COLORS (lotraflcon B) contact lenses: For daily wear only for near/farsightedness. Contact
lenses, even if worn for cosmetic reasons, are prescription medical devices that must only be worn under the prescription, direction,
and supervision of an eye care professional. Serious eye health problems may occur as a result of sharing contact lenses. Although
rare, serious eye problems can develop while wearing contact lenses. Side effects like discomfort, mild burning, or stinging may occur.
To help avoid these problems, patients must follow the wear and replacement schedule and the lens care instructions provided by their
eye doctor.
References: 1. Based on ratio of lens oxygen transmissibilities; Alcon data on fle, 2013. 2. Based on in vitro measurement of contact
angles of unworn lenses; signifcance demonstrated at 0.05 level. Alcon data on fle, 2013. 3. Eiden SB, Davis R, Bergenske P. Prospective
study of lotraflcon B lenses comparing 2 versus 4 weeks of wear for objective and subjective measures of health, comfort, and vision.
Eye & Contact Lens. 2013;39(4):290-294.
2014 Novartis 2/14 AOC14003JAD-B See product instructions for complete wear, care and safety information.
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ACUVUE
Brand Contact Lenses are indicated for vision correction. As with any contact lens, eye problems, including corneal ulcers, can develop. Some wearers may experience mild
irritation, itching or discomfort. Lenses should not be prescribed if patients have any eye infection, or experience eye discomfort, excessive tearing, vision changes, redness or other
eye problems. Consult the package insert for complete information. Complete information is also available from VISTAKON
Helps protect against transmission of harmful UV radiation to the cornea and into the eye.
WARNING: UV-absorbing contact lenses are NOT substitutes for protective UV-absorbing eyewear such as UV-absorbing goggles or sunglasses, because they do not completely cover the
eye and surrounding area. You should continue to use UV-absorbing eyewear as directed. NOTE: Long-term exposure to UV radiation is one of the risk factors associated with cataracts.
Exposure is based on a number of factors such as environmental conditions (altitude, geography, cloud cover) and personal factors (extent and nature of outdoor activities). UV-blocking
contact lenses help provide protection against harmful UV radiation. However, clinical studies have not been done to demonstrate that wearing UV-blocking contact lenses reduces the risk
of developing cataracts or other eye disorders. Consult your eye care practitioner for more information.
References: 1. The big picture: eye protection is always in season. The Vision Council Web site. http://www.thevisioncouncil.org/sites/default/les/VCUVReport2013FINAL.pdf.
Accessed May 7, 2014. 2. Chandler H. Ultraviolet absorption by contact lenses and the signicance on the ocular anterior segment. Eye Contact Lens. 2011;37(4):259-266.
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CONTRIBUTING EDITORS
PAUL C. AJAMIAN, OD, ATLANTA
AARON BRONNER, OD, KENNEWICK, WASH.
MILE BRUJIC, OD, BOWLING GREEN, OHIO
DEREK N. CUNNINGHAM, OD, AUSTIN, TEXAS
MARK T. DUNBAR, OD, MIAMI
ARTHUR B. EPSTEIN, OD, PHOENIX
JAMES L. FANELLI, OD, WILMINGTON, NC
FRANK FONTANA, OD, ST. LOUIS
GARY S. GERBER, OD, HAWTHORNE, NJ
ANDREW S. GURWOOD, OD, PHILADELPHIA
ALAN G. KABAT, OD, MEMPHIS, TENN.
DAVID KADING, OD, SEATTLE
PAUL M. KARPECKI, OD, LEXINGTON, KY.
JEROME A. LEGERTON, OD, MBA, SAN DIEGO
JASON R. MILLER, OD, MBA, POWELL, OHIO
CHERYL G. MURPHY, OD, HOLBROOK, NY
CARLO J. PELINO, OD, JENKINTOWN, PA.
JOSEPH PIZZIMENTI, OD, FORT LAUDERDALE, FLA.
JOHN RUMPAKIS, OD, MBA, PORTLAND, ORE.
DIANA L. SHECHTMAN, OD, FORT LAUDERDALE, FLA.
JEROME SHERMAN, OD, NEW YORK
JOSEPH P. SHOVLIN, OD, SCRANTON, PA.
JOSEPH W. SOWKA, OD, FORT LAUDERDALE, FLA.
MONTGOMERY VICKERS, OD, ST. ALBANS, W.VA.
WALTER O. WHITLEY, OD, MBA, VIRGINIA BEACH, VA.
EDITORIAL REVIEW BOARD
JEFFREY R. ANSHEL, OD, CARLSBAD, CALIF.
JILL AUTRY, OD, RPH, HOUSTON
SHERRY J. BASS, OD, NEW YORK
EDWARD S. BENNETT, OD, ST. LOUIS
MARC R. BLOOMENSTEIN, OD, SCOTTSDALE, ARIZ.
CHRIS J. CAKANAC, OD, MURRYSVILLE, PA.
JERRY CAVALLERANO, OD, PHD, BOSTON
WALTER L. CHOATE, OD, MADISON, TENN.
BRIAN CHOU, OD, SAN DIEGO
A. PAUL CHOUS, MA, OD, TACOMA, WASH.
ROBERT M. COLE, III, OD, BRIDGETON, NJ
GLENN S. CORBIN, OD, WYOMISSING, PA.
ANTHONY S. DIECIDUE, OD, STROUDSBURG, PA.
S. BARRY EIDEN, OD, DEERFIELD, ILL.
STEVEN FERRUCCI, OD, SEPULVEDA, CALIF.
MURRAY FINGERET, OD, HEWLETT, NY
IAN BEN GADDIE, OD, LOUISVILLE, KY.
MILTON HOM, OD, AZUSA, CALIF.
BLAIR B. LONSBERRY, MS, OD, MED, PORTLAND, ORE.
THOMAS L. LEWIS, OD, PHD, PHILADELPHIA
DOMINICK MAINO, OD, MED, CHICAGO
KELLY A. MALLOY, OD, PHILADELPHIA
RICHARD B. MANGAN, OD, LEXINGTON, KY.
RON MELTON, OD, CHARLOTTE, NC
PAMELA J. MILLER, OD, JD, HIGHLAND, CALIF.
BRUCE MUCHNICK, OD, COATESVILLE, PA.
MARC MYERS, OD, COATESVILLE, PA.
WILLIAM B. POTTER, OD, FREEHOLD, NJ
CHRISTOPHER J. QUINN, OD, ISELIN, NJ
JACK SCHAEFFER, OD, BIRMINGHAM, ALA.
MICHAEL C. RADOIU, OD, STAUNTON, VA.
KIMBERLY K. REED, OD, FORT LAUDERDALE, FLA.
LEO P. SEMES, OD, BIRMINGHAM, ALA.
LEONID SKORIN, JR., OD, DO, ROCHESTER, MINN.
BRAD M. SUTTON, OD, INDIANAPOLIS
LORETTA B. SZCZOTKA, OD, PHD, CLEVELAND
TAMMY P. THAN, MS, OD, BIRMINGHAM, ALA.
RANDALL THOMAS, OD, CONCORD, NC
KATHY C. WILLIAMS, OD, SEATTLE
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Understand. Manage. Grow.
Patients look to optometrists for
expertise, knowledge, and direction,
not a goody bag. Lens care makes a
difference in the comfort and safety
of a patients wearing experience, and
most of us have a preferred product.
It is up to the eye care professional
to invest the time to properly educate
and direct patients choices. Lens care
is too essential to be diminished to a
trick or treat equivalent.
ESTABLISHING A PRODUCTIVE
RELATIONSHIP WITH PATIENTS
Whereas about 95% of optometrists in
a recent survey said they handed out a
sample lens care kit for every contact
lens patient, only 31% of patients said
they received an actual recommenda-
tion for a specic product.
1
This is an
excellent reminder that distributing free
sample kits does not
always translate into
a recommendation. In
reality, free samples
have not impacted pa-
tient compliance or pa-
tients decisions about
what to purchase.
Instead, patients
want direction. In a
recent survey, patients
had to choose between
receiving a free sample
of solution or a recom-
mendation for a specic product. The
majority of patients surveyed chose the
doctors recommendation, saying they
would forgo a free sample in exchange
for doctor-driven direction.
2
Optometrists should compare the
ocular products on the market and de-
termine which ones they would prefer
patients to useboth prescription and
OTC products. It is critical to effec-
tively communicate a specic product
recommendation and proper lens
care protocol to the
patient. Using a small
tear-off pad that de-
tails your suggestions
for the lens care, wear
time, and disposal
schedule could be use-
ful for disseminating
this information.
Sample solution kits
are good for rst-time
wearers, who are
receptive to taking
direction in both what
to use and how to properly care for
their lenses. These individuals have
nothing at home to use, and we want
to start them off on the right track with
the right habits.
Patients who have been in contact
lenses for years are typically older
and likely experiencing decreased tear
production and dryer eyes, meaning
they have higher demands to keep their
lenses wet and comfortable. Unfortu-
nately, the established wearers are the
least loyal to branded solutions,
3
and
their propensity to move toward store-
branded solutions may not provide the
desired comfort they need.
Discomfort is the number-one reason
patients discontinue lens wear, and
contact lens care inuences comfort.
4
In
a recent global survey of over 10,000
patients, 58% of contact lens wearers
reported end-of-day dryness after using
their current lens care protocol, but
only 19% continued to have issues after
switching to OPTI-FREE
PureMoist
MPDS for two weeks.
5
These data
highlight the importance of spending
time to educate patients on using the
recommended solution in the correct
manner.
CONCLUSION
The doctors recommendation is the
key to inuencing patient behavior. If it
is true that there is a difference in lens
care productsand it is truethen our
advice on what product to use should
not change according to our supply of
sample kits. It is our responsibility to
research and decide which products
are best for our patients, and it is our
duty to relay that information to our
patients in a manner that translates the
importance of compliance.
Crystal Brimer, OD, has a private
practice in Wilmington, North Caro-
lina, and serves as a primary clinical
investigator, with special interests in
contact lenses, dry eye disease, and
practice management. She is a paid
consultant to Alcon.
Dr. Brimer may be reached at
drbrimer@crystalvisionservices.com.
Free is Not Always Effective
How do we ensure patients use the ocular products we think
are best? For prescription products, the answer is simple; but in
the over-the-counter (OTC) realm, it is much more complex. For
decades, we have handed out free samples and coupons, but do
they affect patients decision making, or does denitive direction
from the doctor have a greater impact on patient purchases?
ADVERTORI AL
2014 Novartis 6/14 OPM14033AD
By Crystal M. Brimer, OD
WHATS THE SOLUTION?
KEY POINTS
Patients look to their eye care provider
for expertise, knowledge, and specic
direction.
Patients in a recent survey
indicated they would forgo a free
sample in exchange for a specic
recommendation from their eye care
provider.
2
Giving patients clear advice about
what products to useand how to
use themmay be the key to ensuring
better compliance with lens protocols.
1. Alcon data on file, 2012.
2. In a survey of 353 contact lens wearers; Alcon data on file, 2012.
3. Alcon data on file, 2010.
4. Rumpakis JMB. New data on contact lens dropouts: an international perspective. Rev Optom. 2010:1-4.
5. Lemp J, Kern JR. Results from a global survey of contact lens-wearer satisfaction with OPTI-FREE PureMoist Multi-Purpose Disinfecting Solution.
Clinical Optometry. 2013;5:39-46.
It is critical
to effectively
communicate a
specic product
recommendation
and proper lens
care protocol to
the patient.
Outlook
18 REVIEW OF OPTOMETRY JULY 15, 2014
E
ven if the annual glaucoma
incidence numbers were
declining, the prospects for
making headway against this insidi-
ous disease could be described as
abysmal. Current estimates are
that 60% to 70% of glaucoma in
the US population is undiagnosed,
notes Mark Swanson, OD, MSPH,
in his article on epidemiology on
page 44 of this issue, our 20th
Annual Glaucoma Report. When
taking into account the low levels
of adherence to glaucoma medica-
tion regimens, he goes on, as
much as 80% of glaucoma in the
US population may be untreated.
But we all know the numbers
arent decliningtheyre increas-
ing, both in the aggregate and in
the lifetime exposure per patient.
Because the population is aging,
and average lifespan has length-
ened, we have more elderly people
than ever, and they live longer
nowadays. If its true that only one
in five glaucoma patients is ade-
quately maintained on therapy, the
challenge to eye doctors seeking to
reverse those trends is formidable.
For minority patients, the future
looks especially grim. Various racial
and ethnic subgroups have higher
rates of glaucoma, higher rates of
poverty and higher rates of popula-
tion growth than the country as a
whole. Put all those together and
they point to a crisis in the making:
more patients in need of care, with
a disproportionate lack of access
to routine medical services, and
cultural and financial obstacles to
contend with too.
For patients, its the perfect
storm; for ODs, the perfect oppor-
tunity to rise to the challenge.
With its chronic, slowly progres-
sive nature, glaucoma is best suited
for doctors who can invest the time
to document its course over a long
time span. The battery of standard
testsvisual fields, OCTs, optic
nerve examscan make patient
visits time consuming for the prac-
tice. The clinical decision-making
responsibilitiesthough potentially
life-changing for the individual
are typically non-urgent, allowing
time for careful analysis and con-
sideration, including consultation
with specialists when needed. And
the doctor/patient rapport must be
strong enough to break through the
barriers to medication adherence.
