Pearls of Glaucoma Management (eBook)

JoAnn A. Giaconi, Simon K. Law, Anne L. Coleman, Joseph Caprioli (Herausgeber)

eBook Download: PDF

2010 | 2010
XIV, 498 Seiten
Springer Berlin (Verlag)
978-3-540-68240-0 (ISBN)

Infos

If you have ever uttered the commonly expressed lament, 'Glaucoma is so confusing!' then this text is for you. You will no longer be bewildered. Why practitioners may be confused about how to be of help to patients with glaucoma - in its many incarnations and reincarnations - is easily understood. The issue seems to be overwhelming when one considers that the already massive popu- tion of those with glaucoma is increasing rapidly as the world's population increases and ages. During the past 50 years the fundamental defnition of glaucoma has changed almost 180°, and the indications for treatment have become more variable and c- troversial, some advising early therapy and others strongly cautioning against such an approach: Various diagnostic tests have come and gone and are interpreted in such different ways that there seems to be no consensus; surgical techniques come in and out of fashion in perplexing ways. There seems to be a constantly shifting, sandy foundation on which are built unsteady schools of ever-varying advice. Why prac- tioners, patients, and the public are often bewildered is understandable.

Inhalt

Foreword 5
Preface 7
Contents 8
Contributors 22
Optic Nerve: The Glaucomatous Optic Nerve 31
1.1 Why is the Optic Nerve Important in the Diagnosis and Management of Glaucoma? 31
1.1.1 The Optic Nerve Head (ONH) is the Principal Site of Glaucomatous Damage to the Visual System 31
1.1.2 The Pathophysiology of Glaucomatous Damage is Separate from the Clinical Phenomenon of “Cupping” 33
1.1.3 The Clinical Appearance and Behavior of the ONH Holds Clues as to the Etiology of a Given Optic Neuropathy 36
1.1.4 The Aged ONH Holds Important Clues About Susceptibility 37
1.1.5 How Age Influences the Susceptibility and Clinical Behavior of the ONH 37
1.1.6 Apart from the Aged ONH, Are There Some Nerves That are Mechanically More Sensitive to Damage? 39
Summary for the Clinician 39
Optic Nerve: Clinical Examination 44
2.1 How Should I Examine the Optic Nerve? 44
Summary for the Clinician 45
2.2 How Does One Establish the Borders of the Nerve and Follow the Neuroretinal Rim Contour? 46
Summary for the Clinician 46
2.3 How Does One Avoid Misinterpreting Rim Loss? 46
Summary for the Clinician 47
2.4 How Much Asymmetry Between Neuroretinal Rims and Nerves Is Important? 47
Summary for the Clinician 47
2.5 How Can I Estimate Disc Size and Compare Disc Size Between the Two Eyes? 47
Summary for the Clinician 48
2.6 How Quickly Can I Expect Optic Nerve Change to Occur? 48
Summary for the Clinician 48
2.7 If I See a Disc Hemorrhage on Healthy Appearing Neuroretinal Rim, How Soon Can I Expect to See a Change in the Rim? 48
Summary for the Clinician 49
Optic Nerve: Heidelberg Retinal Tomography 51
3.1 What Indices Should I Use to Help Me Interpret the Heidelberg Retinal Tomograph (HRT) Printout? 51
Summary for the Clinician 55
3.2 How Big a Change is Meaningful in the Numbers on an HRT Printout? 56
Summary for the Clinician 57
3.3 How Does the HRT Detect Progression? 57
3.3.1 Trend Analysis 57
3.3.2 Topographical Change Analysis (TCA) 58
Summary for the Clinician 61
3.4 Can I Use the HRT Clinically to Diagnose Glaucoma and Glaucomatous Progression? How Certain Can I Be that the Progressio 61
Summary for the Clinician 62
Optic Nerve: Scanning Laser Polarimetry 63
4.1 What is the Physical Principle Behind Scanning Laser Polarimetry (SLP)? 63
4.1.1 How has Scanning Laser Polarimetry Evolved? 63
4.1.2 What is GDxVCC (Variable Corneal Compensation)? 64
4.1.3 What is GDxECC (Enhanced Corneal Compensation)? 64
Summary for the Clinician 64
4.2 How is Image Quality and Artifact Assessed on the GDxVCC Printout? 65
Summary for the Clinician 66
4.3 Can I Use the Scanning Laser Polarimetry Report to Diagnose Glaucoma? 66
Summary for the Clinician 68
4.4 Can I Use Scanning Laser Polarimetry to Assess Progression of Optic Nerve Damage? 68
4.4.1 Detection of Progression with SLP 68
Summary for the Clinician 69
Optic Nerve: Optical Coherence Tomography 72
5.1 What Indices Should I Use to Help Me Interpret the OCT Optic Nerve Head Analysis Report? 72
Summary for the Clinician 75
5.2 What Indices Should I Use to Help Me Interpret the “RNFL Thickness Average Analysis Report” Printout? 75
Summary for the Clinician 76
5.3 Can OCT Detect Progression? How Big a Change is Meaningful in the Numbers on an OCT Printout? 76
Summary for the Clinician 78
5.4 Can I Use OCT Clinically to Diagnose Glaucoma? How Certain Can I Be that the Diagnosis is Real? 78
Summary for the Clinician 79
5.5 Should I Incorporate Spectral Domain-OCT into My Practice? 79
Summary for the Clinician 80
Optic Nerve: Comparison of Technologies 81
6.1 Why Image the Optic Nerve? 81
6.1.1 Confocal Scanning Laser Ophthalmoscope 81
6.1.2 Optical Coherence Tomography (OCT) 83
6.1.3 Scanning Laser Polarimetry (SLP) 85
Summary for the clinician 85
6.2 Is One Optic Nerve Imaging Technique Better or More Promising than the Others for Helping to Detect Glaucoma and Its Progr 86
Summary for the Clinician 86
6.3 Is One Imaging Technique Easier to Use and Interpret than Another? 87
Summary for the Clinician 87
6.4 How Often Should I Image the Nerve? 87
Summary for the Clinician 87
Optic Nerve: Atypical Nerves and Nerve Findings 89
7.1 Should Peripapillary Atrophy (PPA) Concern Me? Should it Be Followed for Enlargement? 89
Summary for the Clinician 90
7.2 In Examining Tilted Optic Discs, How Do I Distinguish Tilt vs. Glaucoma? 90
7.2.1 What are the Characteristics of a Tilted Disc? 90
7.2.2 Can My Patient Help Me to Distinguish Between Tilt and Glaucoma? 91
7.2.3 Can Perimetry Help Me to Distinguish Between Tilt and Glaucoma? 91
7.2.4 Can Optic Nerve Imaging Help Me to Distinguish Between Tilt and Glaucoma? 92
7.2.5 What Management Strategy Can I Use in Equivocal Cases of Tilt vs. Glaucoma? 92
Summary for Clinicians 92
7.3 With Optic Nerve Head Drusen (OND), How Do I Tell If Visual Field Changes are due to Drusen vs. Glaucoma? 93
7.3.1 Description of Drusen 93
