Fine Tuning Glaucoma
Diagnosis and
Management in Haiti
Daniel Laroche MD
Director of Glaucoma, St Lukes-Roosevelt Hospital, NY
President, Advanced Eyecare of New York
Assistant Clinical Professor Ophthalmology
New York Eye and Ear Infirmary
New 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 invitation
and 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. Dic
Rachel Aglae Amedee
Rachel Gauthier
Nathalie Francois
Reginald Rejouis
Myriam Beliard
Marie Dieumane Chaperon
Milon 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 glaucoma
Traumatic 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.
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
Hans Goldmann
Goldmann equation3
P0 = (F/C) + Pv
P0: IOP (mmHg)
F: rate of aqueous formation (µL/min)
Goldmann Applanation Tonometry
C: facility of outflow (µL/min/mmHg)
Reprinted with permission from AgingEye Times.
Pv: episcleral venous pressure (mmHg)
R: resistance to outflow; is the inverse of C and may replace
C in rearrangements of the Goldmann equation
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.
14
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
Optic Disc Size
•
•
Size of cup varies with size of optic disc
Large optic discs have large cups in healthy eyes
1.4
2.4
1.9
Small
 Identify
•
•
Average
Large
small and large optic discs
Small discs: avg vertical diameter < 1.5 mm
Large discs: avg vertical diameter > 2.2 mm
Look at the Neuroreintal rim:
ISNT Rule
Rim
width:
Distance between
border of disc and
position of blood
vessel bending
rule:
Inferior >
Superior >
Nasal >
Temporal
S
N
T
ISNT
I
Localized Rim
Thinning/Notching
Notching
Patterns of Glaucomatous Progression
Normal optic disc
(left eye)
First glaucomatous
optic disc change
Type of progression
of disc abnormality
22%
Disc cup enlargement
Diffuse enlargement:
round-shaped
56%
Disc cup enlargement
with local notching
Diffuse enlargement:
vertically oval
9%
Local notch
Broader local notch
13%
Pale neuroretinal rim;
no change of configuration
Adapted from Tuulonen and Airaksinen. Am J Ophthalmol. 1991.
Pale rim; no change
of configuration
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?
Mean change in visual defect score
AGIS 7
Sustained IOP reduction below 18 mmHg is
correlated with stability of visual field
5
Percent of Visits with IOP Less Than 18 mmHg
4
100% of visits
3
75 - 99% of visits
MEAN IOP
20.2 mmHg
2
50 - 74% of visits
0 - 49% of visits
16.9 mmHg
14.7 mmHg
1
0
-1
12.3 mmHg
0
1
2
3
4
Follow-up (years)
AGIS Investigators, 2000, Am. J. Ophthalmol., 130, 429-440
5
6
7
8
Medical Management vs Surgery
Both Stabilize Visual Fields
Collaborative Initial Glaucoma Treatment Study (CIGTS)
8
Medicine
Surgery
7
6
35%vs
48%
IOP lowering
5
4
3
2
1
0
0
6
12
18
24
30
36
42
Time in Months
Lichter et al, Ophthalmology, 2001 Nov: 108 (11) 1943-53
48
54
60
1- (reference IOP + VF score)/100 x
Reference IOP =40% reduction
Ensuring Compliance With
Antiglaucoma Treatment

Communication





More than 40% of pts being
treated with glaucoma do not
realize it can lead to blindness
GRF 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 meds
Patel, 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 pts
cannot obtain medications.
Dr. Eugene to perform Ahmed
valve with corneal patch with
resident watching
Haitian Ophthalmology 2nd year Ophthalmology
Residents performing trabeculectomy
Glaucoma Surgery




3 Ahmed valves performed
13 Trabeculectomies
3 pediatric examination under anesthesia
2 Trabeculotomy/Trabeculectomy
st
1
nd
2
year residents watching
year ophthalmology Residents
performing glaucoma surgery
Congenital
glaucoma
with trabeculotomy
under general
Anesthesia at the
University Hospital
Main Operating Room
Able to be performed
Still a great need for sutures, instruments,
Glaucoma valves and patches, and medications
Special thanks to New World Medical, Alabama Eye
Bank, 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