Every one of those aligns exactly
with the strengths of optometric
practice (and, not coincidentally,
with deficits in ophthalmology), as
ODs cultivate relationships with
patients through years or often
decades of routine care. With MD
practices fewer in number com-
pared to optometrys footprint, and
their practitioners so overwhelmed
with surgical case loads, glaucoma
is an inherently poor fit for most
busy ophthalmology practices.
Put another way, glaucoma care
wont improve until ODs take charge
of it. Nows your chance to shine.
ODs: Were Up to the Task
Fortunately, optometrists seem
both willing and able to take on the
extra work. In the recently released
AOA manpower study of eye care
supply and demand in the US,
optometrists said that they could fit
in an additional 19.8 patient visits
per week even if they already had a
full schedule, without adding more
hours to their clinic time.
The manpower study cites a
previous AOA research effort, the
2012 National Eye Care Workforce
Survey of Optometrists, in which
responding optometrists indicated
that, if they were able to operate at
their full capacity without increas-
ing their current patient care hours,
they could provide about 32%
more patient visits per year than
they were actually providing.
If we take this excess capacity
into account and compare supply
including excess capacity to the
baseline demand, there is no longer
excess demand, the manpower
report states. In fact, our estimates
indicate that there is significant
excess supply when this excess
capacity is included.
Theres no shortage of patients in
need of care to take up that excess
capacity, of course. The AOA
report cites the often-mentioned
increase in pediatric patient visits in
the wake of the ACA, and also the
need for more diabetic eye health
screenings. Without diminishing
those pressing needs, glaucoma
might be the ideal place to start.
Fitting in lots of extra patient
visits wont be easy. Relating to the
increasingly diverse population will
pose challenges too. But glaucoma
is a public health crisis in the mak-
ingand optometrists are ideally
positioned to conquer it.
ODs are in prime position to address the growing needs of under-served glaucoma
patients, elevating the profession with distinction. By Jack Persico, Editor-in-Chief
Rise and Shine
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iPhone Refraction? iLove It!
An app that refracts is like having an OD in your pocketwhich begs the question:
Is that an OD in your pocket or are you just happy to see me? By Montgomery Vickers, OD
I
hear theres now a smartphone
app that can perfectly refract a
patient in the comfort of his or
her own car in between texts. This
is awesome, as I have been refract-
ing old-school for 34+ years and
have never reached perfection.
One advantage is that the phone
wont have to put up with patients
saying they like number one when
they really like number two.
In those inevitable cases when a
patient has trouble adapting to their
glasses Rx, and they inevitably ask,
Why did this happen? I inevita-
bly smile my most benevolent smile
and inevitably say, Because you
said you liked number one when
you really liked number two!
They think Im joking.
But, now, through the wonderful
power of our phones, this conversa-
tion will never take place! And who
will they complain to when they
cant see through their phony
glasses? Us. I cannot wait to see the
look on their faces when I explain
that I charge $413.34 to recheck
a phone-induced Rx. Should be a
hoot. Perhaps Ill film it on MY
phone for YouTube.
Amazing, life-changing technolo-
gies are all around us these days.
Just look at Google. Do you realize
that Ryan Seacrest is the same exact
height as I am? Thats right! 64!
(If you dig deep enough, there must
be at least one website that will
say hes not 58.) The bad news is
my right leg outweighs him. These
smartphones are awesome!
The power in this little device is
just amazing. For example:
I recently used my phone to
photograph a ladys anterior seg-
ment. (Ill just leave the joke on the
table there.)
I recently used my phone to
trace a rectangle for my grandkids.
I recently used my phone to
keep my napkin from blowing
away at a picnic.
And to think this $500 paper-
weight can replace my need to
refract? I have died and gone to
heaven! Now the world wont
come to an end because opticians
wont have any reason to politick
to refract. Heck, any idiot with an
app can refract now, right? And,
lazy ophthalmologists will finally
stop using Donders Table to decide
what seg power a patient needs!
The phone will decide! Sweet!
Power to the people!
But now that weve learned how
the government uses our phones to
track and control us, what really
happens when you stick your eye
up there to get your new glasses
prescription? Could they really be
shooting rays into our
brains that make us
dumb enough to
keep voting
for them?
How else
could you
explain
it? Must be the phones.
As technology moves forward, I
can envision a time when we wont
really need to see at all. Well just
dangle two smartphones in front
of our eyes from a designer frame.
Your car will drive itself so youll be
free to watch Game of Thrones
on one side and Jeopardy! on the
other.
Daily Double? What are naked
dragons?
How long will it take until you
can get the newest DangleGlasses
for nothing at the mall? Every street
corner will be full of begging bums,
formerly known as eye doctors,
who scramble for a buck now that
their services are no longer needed,
thank you very much.
That may sound crazy but once
the smartphones put all the eye
problems behind us, what else is
behind us?
iColonoscopy? I cant wait!
REVIEW OF OPTOMETRY JULY 15, 2014 20
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REVIEW OF OPTOMETRY JULY 15, 2014 22
Codi ng Abstract
O
ne of the biggest reasons
for failing an insurance
audit is not being specific
enough when performing services
for a patient. A perfect example
of this is what many doctors call
a glaucoma check. I see it in
patient records quite frequently
when Im doing an internal audit
for a practice. The chief complaint
(CC) might say, Patient returning
for glaucoma check, or sometimes
nothing more than IOP check.
Simple phrases mean different
things to different people. Just what
is a glaucoma check? To some,
it may be only measuring IOP. To
others, its a dilated evaluation of
the optic nerve, a visual field and an
OCT of the optic disc. Some may
like to include gonioscopy, while
others prefer anterior segment
OCT.
Because theres so much variation
in services provided, avoid all-pur-
pose phrases in the medical record.
Rather, describe exactly why the
patient is returning to the office.
Patient careand our medical
recordneed to be specific to the
individual patient. We dont per-
form services based on an ICD-9
or ICD-10 code, nor do we bundle
care just because we dont want to
miss something. We should evaluate
each patient as an individual, and
our assessment of their individual
risk is based upon their history and
physical findings. Some patients
may require more or less testing
than others.
For that matter, the same patient
may require different levels of
examination and testing on differ-
ent visits; our records need to prop-
erly reflect that.
State Your Reasons
Keep in mind that medical care
today is based on medical neces-
sitymeaning that the level of the
office visit performed and the addi-
tional testing ordered must be nec-
essary for that individual patient.
Also, remember that the CC
requirement can be fulfilled prop-
erly if you direct the patient to
return to the office for a specific
reason at an appropriate interval.
So, perhaps the plan section of
our medical record should include
a statement such as: Patient to
return to clinic for evaluation of
IOP and optic nerve Q3 months or
PRN should additional symptoms
arise, rather than: RTC three
months for glaucoma check. The
former statement tells the record
what I want the patient to do and
why I want him to do it, while the
latter provides no explicit reasoning
or medical strategy.
Then, when the patient returns,
the CC should read: Patient
returning to clinic per doctor-
directed order for evaluation of
IOP and optic nerve. And, if you
have orders pending for special
ophthalmic testing, those could also
be listed in both the plan and the
reason for the visit.
Last but not least, be aware of
current Correct Coding Initiative
edits, which stipulate whether you
can perform specific ophthalmic
tests on the same day. For example,
you cannot do both an anterior seg-
ment OCT (92132) and a posterior
OCT (either 92133 or 92134) on
the same date of service.
Creating a medical record that is
both specific and individualized for
the patient is critical. Your medical
record is your greatest weakness
and your most powerful weapon
its the only thing that a carrier can
use against you in an audit, and it is
the only thing you can use in your
defense. Most importantly, its one
of the few things that you, as a phy-
sician, have total control over.
So, try to make your medical
record perfect; not only will it help
you pinpoint your patient care, but
help protect you, too.
Please send your questions and
comments to CodingAbstract@
gmail.com.
Avoid vague, stock phrases in your medical record. Get down to specifics.
By John Rumpakis, OD, MBA, Clinical Coding Editor
No More Glaucoma Checks
Just what is a glaucoma check? To some, it may be only
measuring IOP. To others, its a dilated evaluation of the optic
nerve, a visual field, and an OCT of the optic disc.
Better to avoid such all-purpose phrases in the medical record.
THIS IS WHY OPTI-FREE
PureMoist
Solution
allows patients to wear contact lenses
MORE COMFORTABLY
1
AND LONGER each day.
2
PERFORMANCE DRIVEN BY SCIENCE
References: 1. Campbell R, Kame G, Leach N, et al. Clinical benefits of a new multipurpose disinfecting solution in silicone hydrogel and soft contact lens users. Eye & Contact Lens.
2012;38(2):93-101. 2. Alcon data on file, 2011. 3. Lally J, Ketelson H, Borazjani R, et al. A new lens care solution provide moisture and comfort with todays contact lenses. Optician.
2011;241:42-46. 4. Davis J, Ketelson HA, Shows A, Meadows DL, A lens care solution designed for wetting silicone hydrogel materials. ARVO Meeting Abstracts. 2012;38(2):93-101. 5. Lemp
J, Kern JR. Results from global survey of contact lens-wearer satisfaction with OPTI-FREE
PureMoist
Moisture Matrix
attaches and forms a hydrophilic
environment across the surface of
the lensproviding moisture from
morning til night.
2-4
Based on a global survey of 10,611 contact lens wearers who tried OPTI-FREE
PureMoist
PureMoist
PureMoist
MPDS
3X
FEWER PATIENTS
reported end-of-day
dryness
5
Talk to your patients about the benefit of
OPTI-FREE
contact lenses mimics the shift from
hydrophobicity at the corneal epithelial
cell surface, to hydrophilicity and mucin-
binding properties at the glycocalyx. As
the epithelial microvilli and mucins do on
the cornea, the water-binding surface of
DAILIES TOTAL1
water gradient contact lenses, I explain that the lens surface is
moist, lubricious, and very smoothso smooth that they may
not feel the lens at all.
10
Patients appreciate learning about new
technology and, even if they do not opt for DAILIES TOTAL1
contact lenses right away, are reassured to know that a new
level of contact lens comfort is available.
Paul Karpecki, OD, FAAO, works in Corneal Services and
is Clinical Research Director at the Kofer Vision Group in
Lexington, KY.
REFERENCES
1. Craig JP, Willcox MDP, Argeso P, et al. The TFOS international workshop on
contact lens discomfort: report of the contact lens interactions with the tear lm
subcommittee. Invest Ophthalmol Vis Sci. 2013;54:TFOS123-6.
2. Cruz AAV, Garcia DM, Pinto CT, Cechetti SP. Spontaneous eyeblink activity. Ocul
Surf. 2011;9(1):29- 41.
3. Coles C. Coefcient of friction and contact lens comfort. OptomVis Sci. 2012;89.
E-abstract 125603.
4. Korb DR, Greiner JV, Herman JP, et al. Lid-wiper epitheliopathy and dry-eye
symptoms in contact lens wearers. CLAO J. 2002;28(4):211- 6.
5. Thekveli S, Qui Y, Kapoor Y, et al. Structure-property relationship of delelcon A
lenses. Contact Lens Anterior Eye. 2012;35(Supp 1):e14.
6. Alcon data on le, 2011.
7. Angelini T, Nixon R, Dunn At, et al. Viscoelasticity and mesh-size at the surface
of hydrogels characterized with microrheology. Invest Ophthalmol Vis Sci.
2013;54:E-abstract 500.
8. Sawyer WG, Dunn AC, Uruena JM, et al. Robust contact lens lubricity using surface
gels. Invest Ophthalmol Vis Sci. 2012;53: e-abstract 6095.
9. Prez-gmez I, Giles T. European survey of contact lens wearers and eye care
professionals on satisfaction with a new water gradient daily disposable contact
lens. Clinical Optometry. 2014;6:17-23.
10. In a clinical study with 80 patients. Alcon data on le, 2011.
*In vitro measurement of unworn lenses.
When placed on the eye, a contact lens alters the structure
of the tear lm and reduces its stability.
1
Depending on lens
material, tear evaporation can lead to the
formation of dry spots on the lens surface
and to increased friction during blink.
1
Ideally, soft contact lens materials should
minimize impact on tear lm stability and
friction during blink.
But the surface of most soft contact
lenses lacks the corneas ability to bind
mucus, which aids in the formation of the
normal tear lm. In lieu of the corneas
mucin glycocalyx, a moist and lubricious
contact lens surface can create an appropriate environment for
tear lm stability and for the eyelids to pass over smoothly.
LUBRICITY: THE CONCEPT
Lubricity is dened as the inverse of friction, the resistance
between two surfaces when one moves over the other. When
the eyelid slides across a contact lens surface during blink, the
lubricity of that surface determines how smooth the movement is.
Considering that a normal eye blinks more than 1,000 times per
waking hour, the importance of lens surface lubricity is clear.
2
Indeed, recent studies have found that a low coefcient of
friction (high lubricity) is a principal factor in predicting contact
lens comfort.