7.3.2 What are the Characteristics of Field Defects in OND? 93
7.3.3 Are There Other Signs that Can Help Me Distinguish Between OND and Glaucoma? 94
7.3.4 Can Imaging Help Me to Distinguish Between OND and Glaucoma? 94
7.3.5 What Management Strategy Can I Use in Equivocal Cases of OND vs. Glaucoma? 94
Summary for the Clinician 94
7.4 What Differential Diagnosis Should Be Kept in Mind When Looking at a Case of Questionable Glaucoma? 95
7.4.1 What is the Significance of Disc Cupping? 95
7.4.2 How Do I Tell the Difference Between Physiological Large Cupping and Glaucomatous Cupping? 95
7.4.3 What is the Significance of Optic Disc Pallor? 96
7.4.4 When Do I Request Neuro-Imaging or Help from My Neuro-Ophthalmology Colleague? 96
Summary for the Clinician 97
IOP: The Importance of Intraocular Pressure 100
8.1 Why is Intraocular Pressure Important in Diagnosing and Treating Glaucoma? 100
8.1.1 High IOP Can Cause Glaucoma (and Other Harm to the Eye) Although High IOP Itself is Not Glaucoma 100
8.1.2 Glaucoma Can Be Diagnosed Independently of IOP 100
8.1.3 Non-IOP Factors May also Be Involved in the Pathogenesis of Glaucoma 101
8.1.4 The Decision to Initiate Treatment by Lowering IOP 101
8.1.5 Use of IOP in Monitoring a Patient with Glaucoma 101
8.1.6 Treating the Risk of Developing Glaucoma in the Future 102
Summary for the Clinician 102
IOP: Instruments to Measure IOP 104
9.1 What is the Brief History of IOP Measurement? 104
9.2 What Instrument(s) Most Accurately Measures IOP? 105
9.2.1 Maklakov Tonometer 105
9.2.2 Shiøtz Tonometry 105
9.2.3 Goldmann Tonometry 105
9.2.4 McKay-Marg and Tonopen 105
9.2.5 Air-Puff Tonometry 106
9.2.6 Dynamic Contour Tonometry 107
9.2.7 Trans-Palpebral Tonometers 108
Summary for the Clinician 108
9.3 If Goldmann Applanation is not Available During an Exam Under Anesthesia, What Instrument is the Next Most Preferred for 108
Summary for the Clinician 108
9.4 In Cases of Corneal Transplants, Corneal Edema or Scarring, Which Instrument Would Be Best to Use to Obtain Accurate IOP M 109
Summary for the Clinician 109
9.5 In Cases of Prosthetic Corneas How Can I Measure the IOP? 109
Summary for the Clinician 109
9.6 Can I Convert the Readings of One Instrument to Those of Another? 109
Summary for the Clinician 109
IOP: Central Corneal Thickness 111
10.1 Why Has Central Corneal Thickness (CCT) Become So Important? 111
10.1.1 Goldmann Tonometry 111
10.1.2 The Influence of CCT on Tonometry 112
Summary for the Clinician 112
10.2 How Does Central Corneal Thickness Vary? 112
10.2.1 CCT in Different Populations 112
10.2.2 CCT Over Time 113
Summary for the Clinician 113
10.3 Does CCT Predict Glaucoma? 113
10.3.1 Clinical Trials 113
10.3.2 CCT in Established Glaucoma 113
10.3.3 CCT as a Biological Risk Factor 113
Summary for the Clinician 114
10.4 How Should I Use CCT in Clinical Practice? 114
10.4.1 Should IOP Be “Adjusted” for CCT? 114
10.4.2 Special Situations: Children 114
10.4.3 Special Situations: Refractive Surgery 114
10.4.4 Should I Measure CCT in All Patients? 115
Summary for the Clinician 116
IOP: Corneal Hysteresis 118
11.1 What is Corneal Hysteresis and How Does it Influence IOP Measurement? 118
Summary for the Clinician 119
11.2 What Are Typical Corneal Hysteresis Values? 119
Summary for the Clinician 119
11.3 What Is the Relationship Between CCT, IOP, and Corneal Hysteresis? 119
Summary for the Clinician 120
11.4 Should I Invest in Newer Devices to Measure IOP that Claim Less Influence of CCT? 120
Summary for the Clinician 121
IOP: Target Pressures 122
12.1 Should I Establish a Target IOP on Every Patient? 122
Summary for the Clinician 122
12.2 If I Decide to Set a Target IOP, How Should I Set it – Do I Use a Percent Reduction or Aim Toward an Absolute Number? 122
Summary for the Clinician 123
12.3 How Should I Use Information About Diurnal IOP, Nocturnal Peaks, and Inter-Visit Fluctuation in Establishing a Target IOP 124
12.3.1 Diurnal IOP Variation and Glaucoma 124
12.3.2 Intervisit IOP Fluctuation and Glaucoma 124
Summary for the Clinician 125
12.4 Are Supine and Nocturnal IOPs Important to Factor into Target Pressure Estimation? 125
Summary for the Clinician 126
IOP: Fluctuation 128
13.1 Why is IOP Fluctuation a Topic of Interest? 128
Summary for the Clinician 128
13.2 What Factors Should Be Considered When Measuring Short-Term IOP Fluctuation? 129
Summary for the Clinician 129
13.3 What is the Significance of Short-Term IOP Fluctuation? 129
Summary for the Clinician 130
13.4 What Factors Should Be Considered in Measuring Long-Term IOP Fluctuation? 130
Summary for the Clinician 130
13.5 What is the Significance of Measures of Long-Term IOP Fluctuation? 130
Summary for the Clinician 131
13.6 What is the Impact of Medication on Short-Term and Long-Term IOP Fluctuation? 131
Summary for the Clinician 131
13.7 What is the Impact of Surgery on Short-Term and Long-Term IOP Fluctuation? 132
Summary for the Clinician 132
13.8 How Aggressive Should I Be in Eliminating Long-Term IOP Fluctuation Given the Potential Complications of Medications an 132
Summary for the Clinician 132
Gonioscopy: Why Do Indentation? 135
14.1 Which Patients Should have Gonioscopy? 135
Summary for the Clinician 136
14.2 Of What Use is the Van Herick Angle Examination? 136
Summary for the Clinician 136
14.3 What Lens Should be Used for Gonioscopy? 136
Summary for the Clinician 137
14.4 How Do I Perform Indentation Gonioscopy? 137
Summary for the Clinician 139
14.5 What Should I Look for in the Angle? 139
Summary for the Clinician 140
14.6 How Can I Recognize Peripheral Anterior Synechiae? 140
14.7 How Narrow is too Narrow? What are the Indications for Laser Iridotomy in a Patient with No Symptoms of Angle-closure? 140
Summary for the Clinician 141
14.8 What Should I Know about Plateau Iris? 142
Summary for the Clinician 142
14.9 What Racial Differences Exist in Angle Anatomy? 143
Summary for the Clinician 143
14.10 Can Anterior Segment Imaging by Ultrasound Biomicroscopy (UBM) or Anterior Segment OCT Replace Gonioscopy? 143
Summary for the Clinician 143
Visual Fields: Visual Field Test Strategies 145
15.1 What Are the Basic Differences Between Different Visual Field Machines and Tests? 145
15.1.1 Automated vs. Manual 145
