Leading-Edge Glaucoma Management

Chicago-Participants in a Friday evening CME Symposium at The Fairmount Chicago received an update on factors that influence early diagnosis and detection of progression and therefore are crucial to effective patient management. Moderator Robert N. Weinreb, MD, University of California, San Diego, and other speakers discussed recent advances in optic nerve evaluation and the impact of central corneal thickness (CCT) and other factors on IOP measurement.

“CCT is quite a powerful tool in predicting who is at highest risk of progression through all stages of disease,” said George A. “Jack” Cioffi, MD, Devers Eye Institute, Legacy Health System, Portland, OR. Both CCT and elevated IOP are risk factors for glaucoma, but they are independent of each other, he added.

However, it is difficult to apply CCT measurements as a corrective factor because algorithms have not been validated and are not widely accepted. At this time, it appears that the magnitude of diurnal fluctuations in IOP is probably greater than any correction factors in CCT, Dr. Cioffi said.

Dr. Weinreb also discussed diurnal and nocturnal variations in IOP and pointed out that more than two-thirds of cases, peak IOP occurs outside of normal office hours, such as just before patients typically awaken or just afterward.

“We know that a single measurement of IOP during usual office hours is insufficient for optimal glaucoma management,” he said. He added, though, that the optimal times during a 24-hour period for enhancing the diagnosis and treatment of glaucoma are not yet known.

Because of the circadian changes in IOP, clinicians need to prescribe medication that is effective at lowering pressure during both the day and night, such as a prostaglandin or carbonic anhydrase inhibitor, Dr. Weinreb suggested.

Speakers also stressed the importance of understanding the role of patient compliance and strategies for improving compliance to achieve a better outcome. Poor compliance is one of the main reasons that patients go blind, and it represents a failure of physician-patient communication, said Jeffrey M. Liebmann, MD, New York University School of Medicine. He urged physicians to consider the patient’s physical and mental condition and financial ability when prescribing medication and to minimize side effects and dosing frequency.

“Focus on optimal rather than maximal medical therapy,” he added, recommending once-daily therapy, preferably with a prostaglandin, and no more than two bottles if absolutely necessary to achieve adequate pressure lowering.

Kuldev Singh, MD, MPH, Stanford University School of Medicine, also discussed IOP and noted that his preference for establishing a low target pressure was to use a range rather than a number. Clinicians should balance the risks and benefits of the methods they plan to use to reach that target and modify the range accordingly, he added.

Christopher A. Girkin, MD, MPH, University of Alabama at Birmingham, described different technologies for optic nerve evaluation. Studies suggest that the Heidelberg Retina Tomograph, optical coherence tomography (Carl Zeiss Meditec), and GDx nerve fiber analyzer (Carl Zeiss Meditec) have similar efficacy in detecting glaucoma but that more longitudinal comparison studies are needed before it can be concluded that any of these technologies are superior to optic disc photography.

The program was jointly sponsored by Ophthalmology Times and the New York Eye and Ear Infirmary and supported by an unrestricted educational grant from Alcon Laboratories.