3
Further, lens wearers with dryness symptoms
are signicantly more likely to exhibit lid wiper epitheliopathy
than asymptomatic wearers, suggesting a connection between
ocular surface dryness, friction, and epithelial cell damage.
4
IMPROVING LUBRICITY: THE CHALLENGE
Though high surface lubricity is desirable, balancing it with
other material properties has been challenging, particularly
with silicone hydrogels. Silicone hydrogel lenses are highly
oxygen permeable, but because silicone is hydrophobic, they
require modication for enhanced surface hydrophilicity.
Silicone hydrogel lenses have been modied using
plasma surface coatings and wetting agents in the lens matrix
and/or the packaging solution. But with the introduction of
DAILIES TOTAL1
contact
lenses are not composed of a single, uniform bulk material.
Rather, the core of DAILIES TOTAL1
contact lenses is a
highly breathable silicone hydrogel of 33% water content,
which transitions to an ultra-hydrophilic surface gel exceeding
80% water content.
5,6
* This material innovation resolves
the challenge of silicone hydrogel surface wettability, and it
PAUL KARPECKI, OD, FAAO Help patients understand the signicance of contact lens surface lubricity,
and let them experience it rsthand with DAILIES TOTAL1
Contact Lenses
High lubricity makes for smooth
interface with tears, lids
Water gradient surface mimics
corneal epithelium and glycocalyx
A new tool to address contact
lens discomfort
REVIEW OF OPTOMETRY JULY 15, 2014 32
Plotting the Path of
Progression
W
ith just one health sta-
tus variable that yields
to medical or surgical
intervention, glaucoma
management at its core is very fun-
damentallower the intraocular
pressure (IOP) to a level that reins
in visual field loss. In this clinical
model, detecting glaucoma progres-
sion becomes paramount for suc-
cessful management outcomes.
Serial optical coherence tomogra-
phy (OCT) of the retinal nerve fiber
layer (RNFL) and threshold visual
field analysis, herein referred to as
glaucoma progression tests, com-
prise much of our ability to achieve
this task. Both are complemented
by statistical software packages
designed to enhance this ability.
Tonometry, though unsophisticated
in what it tells us about the patient,
remains essential. As such, treating
glaucoma in 2014 requires clinicians
to effectively navigate a variety of
testing modalities and analytical
software that must be logically inte-
grated into a comprehensive, mean-
ingful clinical picture.
This article looks at practical
approaches to reconciling three com-
plex and interrelated components
of glaucoma care: IOP assessment,
serial RNFL OCT analysis and serial
threshold visual field analysis.
Organize IOP Readings
Glaucoma progression tests are
only relevant if we can do some-
thing about the findings; namely,
adjusting the patients IOP range
through either medical or surgical
means. Therefore, it is important to
compare any changes in your glau-
coma progression tests with the IOP
levels during the period in which the
changes occurred.
In a busy practice, it is easy to
only look at the last couple of IOP
readings to gauge the treatment effi-
cacy. However, to successfully treat
glaucoma, it is imperative to dem-
onstrate a real IOP lowering effect
from the treatments that you have
prescribed, and this often requires
gathering all IOP data for analysis.
Quantifying the IOP reduction from
your baseline values will provide
context for any changes seen on
glaucoma progression tests. This is
best achieved by taking the average
IOP for each treatment or combina-
tion of treatments prescribed.
Calculating average IOP when
analyzing therapeutic response is
advantageous in that it has been
shown to correlate with the extent
Our success in managing glaucoma hinges on our ability to recognizeand make
sense ofboth structural and functional changes. By Scott Anthony, OD
Figure 1 (at right). This patient with moder-
ate POAG OS demonstrates the complexity
of contemporary glaucoma management. It
can take years to establish enough visual
fields to accurately determine if progres-
sion has occurred. In that time, treatments
are added or adjusted, and technologies
change, requiring updating of the base-
line exams to determine if the therapy is
adequate.
Each treatment is demarcated by a block
of time to coordinate IOP findings, RNFL OCT
scans and GPA for visual fields. Because
this patient required multiple medication
changes in a relatively short period of time,
it was best to use only the pretreatment
block and an all-treatments block.
Despite a variety of treatments with vary-
ing reductions in IOP, this patients RNFL
OCT and GPA revealed no progression over
a seven-year period, thereby meeting the
overall management goal.
20th Annual GLAUCOMA Report
REVIEW OF OPTOMETRY JULY 15, 2014 33
p
r
e
t
r
e
a
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o
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a
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o
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+
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a
l
l
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r
e
a
t
m
e
n
t
s
IOP
Average 20.7mm Hg
Standard deviation 1.15mm Hg
IOP
Average 16.2mm Hg
Baseline reduction: -22%
IOP
Average 16.2mm Hg
Baseline reduction: -22%
IOP
Average 15.6mm Hg
Baseline reduction: -25%
IOP
Average 15.2mm Hg
Baseline reduction: -27%
Standard deviation 2.7mm Hg
RNFL OCT
NO PROGRESSION
all scans within expected
test-retest variability
HVF glaucoma
progression analysis
NO PROGRESSION FROM
BASELINE SCANS
RNFL time-domain OCT
BASELINE
average RNFL: 68m
RNFL time-domain OCT
FOLLOW-UP 1
average RNFL: +4m
RNFL spectral-domain OCT
BASELINE [JAN. 2010]
average RNFL: 57m
BASELINE [JAN. 2010]
average RNFL: 57m
FOLLOW-UP 2 [FEB. 2011]
average RNFL: 0m
FOLLOW-UP 3 [MAY 2012]
average RNFL: -3m
FOLLOW-UP 4 [SEPT. 2013]
average RNFL: -2m
BASELINE 1
JUNE 2006
BASELINE 2
JULY 2006
FOLLOW-UP 1
SEPT. 2007
FOLLOW-UP 2
MARCH 2008
FOLLOW-UP 3
JUNE 2009
FOLLOW-UP 4
MAY 2010
FOLLOW-UP 5
FEB. 2011
FOLLOW-UP 6
MAY 2012
REVIEW OF OPTOMETRY JULY 15, 2014 34
of glaucoma progression.
1
You may
also consider calculating the degree
of IOP fluctuationthought to be
a factor in glaucoma progression,
although this has been contested.
2
It
can be estimated using the standard
deviation (SD) of IOP (free SD cal-
culators are readily available online)
or taking the difference between
maximum and minimum values.
In studies that did find fluctuating
IOP to be a risk factor for glaucoma
progression, the SD values were
typically greater than 2mm Hg to
3mm Hg. Statistically, estimating the
average IOP and SD of IOP becomes
more powerful as you accumulate
additional IOP measurements.
The process of cataloging IOP
readings is very straightforward
and only requires that you group
all measurements according to the
treatments prescribed at that time,
if any. For instance, if a patient has
been on travoprost monotherapy
for four years and I notice they are
progressing and add dorzolamide in
response, I will establish two treat-
ment groups from which to analyze
all of my clinical data (e.g., IOP,
RNFL OCT, visual fields): a travo-
prost group and a travoprost/dorzol-
amide group. Once this is done, you
can calculate the average IOP for
each treatment group to assess the
extent of IOP lowering.
The pretreatment block of time is
the most critical, as this establishes
the IOP range that is known to
result in a glaucomatous outcome.
Therefore, it is recommended that
multiple IOPs be taken at different
times of day prior to initiating any
glaucoma treatments. As a reference,
the Early Manifest Glaucoma Trial
and Ocular Hypertension Treatment
Study, both highly regarded clinical
trials, used just two pretreatment
IOP measurements from which to
judge the efficacy of the treatments
studied.
3,4
Ideally, recording diurnal IOP
measurements on different days is
best for assessing the true IOP, as
IOP has been shown to fluctuate
both spontaneously over time and
asymmetrically between the eyes.
2,5
Realistically, two to three IOP mea-
surements at different times of day
may be sufficient.
2009
2010
2012
A
B C D E
Average RNFL: 108m
Average RNFL: 109m +1m
Average RNFL: 92m -16m
Right Eye
20th Annual GLAUCOMA Report
REVIEW OF OPTOMETRY JULY 15, 2014 35
Because patient compliance can
vary considerably, attempt to grossly
quantify the compliance level for
each treatment group whenever pos-
sible. For instance, if a patient tells
me he misses his latanoprost drops
about twice a week because he falls
asleep prior to instilling the drops,
I estimate his compliance to be
approximately 70%.
Estimating compliance can be
helpful when glaucoma progression
tests worsen despite the average IOP
meeting the target range. This may
suggest that your patient is compli-
ant in the days leading up to their
examination, but noncompliant
otherwise. Also, when analyzing
each treatment group it is important
to look for any trending of the IOP
values to avoid averaging out poten-
tial problems, such as therapeutic
tachyphylaxis (i.e., a loss of treat-
ment efficacy over time) or a change
in compliance. Always keep in mind
that IOP-independent mechanisms
may contribute to glaucoma pro-
gression, even in the face of low IOP
levels.
By grouping and then averaging
IOP readings for your various treat-
ments, you will be better prepared
to correlate any changes that you
encounter in your glaucoma pro-
gression tests (see figure 1).
Reconciling OCT Findings
The approach to detecting pro-
gressive thinning of the RNFL differs
among OCT devices, particularly in
the use of software modules to help
identify progressive RNFL thinning.
Most, if not all, OCT devices assess
the RNFL thickness based upon a
ring scan centered on the optic disc.
In addition to the parapapillary
circle scan, some OCT devices also
scan the entire area immediately sur-
rounding the optic disc. Irrespective
of your OCTs acquisition and ana-
lytical capabilities, it will be impor-
tant to match the RNFL data with
the IOP groups you have established
for each glaucoma treatment.
Here are a few ideas on how serial
RNFL evaluation can help detect
progression as early as possible.
As we move out of the time-
domain (TD) and into the
spectral-domain (SD) era of OCT
F
A
B C D E
Average RNFL: 99m
Average RNFL: 98m -1m
Average RNFL: 90m -9m
Figure 2. A non-compliant
patient had rapid RNFL progres-
sion detected by SD-OCT:
(A) Optic nerve photo.
(B) Infrared reflectance image
showing parapapillary ring
scan.
(C) Red-free reflectance image
showing RNFL wedge defects
OU.
(D) Volumetric RNFL thickness
map and (E) RNFL deviation
map of the parapapillary region
showing RNFL defects detected
with SD-OCT.
(F) The RNFL OCT changes are
consistent with a step-wise pro-
gressive pattern, with a period
of stability in 2009 and 2010
followed by a dramatic drop in
the average RNFL thickness.
Left Eye
REVIEW OF OPTOMETRY JULY 15, 2014 36
acquisition, our ability to produce
highly repeatable measurements is
vastly improved, as is the ability
to detect microstructural changes
evident in glaucoma progression.
6
With TD-OCT, measurement of the
RNFL was limited to the circular
line-scan mentioned above. Alterna-
tively, volumetric RNFL assessment
of the entire parapapillary region
(not capable with a parapapillary
circle scan) is now possible with SD-
OCT. This method of RNFL analy-
sis yields topographical maps that
can assist in defining areas of RNFL
depression in the form of wedge
defects or generalized thinningfea-
tures that are technically difficult
to appreciate using funduscopy or
photography.
7
Figure 2 provides an
example of this.
In fact, Leung et al. demonstrated
that measuring RNFL thickness
using a 3.46mm circumpapillary
ring is not as sensitive in identifying
progression as using a 6mm x 6mm
volumetric grid pattern centered
over the optic disc, the acquisition
protocol used by the Cirrus HD-
OCT (Carl Zeiss Meditec). The
usefulness of constructing an RNFL
topographical map around the disc
is that it expands the ability to iden-
tify widening, deepening or the for-
mation of new RNFL wedge defects,
all classic signs of glaucoma progres-
sion.
7
Although the parapapillary
ring scan is still the most commonly
used method to assess RNFL thick-
ness, volumetric scans can provide
complementary data for detecting
glaucoma progression.
Regardless of the RNFL scan
type used, detecting RNFL thinning
requires good intratest repeatability
and point-to-point retinal registra-
tion to ensure accurate comparisons
between scans, thereby giving you
the best chance to determine if
progression is occurring.
8
Clinical
studies show that the average RNFL
thickness parameter is useful for
demonstrating glaucoma progres-
sion.
9
This metric is used in guided
progression analysis (GPA) software
available with Cirrus HD-OCT.
In healthy eyes, the average RNFL
thickness should show minimal
change over time due to age. Typi-
cally, test-to-test repeatability for
SD-OCT ranges from 1m to 5m
for average RNFL thickness. There-
fore, if the average RNFL OCT
indices are reduced by greater than
5m from the baseline values, the
clinician should be alerted to pos-
sible glaucomatous progression.
Evaluating RNFL thickness change
by sector and quadrant is also fea-
sible, with the inferior temporal
sector and inferior quadrant having
greater predictive value for identify-
ing progression.
9
Tracking RNFL measurement
changes that fall outside the range
of expected test-retest variability is
termed event analysis.
9,10
Simply put,
with event analysis you establish
two baseline scans at the start of
your treatment period; for instance,
when starting a patient on a glau-
coma medication or switching from
monotherapy to combination ther-
apy. You then judge all future RNFL
scans to the baseline scans taken
at the beginning of the treatment
period, knowing that the RNFL
values should change minimally if
the therapy is effective. This type of
analysis can help you determine if
progression is present, but does not
tell you how fast it is occurring.