15.1.2 Threshold vs. Forecasting/Adaptive Strategies 145
15.1.3 Program Tests: Humphrey Field Analyzer vs. Octopus 146
15.1.4 Testing of Different Mechanisms of the Visual System 146
Summary for the Clinician 146
15.2 What are the Theoretical Advantages of Different Test Strategies (SAP, SITA, FDT SWAP, etc)? 147
Summary for the Clinician 147
15.3 Is There a Visual Field Program of Choice at This Point in Time? 147
Summary for the Clinician 147
15.4 What Visual Field Program is Best for Use in a Glaucoma Subspecialty Clinic? 147
Summary for the Clinician 148
15.5 What Program is Best for Use in a General Clinic to Screen for Glaucoma? 148
Summary for the Clinician 148
15.6 How Can I Convert from One Visual Field Strategy to Another to Help Me Interpret and Compare Tests? 149
Summary for the Clinician 149
15.7 What Can be Done to Obtain Visual Field Information in a Patient who Consistently Tests Unreliably? 149
Summary for the Clinician 150
Visual Fields: Fluctuation and Progression 151
16.1 How Do I Distinguish Between Fluctuation and True Progressive Change on Visual Field Printouts? 151
16.1.1 Usual Pattern of Visual Field Progression in Glaucoma 151
16.1.2 Visual Field Defects Need to be Repeatable 152
16.1.3 Results of Visual Field Tests Should Be Correlated with Other Clinical Data 152
Summary for the Clinician 153
16.2 How Frequently Should Visual Fields Be Tested? 153
Summary for the Clinician 154
16.3 What Are the Methods Available for Determining Visual Field Progression? 154
Summary for the Clinician 154
16.4 What Automated Progression Analysis Software Is Available to Help with Visual Field Interpretation? 154
Summary for the Clinician 155
Visual Fields: Field Interpretation 160
17.1 How Is Information on a Single Field Printout of the Humphrey Visual Field Analyzer Interpreted? 160
17.1.1 Part 1 of the Visual Field Printout 160
17.1.2 Part 2 of the Visual Field Printout 162
17.1.3 Part 3 of the Visual Field Printout 162
17.1.4 Part 4 of the Visual Field Printout 162
Summary for the Clinician 163
17.2 How Is the Information on the Glaucoma Progression Analysis Printout Interpreted? 163
17.2.1 Part 1 of the GPA Printout 163
17.2.2 Part 2 of the GPA Printout 163
17.2.3 Part 3 of the GPA Printout 163
Summary for the Clinician 166
17.3 What Are the Pitfalls to Avoid (or Commonly Made Mistakes) in the Interpretation of Visual Fields? 167
17.3.1 Quality of Visual Field Examinations 167
17.3.2 Automatic Reliance on the Statistical Analysis 167
17.3.3 Visual Field Artifacts 167
17.3.4 An Adequate Number of Visual Field Examinations 167
Summary for the Clinician 168
Other Tests in Glaucoma: Genetic Testing 169
18.1 What Genetic Tests are Currently Available to Test or Screen for Glaucoma? 169
18.1.1 Anterior Segment Dysgenesis 170
18.1.2 Juvenile Onset Open-Angle Glaucoma 170
18.1.3 Congenital Glaucoma 170
18.1.4 Low-Tension Glaucoma 170
18.1.5 Primary Open-Angle Glaucoma (Adult-Onset) 170
18.1.6 Pseudoexfoliation Glaucoma 171
Summary for the Clinician 171
18.2 Are Genetic Tests for Glaucoma of Practical Use in a Clinical Setting Today, or Are They More of Theoretical Use? 171
18.2.1 Anterior Segment Dysgenesis 171
18.2.2 Juvenile-Onset Open-Angle Glaucoma 171
18.2.3 Congenital Glaucoma 171
18.2.4 Low-Tension Glaucoma 172
18.2.5 Primary Open-Angle Glaucoma (Adult-Onset) 172
Summary for the Clinician 172
18.3 How Do I Collect Samples and Where Do I Send Them for Analysis? 172
Summary for the Clinician 173
18.4 How Should the Results of Genetic Testing Be Interpreted for the Patient’s Use? 173
18.4.1 Genetic Counseling 173
18.4.2 Anterior Segment Dysgenesis Syndromes 174
18.4.3 Juvenile-Open Angle Glaucoma 174
18.4.4 Congenital Glaucoma 174
18.4.5 Low-Tension Glaucoma 174
18.4.6 Primary Open-Angle Glaucoma (Adult-Onset) 174
18.4.7 Genotype/Phenotype Correlations 174
Summary for the Clinician 174
Other Testing in Glaucoma: Optic Nerve Blood Flow I 177
19.1 Should Optic Nerve Blood Flow Be Measured in Glaucoma and Glaucoma Suspect Patients? 177
Summary for the Clinician 178
19.2 Is Abnormal Ocular Blood Flow Causal in Glaucoma and Glaucoma Progression, and Does It Correlate with Disease Severity? 178
Summary for the Clinician 178
19.3 Which Glaucoma Patients May Suffer from Ocular Blood Flow Impairment? 178
19.3.1 Patients with a History of Cardiovascular Diseases and Diabetes 178
19.3.1.1 Presence of Systemic Hypertension or Hypotension 178
19.3.1.2 Patients with Vasospasm 179
19.3.1.3 Patients with Nocturnal Blood Pressure Dips 179
19.3.1.4 Diabetes 179
19.3.2 Patients Who Progress despite Reaching Target IOP or with Fluctuating IOP and Pulse Pressure 180
19.3.3 NTG Patients with Migraine and or Disc Hemorrhages 180
Summary for the Clinician 180
19.4 What are the Most Common Techniques to Measure Optic Nerve Blood Flow and what are Their Limitations? 180
19.4.1 Color Doppler Imaging (CDI) 180
19.4.2 Laser Doppler Flowmetry (LDF) 181
19.4.3 Pulsatile Ocular Blood Flow (POBF) 181
19.4.4 Angiography 182
19.4.5 Canon Laser Blood Flowmeter (CLBF) 182
Summary for the Clinician 182
Other Tests in Glaucoma: Optic Nerve Blood Flow II 185
20.1 What Evidence Is There that Vascular Alterations Play a Role in Open-Angle Glaucoma (OAG)? 185
Summary for the Clinician 185
20.2 What Are the Positives and Negatives of Measuring Optic Nerve Blood Flow? 186
Summary for the Clinician 186
20.3 What Technologies Are Available to Measure Blood Flow Velocities? 186
20.3.1 Color Doppler Imaging (CDI) 186
20.3.2 Heidelberg Retinal Flowmeter (HRF) 186
20.3.3 Canon Laser Blood Flowmetry (CLBF) 186
20.3.4 Laser Doppler Flowmetry (LDF) 187
20.3.5 Retinal Vessel Analyzer (RVA) 187
20.3.6 Scanning Laser Ophthalmoscope (SLO) 187
20.3.7 Pulsatile Ocular Blood Flowmeter (POBF)/Pascal Dynamic Contour Tonometer (DCT) 187
Summary for the Clinician 188
20.4 Are There Examples of Ocular Hemodynamic Abnormalities Found in OAG Patients? 188
20.4.1 Color Doppler Imaging 188
20.4.2 Heidelberg Retinal Flowmeter 188
20.4.3 Canon Laser Blood Flowmetry 189
20.4.4 Laser Doppler Flowmetry 189
20.4.5 Retinal Vessel Analyzer 189
20.4.6 FA-Scanning Laser Ophthalmoscopy 189
20.4.7 ICG-Scanning Laser Ophthalmoscopy 189
20.4.8 Pulsatile Ocular Blood Flowmeter/Pascal DCT 189
