
References:
1. Robin AL. Argon laser trabeculoplasty medical therapy to p
pressure rise associated with Argon laser trabeculoplasty. OJan;22(1):3137.
2. Barnes SD, Campagna JA, Dirks MS, et al. Control of intraocafter Argon laser trabeculoplasty: comparison of brimonidi1.0%. Ophthalmol1999 Oct;106(10):20332037.
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8. Bhola RM, Prasad S, McCormick AG, et al. Pupillary distortion following trans-scleral contact diode laser cyclophotocoagulat
clinicopathological study of three patients. Eye 2001 Aug;15
(P9. Geyer ONeudorfer M, Lazar M. Retinal detachment as a com
yttrium aluminum garnet laser cyclophotocoagulation.Ann OMay;25(5):170172.
10. Hardten DR, Brown JD. Malignant glaucoma after Nd:YAG cycAm J Ophthalmol1991 Feb 15;111(2):245247.
11. Trope GE, Ma S. Mid-term effects of neodymium:YAG transsclcyclophotocoagulation in glaucoma. Ophthalmol1990;97(1):7
12. Lam S, Tessler HH, Lam BL, et al. High incidence of sympathetcontact and noncontact neodymium:YAG cyclotherapy. Ophth1992:99(12):18181822.
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2 4 S
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2.4 Surgery
Open angle glaucoma
Outflow enhancement: penetrating and non-penetrsurgery.
Glaucoma drainage device.
Chronic angle closure glaucoma
Pupillary block relief: iridectomy.
Outflow enhancement: trabeculectomy.
Widening of anterior chamber angle inlet: lens extra
Angle surgery: goniosynechialysis.
Glaucoma drainage device.
Acute angle closure ( glaucoma)
Pupillary block relief: iridectomy.
Outflow enhancement: trabeculectomy.
Angle surgery: goniosynechialysis.
Widening of anterior chamber angle inlet: lens extra
Childhood glaucoma
Angle surgery: goniotomy and trabeculotomy.
Outflow enhancement: trabeculectomy with or with
Glaucoma drainage device.
Reasonably effective.1,2
Reasonably safe.
Widely available.
Why?
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Childhood surgery
Goniotomy (primary treatment to be performed
Trabeculotomy (primary treatment to be performe
Failed medical and/or laser treatment.1
Anticipated failure of medical/laser treatments (e.g
Patient preference.
Other forms of therapy are inappropriate: compliaand/or socioeconomic problems.
Pre-operative assessment
Identify risk factors for failure and treat where applic
Asian, African, Hispanic ethnicity.
Previous surgery.
Young age.
Aphakia.
Pseudophakia.
Active ocular inflammation.
Prolonged use of topical glaucoma medications.5
Tendency to form keloids.
Neovascular glaucoma.
Surgical technique
Select appropriate technique.
When?
How?
Enhancement of surgery Use of anti-fibrotic agents:
intra-operative4
post-operative4,6,7
U f i i fl
Use of anti-fibrotics insurgery
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Scarring is the major cause for failure following filtratiAnti-fibrotics have been shown to inhibit scarring and success rate.
Commonly used: 5-Fluorouracil (FU), Mitomycin-C (MMOthers: radiation.
For high risk of failure following standard filtering s
repeat surgery, neovascular glaucoma, glaucoma in uaphakia, younger age, black race.
In primary surgery, especially where a lower target prequired.11, 12
To increase the success rates with artificial drainage
With needling of a failed filter.
In these instances, the enhanced success rates with antthe complications associated with their use more accep
A. Application during surgery:
Dose
Sponge soaked in MMC (varying doses of 0.2 to 0.4 m15 minutes), 0.4 mgs/mL for 1 minute for primary suconcentration for 3 minutes for poor prognosis filter
Sponge soaked in 5-FU (50 mgs per mL) for 13 minu
For subconjunctival use prior to needling of a bleb: aof MMC (0.4 mg/mL) and 0.02 mL of bupivicaine wit
Mode of application Sponge placed under the conjunctiva. A little extra d
multiple sponges and a large surface area treatment
If used prior to needling, 0.01 mL of MMC (0.4 mg/m
Why?
surgery
When?