To assess the rate of RNFL pro-
gression you must perform trend
analysis, which can be estimated
using OCT GPA. Always be cau-
tious when RNFL thickness mea-
surements change, as they may not
always indicate glaucoma progres-
sion. Instead, it may be secondary
to poor signal strength, misaligned
scan, or errors in automated seg-
mentation line placement. To rule
out false progression due to artifact
in the OCT scan, carefully examine
all the parapapillary cross-sectional
OCT images and look for areas
where the retinal layers appear ill-
defined or blurred. These are areas
of poor signal strength and can
result in deviation of the segmen-
tation lines from the anatomical
boundaries of the RNFL, which can
influence the average RNFL thick-
ness values.
If the RNFL is progressively thin-
ning based on your serial RNFL
OCT analysis, close inspection of the
IOP treatment blocks may shed light
on the range of IOP that resulted in
the changes seen. Although RNFL
thinning has been known to be a
precursor to functional loss, there
may be no concordant change in the
visual field status.
Also keep in mind that glaucoma
progression can take on different
rate patterns, with both a continu-
ous and step-wise pattern having
been previously described.
9
The
former will demonstrate a slow-
steady decline, whereas the step-wise
pattern will have periods of stability
interrupted by periods of progres-
sion, typically during intermittent
glaucomatous events such as angle
closure or compliance issues (see
figure 2).
The RNFL is not the only inner
retinal structure that shows attenua-
tion commensurate with glaucoma-
tous damage. The ganglion cell layer
and inner plexiform layer are also
affected, making this a target for
assessing glaucoma progression, spe-
cifically in the macula. For instance,
RTVue (Optovue) OCT assesses
the combined thickness of these two
layers along with the RNFL, known
collectively as the ganglion cell com-
plex (GCC), whereas Cirrus OCT
analyzes exclusively the ganglion cell
layer and inner plexiform layer.
20th Annual GLAUCOMA Report
REVIEW OF OPTOMETRY JULY 15, 2014 37
The utility of ganglion cell OCT
imaging in the macula is emerging
as a viable clinical tool for assessing
glaucoma progression, with some
recent evidence suggesting greater
sensitivity than RNFL OCT analy-
sis. Specifically, Naghizadeh et al.
found that the pattern-based param-
eters of GCC imaging using the
RTVue OCTwhich include focal
loss volume and global loss volume
measurementsmay be more effec-
tive at this task.
11
Although ganglion cell layer OCT
analysis adds yet another dimension
to glaucoma management, many of
the principles used for RNFL OCT
analysis also apply. Notably, the
test-retest variability ranges from
2m to 5m, providing some basis
for event analysis.
12,13
Visual Field Interpretation
The presence of visual field
progression can be detected using
a combination of methods, all of
which rely on statistical analysis
(e.g., glaucoma change analysis,
visual field index, GPA). Both
GPA and visual field index require
customization of the baseline and
follow-up visual fields to improve
their ability to detect progression
and evaluate the success of therapy.
Otherwise, the GPA program auto-
matically selects the baseline scans.
Just as in your RNFL OCT
progression analysis, visual field
analysis also requires that you
appropriately set the baseline visual
fields according to events that occur
during management, such as add-
ing or changing glaucoma drops,
recommending glaucoma surgery or
the presence of a sustained period of
noncompliance.
Despite its ability to recognize
visual field progression, GPA can
produce misleading results if the
baseline visual fields do not correlate
with treatment groups, are unreli-
able, or if the time between the two
baseline exams is too long, as this
introduces the potential for progres-
sion to occur between visual fields.
Choosing the most appropriate
baseline visual field is imperative to
reveal the effectiveness of the treat-
ments being prescribed. Although
resetting the baseline visual field is
important to monitor glaucoma pro-
gression following a change in treat-
ment, it is not always required. For
example, in patients with multiple
medication changes, resetting the
baselines may actually preclude your
ability to accumulate enough follow-
up exams to provide meaningful
results, as it becomes time prohibi-
tive. In such cases, it can be better
to divide your IOP, RNFL and VF
data into a pretreatment group and
treatment group, without assessing
each individual treatment type (see
figure 1). This is usually necessary
in patients who have multiple treat-
ment changes over a shorter period
of time.
Discordance between structural
and functional glaucoma progres-
sion is well-recognized. Surprisingly,
despite stable OCT RNFL thick-
ness values, up to 35% of patients
were shown to develop progressive
threshold visual field loss in a study
that used TD-OCT.
14
Although
these results may not correlate
directly with the performance of
SD-OCT technology, it should be a
reminder to the clinician that stable
RNFL OCT readings do not always
rule out glaucoma progression. As
would be expected, progressive
OCT RNFL thinning significantly
increases the likelihood of future
visual field loss.
As such, if a change in glaucoma
therapy is made in light of serial
RNFL OCT thinning, despite stable
visual fields, you should factor in
the possibility of a delayed onset
of visual field progression when
evaluating the efficacy of your new
therapy.
The Big Picture
It is easy to become mired in the
nuances of glaucoma progression
tests and snapshot views of IOP
recordings. However, an appropri-
ate analysis of IOP and its relation
to glaucoma progression testing can
be maintained to preserve the sim-
plicity of glaucoma management.
Scott Anthony, OD, is on staff at
the Louis Stokes VA Medical Center
in Cleveland, Ohio.
1. The AGIS investigators. Am J Ophthalmol 2000;130:429-
440.
2. Leidl M, Choi C, Syed Z, Melki S. Intraocular pressure
fluctuation and glaucoma progression: what do we know? Br
J Ophthalmol 2014;Epub ahead of print.
3. Leske C, Heijl A, Hyman L, Bengtsson B, et al. Ophthalmo-
lol 1999;106:2144-2153.
4. Gordon M, Beiser J, Brandt J, et al. The Ocular Hyper-
tension Treatment Study: Baseline factors that predict the
onset of primary open-angle glaucoma. Arch Ophthalmol
2002;120:714-720.
5. Realini T. A prospective, randomized, investigator-masked
evaluation of the monocular trial in ocular hypertension or
open-angle glaucoma. Ophthalmol 2009;116:1237-1242.
6. Leung C, Chiu V, Weinreb R, et al. Evaluation of retinal
nerve fiber layer progression in glaucoma: A comparison
between spectral-domain and time-domain optical coherence
tomography. Ophthalmol 2011;118:1558-1562.
7. Leung C, Yu M, Weinreb R, et al. Retinal nerve fiber layer
imaging with spectral-domain optical coherence tomography:
Patterns of retinal nerve fiber layer progression. Ophthalmol
2012;119:1858-1866.
8. Sehi M, Iverson S. Glaucoma diagnosis and monitoring
using advanced imaging technologies. US Ophthalmic Rev
2013;6:15-25.
9. Kotowski J, Wollstein G, Ishikawa H, Schuman J. Imaging
of the optic nerve and retinal nerve fiber layer: An essential
part of glaucoma diagnosis and monitoring. Surv Ophthalmol
2013: Epub ahead of print.
10. Leung, C. Diagnosing glaucoma progression with optical
coherence tomography. Curr Opin Ophthalmol 2014;25:104-
111.
11. Naghizadeh F, Garas A, Vargha P, Hollo G. Detection of
early glaucomatous progression with different parameters
of the RTVue optical coherence tomograph. J Glaucoma
2014;23:195-198.
12. Kotowski J, Wollstein G, Folio L, Ishikawa H, Schuman
J. Clinical use of OCT in assessing glaucoma progression.
Ophthalmic Surg Lasers Imaging 2011;42:S6-S14.
13. Francoz M, Fenolland J, Giraud J, et al. Reproducibility
of macular ganglion cell-inner plexiform layer thickness
measurement with Cirrus HD-OCT in normal, hypertensive
and glaucomatous eyes. Br J Ophthalmol 2014;98:322-328.
14.Sehi M, Zhang X, Greenfield D, et al. Retinal nerve fiber
layer atrophy is associated with visual field loss over time in
glaucoma suspect and glaucomatous eyes. Am J Ophthalmol
2013;155:73-82.
REVIEW OF OPTOMETRY JULY 15, 2014 38
Tailor Your Approach To
PXG Management
P
seudoexfoliation syndrome
refers to an abnormal accu-
mulation of extracellular
exfoliative material in the
anterior segment structures of the
eye.
1,2
Although the condition was
first described in 1917, we now
know that the exfoliative material
isnt isolated to the eye. In fact, this
composite of elastic microfibrillar-
associated glycoproteins also is
found in the skin, lung, heart,
kidney, abdomen and blood vessel
walls.
1,3
Although pseudoexfoliation syn-
drome is the most common identifi-
able cause of open-angle glaucoma
(OAG) worldwide, the condition
has many unique qualities that
merit review.
For example, pseudoexfoliative
glaucoma (PXG) is much more
aggressive than conventional
OAGintraocular pressure (IOP)
may fluctuate widely, it presents
more asymmetrically and it could
be less responsive to topical medi-
cal therapy. Further, PXG patients
often require early detection and
close, careful monitoring.
Epidemiology
Extensive population studies
have shown a marked difference
in pseudoexfoliation syndrome
incidence based on geographic loca-
tion, which is highly suggestive of a
racial predilection.
3
The Framing-
ham Eye Study in Massachusetts
and the Blue Mountains Eye Study
in Australia, for example, showed
a disease prevalence of 1.8% and
2.3%, respectively; however, some
European studies report up to a
50% incidence in some Scandina-
vian countries.
3,4
It is important to
note that psuedoexfoliation is most
commonly found in whites over age
50 with a slight female predilec-
tion.
2,3,5
Recent studies have implicated
the lysyl oxidase-like 1 (LOXL1)
gene in pseudoexfoliation syn-
drome, and showed that individuals
with two specific LOXL1 variants
were more likely to develop the
condition.
5
LOXL1 is responsible
for the biogenesis of connective tis-
sue, so any genetic alteration could
potentially result in increased pro-
duction of extracellular material.
5
Additionally, genetic variants of
contactin-associated protein-like 2
(CNTNAP2) and clusterin (CLU)
are being evaluated as potential
catalysts for PXG.
5
Outside of genetic predilection,
one research group postulated in
1979 that sunlight exposure might
contribute to the expression of
psuedoexfoliation; however, this
association has not been further
evaluated in recent studies.
3,6
Addi-
tionally, the Nurses Health Study
and Health Professionals Follow-
up Study found an increased risk
of pseudoexfoliation secondary to
increased caffeine intake.
5
Glaucoma Risk
As previously mentioned, pseu-
doexfoliation is the most common
identifiable risk factor associated
with open-angle glaucoma.
7
His-
tological and electron microscope
studies have documented unique
pathological and structural changes
to the cornea, iris, trabecular
meshwork and zonules in affected
individualsall of which increase
glaucoma risk.
1
Patients with pseudoexfoliative glaucoma often require a more thorough diagnostic
work-up and earlier intervention than those with POAG. So how do these conditions
differ, and why? By Anupam Laul, OD, and Marta Fabrykowski, OD
20th Annual GLAUCOMA Report
REVIEW OF OPTOMETRY JULY 15, 2014 39
The primary mechanism of glau-
comatous damage in pseudoexfolia-
tion syndrome is the impedance of
aqueous outflow.
1
The accumula-
tion of pseudoexfoliative material
in the trabecular meshwork and
subsequent degenerative changes
to the tissue pose the greatest resis-
tance to proper drainage. Addition-
ally, it has been shown that active,
localized production of pseudoex-
foliative material by the endothe-
lium of Schlemms canal can cause
lumen narrowing.
1
Proliferation of
psuedoexfoliative material by the
corneal endothelial cells, as well
as secondary migration posteriorly
over the trabecular meshwork, may
further lead to increased intraocular
pressure.
1
The mean intraocular pressure
(IOP) of patients with PXG is up
to 1.7mm Hg higher than those
without it.
3
The Olmsted County
Studywhich monitored the
natural course of PXGfound that
44% of patients required glaucoma
medications over a 15-year period.
8
Further, glaucoma patients with
pseudoexfoliation have more vari-
able IOPs, higher rates of treatment
failure and faster progression of
optic nerve damage.
8,9
Systemic Associations
Unlike primary open-angle glau-
coma (POAG), pseudoexfoliation
has a systemic component. Post-
mortem electron microscope exami-
nation of several visceral organs
showed evidence of pseudoexfolia-
tive material, suggesting systemic
involvement.
1
As in the eye, pseudoexfolia-
tion can cause ultrastructural and
immunohistochemical changes in
affected organ systems. This can
precipitate a variety of systemic
complications, including abdominal
aneurysms and an increased risk of
coronary artery disease.
1,10,11
Addi-
tionally, secondary pathological
alterations to the tunica intima can
cause vascular fibrosis and elas-
tosis, which often increase blood
flow resistance.
10,11
Interestingly,
a 30-year epidemiological study
showed no increased risk of mortal-
ity in those with PXF.
12
It is also worth noting that those
with pseudoexfoliation are more
likely to experience sensorineural
hearing loss.