Summary for the Clinician 189
20.5 How Are the Results of Blood Flow Measuring Devices Interpreted and Are There Limitations to These Blood Flow Imaging Tec 190
20.5.1 Color Doppler Imaging 190
20.5.2 Heidelberg Retinal Flowmeter 190
20.5.3 Canon Laser Blood Flowmetry 190
20.5.4 Laser Doppler Flowmetry 191
20.5.5 Retinal Vessel Analyzer 191
20.5.6 Scanning Laser Ophthalmoscopy Angiography 191
20.5.7 Pulsatile Ocular Blood Flowmeter/Pascal Dynamic Contour Tonometer 191
Summary for the Clinician: 191
20.6 How Can the Data from Ocular Hemodynamic Studies Be Used in Clinical Practice? 192
Summary for the Clinician 192
Other Tests in Glaucoma: Multifocal Visual Evoked Potential 194
21.1 What Is a Multifocal Visual Evoked Potential (mfVEP)? 194
21.1.1 The Visual Evoked Potential (VEP) 194
21.1.2 The Multifocal Visual Evoked Potential 194
Summary for the Clinician 196
21.2 How Do I Interpret the Results of mfVEP Tests? 196
21.2.1 Identifying Glaucomatous Damage 196
21.2.2 The mfVEP Provides Topographical Information 197
21.2.3 mfVEP Latency as an Indicator of Other Diseases 197
Summary for the Clinician 198
21.3 Is the mfVEP a Useful Test in Glaucoma? 198
21.3.1 The mfVEP Is Not Ready for Routine Screening of Glaucoma Patients 198
21.3.2 The mfVEP Can Provide Clinically Useful Information 198
21.3.2.1 Inconclusive SAP Visual Field and Disc Examinations 198
21.3.2.2 Unreliable Visual Fields 198
21.3.2.3 Inconsistent Visual Fields 198
21.3.2.3 Visual Fields that Need Confirmation 199
Summary for the Clinician 199
Risk Factors 201
22.1 When I Diagnose a Patient with Glaucoma for the First Time, What Can I Tell Him/Her About the Risk of Going Blind from Gl 201
Summary for the Clinician 202
22.2 What are the Main Risk Factors for Primary Open-Angle Glaucoma? 202
22.2.1 Intraocular Pressure: The Sole Treatable Risk Factor for Glaucoma 202
22.2.2 Demographic Factors 203
22.2.3 Pseudoexfoliation Syndrome and Pigment Dispersion Syndrome 204
22.2.4 Central Corneal Thickness 204
22.2.5 Systemic Factors 204
Summary for the Clinician 205
22.3 Is the Myopic Population at Higher Risk of Glaucoma? Do Myopic Patients with Glaucoma Progress Differently than Other Pat 205
Summary for the Clinician 205
Risk Factors: The Risk Calculator 209
23.1 Is a Risk Calculator Useful? 209
Summary for the Clinician 210
23.2 How Should I Use a Risk Calculator? 210
Summary for the Clinician 211
23.3 Can I Screen for Glaucoma with a Risk Calculator? 211
Summary for the Clinician 211
23.4 What Does It Mean to Me and My Patient If the Risk Score Is High? 211
Summary for the Clinician 211
Medical Treatment: First Line Agents and Monotherapy 213
24.1 Should Beta Blockers Still Be Used as a First-Line Agent? 213
24.1.1 What is the Topical Beta Blocker Mechanism of Action? 214
24.1.2 What Magnitude of IOP Decrease Is Seen with Beta Blockers? 214
24.1.3 How Should Beta Blockers Be Initiated? 214
24.1.4 What Are the Differences Between Individual Beta Blockers? 215
24.1.5 What Are the Side Effects of Beta Blockers? 215
24.1.6 How Much Does Beta-Blocker Treatment Cost? 216
Summary for the Clinician 216
24.2 If a Single Agent Does Not Provide Adequate IOP Lowering, Is It Better to Switch to Another Medication in the Same Class 216
Summary for the Clinician 217
24.3 When Combining Topical Medications, Do Certain Combinations Work Better Together than Others, i.e., What Should I First 217
Summary for the Clinician 218
24.4 Should Miotics Still Be Used? 218
Summary for the Clinician 218
Medical Treatment: The Pregnant and Nursing Woman 220
25.1 Which Glaucoma Medications Are Safe to Use in Pregnancy? 220
Summary for the Clinician 221
25.2 What Medications Are Safe to Use in a Nursing Mother? 221
Summary for the Clinician 222
Medical Treatment: Carbonic Anhydrase Inhibitors 223
26.1 Are Oral Carbonic Anhydrase Inhibitors (CAIs) Still to Be Used Now that There Are Numerous Effective Topical Medications? 223
Summary for the Clinician 223
26.2 How Should Oral CAIs Be Dosed? 223
Summary for the Clinician 224
26.3 What Are the Toxic Effects of Systemic CAIs? 224
Summary for the Clinician 225
26.4 Can CAIs Be Used in Pregnant Women or Pediatric Patients? 225
Summary for the Clinician 226
26.5 Can CAIs Be Used in Patients with Sickle Cell Anemia? 226
Summary for the Clinician 226
26.6 How Does Acetazolamide Differ from Methazolamide? 226
Summary for the Clinician 226
26.7 Are Systemic and Topical CAI Effects Additive? 227
Summary for the Clinician 227
Medical Treatment: Osmotic Agents 228
27.1 When Using Hyperosmotics Agents, What Is a Typical Dose for Acutely Elevated Intraocular Pressure (IOP)? 228
Summary for the Clinician 231
27.2 What Systemic History Should I Gather Prior to Administering Hyperosmotic Agents? 231
Summary for the Clinician 231
27.3 Should Hyperosmotic Agents Be Used to Lower IOP Prior to Surgery? 231
Summary for the Clinician 232
Medical Treatment: Neuroprotection 233
28.1 What Exactly Is Neuroprotection? 233
Summary for the Clinician 234
28.2 What Is the Basis of Neuroprotection? 234
Summary for the Clinician 235
28.3 What Medications Are Neuroprotective? 235
28.3.1 Memantine 235
28.3.2 Brimonidine 236
28.3.3 Betaxolol 236
28.3.4 Calcium Channel Blockers 236
23.3.5 Other Possible Treatments 236
Summary for the Clinician 237
28.4 Is There a Clinical Role for Systemic Medications in the Treatment of Glaucoma? 237
Summary for the Clinician 237
Medical Treatment: Treated vs. Untreated Glaucoma and Ocular Hypertension 239
29.1 What Is the Natural History of Treated and Untreated Glaucoma and Ocular Hypertension? 239
29.2 What Is the Natural History of Treated and Untreated Glaucoma? 240
29.2.1 Olmsted County, MN 240
29.2.2 St. Lucia Study 241
29.2.3 Collaborative Normal Tension Glaucoma Study 241
29.2.4 Early Manifest Glaucoma Treatment Study 242
Summary for the Clinician 242
29.3 What Is the Natural History of Untreated vs. Treated Ocular Hypertension? 243
29.3.1 Ocular Hypertension Treatment Study 243
29.3.2 The European Glaucoma Prevention Study 243
Summary for the Clinician 243
Medical Treatment: Adherence and Persistence 245
30.1 What Issues Are at Work in Patient Noncompliance? 245
30.1.1 What Is Adherence? 245
30.1.2 What Is Persistence? 245
