Glaucoma Care Project Team Members: Geoffrey T. Emerick, M.D. Erin Herlihy, B.S. Marilyn Hauser, M.B.A. Dianna Greening, R.N. Walter M. Jay, M.D Opportunity or Problem Statement: To standardize the initial treatment of chronic open angle glaucoma and ocular hypertension.

Goals Attempt to maintain IOP at or below this target level by initiating appropriate therapeutic intervention(s). Monitor the status of the optic nerve for further damage. Minimize the side effects of management and their impact on the patient’s vision, general health, and quality of life. Minimize the financial impact of treatment on the patient.

Goals Document the status of optic nerve structure (disc photos and drawings) and function (visual fields) on presentation. Estimate a pressure below which further optic nerve damage is unlikely to occur (target pressure).

Background Primary open-angle glaucoma (POAG) is a major health problem. Glaucoma is the second most common cause of blindness in the US and the leading cause of blindness among African Americans. 2.5 million Americans have POAG; half of them may be unaware that they have the disease. About 130,000 Americans are blind from glaucoma and any others are visually handicapped.

Background In the US, more than 7 million office visits occur per year for the primary purpose of monitoring patients with glaucoma and patients at risk for developing glaucoma. The magnitude of the problem will increase as the American population ages.

Most Likely Causes Identified Through Data Individual physicians use differing, nonstandardized management strategies. Critical elements of the clinical history, physical examination, and ancillary studies may not be completed. A target pressure may not be identified, and subsequent care not focused on achieving this target pressure, as well as detecting clinical progression.

Solutions Implemented A Glaucoma Care Flowsheet was implemented on 4/22/02. A flowsheet is initiated for all patients with newly diagnosed glaucoma or ocular hypertension and their clinical course monitored. In addition, we have undertaken a retrospective review of patients diagnosed before the care management guidelines were initiated to measure the effect of implementation.

Measured elements- History Review of family, ocular, and systemic history Review of pertinent records, esp. status of optic nerve, visual field, and IOP Use of ocular and systemic medications Ocular surgery Known local or systemic intolerance to the use of glaucoma medications Time of last use of glaucoma medications Severity and outcome of glaucoma in family members Assessment of the impact of visual function on daily activities.

Measured Elements- Physical Examination Pupils Slit-lamp examination Intraocular pressure with time of day recorded Corneal pachymetry Gonioscopy Examination of optic nerve head and retinal nerve fiber layer (magnified stereoscopic visualization through a dilated pupil Color stereo photographs of the optic nerve Detailed drawing of the optic nerve Examination of the fundus through a dilated pupil Visual field evaluation (via automated static threshold perimetry)

Measured Elements- Treatment Establishment of a target pressure (i.e. upper limit of a range of intraocular pressures deemed likely to slow or stop further optic nerve damage) Initial target pressure should be at least 20-30% lower than the pretreatment range. Topical ocular hypotensive treatment should be performed by monocular trial. Effectiveness of treatment in reaching and maintaining target pressure over a 1 year period.

Methods 100 charts of patients carrying the diagnosis of primary open-angle glaucoma or POAG (ICD-9 code ) seen in the ophthalmology clinic in the years 2000 and 2001 were reviewed. 12 met the criteria of newly diagnosed POAG. Since implementation of the care management protocol, 35 patients newly diagnosed with POAG have been identified. 5 patients with ocular hypertension or glaucoma suspects are not included in the analysis.

Data chosen for initial analysis Documentation of family history of glaucoma Gonioscopy Examination of the fundus through a dilated pupil Color stereo photographs of the optic nerve. Other data will continue to be collected and will be analyzed once data collection is complete.

Results

Recommendations for Further Study and Action A high rate of compliance with assessment of family history and performance of dilated fundus examination is seen in the current group of patients and in historical controls. Compliance with gonioscopy and stereo fundus photos has been low, but has improved in the past three months.

Recommendations for Further Study and Action Results have been shared with faculty, residents, and clinical staff in a Grand Rounds format to enhance understanding of and compliance with the management protocol. Compliance with the protocol will be followed in monthly meetings and in quarterly reports. We will examine compliance with other elements of the care standards as well.