13
Although not com-
pletely understood, extracellular
fibrils likely accumulate in the
structures of the inner ear, resulting
in decreased sensitivity.
13
Clinical Aspects
Physiologic ocular findings of
this aggressive disease may be
subtle. The ocular presentation
generally is bilateral, but not neces-
sarily symmetrical. Corneal findings
in pseudoexfoliation syndrome
are fairly rare; however, careful
examination of the endothelium
may show flakes of bright white
fibrillar material.
14,15
These deposits
often appear as irregularly spaced
aggregates, reminiscent of small
filaments. The flakes can vary in
shape and size, anddue to con-
vection currents of the aqueous in
the anterior chambermay evolve
over time.
The corneal endothelial cells
often are affected dramatically
in pseudoexfoliation syndrome
patients. Most individuals exhibit
fewer total endothelial cells with
morphological alterations. Such
endothelial changes are also seen in
Fuchs dystrophyalthough they
do not present in conjunction with
other pseudoexfoliative changes
observed in the eye.
In certain instances, these
changes are accompanied by
increased central corneal thick-
ness.
14
Fine measurements via
specular microscopy can show a
measureable decrease in the number
of endothelial cells, as well as poly-
morphism.
15
Clinically, these cell
alterations may appear as a light
paracentral area of pigmentation
on the corneal endothelium thats
occasionally organized in the pat-
tern of a Krukenberg spindle.
Further evaluation should
include a 360 assessment of ante-
rior chamber depth, in addition
to a measurement comparison
between both eyes. Although there
are many direct indications of lens
dislocation, one indirect sign is an
alteration in chamber depth. A lens
can subluxate forward, leading to a
shallow anterior chamber, or may
fall backward towards the vitreous,
resulting in a hyper-deep chamber.
16
Examine trabecular meshwork
pigementation via gonioscopy,
looking specifically for pigment
located anterior to Schwalbes
line.
17,18
Pseudoexfoliation patients
often have an abnormally high
volume of angle pigmentation,
even without any other syndrome
findings. Pseudoexfoliation is also
classically associated with pigment
lossboth at the pupillary margin
and around the iris sphincter.
On iris transillumination, the
margin may exhibit a moth-eaten
appearance.
15
Gray-white flakes
1. Telltale clinical sign of peripupillary
accumulation of fibrillar material on a
patient with dark irides.
REVIEW OF OPTOMETRY JULY 15, 2014 40
may be present at the pupillary
margin, and frequently are the only
overt sign of disease (figure 1).
15,16
Several researchers have linked
deposition of this material with
changes in iris function.
15,16
Because
the iris sphincter may be compro-
mised, there may be a reduced
response to mydriatics. Iris flutter is
another indirect sign of weak zon-
ules, which hold the lens in place;
however, sometimes the iris may
be more rigid in pseudoexfoliation
patients, so this clinical sign may
not be evident.
15,16
Iris changes in psuedoexfoliation
syndrome closely correlate with
lenticular findings. Most often,
exfoliative material presents on the
anterior capsule of the lens. This
finding commonly manifests in a
target or bulls eye pattern,
which consists of three zones after
dilation: the central disk (approxi-
mately the diameter of the pupil),
the clear zone and a peripheral
band of fibrillar material (figure
2).
14,15
This is another sign that clas-
sically presents asymmetrically.
A definitive indication of zonular
damage is phacodonesis, or lens
flutter.
15,16
Although crude, jolt-
ing the slit lamp table during lens
examination can produce a subtle
vibration or movement indicative
of zonular weakness. A loose or
subluxated lens is best viewed after
dilationalthough looking for a
decentered fetal nucleus may be
helpful in poorly dilating eyes.
14
Individuals with pseudoexfo-
liative glaucoma exhibit a similar
optic nerve appearance to that
observed in POAG patients, includ-
ing axonal loss, increased central
cupping and disc rim thinning
at both the superior and inferior
poles.
19
In advanced cases, a Drance
hemorrhage may be seen.
As with other glaucomatous
presentations, optical coherence
tomography or Heidelberg Retinal
Tomography (Heidelberg Engineer-
ing) will help you assess retinal
nerve fiber layer thinning. The
standard of care for visual field
evaluation in all glaucoma patients
is a Humphrey 24-2, which remains
true for patients suspected of, or
already diagnosed with, PXG.
Although the general appearance
of a nerve with PXG is similar to
one with open-angle glaucoma,
asymmetrical presentation often
helps you differentiate accurately.
Interestingly, recent studies have
indicated that, similar characteris-
tics aside, nerves with pseudoex-
foliation are histopathologically
uniquewith higher capillary den-
sity, despite axonal loss.
20
Because pseudoexfoliative
material can potentially rest in a
multitude of anatomical locations,
intraocular pressure may vary
widely. A patients diurnal and
daily IOPs can spike dramatically.
Further, depending on the extent
of pseudoexfoliative asymmetry,
IOP varies significantly between
eyes. This can make PXG treatment
difficult, because establishing the
patients baseline pressure can be a
challenge. Multiple IOP measure-
ments over a series of visits may be
necessary to determine an accept-
able pressure range.
There is no specific algorithm
for quantifying IOP oscilation
although one report indicated that
patients with PXG fluctuate the
highest outside office hours, mak-
ing diurnal mapping even more
difficult.
21
In some studies, patients
IOPs were measured six times
over a 24-hour period, which is
impractical and unrealistic.
22
From
experience, however, it seems that a
minimum of two measurements per
day (i.e., one in the morning, and
one in the afternoon) is both ade-
quate and relatively easy to obtain.
Topical Hypotensive
Treatment
Managing cases of pseudoex-
foliative glaucoma with topical
hypotensive therapy may require
increased vigilance and a certain
element of creativity. In 2013,
Murray Fingeret, OD, indicated
that 16% of PXG patients require
therapeutic intervention upon ini-
tial presentation.
17
So, a treatment
decision may need to be made early
or even immediately in the manage-
ment process.
Traditional medications are less
effective for PXG than POAG, but
are still often used as first-line ther-
apy because they are more effective
than carbonic anhydrase inhibi-
tors or alpha agonists.
23
Both beta
blockers and prostaglandin ana-
logs are ideal places to start, with
carbonic anhydrase inhibitors and
alpha adrenergic agonists following
as likely adjunctive medications.
Similar to the management of
pigmentary glaucoma, the use
of miotics has some theoreti-
cal advantage for PXG patients.
Miotic agents forcefully open the
trabecular meshwork and increase
drainage, as well as limit pupillary
movement.
18,24
By reducing pupil
motion, less pigment and pseudoex-
foliative material are released from
their respective locations.
18
Take
note that miotics should be used
with discretion in individuals with
cardiac risk factors, and may pre-
cipitate retinal detachments in some
patients.
25
Typically, the managing clinician
will begin dosing with one class
of ocular hypotensive agents, and
then add secondary medications as
needed. Because PXG has a higher
incidence of progression and is
more likely to be resistant to medi-
cal management than POAG, fur-
ther therapeutic intervention often
is required.
26
20th Annual GLAUCOMA Report
REVIEW OF OPTOMETRY JULY 15, 2014 41
Surgical Intervention
The Early Manifest Glaucoma
Trial showed us that PXG is more
rapidly progressive and is more
likely to require surgical interven-
tion than POAG.
27
When topical
treatment fails, or if maximum
medical therapy is inadequate in
achieving the desired IOP, surgical
management should be considered.
Non-incisional. Laser trabecu-
loplasty is a commonly performed
procedure that increases aqueous
outflow in eyes with POAG.
28
Argon laser trabeculoplasty (ALT)
was once thought to yield trabecu-
lar meshwork contraction and sub-
sequent aqueous collector channel
widening.
However, a histological study
published in 2007 indicated that
ALTs effect actually causes a
remodeling of the juxtacanalicular
region of the meshwork.
29,30
Selec-
tive laser trabeculoplasty (SLT), on
the other hand, uses a Q-switched
frequency-doubled Nd:YAG laser
to selectively target pigmented cells
within the trabecular meshwork
and increase aqueous outflow.
31
Use of either ALT or SLT on
eyes with POAG or PXG has been
found to yield comparable levels of
IOP reduction across the board.
28
In a series of studies, POAG eyes
exhibited nearly a 22% IOP reduc-
tion one day following surgery,
compared to a 29% IOP reduction
in PXG eyes.
28
However, at three-
year follow-up, POAG eyes main-
tained an average IOP reduction of
34%, whereas PXG eyes remained
just 21% below baseline.
28
Because
PXG tends to be more aggressive
than POAG, pseudoexfoliative
patients often require additional
management once the pressure-
lowering effect from ALT or SLT
subsides.
Cataract removal. It is well
documented that oxidative stress in
pseudoexfoliation syndrome leads
to early cataract formation.
32
In
many cases, patients with PXG will
require cataract surgery. A retro-
spective study of more than 1,000
patients with pseudoexfoliation
showed a significant improvement
in IOP after uncomplicated phaco-
emulsification.
33
Those with PXG
had a more significant and sus-
tained IOP reduction than patients
without PXG.
33
Further, only about
3% of eyes with early evidence
of pseudoexfoliation syndrome
progressed to PXG over a 10-year
postoperative period.
33
Trabeculectomy. In cases of
more advanced glaucoma, tra-
beculectomy is one of the most
commonly indicated surgical inter-
ventions.
34
The procedure involves
scleral flap formation and ostium
creation, which allows aqueous dis-
sipation into the subconjunctival
space.
34-36
Trabeculectomy for PXG
patients is a successful means of
reducing intraocular pressure; how-
ever, some clinicians believe there
might be a higher incidence of post-
operative pressure spikes compared
to POAG patients who undergo the
procedure.
36
Combined cataract
removal and trabeculectomy often
yields fewer pressure spikes than
trabeculectomy alone.
35,37
Minimally invasive glaucoma
surgery (MIGS). These surgical
procedures are relatively new, and
are intended to increase aqueous
drainage through the trabecular
meshwork.
38-40
The two most com-
mon MIGS procedures are the Tra-
bectome (NeoMedix) and the iStent
(Glaukos). Take note that only
the Trabectome has been studied
in a large pseudoexfoliation study
sample.
40
In a Trabectome procedure, the
surgeon removes the trabecular
meshwork through a clear corneal
approach, which exposes the col-
lector channels of Schlemms canal.
In the study mentioned above, 173
PXG eyes underwent Trabectome
surgery.
40
Of these, 34% were pha-
kic, 25% were pseudophakic and
41% underwent combined cataract
and Trabectome surgery.
40
At one-
year follow-up, the entire patient
population exhibited a mean IOP
reduction of 30%.
40
Although not thoroughly studied
in the pseudoexfoliation popula-
tion, the iStent is placed into the
angle via a clear corneal incision.
38
The stent is a 1.0mm nonferro-
magnetic, L-shaped device that is
inserted into Schlemms canal.
38
Because the iStent facilitates bypass
of the trabecular meshwork, the
resultant IOP is based on the cir-
cumferential flow of Schlemms
canal, the collector ducts and the
episcleral venous pressure.
38
Fol-
lowing the procedure, IOPs typi-
cally range in the high teens.
38
Endocyclophotocoagulation
(ECP). Cyclodestruction of the
ciliary body as a treatment for
glaucoma was first attempted in the
1970s.
41
Historically, the procedure
2. Apparent bulls eye pattern of
fibrillar material on a dilated, lightly
pigmented patient. Looking closely,
theres also a peripupillary accumulation
of material.
P
h
o
t
o
:
S
t
e
p
h
e
n
A
.
O
b
s
t
b
a
u
m
,
M
D
REVIEW OF OPTOMETRY JULY 15, 2014 42
was performed transsclerally with
cryotherapy, an Nd:YAG laser or
a diode laser, and was reserved for
eyes with severe disease and/or little
potential for visual gain.
41
Because
the target is not visible to the sur-
geon transsclerally, there is risk of
adjacent tissue damage and resul-
tant inflammation, decreased visual
acuity, hypotony and phthisis.
42
ECP is performed intraocularly
with the aid of an endoscope (usu-
ally in conjunction with cataract
extraction), which permits direct
visualization of the targeted ciliary
body tissue.
41
In a case series of
68 patients (including those with
PXG), researchers documented a
34% mean IOP reduction following
ECP.
41
Although a large prospective
study of ECP in eyes with pseudo-
exfoliation has not been performed,
this seems like a promising therapy
going forward.
Pseudoexfoliative glaucoma, a
well-known member of the OAG
family, is a fairly unique clinical
entity. While PXGs signs can be
subtle, its impact can be visually
devastatingso we are tasked with
identifying the condition as early as
possible.
In comparison to those with pri-
mary open-angle glaucoma, PXG
patients often need topical ocular
hypotensive agents earlier in the
disease process. Additionally, they
require more frequent follow-ups
and testing, as well as adjunctive
therapy, to reduce the likelihood of
irreversible vision loss.
Dr. Fabrykowski is on staff at
the Manhattan Eye, Ear and Throat
Hospital Faculty Ophthalmology
Practice, operated by Lenox Hill
Hospital, in New York.
Dr. Laul is an instructor of
ophthalmology at the Wilmer Eye
Institute, Johns Hopkins School of
Medicine, in Baltimore.