30.1.3 What Are the Challenges Facing Patients in Terms of Adherence and Persistence? 246
Summary for the Clinician 246
30.2 How Can One Help Patients to Be More Compliant with Treatment? 247
Summary for the Clinician 248
30.3 How Can One Educate Patients to Realize the Long-Term Impact of Glaucoma and Encourage Adherence? 248
Summary for the Clinician 250
Medical Treatment: Alternative Medicine and Glaucoma 251
31.1 Is There Anything the Patient Can Do to Improve the Outcome of Their Disease Besides Using Conventional Treatments (Medic 251
Summary for the Clinician 253
31.2 When a Patient Asks About the Effect of Lifestyle on Glaucoma, How Can I Answer this with Regard to Exercise, Smoking, Al 253
31.2.1 Exercise 253
31.2.2 Smoking 254
31.2.3 Alcohol Consumption 254
31.2.4 Diet 254
Summary for the Clinician 255
31.3 How Should I Counsel Patients Who Inquire Regarding to Alternative and Complementary Therapy, Specifically Marijuana Use, 255
31.3.1 Marijuana Use 255
31.3.2 Gingko Biloba 256
31.3.3 Bilberry 256
31.3.4 Acupunture 256
Summary for the Clinician 257
Procedural Treatments: Laser Trabeculoplasty 260
32.1 Should Laser Trabeculoplasty or Medication Be Used as First-Line Treatment? How Can Trabeculoplasty Be Used as Adjunctive 260
32.1.1 what is the Efficacy of Trabeculoplasty 260
32.1.2 Does Trabeculoplasty benefit Compliance? 261
32.1.3 How well does Trabeculoplasty control the Diurnal IOP curve? 261
32.1.4 What are the Side Effects/Risks of Trabeculoplasty? 262
32.1.5 What are the Economic Issues Involved with Trabeculoplasty? 262
Summary for the Clinician 262
32.2 Is There Still a Place for ALT Given the Availability of SLT? (In Other Words, as a Practitioner Should One Invest in Buy 262
32.2.1 What is the Efficacy of ALT Versus SLT? 262
32.2.2 What are the Complications of ALT Versus SLT? 263
32.2.3 How does Retreatment compare between ALT and SLT? 263
32.2.4 How does the Versatility of the laser sources compare? 263
Summary for the Clinician 263
32.3 When Should SLT or ALT not Be Performed? 264
32.3.1 Types of Glaucoma 264
32.3.2 IOP Reduction 264
32.3.3 Maximal Medical Therapy 264
Summary for the Clinician 264
32.4 What are the Laser Settings and Techniques for ALT and SLT? 264
32.4.1 Argon Laser Trabeculoplasty 264
32.4.2 Selective Laser Trabeculoplasty 264
Summary for the Clinician 265
32.5 What Pearls are There for Performing ALT and SLT? 265
Summary for the Clinician 266
32.6 What Complications Can I Expect and How Do I Deal with Them? How Frequently Should a Patient Be Seen in Follow-Up After T 266
Summary for the Clinician 266
32.7 What is the Mechanism of Action of ALT and SLT? 267
32.7.1 Mechanical Theory 267
32.7.2 Biologic Theory 267
32.7.3 Repopulation Theory 267
Summary for the Clinician 267
32.8 What Newer Laser Trabeculoplasty Modalities are on the Treatment Horizon? 267
32.8.1 Micropulse Laser Trabeculoplasty (MLT) 267
32.8.2 Titanium Sapphire Laser Trabeculoplasty 268
Summary for the Clinician 268
Procedural Treatments: Endoscopic Cyclophotocoagulation 270
33.1 When Can or Should Endoscopic Cyclophotocoagulation (ECP) Be Used? 270
Summary for the Clinician 271
33.2 Should ECP Be Used as a Primary Surgery for Glaucoma? 271
Summary for the Clinician 271
33.3 Is Burning the Ciliary Processes a Safe Thing to Do? 271
Summary for the Clinician 271
33.4 Technically, How Is ECP Performed? 272
Summary for the Clinician 273
33.5 How Is the Postoperative Course of ECP Managed? 273
Summary for the Clinician 273
33.6 What Are Complications that May Be Encountered and How Are They Specifically Managed? 274
Summary for the Clinician 274
33.7 When Can I Expect the Pressure Drop to Occur? 274
Summary for the Clinician 274
33.8 What Is the Long Term Safety Data on this Procedure? 274
Summary for the Clinician 274
Procedural Treatments: Transcleral Cyclophotocoagulation 276
34.1 What is Transscleral Cyclophotocoagulation (TCP)? 276
Summary for the Clinician 277
34.2 When Should I Use TCP? Should it be Used as a Primary Surgery for Glaucoma? 277
Summary for the Clinician 277
34.3 Technically, How is TCP Performed? 277
Summary for the Clinician 279
34.4 How Should One Manage the Postoperative Course? When Can One Expect the Pressure to Drop After TCP? When Can Medications 279
Summary for the Clinician 279
34.5 What Complications May be Encountered and How Can I Specifically Manage Each One? What is the Long-Term Efficacy and Saf 279
Summary for the Clinician 280
Procedural Treatments: Trabeculectomy 283
35.1 Is a Limbus-Based Trabeculectomy Better than a Fornix-Based Trabeculectomy? 283
Summary for the Clinician 284
35.2 Should Antimetabolites be Used in All Cases of Trabeculectomy? 284
35.3 Do You Adjust Antimetabolite Usage and Dose Based on Patient Age or Race? 285
Summary for the Clinician 285
35.4 What Different Techniques Can I Utilize to Apply Mitomycin-C? 286
Summary for the Clinician 286
35.5 Intraoperatively, What Can I Technically Do to Ensure the Best Surgical Outcome? 287
Summary for the Clinician 288
35.6 When Should I Use Adjustable Sutures? When Should I Use Laser Suture Lysis? 288
Summary for the Clinician 289
Procedural Treatments: Perioperative Medication 291
36.1 Should Topical Glaucoma Medication Be Discontinued Before Performing Trabeculectomy? 291
Summary for the ClinicianConjunctival inflammation may have detrimental effects on the success of trabeculectomy.Topic 292
36.2 What Preoperative and Postoperative Medications Are Needed for Trabeculectomy? How Long Should I Continue Topical Steroid 292
Summary for the Clinician 293
36.3 Which Topical Steroid Should Be Used Perioperatively? 293
Summary for the Clinician 293
36.4 If IOP Reduction Is Needed Following Glaucoma Surgery, What Topical Medication Is Most Effective in Lowering IOP and Safe 293
Summary for the Clinician 293
36.5 How Should Anticoagulation and Antiplatelet Therapies Be Managed Perioperatively? 294
Summary for the Clinician 295
36.6 Should Glaucoma Surgery Technique Be Modified to Reduce the Chances of Hemorrhagic Complications? 295
Summary for the Clinician 296
Procedural Treatments: Bleb Needling 297
37.1 What Are the Different Techniques to Needle a Bleb? 297
37.1.1 Slit Lamp Bleb Needling 298
37.1.2 Bleb Needling in the Procedure or Operating Room 300