What?
How?
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over the area of injection may be tamponaded with about 1 minute after the injection.
Note: The use of anti-fibrotic agents can be associated with sighcomplications and they must be used with caution. Use of an al
those experienced in the use of such agents is desirable.15
An implant allows aqueous to flow from the anteriomaintained episcleral space from where it can be abssurrounding blood vessels.
Molteno, Ahmed, Baerveldt.
Where there is a very high risk of failure of trabeculeanti-fibrotics these eyes invariably have severe, refr
Previously failed trabeculectomies with anti-fibrot
Prior multiple ocular surgeries with conjunctival sc
Traumatic, inflammatory or chemically induced sur
Intraocular membrane formation likely to occlude
drainage procedure (e.g., irido-corneal endothelianeovascular glaucoma).
This surgery, and the management of the patient pocomplicated. An ophthalmologist with appropriate texperience should perform it.
Depending on the surgeons preference, one of the dpositioned on the scleral surface, usually in the supersuperonasal quadrant (or both for a two-plate implathe anterior chamber by an attached tube.
Why?
Glaucomadrainageimplants
When?
What?
How?
Cataract and glaucoma are both common conditions aCataract and
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Cataract and glaucoma are both common conditions aco-exist. A recent review has assessed current surgical m
Table 2.4: Evidence for surgical management of catara
Evidence grades:
A strongB moderateC weakI insufficient
For the surgical management of coexisting cataract andsome evidence of efficacy for using MMC.
*Extracapsular cataract extraction.
Cataract andglaucoma
surgery
Review comments
MMC (but not 5-FU) has a small benefit (24 mmHg) for ECCE*-trabeculectomy
Two-site surgery provides slightly lower IOP (13 mmthan one-site surgery
IOP is lowered more (13 mmHg) by phacoemulsificatthan by ECCE in combined procedures
Two-staged versus combined procedures
Alternative glaucoma procedures versus trabeculectoin combined procedures
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References:
1. Nouri-Mahdavi K, Bigatti L, Weitzman M, et al. Outcomes o
primary open-angle glaucoma. Ophthalmol 1995;102:1760
2. Jay JL, Murray SB. Early trabeculectomy versus conventionaopen angle glaucoma. Brit J Ophthalmol1988;72:881889.
3. European Glaucoma Society. Treatment principles and optioTerminology and Guidelines for Glaucoma, IInd edition, 2003
4. Ritch R, Shields MB, Krupin T. Glaucoma Surgery. In: The GlaTherapy,1996, vol III, 2nd ed, pp.16331652. Missouri: Mosb
5. Broadway DC, Grierson A, OBrien C, et al. Adverse effects omedication. II. The outcome of filtration surgery.Arch Opth1994;112(11):11461154.
6. Weinreb RN. Adjusting the dose of 5-fluorouracil after filtrside effects. Ophthalmol1987;94(5):564570.
7. Hurvitz LM. 5FU supplemented phacoemulsification, posterimplantation and trabeculectomy. Ophthalmic Surg 1993;24
8. Araujo SV, Spaeth GL, Roth SM, et al. A ten-year follow-up randomized trial of postoperative corticosteroids after trab1995;102(12):17531759.
9. Starita RJ, Fellman RL, Spath GL, et al. Short- and long-termcorticosteroids on trabeculolectomy. Ophthalmol1985;92(7
10. Kolker AE, Kass MA, Rait JL. Trabeculectomy with releasablOphthalmol1994;112(1):6266.
11. Ramakrishnan R, Michon J, Robin AL, et al. Safety and effictrabeculectomy in southern India. A short-term pilot study.100(11):16191623.