They thank Harry A. Quigley,
MD, professor of ophthalmology at
Wilmer Eye Institute, and Bradford
J. Shingleton, MD, Ophthalmic
Consultants of Boston and associate
clinical professor of ophthalmology
at Harvard School of Medicine for
their research guidance.
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20th Annual GLAUCOMA Report
wettability and lipid deposit resistance
compared to other silicone hydrogel
lenses.
4
CLINICAL RELEVANCE
The lipid deposits and lens changes
induced by cosmetics may interfere
with contact lens shape and optical
performance.
1,2
One obvious way to reduce buildup
of cosmetic residues is to use daily
disposable lenses. But when this is not
an option, selecting a lens material
that maintains wettability and resists
depositsof both tear lm lipids and of
cosmetic productsmay increase the
likelihood of successful lens wear.
In addition to appropriate lens
selection, contact lens exposure to
cosmetics can be further minimized by
giving patients clear instructions about
cosmetic application and removal. In
addition to thoroughly washing and
drying hands prior to handling their
lenses, patients should insert lenses
before applying eye makeup and
remove lenses before using makeup
remover. Patients who believe their
lenses have been damaged due
to cosmetics exposure should be
instructed to replace their lenses with a
new pair.
Gina Wesley, OD, MS, FAAO,
practices at Complete Eye Care of
Medina, in Medina, MN.
REFERENCES
1. Srinivasan S, Luensmann D, Otchere H, et al. The impact
of cosmetics on the surface appearance and wettability
of silicone hydrogel contact lenses. Presented at the
American Academy of Optometry Meeting; October 24-27,
2012; Phoenix, AZ. Abstract 120317.
2. Luensmann D, Srinivasan S, Yu M, et al. The impact
of cosmetics on the physical dimension and optical
performance of silicone hydrogel contact lenses. Presented
at the British Contact Lens Association Meeting; May 25-
27, 2012; Birmingham, UK.
3. Keir N, Jones L. Wettability and silicone hydrogel lenses: a
review. Eye Contact Lens. 2013;39:100-8.
4. Carney FP, Nash WL, Sentell KB. The adsorption of major
tear lm lipids in vitro to various silicone hydrogels over
time. Invest Ophthalmol Vis Sci. 2008;49:120-4.
The Makeup Factor: Expanding the Denition
of Deposit Resistance
Cosmetics on the surface of a soft contact lens can affect wettability, t, and, ultimately, comfort
but in vitro testing shows that not all lenses are equally affected. Gina Wesley, OD, MS, FAAO
Important information for AIR OPTIX
AQUA (lotralcon B) contact lenses: For daily wear or extended wear up to 6 nights for near/far-sightedness. Risk of serious eye
problems (i.e., corneal ulcer) is greater for extended wear. In rare cases, loss of vision may result. Side effects like discomfort, mild burning or stinging may occur.
See product instructions for complete wear, care and safety information.
2014 Novartis 1/14 AOA14003AD-C
Many contact lens wearers use
cosmetics on and around the eye, but
the impact of these products on contact
lenses has received little attention. Recent
in vitro research, however, has shown
that hand creams, mascaras, and makeup
removers can alter contact lens shape
and optics and, over time, interfere with
lens comfort and performance.
EFFECTS OF COSMETICS
Investigators at the University
of Waterloo Centre for Contact Lens
Research measured the effect of
commonly used cosmetic products
on silicone hydrogel contact lenses.
1,2
Following in vitro exposure to test
products (hand cream, mascara, and eye
makeup remover), lenses were assessed
for change in surface appearance and
physical and optical parameters. Lenses
were then cleaned with a commercially
available hydrogen peroxide contact
lens solution and reevaluated.
Among the products tested,
mascara was associated with the
greatest degree of surface deposition, as
observed by researchers and quantied
by mean pixel brightness using darkeld
microscopy.
1
Cleaning with hydrogen
peroxide only partially removed these
deposits, with those left by waterproof
mascara least responsive to cleaning.
Liquid makeup removers induced the
greatest changes to lens diameter,
sagittal depth, and base curve.
2
Of the seven lens materials tested,
AIR OPTIX
DIFFERENCE
The hydrophobic domains in
silicone hydrogel lenses attract tear lm
lipids as well as the oil components of
cosmetic products used on the eye.
3
Because of this, developers of silicone
hydrogel lenses have employed various
strategies to render them more water-
loving.
4
Some lenses are made more
wettable by embedding hydrophilic
polymers within the lens material or in
the soaking solution, others by surface
modication.
3
AIR OPTIX
Mascaraespecially
waterproofand eye
makeup removers are
particularly prone to lens
deposition
contact lenses
were least affected by
tested cosmetic products
contact lenses wettable and
deposit resistant
Sponsored by Alcon
REVIEW OF OPTOMETRY JULY 15, 2014 44
Glaucoma
The Changing and Challenging
Epidemiology of
W
hen asked to think about
the prototypical glau-
coma patient, most eye
care providers would
likely picture an older African-
American patient. While African
Americans and Hispanics have a
higher risk of developing glaucoma
than do whites, the overwhelm-
ing majority (75%) of current
glaucoma patients within the US
population are in fact white.
1
This
stems from the fact that, at this
point in time, the preponderance of
US population at risk for glaucoma
is white. About 85% of all adults
over 65 in the US population are
white; for the population over age
75, whites make up an even larger
percentage of the total population
(90%).
1
However, shifts that are occur-
ring in the demographics of the US
population are going to markedly
change the make-up and prevalence
of glaucoma in the coming decades.
Two major population trends are
affecting, and will continue to
affect, the prevalence of glaucoma
for decades. Those are the aging
of US society and the growth of
minority populations.
An Aging Population
The prevalence of glaucoma
is believed to be about 2% (with
estimates ranging between 1.6%
and 2.7%) in adults over the age of
40.
1,3
In the year 2000, an estimated
2.2 million Americans had glau-
coma, including those either diag-
nosed or unknown.
1,3
This number
is expected to reach 3.3 million by
the year 2020.
3
The rapid growth
in glaucoma is due to the aging of
baby boomer population.
Various definitions for baby
boomers exist, but it is generally
regarded as the cohort born from
1946 to 1964. The first of the baby
boom population turned 65 in
2011, and by 2034 all of the baby
boom population will be over 65.
Based on 2012 census data, 41 mil-
lion Americans are over the age of
65. Population predictions indicate
that from 2010 to 2050 the number
of adults over 65 will more than
double, to 88.5 million.
4
The cur-
rent aging of the US population has
been accompanied by phenomenal
growth in the number of the old-
est-old. The single-fastest growing
segment of the US population cur-
rently is the group over the age of
90.
4
The number of the oldest-old
population will continue to grow in
the coming decades, with the num-
bers of Americans reaching age 90
accelerating rapidly after 2030.
Numerous studies have shown
that the prevalence of glaucoma
increases with age. The Eye Dis-
ease Prevalence Research Group
developed estimates of glaucoma
prevalence from data that included
multiple US-based and international
studies. The group estimated that
open-angle glaucoma prevalence
increased from 0.7% at age 40 to
7.7% for those over age 80.
3
Self-
As the aging population doubles and minority groups skyrocket, we face increased
challenges in tailoring our glaucoma care to each patient. By Mark Swanson, OD, MSPH
20th Annual GLAUCOMA Report
REVIEW OF OPTOMETRY JULY 15, 2014 45
reported epidemiologic data from
the National Health Interview
Survey found glaucoma prevalence
increasing from 0.2% at age 18 to
over 10.7% for those over 75.
3
The
growth in the oldest-old is impor-
tant, as the prevalence of glaucoma
triples in those over 75 compared
to those aged 65.
3
While data is limited, there is
no indication that new cases of
glaucoma decline in those who
reach very advanced age. As such,
the number of people who develop
glaucoma can be expected to
increase throughout the lifespan.
The growth of early glaucoma in
octogenarians and nonagenarians
will present both logistical chal-
lenges in caring for adults who may
have multi-morbidity, cognitive
impairment and frailty, and ethical
ones in balancing the benefits of
treatment of a disease with a long-
term course to impairment with the
remaining life expectancy.
Growth of Minority
Populations
A second significant contribu-
tor to the increasing prevalence of
glaucoma is the growth of the non-
Caucasian older adult population.
It is well known that race plays
a role in glaucoma development,
with minorities over-burdened by
the disease. Over the next several
decades, growth in the minority
population will be most rapid in
those under 65, but by 2050 minor-
ities will make up 42% of the adult
population over 65 and 33% of the
population over age 85.
4
Based on
this, the number of minorities with
glaucoma will exceed the number
of non-Hispanic whites with the
disease by the year 2035.
5
Among adults over 40, African
Americans and Hispanics have
between 50% and 300% higher
odds of having glaucoma than
do whites, at all ages.
3
Glaucoma
will be particularly significant
among older Hispanics due to the
exponential growth of this group.
Hispanics accounted for 50% of
the total growth in the entire US
population between the 2000 and
2010 Census reports.
6
This rapid
growth will continuethe Hispanic
population is expected to make up
20% of adults over 65 and 15% of
adults over 85 by 2050.
6
Other minority populations
(Asians, Pacific Islanders, Ameri-
can Indians, Native Alaskans) are
expected to increase in numbers rel-
ative to whites as well. Among this
group, glaucoma risk is most well
defined among Asian Americans.
Older Asian populations have a risk
of open-angle glaucoma estimated
100
90
80
70
60
50
40
30
20
10
0
2010 2015 2020 2025 2030 2035 2040 2045 2050
Projected Population Aged 65 and Over by Race for the United States: 2010 to 2050
White
Millions
Black Asian American Indian
and Alaska Native
Native Hawaiian
and Other Pacific
Islander
Two or
More
Races
Unless otherwise specified, data refer to population who reported a race alone. Populations for each race group include both Hispanics
and non-Hispanics, as those of Hispanic ethnicity may be of any race. Source: US Census Bureau.
REVIEW OF OPTOMETRY JULY 15, 2014 46
to be 6.6% for those over the age
of 40. This rate is slightly higher
than that seen among Latinos and
much higher than that seen in non-
Hispanic whites.
7
In assessing glaucoma risk among
the growing minority older adult
population, its important to rec-
ognize the difference between race
and ethnicity. For purposes of the
US Census, Hispanic is considered
an ethnicity, not a race. The terms
Hispanic and Latino are frequently
used interchangeably. More specifi-
cally, Latino refers to individuals
with geographic ties to the Carib-
bean and Central or South Amer-
ica. Hispanic refers more broadly
to those with Spanish ancestry or
who are Spanish speakers. Latino
ethnicity would include Portuguese-
speaking Brazilians, whereas His-
panic ethnicity would not.
When filing out Census forms,
individuals may self-identify in a
yes/no format as Hispanic/Latino or
not Hispanic/Latino. A follow-up
question allows individuals who
answered yes to identify themselves
among one of 23 subgroups largely
based on country of origin.
There is a separate race question
in the Census, where individual
Hispanics may identify themselves
as white, black, multiracial or other
race. This leads to groups of Ameri-
cans who identify themselves as
Hispanic-whites, Hispanic-blacks
or Hispanic of multiracial origin,
among several other possibilities.
The growth in the racial group
identified as white in the US has
largely been driven by Hispan-
ics who self-identify their race as
white.
6
Importantly, the risk of devel-
oping glaucoma is not the same
among all Hispanic subgroups.
Latinos have been found to have
higher rates than other Hispanics.
3
Among Latinos, Mexican-Ameri-
cans have generally been found to
have a higher risk of open-angle
glaucoma than do others who iden-
tify themselves as Hispanic. It has
been speculated that these differ-
ences may be due to the degree of
Native American ancestry among
Hispanic subgroups.
The two major studies that
looked at glaucoma among Hispan-
ics (Proyecto VER) and Latinos
(LALES) had significant differences
in Native American admixture in
their study cohorts. In Proyecto
VER, 40% of participants had
Native American ancestry, while
just 5% of LALES participants
did.
8
The Mexican-American ethnic
group is a key demographic, given
that it is the largest among the
growing US Hispanic/Latino popu-
lation.
A similar issue is found among
the population of older Asian
Americans. While not as numerous
as Hispanics and African Ameri-
cans in the population, the number
of older Asians is expected to triple
in the US by 2050. Asians of Viet-
namese and Chinese descent have a
much higher risk of narrow-angle
glaucoma than do other ethnic
Asians.
7
Americans of Japanese
descent have a 10-fold higher risk
of normal tension glaucoma than
do other Asian subgroups.
7
Why ethnicity and race impact
glaucoma is unclear. There are a
variety of anatomical, biochemical
and genetic associations with the
glaucomas that have been found
to segregate by race and ethnicity
without being exclusive to a single
race. African Americans are known
to have a greater likelihood of
having thinner corneas, anatomi-
cally larger optic discs and variant
lamina cribrosa configurations
compared to other ethnic groups.
9
Mongolians, Indians and Chinese
have been found to have differ-
ences in anterior chamber angle
depth and configuration compared
to other ethnic Asian groups and
non-Asians.
10
The ability to man-
age ocular oxidative stress appears
lower among African Americans.