37.1.3 Antimetabolite Use with Needling 300
Summary for the Clinician 301
37.2 Is It Ever Too Early or Too Late to Needle a Bleb? 301
Summary for the Clinician 301
37.3 Are There Any Limits on How Often I Can Perform Needling and Injection of Antimetabolite? Should Antimetabolite Always 302
Summary for the Clinician 302
37.4 What Complications Should I Anticipate After Needling? 302
Summary for the Clinician 302
37.5 Is It Better to Needle or Reoperate on a Failing Bleb? 302
Summary for the Clinician 303
Procedural Treatments: Glaucoma Drainage Devices 305
38.1 Is One Tube Shunt Design Better than Another at Lowering IOP? 305
Summary for the Clinician 308
38.2 Are There Certain Circumstances/Diagnoses Where One Type of Shunt May Be Preferred Over Another? 308
Summary for the Clinician 309
38.3 What Kind of IOP Results Can I Expect with a Tube Implant? 309
Summary for the Clinician 309
38.4 What Are the Differences in Postoperative Course Between a Valved and Nonvalved Tube Shunt? 309
Summary for the Clinician 310
38.5 What Can I Do If the Conjunctiva Will Not Close and Cover the Tube-Shunt as I am Finishing the Surgery? 310
Summary for the clinician 310
38.6 Should My Surgical Technique Change If the Eye Is Aphakic? 311
Summary for the Clinician 311
38.7 Should Technique Change If the Patient Has a Great Deal of PAS? 311
Summary for the Clinician 312
Procedural Treatments: New Surgical Options 313
39.1 What New Technologies or Surgical Options Have Emerged for the Treatment of Intraocular Pressure (IOP) in Glaucoma? Is On 313
39.1.1 Aqueous Shunts for Glaucoma (Supporting Evidence Level I/1c) 314
39.1.2 Cyclodestruction with Diode G-Probe (Supporting Evidence Level III/4) 314
39.1.3 Cyclodestruction with Diode Endocyclophotocoagulation (Supporting Evidence Level I/1c) 315
39.1.4 ExPRESS Mini-Shunt (Supporting Evidence Level III/4) 315
39.1.5 Trabectome (Supporting Evidence Level III/4) 315
39.1.6 Solx Suprachoroidal Shunt (Supporting Evidence Level III/5) 316
39.1.7 Glaukos Trans-Trabecular Micro Bypass Shunt (Supporting Evidence Level III/5) 317
39.1.8 iScience (Canaloplasty) (Supporting Evidence III/4) 317
Summary for the Clinician 317
Procedural Treatments: Ex-PRESS Mini Glaucoma Shunt 319
40.1 How Often Is the Ex-PRESS Mini-Shunt Being Used in Place of More Traditional Glaucoma Surgery? Have Glaucoma Specialist 319
Summary for the Clinician 319
40.2 What Is the Ex-PRESS Mini-Shunt and How Does It Work? 319
Summary for the Clinician 320
40.3 What Are the Ex-PRESS Mini-Shunt’s Dimensions? How Is It Implanted? 321
Summary for the Clinician 323
40.4 Should An Ex-PRESS Mini-Shunt Procedure Be Performed in Place of a Trabeculectomy? 323
Summary for the Clinician 325
40.5 How Does Surgical Technique Differ Between an Ex-PRESS Shunt Procedure and a Trabeculectomy, and What Can Be Done to Obta 325
Summary for the Clinician 326
40.6 What Complications Are Specific to the Ex-PRESS Shunt Procedure? 326
Summary for the Clinician 326
Procedural Treatments: Phacotrabeculectomy 328
41.1 Under What Circumstances Should a Combined Phacotrabeculectomy Be Performed? 328
41.1.1 When to Add a Trabeculectomy to Cataract Surgery 328
41.1.2 When to Add Phacoemulsification to a Trabeculectomy 329
Summary for the Clinician 329
41.2 Under What Circumstances Should a Phacotrabeculectomy Not Be Performed? 330
41.2.1 Glaucoma as the Primary Problem 330
41.2.2 Cataract as the Primary Problem 330
Summary for the Clinician 330
41.3 How Is the Postoperative Course of a Phacotrabeculectomy Different than that After the Individual Surgeries? 330
41.3.1 Postoperative Course of a Phacotrabeculectomy vs. Trabeculectomy Alone 330
41.3.2 Postoperative Course of a Phacotrabeculectomy vs. Phacoemulsification Alone 331
Summary for the Clinician 331
Procedural Treatments: Surgery in End-Stage Glaucoma 333
42.1 What Is End-Stage Glaucoma? 333
Summary for the Clinician 334
42.2 Should I Operate on a Patient with End-Stage Glaucoma? 334
Summary for the Clinician 335
42.3 What Is the Risk of Losing Remaining Vision from a Surgical Procedure in End-Stage Glaucoma Eyes? 335
Summary for the Clinician 336
42.4 How Do Specific Complications of Surgery in End-Stage Glaucoma Lead to Vision Loss? 336
42.4.1 Hypotony Maculopathy 336
42.4.2 Retinal Detachment 336
42.4.3 Endophthalmitis 336
42.4.4 Malignant Glaucoma and others 337
Summary for the Clinician 337
42.5 What Can Be Done to Minimize Potential Vision Loss Due to Surgery in End-Stage Glaucoma? 337
Summary for the Clinician 337
Glaucomas: Managing Normal-Tension Glaucoma 341
43.1 How Low an Intraocular Pressure Do I Need to Target in Normal-Tension Glaucoma? 341
Summary for the Clinician 342
43.2 If a Patient with Normal Tension Glaucoma Is Started on Topical Medication and the Intraocular Pressure Is Lowered 1–2 mm 342
Summary for the Clinician 343
43.3 What Is the Treatment of Choice in Normal-Tension Glaucoma – Medication, Laser, or Surgery? 344
Summary for the Clinician 344
43.4 What Time Course of Progression Can I Expect in Normal-Tension Glaucoma Patients and Can I Predict Who May Progress Over 344
43.4.1 Risk Factors for Progression in NTG 345
43.4.2 Disc Hemorrhage in NTG 345
Summary for the Clinician 346
Glaucomas: Pseudoexfoliation Glaucoma 347
44.1 Is There a Gene for Pseudoexfoliation Syndrome? 347
Summary for the Clinician 347
44.2 Is Pseudoexfoliation Associated with Systemic Disease? 347
Summary for the Clinician 348
44.3 What Is the Risk of Developing Glaucoma Once PXF Material Is Observed in the Eye? 348
Summary for the Clinician 349
44.4 What Are Surgical Considerations and Management Issues in Cataract Surgery Associated with Pseudoexfoliation? 349
44.4.1 Dilation of the Pseudoexfoliation Pupil 349
44.4.2 Cataract Extraction Technique 350
44.4.3 Management of Zonular Dehiscence and Laxity 350
44.4.4 Postoperative Surgical Care of the Pseudoexfoliation Eye 351
Summary for the Clinician 351
Glaucomas: Pigment Dispersion Glaucoma and Angle Recession Glaucoma 354
45.1 How Does Glaucoma in Pigment Dispersion Syndrome Differ Clinically from Other Glaucomas? 354
Summary for the Clinician 356
45.2 Is PDG Managed Differently than Primary Open Angle Glaucoma? 356