12. Lamba PA, Pandey PK, Raina UK et al. Short-term results ofwith intraoperative or postoperative 5-FU for primary glauc1996;44:157160.
13. Mardelli PG, Lederer CM Jr, Murray PL, et al. Slit-lamp needfiltering blebs using mitomycin C. Ophthalmology1996;103
14. Khaw PT. Advances in glaucoma surgey: evolution of antimtherapy.J Glaucoma 2001;10(Suppl 1): S81S84.
15. Khaw PT, Chang L, Wong TTL, et al. Modulation of wound surgey. Opin Ophthalmol2001;12:143148.
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Section 3
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3.1 Follow-up
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p
The aim of follow-up is:
to detect progression
to detect effects of treatment
to detect any change in health that may affect the gmanagement plan.
The follow-up process starts with the management plainitiation of therapy. At the follow-up visits the doctor
briefly discuss the patients subjective well being and
reassess risk factors: especially intraocular pressure (Igonioscopic change(s)
reassess structure and function of the optic nerve estimate rate of (any) progression
identify adverse effect(s) of treatment
assess compliance
identify change(s) in current medical and ophthalmo
discuss quality of life issue(s)
reinforce appropriate patient information: revise management plan follow-up.
The more severe the damage, the worse the risk factorbe the follow-up.
Patients will often wish to tell the doctor how they fhas (or has not) changed.
This discussion helps build a good doctorpatient rel
Why?
What?
When?
Patientssubjectivewellbeingand visual
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Intraocular pressure (IOP)Reassess thei k f t
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IOP is the only currently modifiable risk factor for
Assessment at every visit is vital.
Establish whether target IOP has been achieved.
A single measurement of IOP cannot detect all fluc
Repeat unexpected readings at the same visit and
Gonioscopic changes
Maintain baseline examination conditions.
Perform gonioscopy regularly in patients with angperiodically in patients with open angles.
Look for increased appositional and/or synechial c
Pupil size changes have dynamic effects on the ang
Look for change in angle width, synechiae, and pig
Causes of change in IOP at follow-up
Increased IOP: progression of disease gradual loss of efficacy of a drug (tachyphylaxi poor compliance
Reduced IOP: therapeutic effect
Reduced or increased IOP: variation during the day and between days change in systemic medications
risk factors
Optic discReassessstructure
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Progression of GON usually occurs over a long period, wdetection of change difficult.
The occurrence of the following indicate GON progressAppendix 8: Glaucomatous optic neuropathy):
disc hemorrhage
focal rim notching
change in vessel position
wedge-type nerve fiber layer defects
generalized rim thinning
increased cupdisc ratio.
Where baseline optic disc photographs and serial phot
available, detection of these changes is substantially enIf photographs are not available, the pupil should be dpossible to do this safely, consider prophylactic iridotomobtain an adequate view of the disc.1
Visual field
Change is frequent in perimetry. Usually only a small pto GON progression.
structure
andfunction ofthe opticnerve
Causes of change
Learning field performance usually improves oveattempts.
Reliability changes, poor concentration may cause depression, look for false negatives.
False negative errors may indicate progression. Falreflect poor reliability and may mask progression
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Progression is characterized by: widening or deepening of an existing scotoma
development of a new glaucomatous scotoma
occasionally generalized field depression (althougby media opacity or miosis).
(Refer toAppendix 9: Field progression print-outs).
Changes in visual field should be confirmed by at learepeat tests.
There is a close correlation between glaucomatous chthe optic disc and consequent visual field loss.5, 6 Howconsiderable variation in morphology of a normal ability to perform visual field tests adequately.
Changes should be regarded skeptically until the devstandard deviation of serial measurements.
Adverse effects of treatment should be actively sougspecific questioning. These include:
General effects: self-rated health, feelings about/atreatment.
Systemic effects: respiratory, cardiovascular, digest
Local effects: stinging/burning, blurring, itching, re
The patients quality of life (QOL) should be estima
of the glaucoma management on QOL assessed. This forms part of the assessment of burden of dis
treatment.