11
Latinos may have an inherently
lower tolerance to factors relating
intraocular pressure to blood pres-
sure.
8,9
Gene-wide association studies
have identified a number of single
nucleotide polymorphisms associ-
ated with open-angle glaucoma,
angle closure and normal tension
that seem to segregate by race.
12
It is entirely possible that race and
ethnicity are simply markers for
these and other, as-yet unknown
biomarkers of glaucoma. Under-
standing the race-based risk of
glaucoma will become even more
complex in the future as the num-
ber people identified as multiracial
grows.
A secondary effect of the increase
in the number of minority glau-
coma patients will be an increase
in the number of years these indi-
viduals will likely suffer from the
disease. In addition to having a
higher risk of glaucoma, African
Americans and Hispanics begin to
develop glaucoma at earlier ages
than do whites.
3
The prevalence
of glaucoma in African Americans
and Latinos is about 2% for those
in their early 50s. It does not reach
2% for whites until age reaches the
late 60s to early 70s.
At the other end of the glaucoma
age continuum, life expectancy is
longer for Hispanics and Asians
than for other ethnic groups.
Among those in the US population
who live to 65, Hispanics have the
longest remaining life expectancy
of any ethnic group, at more than
20 years.
4
At younger ages, African
Americans have lower life expec-
tancy than other ethnic groups;
20th Annual GLAUCOMA Report
REVIEW OF OPTOMETRY JULY 15, 2014 47
however, among the oldest Ameri-
cansthose 85 and olderthere is
a shift and African Americans have
a slightly longer life expectancy
than other racial groups.
4
The end
result will be a longer required
treatment period.
Gender Distinctions
The expected time course of the
disease is also impacted by gender.
In studies done across the world,
the absolute number of women
with glaucoma exceeds that of men
with the disease (a 60:40 ratio).
13
The gender gap in glaucoma is
largely due to the differential sur-
vival of women and men.
At birth, across all racial and
ethnic groups in the US population,
women are expected to live about
four to five years longer than men.
The gap in the life expectancy of
men compared to women narrows
with advancing age over 65, but
men never quite catch up in terms
of expected survival, even among
those men over 90.
4
In terms of absolute risk, women
have higher odds of developing
narrow-angle glaucoma than do
men. There is variation among
ethnic groups, but most estimates
place the gender risk at two to four
times higher for women than men.
The excess risk is largely attributed
to the anatomically smaller anterior
chambers found in women.
13
The
evidence for gender differences in
open-angle glaucoma risk is less
clear. Studies of gender differences
in POAG when stratified by age
and race or ethnicity produce rela-
tively small numbers. This leads
to wide estimate intervals, making
interpretation of the exact gender
impact difficult. Studies do indicate
that women are more likely than
men to become visually impaired
from glaucoma.
The differential survival of
women gives them more years of
disease exposure. Life expectancy
alone does not account for all of the
gender disparity in visual impair-
ment associated with glaucoma,
however. Socioeconomic and edu-
cational opportunity is thought to
play a role in this disparity, particu-
larly outside of the US population.
Poverty Status
Poverty is associated with the
development of myriad health
conditions. The question, Does
poverty lead to glaucoma? has
not been fully answered, but has
had some study. The US govern-
ment uses a metric the poverty-to-
income ratio (PIR) as a measure
of socioeconomic status. The PIR
is a continuous measure that takes
into account the income, expenses
and family size. Those with PIR
<1.0 have income below the federal
poverty level for families, whereas
those with PIR >4 are considered to
have high income.
Elongation of the vertical cup/
disc (CD) ratio is a hallmark sign
of glaucoma. Many studies use
the vertical cup/disc ratio at the
97.5th population percentile as
the cut point for a disc defined as
glaucomatous. Within the overall
US population, this level is a verti-
cal CD ratio of 0.63.
1
One study
has compared the 97.5th percentile
of vertical CD ratio among the US
population at various PIR catego-
ries. No differences in the vertical
CD ratio size that defined glaucoma
were found between PIR categories.
This indicates that socioeconomic
status does not seem to be related
to early glaucoma.
This same study showed that PIR
did have an impact on the vertical
CD ratio at the 99.5th popula-
tion percentile.
1
As PIR category
changed from high income to
middle income to the poverty level,
the vertical cup/disc ratio increased.
This change is likely representative
of an overall delay in the diagnosis
of glaucoma or higher numbers of
treatment failures for those in lower
socioeconomic classes producing
larger vertical CD ratios even at the
most extreme range found within
the population.
Studies in the United Kingdom
and Canada have shown that those
in lower socioeconomic classes are
more likely to present with more
Percent Female for Older Population by Age for the
United States: 2010, 2030 and 2050
2010
57
55 55
54
53
52
58
56
55
67
62
61
2030 2050
65 years and over 65 to 74 years 75 to 84 years 85 years and over
S
o
u
r
c
e
:
U
S
C
e
n
s
u
s
B
u
r
e
a
u
REVIEW OF OPTOMETRY JULY 15, 2014 48
advanced glaucoma at the time
of the initial diagnosis.
14
Lower
socioeconomic status within the
US population has been associated
with lower medication adherence
in studies using electronic drop
monitoring.
15
Race and age also
appear to play a role with adher-
ence, with African Americans and
older adults showing lower adher-
ence compared to younger adults
and people of European ancestry.
15
Insurance claims data monitoring in
the US population has shown that
half of all patients stop glaucoma
medications within six months of
initiating therapy and less than
40% fill prescriptions three years
after diagnosis.
16
Additionally, in the US popula-
tion, those in lower socioeconomic
classes are known to have lower
utilization of eye care services.
17
Education level and socioeconomic
status are closely tied together, and
lower eye care utilization rates are
also seen in Americans with lower
educational attainment.
17
While not directly related to edu-
cation level, health literacy (or the
ability to understand health-related
information) has been shown to
play a role in glaucoma adher-
ence. Glaucoma patients with poor
health literacy are less likely to fill
prescriptions and adhere to medica-
tion dosage schedules, and more
likely to miss scheduled appoint-
ments.
18
Simplified dosages schemes,
improved doctor/patient commu-
nication and better education have
been shown to increase patient
adherence in glaucoma treatment.
19
Providing appropriate education
and strategies to patients that are
increasingly diverse will be an
ongoing challenge for ODs.
The increasing diversity of the US
population will present challenges
in delivering care to patients with
glaucoma. The public health task is
daunting. Current estimates are that
60% to 70% of glaucoma in the US
population is undiagnosed.
21
This
may be even higher among the rap-
idly growing Latino population.
8
When taking into account the
low levels of adherence to glaucoma
medication regimens, as much as
80% of glaucoma in the US popu-
lation may be untreated.
20,21
This
is despite the fact that more than
double the number of patients
estimated to have glaucoma in the
US population report using drops
for the disease or ocular hyperten-
sion.
20
This suggests that there is a
nationwide issue of diagnostic accu-
racy among both optometrists and
ophthalmologists.
The Challenges Ahead
Optometrists need to be prepared
to see a larger and more diverse
glaucoma population. To meet
the coming demand, vastly greater
numbers of the higher at-risk
population will need to be screened.
The absence of a simple screen-
ing test for glaucoma means more
comprehensive examinations with
appropriate follow-up testing are
going to be need to be provided by
optometrists.
Larger societal issues, such as
lower levels of health insurance
coverage, higher levels of poverty
and lower education level, will
make reaching this population dif-
ficult. Once glaucoma patients are
diagnosed, optometrists as a group
need to take a far greater role in
treatment.
The use of culturally sensitive
materials and approaches can help
reach the ultimate goal of preven-
tion of visual impairment in this
rapidly changing segment of the
patient population.
Dr. Swanson is an associate
professor of optometry at the Uni-
versity of Alabama at Birmingham
School of Optometry.
1. Swanson MW. The 97.5th and 99.5th Percentile of Vertical
Cup Disc Ratio in the United States Optometry & Vision Sci-
ence: January 2011, Vol. 88, Issue 1, pp. 86-92 doi:10.1097/
OPX.0b013e3181fc3638
2. Vincent GK, Velkoff VA. The Next Four Decades, The Older
Population in the United States: 2010 to 2050, Current Popula-
tion Reports.2010, U.S. Census Bureau, Washington, DC
P25-1138.
3. Klein R, Klein BE. The prevalence of age-related eye
diseases and visual impairment in aging: current estimates.
Invest Ophthalmol Vis Sci. 2013 Dec 13;54(14): doi: 10.1167/
iovs.13-12789.
4. Arias E. United States Life Tables, 2009. National Vital Sta-
tistics Reports, Vol. 62, No. 7, January 6, 2014 .
5. Vajaranant TS, Wu S, Torres M, Varma R. The changing
face of primary open-angle glaucoma in the United States:
demographic and geographic changes from 2011 to 2050. Am
J Ophthalmol. 2012 Aug;154(2):303-314.e3. doi: 10.1016/j.
ajo.2012.02.024. Epub 2012 Apr 27.
6. Ennis SR, Ros-Vargas M, Albert NG. The Hispanic Popula-
tion: 2010 Census Briefs. Issued May 2011
C2010BR-04 Available at www.cdc.gov/nchs/data/nvsr/
nvsr62/nvsr62_07.pdf. Accessed 6/2/2014.
7. Stein JD. Differences in Rates of Glaucoma among Asian
Americans and Other Racial Groups, and among Various Asian
Ethnic Groups Ophthalmology; 2011:1031-7.
8. Kim E, Varma R. 9. Arch Ophthalmol. Glaucoma in Latinos/
Hispanics.Current Opinion in Ophthalmology 2010 ;21:100
105. doi:10.1001/archopht.123.4.527.
9. Karmel M. Glaucoma in the African American and Latino
Communities. EyeNet Available at www.aao.org/publications/
eyenet/201006/glaucoma.cfm. Accessed July 1, 2014.
10. Aung T, Winifred P, Nolan WP, et al. Anterior Chamber
Depth and the Risk of Primary Angle Closure in 2 East Asian
Populations FREE Arch Ophthalmol. 2005;123(4):527-32.
doi:10.1001/archopht.123.4.527.
11. Siegfried CJ, Shui YB, Holekamp NM, et al. Racial Differ-
ences in Ocular Oxidative Metabolism, Implications for Ocular
Disease. Arch Ophthalmol. 2011;129(7):849-54. doi:10.1001/
archophthalmol.2011.169
12. Chandra A, Mitry D, Wright A, et al. Genome-wide
association studies: applications and insights gained in Oph-
thalmology.Eye advance online publication 27 June 2014; doi:
10.1038/eye.2014.145
13. Vajaranant TS1, Nayak S, Wilensky JT, Joslin CE. Gender
and glaucoma: what we know and what we need to know.
Curr Opin Ophthalmol. 2010 Mar;21(2):91-9. doi: 10.1097/
ICU.0b013e3283360b7e
14. Buys YM, Jin YP; Canadian Glaucoma Risk Factor Study
Group. Socioeconomic status as a risk factor for late pre-
sentation of glaucoma in Canada. Can J Ophthalmol. 2013
Apr;48(2):83-7. doi: 10.1016/j.jcjo.2012.10.003
15. Dreer LE, Girkin C, Mansberger SL. Determinants
of medication adherence to topical glaucoma therapy. J
Glaucoma. 2012 Apr-May;21(4):234-40. doi: 10.1097/
IJG.0b013e31821dac86
16.Nordstrom BL, Friedman DS, Mozaffari E, et al. Persistence
and adherence with topical glaucoma therapy. Am J Ophthal-
mol. 2005 Oct;140(4):598-606.
17. Zhang X, Beckles GL, Chou CF, et al. Socioeconomic dis-
parity in use of eye care services among US adults with age-
related eye diseases: National Health Interview Survey, 2002
and 2008. JAMA Ophthalmol. 2013 Sep;131(9):1198-206. doi:
10.1001/jamaophthalmol.2013.4694
18. Muir KW, Christensen L, Bosworth HB. Health literacy and
glaucoma. Curr Opin Ophthalmol. 2013 Mar;24(2):119-24.
doi: 10.1097/ICU.0b013e32835c8b0e
19. Okeke CO, Quigley HA, Jampel HD, et al. Interventions
improve poor adherence with once daily glaucoma medications
in electronically monitored patients. Ophthalmology. 2009
Dec;116(12):2286-93. doi: 10.1016/j.ophtha.2009.05.026.
Epub 2009 Oct 7.
20. Swanson MW. Undiagnosed and Over Diagnosed glau-
coma in the United States. Invest Ophthalmol Vis Sci 2012;53:
ARVO E-Abstract 6379/A17
21. Varma R, Ying-Lai M, Francis BA, et al; Los Angeles Latino
Eye Study Group. Prevalence of open-angle glaucoma and
ocular hypertension in Latinos: the Los Angeles Latino Eye
Study. Ophthalmology. 2004 Aug;111(8):1439-48.
20th Annual GLAUCOMA Report
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REVIEW OF OPTOMETRY JULY 15, 2014 50
Glaucoma on Trial:
Clinical Implications of the
Landmark Glaucoma Studies
Release Date: July 2014
Expiration Date: July 1, 2017
Goal Statement: Major glaucoma studies have asked the perplexing
diagnostic and treatment questions that clinicians face each day.
