1. OPEN ANGLE GLAUCOMA Frank J. Weinstock, MD, FACS Professor of Ophthalmology- NEOUCOM Canton, Ohio USA

2. TYPES OF GLAUCOMA PRIMARY CHRONIC SIMPLE OPEN ANGLE PRIMARY CHRONIC SIMPLE OPEN ANGLE ANGLE CLOSURE- NARROW ANGLE ANGLE CLOSURE- NARROW ANGLE SECONDARY SECONDARY TRAUMATIC TRAUMATIC

3. PRIMARY CHRONIC SIMPLE OPEN ANGLE GLAUCOMA SERIES OF CONDITIONS SERIES OF CONDITIONS OPTIC NERVE AND VISUAL FIELD LOSS SECONDARY TO ELEVATED INTRAOCULAR PRESSURE OR POOR NUTRITION TO OPTIC NERVE OPTIC NERVE AND VISUAL FIELD LOSS SECONDARY TO ELEVATED INTRAOCULAR PRESSURE OR POOR NUTRITION TO OPTIC NERVE ETIOLOGY- NOT TRULY KNOWN ETIOLOGY- NOT TRULY KNOWN

4. VARIANTS TRAUMATIC TRAUMATIC SECONDARY SECONDARY LOW TENSION LOW TENSION

5. OPEN ANGLE GLAUCOMA US- 2.2 MILLION (3.4 MILLION BY 2020) US- 2.2 MILLION (3.4 MILLION BY 2020) 175000 IN US BLIND (10% OF BLINDNESS) 175000 IN US BLIND (10% OF BLINDNESS) BLACKS-HISPANICS (30% OF BLINDNESS) BLACKS-HISPANICS (30% OF BLINDNESS) 1 IN 1000 OVER 40 YR OLD- BLIND 1 IN 1000 OVER 40 YR OLD- BLIND OVER 75 YEARS- 2.7/1000 BLIND (6.7/1000 VISUALLY IMPAIRED) OVER 75 YEARS- 2.7/1000 BLIND (6.7/1000 VISUALLY IMPAIRED)

6. SOPHISTICATED OFFICE EQUIPMENT

7. AUTOMATIC PERIMETER (VISUAL FIELD TESTING)

8. COMPLIANCE SCREENING $60/SCREENING AND $1000/CASE DISCOVERED SCREENING $60/SCREENING AND $1000/CASE DISCOVERED (SCREEN HIGH RISK-RELATIVES-AFRICAN AMERICANS-HISPANICS-) (SCREEN HIGH RISK-RELATIVES-AFRICAN AMERICANS-HISPANICS-) 25-40% OF PTS. TAKING Rx TO STORE- DON’T PICK IT UP 25-40% OF PTS. TAKING Rx TO STORE- DON’T PICK IT UP 60% PICKING UP Rx D/C XALATAN DURING YR AND 76% WITH OTHER MEDS 60% PICKING UP Rx D/C XALATAN DURING YR AND 76% WITH OTHER MEDS

9. DIAGNOSIS OPTIC NERVE FIBER EVALUATION (OPHTHALMOCSCOPE) OPTIC NERVE FIBER EVALUATION (OPHTHALMOCSCOPE) VISUAL FIELD EVALUATION- OFFICE VISUAL FIELD EVALUATION- OFFICE OPTIC NERVE IMAGING AND ANALYSIS- OFFICE OPTIC NERVE IMAGING AND ANALYSIS- OFFICE MEASUREMENT OF INTRAOCULAR PRESSURE (PORTABLE) MEASUREMENT OF INTRAOCULAR PRESSURE (PORTABLE) MEASUREMENT OF CORNEAL THICKNESS MEASUREMENT OF CORNEAL THICKNESS GENETIC PREDISPOSITION ???? GENETIC PREDISPOSITION ????