Quality oflife issues
Identifyadverseeffects of
treatment
SEAGIG DECISION SQUAREFOR GON
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The table below illustrates how various combinationprofiles and levels of disease stability/progression woaggressiveness of medical, surgical or laser intervent
Intervention is graded +, ++, +++, with the last indicactive level of intervention.
A +++ grade may be associated with a rapid, stepwisthrough medical to surgical management.
A indicates no addition to therapy.
Table 3.1: SEAGIG Decision Square for GON
Cop
Risk factors*
The following factors confer a higher risk of loss of visi
high or rising IOP
any appositional angle closure
any peripheral anterior synechiae (PAS), or an increabefore
longer life expectancy.*The more risk factors there are, the higher the risk. Thereforeadditional risk factor.
RiskDisease statu
Stable Uncertain
Increased + ++
Uncertain Reassess risk Reassess both
Stable Reassess diseas
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THE GLAUCOMA LIFE STORY (GLS)
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The determinants of the GLS are: state of damage
life expectancy
rate of progression.
The graph plots life expectancy against the extent ofdamage at diagnosis. The slope of the line is the rateis determined by risk factors Although rate is the key
Diagnosis
Damage
0
100
50
Increasing aggressiveness of trea
Medium riskfactors
Low
Highriskfactors
Increasingdam
age
Normal aging attrition
Follow-up timing
Th t t i th IOP t hi h it i b li d th
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The target pressure is the IOP at which it is believed th
vision for the rest of his/her life. However this needs totime to time.
Follow-up timing is determined by the treatment regimchanged. If the patient is stable the timing is determinextent of damage: for glaucoma suspect, 624 months;612 months; moderate damage, 46 months; severe d
References:
1. Kirwan JF, Gouws P, Linnell AET, et al. Pharmacological mydriaexamination. Br J Ophthalmol2000;84:894898.
2. Budenz DL, Feuer WJ, Anderson DR. The effect of simulated cglaucomatous visual field. Ophthalmology1993;100:511517.
3. Lam BL, Alward WL, Kolder HE. Effect of cataract on automatOphthalmology1991;98:10661070.
4. Smith SD, Katz J, Quigley HA. Effect of cataract extraction onautomated perimetry in glaucoma.Arch Ophthalmol1998;11
5. Quigley HA, Katz J, Derick RJ, et al. An evaluation of optic disexaminations in monitoring progression of early glaucoma da1992;99:1928.
6. Yamagishi N, Antn A, Sample PA, et al. Mapping structural dto visual field defect in glaucoma.Am J Ophthalmol1997;123
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Case Detection
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The Epidemiologysection outlines our current understamagnitude of glaucoma blindness in Asia. This large buquestion of screening the population to detect and inittreatment for glaucoma.
The World Health Organization recommends that certa
be fulfilled before any population-based screening is u
The disease must be an important public health prob
There must be a recognizable latent or early stage, dpersons with the disease can be identified before sym
There must be an appropriate, acceptable and reasoscreening test.
There must be an accepted and effective treatment the disease that must be more effective at preventininitiated in the early asymptomatic stage than whensymptomatic stages of the disease.
The cost of case finding must be economically balanpossible expenditure on medical care as a whole.
Other questions that need to be asked before embarkiprogram are listed below.2
1. Does early diagnosis lead to improved clinical outcomvisual function and quality of life?
2. Can the health system cope with the additional clini
resources required to confirm the diagnosis and provfor those who screen positive for a chronic disease su
3. Will the patients in whom early diagnosis is achievedb t d ti d t t t i
Whycase detector screen?
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Population-based screening versus case detectioWhat is thebest
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Population-based screening2 Cas
Patients are sought, there is animplied pledge that the process isgoing to make them better butthis may not be true.