45.2.1 Medical Treatment 356
45.2.2 Trabeculoplasty 356
45.2.3 Trabeculectomy 356
Summary for the Clinician 357
45.3 Is Laser Iridotomy Recommended in PDS/PDG Patients? 357
Summary for the Clinician 357
45.4 What Problems Should Be Anticipated in PDS/PDG? What Kind of Outcomes Can Be Expected in These Patients? 357
Summary for the Clinician 358
45.5 How Does Glaucoma in Angle Recession Differ from Other Glaucomas? 358
Summary for the Clinician 359
45.6 What Are the Expected Medical, Laser, and Surgical Treatment Outcomes in Angle Recession Glaucoma? 360
45.6.1 Medical Therapy 360
45.6.2 Laser and Incisional Surgery 360
Summary for the Clinician 360
45.7 What Problems Should Be Anticipated in Patients with Angle Recession? 361
Summary for the Clinician 361
Glaucomas: Sturge Weber Syndrome 363
46.1 How Does Glaucoma in Sturge-Weber Syndrome (SWS) Differ Clinically from Other Glaucomas? 363
Summary for the Clinician 365
46.2 Is Management of Glaucoma in SWS Different from the Typical Management of Primary Open Angle Glaucoma (POAG)? 365
46.2.1 Medical Treatment of Glaucoma in SWS 365
46.2.2 Surgical Treatment of Glaucoma in SWS (Angle Surgery and Trabeculectomy) 365
46.2.3 Glaucoma Drainage Devices in SWS Glaucoma 366
46.2.4 Cyclodestruction in SWS Glaucoma 366
Summary for the Clinician 367
46.3 What Problems Should Be Anticipated in the Management of SWS Glaucoma? 367
Summary for the Clinician 368
46.4 What Kind of Outcomes Can Be Expected in this Type of Glaucoma? 368
Summary for the Clinician 368
Glaucomas: Glaucoma and the Cornea 370
47.1 How Do Glaucoma and IOP Affect the Cornea? 370
Summary for the Clinician 371
47.2 What Effect Do Topical Medications Have on the Corneal Endothelium and Epithelium? 371
Summary for the Clinician 372
47.3 What Effect Does Laser Glaucoma Surgery Have on the Cornea? 372
Summary for the Clinician 373
47.4 What Effect Does Incisional Glaucoma Surgery Have on the Cornea? 373
47.4.1 Antimetabolite Use and the Cornea 373
47.4.2 Glaucoma Drainage Devices and the Cornea 373
Summary for the Clinician 374
47.5 How Do Corneal Diseases Affect Glaucoma? 374
Summary for the Clinician 375
Glaucomas: Uveitic Glaucoma 377
48.1 How Often Does One See Glaucoma as a Consequence of Uveitis? 377
Summary for the Clinician 378
48.2 Is There a Way to Distinguish Between Elevated IOP Due to a Steroid Response vs. Uveitis? 378
Summary for the Clinician 379
48.3 How Do Inflammation and Steroids Cause an Increase in IOP? 379
Summary for the Clinician 379
48.4 When Should I Operate on Uveitic Glaucoma? 380
Summary for the Clinician 380
48.5 Is There a Preferred Surgery for Uveitic Glaucoma (Trabeculectomy vs. Tube vs. Laser)? 380
Summary for the Clinician 381
48.6 Is One Tube Preferred over Another in Uveitic Glaucoma? 381
Summary for the Clinician 382
48.7 Do Prostaglandin Analogues Worsen Uveitic Inflammation? 382
Summary for the Clinician 382
48.8 Can One Expect a Greater Inflammatory Response in Uveitics After Glaucoma Surgery? 383
Summary for the Clinician 383
Glaucomas: Neovascular Glaucoma 385
49.1 What Medications Can Be Used to Control Neovascular Glaucoma? 385
49.1.1 IOP Lowering Agents 385
49.1.2 Anti-Inflammatory and Anti-Angiogenic Medications 386
49.1.3 Cycloplegics/Mydriatics 386
Summary for the Clinician 387
49.2 What Is the Surgical Treatment of Choice for Neovascular Glaucoma? Should Everyone Always Get a Tube Shunt to Control IO 387
Summary for the Clinician 390
49.3 How Should PRP and Glaucoma Surgery Be Timed? 390
Summary for the Clinician 390
49.4 Is Bevacizumab Useful in Neovascular Glaucoma? What Kind of Results and Time-Course Can I Expect from Its Use? For NV of 390
Summary for the Clinician 392
Pediatric Glaucoma: IOP, Axial Length, and Surgery Indications 394
50.1 What Is the Best Way to Measure IOP in the Pediatric Patient? 394
50.1.1 What Factors in Pediatric Examination Elevate and Reduce IOP? 394
50.1.2 How Do Central Corneal Thickness and Hysteresis Affect IOP Measurement in Children? 395
Summary for the Clinician 396
50.2 Is One Instrument Better than Another for Measuring IOP in the Pediatric Age Group? 396
Summary for the Clinician 396
50.3 How Is Axial Length Measurement Used in Pediatric Glaucoma? 396
Summary for the Clinician 397
50.4 When Should Surgery Be Performed in Congenital Glaucoma, in Juvenile-Onset Glaucoma, and in Secondary Type Pediatric Glau 397
Summary for the Clinician 400
Pediatric Glaucoma: Glaucoma Medications and Steroids 402
51.1 Which Glaucoma Medications Can Be Used Safely in the Pediatric Population and How Are Medication Side Effects in the Ped 402
51.1.1 Which Medications Can Be Used as First Line Agents in Children? 403
51.1.2 What Are the Side Effects of Beta Blockers in the Pediatric Age Group? 403
51.1.3 What Are the Side Effects of Carbonic Anhydrase Inhibitors in the Pediatric Age Group? 403
51.1.4 Can Topical a-Blockers Be Used in Children? 403
51.1.5 Can Prostaglandin Analogues Be Useful in Children? 404
51.1.6 Should Parasympathomimetics Be Used in Pediatric Glaucoma? 404
Summary for the Clinician 404
51.2 Do Topical Steroids Induce a Different Steroid Response in Children? 405
Summary for the Clinician 406
Pediatric Glaucoma: Angle Surgery and Glaucoma Drainage Devices 408
52.1 How Do I Perform Goniosurgery? 408
52.1.1 What Can I Do Technically to Perform a Better Goniotomy? 408
52.1.2 What Can I Do Technically to Perform a Better Trabeculotomy ? 409
52.1.3 What Complications Can Be Expected Following Goniosurgery and How Do I Manage Them? 410
Summary for the Clinician 410
52.2 How Do I Peform Glaucoma Drainage Devices (GDD) in Children? 411
52.2.1 Is a GDD Preferred Over Trabeculectomy in Children? Is Age Important in the Selection of this Surgery? What Other Fact 411
52.2.2 What Are the Potential Complications of Childhood GDD Surgery? 411
52.2.3 What Can Be Done Technically to Perform a Better Tube Shunt Procedure in Children? 412
Summary for the Clinician 413
Pediatric Glaucoma: Trabeculectomy and Glaucoma Drainage Devices1 414
53.1 Is Trabeculectomy the Preferred Surgery in Children Following Angle Surgery (Goniotomy and Trabeculotomy)? 414
Summary for the Clinician 415
53.2 Is Trabeculectomy Preferred over Tube Shunt Surgery in Children? 415
