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Panel: Do not base decision to initiate glaucoma treatment on one IOP reading
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NEW YORK — A panel of clinicians at Vision Expo East debated the finer points of glaucoma diagnosis and management but agreed that more than just one intraocular pressure measurement must be taken before starting treatment. "Should you ever start treatment the first day?" Murray Fingeret, OD, FAAO, asked the panel here at this continuing education session. "The IOP can vary, and you don't know if that 29 mm Hg is high, low or the midpoint. "You need to get two or three IOP measurements over the next few days," he continued. "That's not as much for me to make the diagnosis as it is for me to know if any therapy we start is working out."
Eye rubbing, necktie wear, head position, fluid intake and other medications can also make IOP higher or lower, panelist Leo P. Semes, OD, FAAO, said. "Your patient may smoke marijuana and not admit it to you," he said.
You never know if a single reading is an aberration, Dr. Semes added. "Consider charting a diurnal IOP pattern to see variability from visit to visit."
"A diagnosis of glaucoma cannot be made on an IOP measurement, because glaucoma is an optic neuropathy," panelist Richard J. Madonna, OD, MA, FAAO, said. "You have to show damage to the optic nerve to call it glaucoma."
"Do you even use IOP in any context of making the diagnosis of glaucoma?" Dr. Fingeret asked.
He presented an example: A patient has pressures of 29 mm Hg in one eye and 25 mm Hg in the other. The optic nerves are damaged and there is field loss. "Can you start treatment that day?" Dr. Fingeret said.
"I tell my students you have to separate the diagnosis of the disease from when you're going to start treatment for the disease," Dr. Madonna said. "You may be able to make the diagnosis that day, but I wouldn't start treatment that day because I want to know whether or not I'm catching the pressure at its peak."
"Say you get a pressure of 25 mm Hg and the nerves and fields look good," Dr. Fingeret said. "Is the patient an ocular hypertensive based on one visit? If you diagnose them with glaucoma, they'll have that stigma forever. It could be an induced elevated IOP from an outside influence."
Dr. Semes said, "Assuring ourselves of the diagnosis of ocular hypertension is the first step; the second step is to gather information to calculate a risk for converting from ocular hypertension to glaucoma. You get additional IOP information, additional clinical findings and develop a risk profile for the patient."