Relies on detepatients who for other comus out; we treof our ability
guarantee of Obliged to establish a diagnosisand treatment using sophisticatedtechniques, which may not bewidely available for generalscreening. Without the requisiteequipment, trained personnel andinfrastructure, screening is notjustified.
The patients who turn out to befalse positives carry the burden ofbeing labelled. The consequencesmay be severe.3
Based on deteat risk patienprevalence ofThus, most ofbelow tonomophthalmosco
have a reasonpredictive val
Patients who actually have the
disease but have tested negativeare given a clean bill of health,which can be dangerous.
Many countries in the region maynot have the requisiteinfrastructure to follow-up andcategorize test positives or eventreat them appropriately.
The general pimportant rolopen angle glOphthalmoscodoubling peria physicians o
Screening cannot be a one-time Most elderly p
strategy?
Primary open angle glaucoma (POAG)
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* Clinic-based study with selected normals which may overestimat
Primary angle closure glaucoma (PACG)
According to population-based studies in Western counprevalence of POAG is five times that of PACG.11,12 Howglaucoma blindness in the world is caused by angle cloA i l 75% f bj i h PACG i A i h
Test Sensitivity Specificity C
Tonometry At cut off of >21mm: Poor sen
Half of tPOAG haat a sing
47.1%5 92.4%5
Automatedperimetry
97%6 84%6 Test can specific o
Time-con
Frequencydoublingperimetry
9094%79* 9196%79* Rapid
Relativel
Disc and nervefiber layerexamination
Cupdisc ratio of0.55 cut off:
Best perflamp bio60, 78 or
Direct opreasonab
Inter-obs
disc exammethodsphotogra
59%10 73%10
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Methods to identify eyes at risk of angle closure includepth as well as anterior chamber depth/axial length
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and specificity of these techniques do not make themscreening.
Other easier techniques include the flash light test anIn the flash light test a light is shone from the tempocornea, parallel with but anterior to the iris. A shadoidentifies an eye with a shallow anterior chamber, atsensitivity of the flash light test is 8086% and specif
The van Herick test uses a slit beam to compare the pchamber depth with the thickness of the cornea. Thespecificity of the test is 61.9% and 89.3%, respectivetest in decimals yields similar results.16
The flashlight and van Herick tests are also inapprop
their own.
If the van Herick test is positive AND the IOP is raisedimproves to 99.3%. This is high enough actually to trhaving angle closure.
Population-based screening
This is not recommended as a strategy. Population-baespecially inappropriate for developing countries witinfrastructure. Adequate infrastructure here implies texpertise (trained ophthalmologists), time and instruto confirm the diagnosis among test positives in an aIt also means the availability of expertise (trained sur
instrumentation to treat appropriately those in whomconfirmed. The operative word is appropriate and preferred practice. The requirements for diagnosis ancovered in the relevant sections.
Recommend-ations
Test Ideal AcceptableLess than
ideal
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Tonometry Applanationtonometry
Tonopen Pneumo-tonometeror Schitztonometer
Dilatedevaluation ofthe optic disc
Dilatedstereoscopicevaluation by
slit lamp bio-microscopy,fundusphotography
Directophthalmo-scope
Slit lampbiomicroscopyand van Hericktest
NA NA NA The flaHerick tappropangle c
A positHerick tconfirm
If the flnegativiris on tpupil co
AND thnegativchambe1/4 thicperipheoccludaunlikelygonioscof rulin
angle m
Gonioscopy Indentationgonioscopyusing a Sussman
Goldmannsingle or twomirror with
Mandaglaucom
f h
Asia Pacific Glaucoma Guidelines
Currently, the optimal method for detection of indivis periodic routine comprehensive eye examinations.
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depends on the current state of the healthcare systemcountry. In lieu of the ideal, case detection should be
Definitions
The predictive value of a test is dependent on the prin the population being tested. As shown in Figure 1factors remain constant, the positive predictive value
with increasing prevalence.