10. SCREENING OPTIC NERVE EVALUATION- OPHTHALMOLOSCOPE OPTIC NERVE EVALUATION- OPHTHALMOLOSCOPE INTRAOCULAR PRESSURE (IOP) MEASUREMENT- APPLANATION TYPE TONOMETER INTRAOCULAR PRESSURE (IOP) MEASUREMENT- APPLANATION TYPE TONOMETER IOP HAS DIURNAL VARIATION IOP HAS DIURNAL VARIATION

11. GOALS OF SCREENING EDUCATION EDUCATION DETECTION OF GLAUCOMA (NOT PROVEN) DETECTION OF GLAUCOMA (NOT PROVEN) TESTS NOT SPECIFIC OR SENSITIVE TESTS NOT SPECIFIC OR SENSITIVE SCREENING- NO VALUE IF: SCREENING- NO VALUE IF: NOT ABLE TO REFER FOR DEFINITIVE DIAGNOSIS, TREATMENT AND FOLLOWUP

12. SCREENING CHOOSE HIGH RISK GROUPS E.G. HISPANICS, BLACKS (OVER AGE 40, WHITES (OVER 65 YEARS OLD), HISTORY OF EYE TRAUMA; DIABETICS; CHOOSE HIGH RISK GROUPS E.G. HISPANICS, BLACKS (OVER AGE 40, WHITES (OVER 65 YEARS OLD), HISTORY OF EYE TRAUMA; DIABETICS; FAMILY HISTORY OF GLAUCOMA FAMILY HISTORY OF GLAUCOMA DIABETICS DIABETICS PATIENTS WITH SEVERE MYOPIA PATIENTS WITH SEVERE MYOPIA

13. INTRAOCULAR PRESSURE VERY EASY TO DO- PORTABLE INSTRUMENTS VERY EASY TO DO- PORTABLE INSTRUMENTS POOR SENSITIVITY AND SPECIFICITY POOR SENSITIVITY AND SPECIFICITY NORMAL- 20 mmHg OR LESS NORMAL- 20 mmHg OR LESS MEASURED BY: APPLANATION TONOMETER- NOT PRACTICAL MEASURED BY: APPLANATION TONOMETER- NOT PRACTICAL FINGER PALPATION- INACCURATE FINGER PALPATION- INACCURATE APPLANATION TONOMETRY

14. SCHIOTZ TONOMETER ADVANTAGES:INEXPENSIVEPORTABLE EASY TO USE READILY AVAILABLE DISADVANTAGES: NOT THE MOST ACCURATE REQUIRES TOPICAL ANESTHETIC

15. OPHTHALMOSCOPY EASY; QUICK EASY; QUICK REQUIRES OPHTHALMOSCOPE- AVAILABLE REQUIRES OPHTHALMOSCOPE- AVAILABLE REQUIRES EXPERT AT OPHTHALMOSCOPY REQUIRES EXPERT AT OPHTHALMOSCOPY PICKS UP DEFINITIVE GLAUCOMA ( A LATE STAGE)- MAY BE TOO LATE TO HAVE MUCH BENEFIT PICKS UP DEFINITIVE GLAUCOMA ( A LATE STAGE)- MAY BE TOO LATE TO HAVE MUCH BENEFIT INTER-OBSERVER VARIABILITY INTER-OBSERVER VARIABILITY NORMAL C:D RATIO- 0.3 OR LESS THAN 0.2 DIFFERENCE NORMAL C:D RATIO- 0.3 OR LESS THAN 0.2 DIFFERENCE (STEREO VIEWS ARE BEST (NOT PRACTICAL) (STEREO VIEWS ARE BEST (NOT PRACTICAL)

16. E-11 Normal and Cupped Disc NORMAL CUPPED DISC ENLARGED CUP

17. PERIPHERAL VISUAL FIELD TESTING PICKS UP LATER GLAUCOMA PICKS UP LATER GLAUCOMA REQUIRES EXPENSIVE EQUIPMENT- DIFFICULT TO PERFORM- NOT PRACTICAL FOR SCREENING REQUIRES EXPENSIVE EQUIPMENT- DIFFICULT TO PERFORM- NOT PRACTICAL FOR SCREENING OPTIC NERVE ANALYSIS- PICKS UP PROBLEMS EARLIER (REQUIRES EXPENSIVE EQUIPMENT AND TECHNNICAL SUPPORT)- NOT PRACTICAL FOR SCREENING OPTIC NERVE ANALYSIS- PICKS UP PROBLEMS EARLIER (REQUIRES EXPENSIVE EQUIPMENT AND TECHNNICAL SUPPORT)- NOT PRACTICAL FOR SCREENING