Summary for the Clinician 415
53.3 Is There an Age Cut-Off for Performing Trabeculectomy in the Pediatric Age Group? 415
Summary for the Clinician 415
53.4 What Factors Help One Decide for or Against One Surgery over the Other? 416
Summary for the Clinician 416
53.5 What Complications and Issues Should Be Anticipated in the Intraoperative and Postoperative Periods? 416
53.5.1 In Trabeculectomy 416
53.5.2 In Tube-Shunts 416
Summary for the Clinician 417
53.6 What Can Be Done Technically to Perform a Better Trabeculectomy in Kids? 417
Summary for the Clinician 417
53.7 What Can Be Done Technically to Perform a Better Glaucoma Drainage Device Surgery in Kids? 418
Summary for the Clinician 418
Angle-Closure Glaucoma: Risk Factors 420
54.1 Who Is at Risk for Acute Angle-Closure? 420
54.1.1 What are the Anatomical Risk Factors? 420
54.1.2 Age, Gender and Ethnicity 421
54.1.3 Family History and Genetic Susceptibility 421
Summary for the Clinician 421
54.2 Can I Predict Who Will Have an Angle-Closure Attack? 421
Summary for the Clinician 422
54.3 What Systemic Medications Must Narrow Angle Patients Be Counseled Against Using? Is It Safe to Use These Medications If T 422
Summary for the Clinician 423
Angle-Closure Glaucoma: Iridotomy 425
55.1 What Settings Should Be Used to Perform Laser Peripheral Iridotomy (LPI)? 425
55.1.1 Settings for Argon LPI 425
55.1.2 Settings for Nd-YAG LPI 425
Summary for the Clinician 426
55.2 How Does Iris Color Affect the Laser Settings? 426
Summary for the Clinician 426
55.3 If It Is Difficult to Penetrate the Iris, What Adjustments Can Be Made to the Laser Settings? 426
Summary for the Clinician 427
55.4 What Potential Complications Should Be Anticipated with Laser Peripheral Iridotomy and How Should Each One Be Managed? 427
55.4.1 Visual Discomfort 427
55.4.2 Diplopia and/or Glare 427
55.4.3 Hemorrhage 427
55.4.4 Corneal Damage 427
55.4.5 Lens Damage 428
55.4.6 IOP Elevation 428
55.4.7 Progression of PAS Formation 428
55.4.8 Posterior Synechia 428
55.4.9 LPI Closure 428
Summary for the Clinician 428
55.5 Under What Circumstances Is Surgical Iridectomy Indicated? How Should a Surgical Iridectomy Be Performed? 428
Summary for the Clinician 429
Angle-Closure Glaucoma: Imaging 430
56.1 Is New Imaging Technology Useful in Angle Examination? 430
Summary for the Clinician 431
56.2 What Imaging Devices Are Currently Available to Examine the Anterior Chamber Angle? 431
56.2.1 Ultrasound Biomicroscopy (UBM) 431
56.2.2 Anterior Segment Optical Coherence Tomography (AS-OCT) 431
56.2.3 Scheimpflug Photography 432
Summary for the Clinician 433
56.3 When Should UBM and AS-OCT Be Ordered: Is One Device Considered Better than the Other? 433
Summary for the Clinician 433
56.4 How Should Test Results Be Interpreted and Used to Help Treat the Patient? 433
56.4.1 Qualitative Analysis 434
56.4.2 Quantitative Analysis 436
Summary for the Clinician 436
Angle-Closure Glaucoma: Medical Therapy 438
57.1 During an Acute Angle-Closure Attack, What Medications Are Indicated? 438
57.1.1 Carbonic Anhydrase Inhibitors 438
57.1.2 Beta-Blockers 438
57.1.3 Alpha-Agonists 439
57.1.4 Prostaglandin Analogs 439
57.1.5 Hyperosmotic Agents 439
57.1. 6 Miotics 439
Summary for the Clinician 439
57.2 Should Pilocarpine Be Avoided in Angle-Closure Patients? 439
Summary for the Clinician 440
Angle-Closure Glaucoma: Surgical Management of Acute Angle-Closure Glaucoma 442
58.1 What Is the Role of Paracentesis in the Management of AcuteAngle-Closure Glaucoma? Technically, How Should this Be Perfo 442
Summary for the Clinician 443
58.2 Is There a Role for Cataract Extraction in Acute Angle-Closure? If Cataract Surgery Must Be Performed Under Conditions of 443
Summary for the Clinician 444
58.3 How Should Angle-Closure Due to Phacomorphic Glaucoma or Loose Zonules Be Managed? 444
Summary for the Clinician 445
58.4 In Routine Cataract Surgery Where the Patient Has an Occludable Angle, Should LPI Be Performed Before Cataract Extraction 445
Summary for the Clinician 446
Complications: Hypotony 448
59.1 What are the Options in the Treatment of Early Postoperative Hypotony? 448
59.1.1 Compression Sutures 448
59.1.2 Anterior Chamber Reformation 449
59.1.3 Choroidal Drainage 449
59.1.4 Repairing Wound Leaks 450
59.1.5 Resuturing of Trabeculectomy Flap 450
Summary for the Clinician 450
59.2 If There Is Hypotony Maculopathy, What Should Be Done to Manage It? 450
59.2.1 Cataract Surgery and Hypotony 450
Summary for the Clinician 450
59.3 How Can I Manage Late Hypotony Due to a Scleral Melt? 451
Summary for the Clinician 451
59.4 Which Patients Are at Risk for Hypotony? 451
Summary for the Clinician 451
Complications: Bleb Leaks 452
60.1 Does an Early Bleb Leak Need to Be Fixed? 452
60.1.1 With a Small, Early Postoperative Bleb Leak, What Options Are Available to Help It Heal? 452
60.1.2 With a Large/Brisk, Early Postoperative Bleb Leak, What Options Are Available to Help It Heal? 453
60.1.3 What Can I Do If the Leak Continues to Persist? 454
Summary for the Clinician 454
60.2 How Should I Treat a Late-Onset Bleb Leak? 454
60.2.1 Conservative Treatments for Late Bleb Leaks 455
60.2.2 Autologous Blood Injection 455
60.2.3 Compression Sutures 455
60.2.4 Laser 455
60.2.5 Surgical Bleb Revision 456
Summary for the Clinician 456
60.3 What Can I Do to Decrease the Chances of a Future Bleb Leak? 457
Summary for the Clinician 457
Complications: Blebitis 459
61.1 What Topical Antibiotics Should I Use in Blebitis? 459
Summary for the Clinician 460
61.2 When Should I Move on to Intravitreal Injections? 460
Summary for the Clinician 460
61.3 How Do I Manage a Patient After the Blebitis Is Resolved? 460
Summary for the Clinician 461
Subject Index 462

Produkt-Details

• Erscheint lt. Verlag: 2.3.2010
• Zusatzinfo: XIV, 498 p. 176 illus., 149 illus. in color.
• Verlagsort: Berlin
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Medizinische Fachgebiete ► Augenheilkunde
• Schlagworte: Angle Closure Glaucoma • Hypertension • IOP measurement • Laser • Low tension glaucoma • Neovasuclar glaucoma • Optic disc evaluation • Pediatric glaucoma • retina • visual evoked potential (VEP)
• ISBN-10: 3-540-68240-6 / 3540682406
• ISBN-13: 978-3-540-68240-0 / 9783540682400