Figure 1: Positive predictive value (PPV)
Screening Population-based detection of g
Case detection(opportunisticscreening)
Active detection of glaucoma wclinics and hospitals for other pu
Prevalence The proportion of patients with(glaucoma) in the population te
Sensitivity The ability of a test to correctly
have glaucoma (true positives)
Specificity The ability of a test to correctly do not have glaucoma (true neg
Positivepredictive value
The proportion of patients withwho actually have glaucoma
Negativepredictive value
The proportion of patients withwho do not have glaucoma
With a low prevalence of glaucoma, most of those whofact be false positives.
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In order to increase the effectiveness of all tests, the prglaucoma in the population to be tested must be reasoprevalence of glaucoma can be increased by targetingsuch as the elderly, persons with family history of glauchypermetropes (angle closure) and myopes (open angl
References:
1. Wilson JMG, Jungner F. Principles and practice of screening foWHO, 1968, Public Health Papers No 34.
2. Sackett DL, Haynes RB, Guyatt GH, et al. Early diagnosis. In: CA basic science for clinical medicine, 1991, pp.153170. Boston
3. Sackett DL, Haynes RB, Guyatt GH, et al. The Clinical ExaminaEpidemiology: A basic science for clinical medicine, 1991, pp.1Brown and Co.
4. Stamper RL. Glaucoma Screening.J Glaucoma 1998;7:149150
5. Tielsch JM, Katz J, Singh K, et al. A population-based evaluatiscreening: the Baltimore Eye Survey.Am J Epidemiol1991;134
6. Katz J, Sommer A, Gaasterland DE, et al. Comparison of analy
detecting glaucomatous visual field loss.Arch Ophthalmol197. Quigley HA. Identification of glaucomarelated visual field ab
screening protocol of frequency doubling technology.Am J O1998;125:819829.
8. Patel SC, Friedman DS, Varadkar P, et al. Algorithm for interpFrequency Doubling Perimeter.Am J Ophthalmol2000;129:32
9. Thomas R, Bhat S, Muliyil JP, et al. Frequency doubling perimeJ Glaucoma 2002;11(1):4650.
10. Quigley HA, Katz J, Derick RJ, et al. An evaluation of optic disexaminations in monitoring progression of early glaucoma da1992; 99:1928.
11 Tielsch JM Sommer A Witt K et al Blindness and visual impa
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Appendices
Appendix 1: How to test calibration oftonometer
1. Set the tonometer in position on its slit lamp stand, with its Pe
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place and the tension on the circular dial on its right side (from
the slit lamp) set at 5 mmHg. The head should lean slightly for
examiner).
2. Slowly twirl the circular dial counter-
clockwise until the head rocks back towards
you. The tension should read 02 mmHg
below zero (Figure A).
3. Slowly twirl the dial clockwise until the head
rocks forwards again. The tension should
read 02 mmHg (Figure B).Figur
4. Remove the calibration rod from its box.
Firmly screw into position the holding
bracket that slides along the rod so that the
closest mark in front of the center one (i.e.,on the other side of the center from you) is
aligned as exactly as you can (Figure C).
5. Slip the rod and its holder into the
receptacle on the right side of the
tonometer. The head will rock backwards towards you.
6. Slowly twirl the circular dial clockwise until the head rocks for
reading on the dial: it should be 2023 mmHg.
7. Slowly twirl the circular dial counter-clockwise until the head
tension on the dial should read 1720 mmHg.
8. Remove the rod and holding bracket from
the tonometer and reposition the bracket so
that it is aligned exactly with the most
forward mark on the rod furthest away
from you (Figure D).
9. Replace the rod in its bracket in the
tonometer receptacle. The tonometer head
Appendix 2: Tonometry mires
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(Courtesy of Ivan Goldberg, Australia)
Excess corneal applanation (IOP lower than tonom
(Courtesy of Ivan Goldberg, Australia) (Courtesy of Ivan
Insufficient corneal applanation (IOP higher than to
Appendix 3a: Gonioscopy
Gonioscopy
Bi i i i ti f th t i h b
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Biomicroscopic examination of the anterior chambe Essential for glaucoma diagnosis, treatment and pr
Methods
Gonioscopic contact lens permits the angle to be seen.
