Eyeworld

EW GLAUCOMA 110 March 2017 by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer have IOPs that are a little more vola- tile. You will often find normal IOPs in the office with advanced damage to the optic nerve. The treatment of these conditions is rather different for me compared to true NTG," he said. Miotics Moving on from diagnostics to some pointers surrounding treatment options in glaucoma patients, Dr. Panarelli reminded ophthalmolo- gists of the benefits of miotic medi- cations. Although there are patients who poorly tolerate some of these medicines, miotics are quite effec- tive and should be a part of an eye doctor's medicine cabinet. "We have so many new families of medicine and drug delivery systems coming out, which will enhance our already extensive repertoire. But don't forget some of the classics, like pilocarpine or even phospholine iodide, for patients with elevated intraocular pressure who are not necessarily going to be great surgical candidates. It may often be a last-ditch effort, but they really work. You have to remember to use them. The younger generations that are being trained now do not reach for these medica- tions as much and therefore don't think about it when they go into practice. Don't forget these classic medicines—they do work well," he said. Take time New information needs time to sink in, even if that means a second con- sultation. Patients can better handle issues regarding their eyesight if they feel comfortable with their doc- tor and have been given time to talk and think about it. According to Dr. Panarelli, this is not accomplished in one visit. He emphasized the impor- tance of a good, honest conversation with surgical candidates, discussing the risks, benefits, and expectations of surgery. As glaucoma surgery is different from other types of eye surgeries, he feels that patients need to understand the surgery goals, Panarelli elucidated, "In the last decade or so, more attention has been paid to normal tension glauco- ma as a sort of separate disease en- tity, which can be more difficult to treat. Before you diagnose somebody with normal tension glaucoma, you need to do a very good clinical examination to make sure you are not missing subtle signs of other conditions, such as old pigmentary glaucoma (PG) or pseudoexfoliative glaucoma (PXG). Although these last two conditions have classic signs, not every patient presents with text- book findings." Dr. Panarelli recommends doing a careful gonioscopic evaluation of suspicious patients as this can often aide in the diagnosis of pigmentary and/or pseudoexfoliative glaucoma. Key findings can be missed if one proceeds too quickly through this part of the examination. Looking at the lens is also critical, as pigment deposition or exfoliation deposits can be subtle. Finally, take the extra steps post-dilation and measure the IOP again (can go up with PG), check the anterior chamber for pig- mented cell, and look in the anterior vitreous for exfoliative material. "The signs of PG/PXG are not always striking, and patients tend to ensure the right course of action, as substantiated by evidence from the Collaborative Normal Tension Glaucoma Study. 1 "The first thing that I always recommend, be it for a general ophthalmologist or even a glaucoma specialist, is the impor- tance of repeating [the] visual field to confirm or refute progression. Often we will get a visual field at a follow-up visit that looks concern- ing, or one that might necessitate a change in management. The first step, always, is to repeat the visual field because often—even if a test has good reliability—there can be a variety of reasons why the field could look different compared to a prior exam. This is the foundation of what we do—if the visual field looks different to you, repeat it," he explained. Normal tension glaucoma In normal tension glaucoma (NTG), the optic nerve sustains damage despite the IOP not being very high. Normal tension glaucoma is essentially a diagnosis of exclusion as other types of glaucoma need to be ruled out before this diagnosis is made. Mount Sinai glaucoma specialist shares important points for the next generation of ophthalmologists A ccording to glaucoma spe- cialist Joseph F. Panarel- li, MD, assistant professor of ophthalmology, New York Eye and Ear Infirma- ry of Mount Sinai, New York, each day we are faced with challenging issues concerning glaucoma patients and there are several tips that can make dealing with this disease a little easier. He spoke to EyeWorld about five points he'd highlight for the new generation of ophthalmolo- gists and glaucoma specialists. Repeat the visual field exam Glaucoma patients must be mon- itored carefully, as elevated pres- sures may warrant action, such as a change in their management plan or the decision to proceed with pressure-reducing surgery. As simple as it sounds, Dr. Panarelli thinks that repeating the visual field exam during follow-up sessions is criti- cal to rule out false readings and Five key reminders for everyday glaucoma practice The Xen Gel Stent is a new surgical device that is implanted through an ab interno approach which is simple in concept, but can be challeng- ing to perform initially. Like all new procedures, there is a learning curve. Source: Joseph F. Panarelli, MD

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