18. REFERRAL SET CRITERIA FOR EACH SCREENING SET CRITERIA FOR EACH SCREENING E.G PRESSURE OVER 20 MM hG E.G PRESSURE OVER 20 MM hG INDIVIDUALS WITH SUSPICIOUS DISCS (LARGE CUPS) INDIVIDUALS WITH SUSPICIOUS DISCS (LARGE CUPS) OPTIC NERVE- HEMORRHAGES; LARGE CUP:DISC RATIO (OVER 0.4) OR ASYMMETRY OF CUPS (HORIZONTAL AND VERTICAL CUP:DISC RATIO)- 0.3 DIFFERENCE OPTIC NERVE- HEMORRHAGES; LARGE CUP:DISC RATIO (OVER 0.4) OR ASYMMETRY OF CUPS (HORIZONTAL AND VERTICAL CUP:DISC RATIO)- 0.3 DIFFERENCE

19. BEST SCREENING COMPREHENSIVE EYE EXAM IN OFFICE SETTING- BY SPECIALIST COMPREHENSIVE EYE EXAM IN OFFICE SETTING- BY SPECIALIST

20. ADDITIONAL SCREENING BENEFITS POSSIBLY MORE IMPORTANT THAN DIAGNOSING GLAUCOMA POSSIBLY MORE IMPORTANT THAN DIAGNOSING GLAUCOMA EDUCATION OF NEED FOR EYE CARE EDUCATION OF NEED FOR EYE CARE OPHTHALMOSCOPIC EXAM WILL PICK UP: OPHTHALMOSCOPIC EXAM WILL PICK UP: CATARACTS CATARACTS CORNEAL SCARS CORNEAL SCARS RETINAL DISEASE- DIABETES, HYPERTENSION, TUMORS RETINAL DISEASE- DIABETES, HYPERTENSION, TUMORS

21. TREATMENT OF GLAUCOMA MEDICATIONS- MANY NEW MEDICATIONS- POTENTIAL SIDE-EFFECTS MEDICATIONS- MANY NEW MEDICATIONS- POTENTIAL SIDE-EFFECTS ONCE A DAY DOSAGE- BEST COMPLIANCE ONCE A DAY DOSAGE- BEST COMPLIANCE TREAT EARLIER TREAT EARLIER LASER OR SURGERY- EARLIER ????- BEING EVALUATED LASER OR SURGERY- EARLIER ????- BEING EVALUATED WHICH FIRST? – BEING EVALUATED WHICH FIRST? – BEING EVALUATED NEW PROCEDURES NEW PROCEDURES GOAL- < 20mmHg. (LOWER IN MANY SITUATIONS) GOAL- < 20mmHg. (LOWER IN MANY SITUATIONS)

22. SUMMARY GLAUCOMA SCREENING GLAUCOMA SCREENING QUESTIONNABLE BENEFIT FOR PREVENTING BLINDNESS QUESTIONNABLE BENEFIT FOR PREVENTING BLINDNESS WILL PICK UP A NUMBER OF CASES GLAUCOMA AND OTHER EYE CONDITIONS WILL PICK UP A NUMBER OF CASES GLAUCOMA AND OTHER EYE CONDITIONS CONCENTRATE ON HIGH-RISK GROUPS CONCENTRATE ON HIGH-RISK GROUPS EASY TO DO EASY TO DO MARKED EDUCATIONAL AND PUBLIC RELATIONS BENEFIT MARKED EDUCATIONAL AND PUBLIC RELATIONS BENEFIT