1. Direct gonioscopy
Place the Koeppe goniolens on an anesthetizedpatient supine. Fill the space between the lens a
a contact fluid (e.g., saline or methylcellulose). V
a handheld biomicroscope and an illuminator.
2. Indirect gonioscopy
At the slit lamp, place a mirrored lens (e.g., Gold
four-mirror indentation) on the cornea.
Indentation (pressure/dynamic) gonioscopy
With a four-mirror indirect contact lens press on the co
fluid into the angle to expose anatomic landmarks and
presence of peripheral anterior synechiae.
Appendix 3b: Goniogram/gonioscopic
Grading system for gonioscopic findings (without inden
i k h d l hi k i
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A. van Herick method uses corneal thickness as a unit
Grade 0 Iridocorneal contact
Grade I Peripheral anterior chamber depth betwendothelium is less than 1/4 corneal thick
Grade II Greater than 1/4 but less than 1/2 of cor
Grade III Greater than or equal to 1/2 of corneal t(non-occludable)
Grade 0 I II
1. Shaffer closed 10 20
2. Modified Schwalbes Schwalbes Anterior TMShaffer line is line is is visiblenot visible visible
B.
C. Spaeth
1. Iris insertion
Anterior to Schwalbes line or TMBehind Schwalbes line
Centered at scleral spur
Deep to scleral spur
Extremely deep/on ciliary band
2. Angular width
slit10
20
30
Appendix 3c: Corneal wedge diagram
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Appendix 4: How to optimize patient pin subjective perimetry
1 Choose the most appropriate investigation
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1. Choose the most appropriate investigation Test pattern 242: early/moderate damage and gla
advanced damage or paracentral scotomas.
Test strategy e.g., SITA (Humphrey field analyzer): suspects.
2. Patient set-up at the perimeter
Use near lens power based on current refraction. Support the patients feet comfortably so that the th
Support the patients back.
Adjust chin rest height so the forehead touches its h
Cover other eye fully some patients prefer it open
Support the arms so shoulders and neck do not tire.
3. Instructions to the patient before starting the test We are getting you to do this test to give us inform
how full and perfect your vision is, or if it isnt, we wthe damage is, and what sort of damage it is.
The test is not difficult, but to get the best informaneeds to be done in a particular way.
The key to success is to look straight ahead all the
want them to look.) Let the light come to you don You wont see the light a good deal of the time, so
seems to be passing without a light appearing. The light very dim so that it can tell when you can just se
Press the button when you think you see the light.count they can be fuzzy, dim, bright, it doesnt ma
Blink whenever you need to, but do so when you pwill stop your eyes drying out and hurting, and you
Hold the button down when you want to rest. Thamachine. Release the button when you want to contcan rest as often as you like. Youre the one controll
Lets have a practice run now so you can get a feel
Appendix 5: Secondary glaucomas prmanagement
Strategy An example fo
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Strategy An example fomanagement
Diagnose the underlying cause(s) Diagnose uveit
Treat the underlying cause(s) Anti-infla
Identify the mechanism(s) Posterior synechi
Treat the mechanism(s) Laser periphthey may change over the
course of the disease
Medical therapy first-line -blockersagents are aqueous Carbonic anhy
inflow inhibitors
Appendix 6: Angle closure mechanisms
Site one: pupil block iris bomb appearance
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(Courtesy of Paul Chew, Singapore)
Site two: anteriorly rotated ciliary processes tha
forward and/or thick peripheral iris plateau ir
Site three: lens induced forward displacement
volcano configuration
(Courtesy of Paul Chew, Singapore)
Appendix 7a: Argon laser trabeculopla
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About 100 equally spaced laser spots (diameter 50 micr
