Eyeworld

56 | EYEWORLD | NOVEMBER 2019 G UCOMA YES CONNECT Contact information Richter: Grace.Richter@med.usc.edu Sheybani: sheybaniar@wustl.edu by Liz Hillman EyeWorld Editorial Co-Director central corneal thickness, myopia, older age, and African or Latino ancestry are associated with an increased risk for glaucoma and should be taken into consideration with exam findings as well, Dr. Richter said. The most important thing to do with glaucoma suspects, Dr. Sheybani said, is serial follow-ups. First, you can catch something that you just missed the first time, he said. And, second, they allow you to assess whether it's a person who might progress rapidly or not. "Sometimes you'll do a field every 6–9 months for a couple of years. You get 3–4 visual fields as baselines, and if things are steady and there is no change, then you feel a little better about it," he said, adding that, generally, yearly follow-ups of glaucoma suspects are handled by referring doctors or optometrists in his practice. In addition to establishing a baseline with a series of visual field tests and monitoring that over time, Dr. Sheybani sees a value in using OCT. "Sometimes there is variability between scans and sometimes it's kind of burdensome, but if you're really trying to do it right, you want to get a couple of scans at the start, the first visit. Then follow those scans over time with some sort progression analysis, if you have it," he said. Here's a breakdown of the studies Dr. Richter performs the first time she sees a glaucoma suspect: • Gonioscopy to determine whether the angle is open • Visual field testing to assess any defects that could suggest actual glaucoma and to set a baseline in case there is other pathology pres- ent • Stereoscopic examination of the optic nerve to identify focal defects of the neuroretinal rim and retinal nerve fiber layer defects • Disc photos to capture a baseline of the optic nerve that can be followed over time with truly longitudinal comparisons W ith glaucoma, once the damage is done, it's irreversible, which is why identifying—and follow- ing—glaucoma suspects before they even have an optic nerve defect is vital to protecting their vision. What is considered suspect? How often should these patients be assessed? Arsham Sheybani, MD, and Grace Richter, MD, shared their thoughts on how to navigate identification and monitoring of glaucoma suspects. "Unfortunately, there is no hard science on who is a true glaucoma suspect, and we can never know which of these patients will actually develop glaucoma in the future," Dr. Richter said in an email to EyeWorld. Red flags on an exam that put a patient in glaucoma suspect category, according to Dr. Richter, include: an enlarged cup-disc ratio (CDR), CDR asymmetry, focal thinning of the neuroretinal rim, disc hemorrhage, or retinal nerve fiber layer defect. Elevated IOP and a glaucomatous visual field are other factors that would lead Dr. Richter to monitor a patient over time for the progressive condition. Fac- tors such as a family history of glaucoma, thin A close look at the glaucoma suspect About the doctors Grace Richter, MD Assistant professor of clinical ophthalmology Glaucoma Service University of Southern California, Roski Eye Institute Los Angeles Arsham Sheybani, MD Assistant professor of ophthalmology and visual sciences Washington University School of Medicine St. Louis Relevant financial interests Richter: Carl Zeiss Meditec Sheybani: Allergan, Katena, Glaukos, Ivantis Glaucoma suspect is one of the most common conditions we see as ophthalmologists, and I thought I knew everything there was to know about it until I heard what Drs. Richter and Sheybani had to say about this stubbornly inconclusive condition. In this month's column our specialists share their tips and tricks for getting reliable baseline studies, new diag- nostic techniques, and when to be suspicious of some- thing besides glaucoma. For both our YES members and ophthalmologists who have been in practice for years, reexamining how we manage these patients can help to streamline their care and yield a more accurate final diagnosis. I will start adding more OCT studies to my workup —read on, and see what changes you might be making to your practice! —Julie Schallhorn, MD YES Connect Co-Editor

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