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Test for structural loss in glaucoma suspects
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NEW YORK – The topics of structure vs. function, “to treat or not to treat” and the use of technology for early detection were explored in two glaucoma presentations at the Fifth Annual PRIMARY CARE OPTOMETRY NEWS symposium here Friday.
Speakers Ben Gaddie, OD; Leo P. Semes, OD, FAAO; and Jerome Sherman, OD, FAAO, discussed risk factor analysis, the implementation of new technology and treatment strategies.
“When we evaluate new technologies, we have to look at the benefits of those technologies in detecting early structural and early functional changes,” Dr. Semes said. “The goal is to detect the earliest possible change and implement treatment.”
Dr. Semes said contemporary reports suggest the existence of significant structural damage prior to the manifestation of functional damage. He cited the Ocular Hypertension Treatment Study (OHTS) findings in which the majority of ocular hypertension patients converted to glaucoma on the basis of disc damage. “If we wait until the patient shows structural and functional damage, we may miss patients,” he said.
Dr. Semes emphasized the value of digital technology in glaucoma detection. “It’s like having expert advice, an expert opinion,” he said.
He also discussed the Glaucoma Risk Calculator (GRC), which assesses factors such as age, diabetes status, central corneal thickness, vertical cup:disc and intraocular pressure. “We can use this as the basis for a treatment option,” he said.
Regarding visual field testing, Dr. Semes said the practitioner should be mindful of the need to repeat these tests. “Your mantra should be ‘repeat visual fields,” he said. “You want to be sure a visual field effect is not a one-time event. The technology needs to be consistent.”
Dr. Sherman said retinal nerve fiber layer loss is arguably the one symptom all glaucoma patients share. “All glaucoma patients should have retinal nerve fiber layer loss,” he said.
Regarding the structure vs. function debate, Dr. Sherman said both are crucial. “The great debate is a myth,” he said. “We need both structure and function to make an early diagnosis. We need to look at whether the findings match. We’re looking for concordance.”
Dr. Gaddie stressed the importance of central corneal thickness (CCT) in treating glaucoma, but urged practitioners not to correct intraocular pressure based on CCT.
In discussing contemporary treatment options, the speakers covered beta-blockers, alpha-2 agonists and topical carbonic anhydrase inhibitors (CAIs). The advantages of monotherapy and combination therapy were also discussed. “To me, a more contemporary approach to monotherapy is prostaglandin analogs,” Dr. Semes said.
The importance of measuring IOP at all time points was also emphasized. “What happens to IOP over the course of a day?” Dr. Semes said. “More than 25% of patients have their peak IOPs measured at midnight. We tend to miss that peak IOP.”