seconds are applied over 360 degrees of trabecular me
t i f 180 d t d b 1 2 k Id
Copyright 20032004 SEAGIG
Appendix 7b: Contact transscleral diod
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Appendix 8: Glaucomatous optic neuro
Moderate g
optic neurop
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p p Localized lo
and superio
A classic inf
arrows)
Nerve fiber
superior andarea (large
Advanced gloptic neurop
Neuroretina
The cup exte
Circumlinea
baring
Bayoneting Peripapillary
Nerve fiber l
(Courtesy of Prin RojanaPongpun, Thailand)
(Courtesy of Prin RojanaPongpun, Thailand)
Appendix 9: Field progression print-ou
New scotoma
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Deepening and enlarging scotoma
(Courtesy of Prin RojanaPongpun, Thailand)
Suggested Areas for Further Research
Prevalence and incidence of primary open angle glauco
angle closure glaucoma in Asia Pacific
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Natural history of glaucoma in Asia Pacific
Natural history of angle closure
Risk factors ranking risk factors among Asians accord
Normal values of central corneal thickness and optic diAsian countries
Applicability of ISNT Rule in Asian eyes
Target pressure reduction evidence on extent of redu
Clinical classification of angle closure glaucoma based u
outcomes
Clarification of mechanisms responsible for angle closu
Structural and functional change pattern, rate and extglaucoma versus open angle glaucoma
Randomized, controlled trials of all aspects of managem
closure particularly roles of laser iridotomy, laser iridoextraction and filtering surgery
Treatment outcomes in angle closure glaucoma versus glaucoma medical, laser and surgery
Efficacy of screening and prophylaxis of angle closure
Cost-efficient glaucoma screening program
Definition of Terms
Angle neovascularization New vessel formatio
surface of angle str
without formation
b
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membrane.
Anterior ischemic optic Optic nerve head is
neuropathy (AION) from disturbance in
ciliary artery circula
Aqueous misdirection syndrome Misdirection of aqu
vitreous resulting fr
abnormality at the
zonule/anterior vitr
processes.
Cupdisc ratio (CDR) The fractional decim
dividing the cup dia
diameter. The closethe worse the dama
Glaucomatous optic Characteristic patte
neuropathy (GON) optic nerve head ca
Glaucoma suspect disc (GSD) Optic nerve head ap
suggestive of glauco
Neovascular glaucoma (NVG) Glaucoma resulting
fibrovascular memb
angle in response to
Normal pressure glaucoma (NPG) Characteristic glauc
neuropathy in the p
statistically normal
Occludable angle Clinical term for an
gonioscopically ope
enough to be consi
Pigment dispersion Abnormal scatterin
syndrome (PDS) into the anterior se
Plateau iris configuration An occludable anglepupil block.
Definition of Terms
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p p
Plateau iris syndrome Angle closure in the
iridectomy.
Posner-Schlossman Syndrome Episodic anterior uv
trabeculitis with sec
of IOP.
Primary angle closure An eye in which app
suspect (PACS) between the periph
posterior trabecular
present or consider
Epidemiologically, t
defined as an angle
degrees of the post
meshwork cannot b
gonioscopically.
Primary angle closure (PAC) PACS with either sta
and/or peripheral a
Primary angle closure PAC with glaucomaglaucoma (PACG) neuropathy.
Primary open angle Chronic progressive
glaucoma (POAG) with characteristic c
nerve head and/or v
absence of seconda
Primary open angle Significant risk factoglaucoma suspect (e.g., ocular hyperte
history) and/or glau
in the absence of fr
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P
Perimetryautomated, 22frequency doubling, 23, 71
how to optimize patient performance,Appendix 4i i bl f
Surgery, 51penetrating filnon-penetratinuse of anti-fibr
Slit lampexamination, 1minimum acce
Index
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minimum acceptab