Glaucoma: one step forward?
Audrey Kaplan-Messas
Director of glaucoma Unit
Assaf Harofe Medical Center
What have we learnt in 10
years? (hebrew?)
How does it impact our practice?
Glaucoma/ IOP?
Out of the definition but…
Target IOP ?
Appears 10 years ago,PPAAO
% of baseline, or absolute value
Target IOP=
[baseline IOP x (1- baseline IOP/ 100)- Z-Y]
Z= VF index 1-3, Y= QOL index 1-3
Jampel 1997
Individual Target Pressure
B
Ganglion
cell
loss
Patient B
Treatment gain
Patient A
A
No gain
0
10
IOP
Treated
30
20
Untreated IOP
IOP
40
50
Target IOP = Max Acceptable
Lower is Better
Higher
Target
IOP
Early
Short
High
Damage
Life
Expectancy
IOP at Which
Damage
Occurred
Long
Low
Advanced
Lower
Target
IOP
The above factors need to be considered as a whole in
deciding the individual target pressure required
© E.G.S
Lower is Better For Every Optic Nerve
45
Decrease
40
20%
25%
30%
40%
35
30
25
Target IOP
21 mm Hg
20
15
Target pressure
according to risk
10
5
Target IOP range
0
0
5
10
15
20
25
30
35
Initial IOP
When Damage Occurred
OHTS 20%
EMGT 25%
NTG
30%
CIGTS > 35%
40
45
Diurnal Variations:
Relative risk* of disease progression/5 years
6
5.76
5
4
relative risk
3
2
1
0
1.00
diurnal IOP range diurnal IOP range
5.4 mm Hg
3.1 mm Hg
* ratio between the incidence of a disease among individuals
with a given risk factor to the incidence among those without it
Asrani S, et al. J Glaucoma. 2000;9:134-142
Nothing to do with cornea?
Not anymore…
Central corneal thickness
as a risk factor for conversion and progression
baseline IOP (mmHg)
>25.75
36%
13%
6%
>23.75 to < 25.75
12%
10%
7%
< 23.75
17%
9%
< 555 >555 to < 588
2%
>588
central corneal thickness (microns)
Gordon et al, Arch Ophthalmol, 2002
* through 8 Nov 2001
Significant baseline predictive factors
from multivariate proportional hazard models
age (decade)
1.22 (1.01, 1.49)
diabetes mellitus
0.37 (0.15, 0.90)
IOP (per mmHg)
1.10 (1.04, 1.17)
CCT (per 40 µM decrease)
1.71 (1.40, 2.09)
PSD (per 0.2 dB increase)
1.27 (1.06, 1.52)
horizontal C/D ratio (per 0.1 increase)
1.27 (1.14, 1.40)
1.32 (1.19, 1.47)
vertical C/D ratio (per 0.1 increase)
0.0
Kass et al, Arch Ophthalmol, 2002
1.0
2.0
3.0
4.0
5.0
hazard ratio (95% CI)
Normal Tension Glaucoma
How many do we still miss?
Many glaucoma patients
have IOP <22 mm Hg
80
71
60
number
of POAG 40
patients
33
20
0
IOP >21 mm Hg
Beaver Dam Eye Study (N = 4926)
IOP <22 mm Hg
Klein et al, 1992
I think it’s glaucoma and the
VF is normal?
Pre-perimetric glaucoma
Disc shows rim thinning and verticalisation
of cup
Sita Standard 24-2 is Normal
Pre-perimetric glaucoma
Normal Visual FieldOCT
Glaucoma treatment
a big step forward…
from Bb-, diamox and Pilo
What is Rx achieving ?
with disease
progression
medications
Risk of VFL
laser techniques
surgical approaches
age
genetics
BP
non-IOP factors
diabetes
sleep apnea
IOP
lipids
vasospasm
Goal of Antiglaucoma Rx
Preserve visual function
Insure acceptable Quality of Life
Strategy: to find the right pathway between
efficacy and side effects of Rx
Introducing …
new anti-glaucoma agents
1870s
1920s
1950s
miotics topical systemic CAIs
adrenergics
1970s
BBs
1990s 2000s
PGs
topical CAIs
a-2 agonists
Combinations
Compliance / Non-Compliance
Compliance:
“The extent to which the patient’s behaviour (drugs,
diets, life-style changes) coincides with the clinical
prescription.”
Sackett D, 1976
Non-Compliance:
“The intentional or accidental failure to comply with
a physician’s express or implied directions in the
self-administration of any treatment.”
Boyd JR et al, 1974
Laser Trabeculoplasty
we can do it more!
Human TM: ALT 50 microns spot
SLT 400microns spot
SLT in the glaucoma
armamentarium
Still waiting for the big step
forward in surgery?
CIGTS
Medical management and surgery both lower IOP
IOP (mm Hg)
30
medicine
surgery
26
22
18
14
10
0
12
24
36
time (months)
48
60
Lichter et al, 2001
Larger area of MMC exposure
Trabeculectomy +MMC + RS
Pre-operative IOP 26 mmHg on
MTM.
Day 1: IOP 17 mmHg
Where does the aqueous go?
Tube
Lens extraction in PAC
Pre-Phaco/IOL
Post-Phaco/IOL
In conclusion, 10 years later
Realisation that the glaucomas Are different in their causation
Probably channel into a final common intracellular pathway of destruction
Have a complex relationship with IOP
Treat glaucoma or
…reduce the IOP
IOP reduction is up to date THE approach
to slow down GON
We have new diagnosis too;ls, new
definitions, new drugs, new lasers, new
surgeries
And we can look after our patients’ ON in
respect of their QOL
Thank you