This course reviews these landmark clinical trials and highlights the
clinical implications and practical usage of each study for optom-
etrists.
Faculty/Editorial Board: David Lynne, OD, Maria Mandese, OD, and
Erika Walker, OD
Credit Statement: COPE approval for 2 hours of CE credit is pending
for this course. Check with your local state licensing board to see if this
counts toward your CE requirement for relicensure.
Joint-Sponsorship Statement: This continuing education course is
joint-sponsored by the Pennsylvania College of Optometry.
Disclosure Statement: Drs. Lynne, Mandese and Walker have no
financial relationships to disclose.
A
51-year-old white female
presented for a routine eye
examination. She had no
visual or ocular complaints,
and her visual acuity was 20/20 in
each eye. But her intraocular pres-
sure measured 25mm Hg OD and
26mm Hg OS. Her angles were
open to the ciliary body on goni-
oscopy, and her corneal thickness
measured 477m OD and 473m
OS.
Dilated fundus exam revealed
cup-to-disc ratios of 0.55 OD and
0.60 OS. Optical coherence tomog-
raphy (OCT) found the nerve fiber
layer in each eye to be within nor-
mal limits.
The patient returned in a month
for further glaucoma workup. IOP
on that visit was 26mm Hg OD and
24mm Hg OS. Visual field results
showed no significant defects OD
and early inferior arcuate defect OS.
The patient returned for repeat
visual field testing on the left eye,
which now showed reduced depres-
sions with good reliability.
Now what do we do? Should this
patientwith moderately high IOP
and thin corneas but relatively nor-
mal visual field results and OCT of
the nerve fiber layerbe treated?
In order to answer these ques-
tions, and to understand the behav-
ior of glaucoma and the correct
treatment for its various offenses,
glaucoma has been put on trial
clinical trial, that is. While expen-
sive and time consuming, these
clinical trials are the gold standard
for evaluating glaucoma therapies
and management strategies, and
their results have the power to influ-
ence clinical practice.
1
These landmark glaucoma stud-
ies have asked the difficult diag-
nostic and treatment questions
that clinicians face each day: How
do you deal with ocular hyperten-
sion or early glaucoma? What is
the best initial treatment for glau-
coma? What do you do to manage
advanced glaucoma? How do you
best treat normal-tension glaucoma?
And, what is the role of laser in
glaucoma treatment?
To reach a verdict, lets look at
the results of several landmark glau-
coma studies.
Treatment without evidence is like taking a shot in the dark.
These major studies provide proof to apprehend the sneak thief of sight.
By David Lynne, OD, Maria Mandese, OD, and Erica Walker, OD
EARN 2 CE CREDITS
(COPE approval pending)
20th Annual GLAUCOMA Report
OPTOMETRI C STUDY CENTER
REVIEW OF OPTOMETRY JULY 15, 2014 51
To Treat or Not to Treat?
EMGT
The Early Manifest Glaucoma
Trial (EMGT) was the first ran-
domized, clinical glaucoma trial
to address whether treating or not
treating intraocular pressure in
patients with newly diagnosed pri-
mary open-angle glaucoma (POAG)
could delay disease progression.
2
Researchers in Sweden recruited
255 participants between ages 50
to 80 with early POAG, visual field
defects and median IOP of 20mm
Hg. Testing included full-threshold
automated 30-2 visual fields and
tonometry every three months as
well as optic nerve head photos
every six months. Progression was
defined as greater than or equal to
three consecutive points decreased
from baseline visual field in three
different consecutive tests. The treat-
ment group received full 360 laser
trabeculoplasty plus Betimol (betax-
olol, Alcon) twice daily.
At the end of the study, EMGT
showed that IOP reduction delayed
disease progression in POAG. Spe-
cifically, treatment reduced IOP by
25% on average (from 20.6mm
Hg at baseline to 15.5mm Hg at
the three-month visit), which was
maintained throughout six years of
follow up.
The magnitude of this depen-
dence on IOP change was impres-
sive: an estimated 10% decrease in
risk of progression with each milli-
meter of mercury of IOP reduction,
the authors wrote.
2
The study also provided a long-
term comparison for the progression
rate between treated and untreated
patients with POAG. Progression
was less frequent in the treatment
group (45%) and occurred later
than in the controls (62%).
2
However, the study had several
limitations: a homogeneous popula-
tion (only whites), inclusion of only
early glaucoma patients, exclusion of
those with high IOP and advanced
glaucoma, and no long-term follow-
up of patients who displayed glau-
coma progression beyond the study
period.
Conclusion: The EMGT showed
that IOP-lowering treatment offers
beneficial effects by significantly
delaying progression.
Clinical implications:
Even small reductions in IOP
can make a difference. Every 1mm
of IOP reduction was associated
with a risk reduction of 10% to
13%, depending on the analysis,
says lead author Anders Heijl, MD,
PhD.
3
But that doesnt necessarily
mean all patients must be treated.
Because we cant know which
patients will progress, in some
cases, we can observe closely and
tailor management to the individual
patient. In particular, Its beneficial
to lower pressure in patients pro-
gressing quickly, even if IOP levels
have been in the range of 15 to
18mm Hg, Dr. Heijl says.
OHTS
Before the Ocular Hypertension
Treatment Study (OHTS), we had
no consensus on whether to treat or
to observe patients who had elevat-
ed IOP but no glaucomatous
A 51-year-old white female presented for a routine eye exam, but her intraocular pressure measured 25mm Hg OD and 26mm Hg OS.
Her corneas were thin and her cup-to-disc ratios were 0.55 OD and 0.60 OS. Does this patient have glaucoma? And if so, should she
be treated? The answers may be found in the landmark glaucoma studies, such as the Ocular Hypertension Treatment Study.
REVIEW OF OPTOMETRY JULY 15, 2014 52
OPTOMETRI C STUDY CENTER
damageotherwise known as
ocular hypertensives or glaucoma
suspects. Treatment might prevent
nerve fiber loss in some patients, but
then again we could be unnecessar-
ily medicating many suspects who
might never convert to glaucoma.
Enter OHTS. The studys purpose
was to evaluate the safety and effi-
cacy of topical ocular hypotensive
medication in delaying or preventing
the onset of POAG in individuals
with elevated IOP.
OHTS enrolled a total of 1,636
participants, ages 40 to 80, who had
no evidence of glaucomatous dam-
age but whose IOP was elevated
between 24mm to 32mm Hg in one
eye and 21mm to 32mm Hg in the
other eye. (Because glaucoma is the
leading cause of blindness in blacks,
investigators made sure that 25% of
the patient sample was of African-
American origin.) The overall treat-
ment goals were to reduce IOP by
20% or more and reach an IOP of
24mm Hg or less.
4
Progression was defined more
stringently than in similar studies.
OHTS required three abnormal
visual fields to confirm a defect as
well as clinically significant changes
to the optic disc neuroretinal rim.
During the five-year study period,
an IOP reduction was achieved in
22.5% (+/-9.9%) of the medication
group and 4% (+/-11.6%) of the
observation group. At the end of the
study, the probability of developing
POAG was 4.4% in the medication
group and 9.5% in the observation
group.
4
Conclusion: This study shows
strong evidence that lowering IOP in
ocular hypertensive patients delays
or even prevents the onset of POAG.
The study also identified which
factors are more predictive for the
development of POAG: older age,
larger vertical or horizontal cup-to-
disc ratio, higher IOP, greater Hum-
phrey visual field pattern standard
deviation, and thinner corneal thick-
ness measurement.
5
Clinical implications:
Not all patients with high IOP
require hypotensive treatment. Con-
sider all factorssuch as the age
and health of the patient, as well as
the condition of the disc, visual field
testing results, optical coherence
tomography, family history, corneal
hysteresis, clinical appearance and
pachymetrybefore starting ocular
medications.
Subjects with corneal thickness
of 555m or less had three times the
risk of developing primary open-
angle glaucoma compared with
those who had corneal thickness of
588m or more. Therefore, measure
central corneal thickness of all new
glaucoma suspects.
5
Investigators concluded it is
possible to separate ocular hyper-
tensive patients into categories of
high, medium and low risk. The
ocular hypertensive patients at high
risk may benefit from close follow-
up and some from early treatment,
whereas the low-risk patients can
have less frequent follow-up and
may not need early treatment,
said OHTS principal investigator
Michael A. Kass, MD.
3
CIGTS
When treating patients with
open-angle glaucoma, an important
decision concerns choosing an IOP-
lowering treatment method. Have
you ever wondered whether your
patients would have better outcomes
if you chose one treatment initially
vs. another? Would immediate surgi-
cal intervention ever be warranted?
The Collaborative Initial Glau-
coma Treatment Study (CIGTS)
attempted to determine whether
patients with newly diagnosed
open-angle glaucoma would be bet-
ter managed using IOP-lowering
medications or having an immediate
trabeculectomy.
6
The study involved 607 patients
with an IOP of 20mm Hg or greater,
as well as optic nerve damage and/or
visual field (VF) loss in one or both
OCT scans in our patient found the nerve fiber layer in each eye to be within normal
limits. Does this mean she wont convert to glaucoma? Again, we must look to the
studies for insight.
REVIEW OF OPTOMETRY JULY 15, 2014 53
eyes. The patients were randomly
assigned to either initial treatment
with a stepped regimen of topical
medications or trabeculectomy. The
main outcome measure used was
progression of VF loss. In addition,
a secondary measurea health-
related quality of life question-
nairelooked at how the treatment
affected the patients lifestyle.
7
After five years, the results
showed that both treatment groups
had a substantial reduction of IOP
(48% in the surgical group, 35%
in the topical medication group)
and no significant difference in
their rates of VF progression.
6,8
As
expected, the surgical group was
much more likely to develop a cata-
ract, which affected their VF results.
Patients who were older, diabetic,
non-white, required cataract surgery
and had more advanced VF loss at
baseline were more likely to have VF
loss progression.
6
Those with greater
IOP fluctuations (more often if treat-
ed with topical medication initially)
also had more VF progression.
9
Interestingly, after more than eight
years of follow-up, those patients
with mild VF loss at baseline also
did equally well in either treatment
group.
9
However, the patients with
more advanced loss at baseline
(with the exception of non-whites
and those with diabetes) had better
results with initial trabeculectomy,
and major surgical complications
were few.
9
Conclusion: When aggressive
treatment aimed at substantial
reduction in IOP from baseline
is used, loss of visual field can be
seen to be minimal in general, the
researchers wrote.
6,10
The results also revealed that
either treatment had a remarkably
similar effect on patients quality of
life. Though not associated with a
particular treatment group, the fear
of blindness was common, affect-
ing 34% at diagnosis.
11
Patients
who reported a decrease in visual
functioning were more likely to
experience depression and mood
changes.
12
Clinical implications:
Both topical and surgical inter-
ventions are safe and effective in
treating most OAG patients. While
this may not signal a major shift in
glaucoma treatment, consider surgi-
cal intervention earlier for patients
with more advanced disease at the
time of diagnosis (excluding non-
whites and those with diabetes).
It is very important to educate
patients on glaucoma. Reassure
patients that with proper treatment
and follow-up, the risk of blindness
is low, especially if the diagnosis is
made before the disease is advanced.
Normal-Tension Glaucoma:
How Low Can You Go?
CNTGS
Lowering IOP in patients with
normal-tension glaucoma (NTG)
can be challenging. Is it even worth
trying to lower an already-low IOP?
The Collaborative Normal-
Tension Glaucoma Study (CNTGS)
provided some valuable insight. The
study, published in 1998, set out
to determine whether IOP plays a
role in NTG, and if lowering IOP
in NTG patients can slow disease
progression.
Investigators randomized 145
glaucoma patients, who had a
median IOP of 20mm Hg or less in
10 baseline readings, into a treat-
ment group and a non-treatment
group.
13
Patients in the treatment
group were given medications, laser
trabeculoplasty, filtration surgery or
any combination in order to reduce
the IOP by 30%. The main out-
come measure used was visual field
progression from baseline. Progres-
sion was confirmed on two of three
visual fields within one month, and
verified on two of three visual fields
done three months later.
After five to seven years of
follow-up, the results showed that
by decreasing IOP 30%, glaucoma
progression could be reduced by
50%. The 30% reduction of IOP
was achieved about 50% of the
time using medication (pilocarpine
or systemic CAI) and laser trabecu-
loplasty.
14
Cataracts developed in
38% of treated patients, predomi-
nately those undergoing filtering
surgery, and in 14% of non-treated
patients.
13
The study further looked at the
natural course of NTG and found
that progression in untreated
patients was quite variable. More
than 50% showed no progression
after five to seven years, while oth-
ers progressed quickly, threatening
blindness.
13
So, how is an eye care pro-
vider to know who will progress
and who will remain stable? The
study revealed some risk factors to
help predict those who are at risk
for faster progression: history of
migraine, female gender and the
presence of a disc hemorrhage at
diagnosis.
Conclusion: While there is still
much to learn about NTG, the
CNTGS clearly demonstrated that
IOP plays a role in NTG and that,
in such patients, the disease (or at
least visual field progression) can
be slowed by lowering IOP at least
30%.
Clinical implications:
Because of the variable natural
course of NTG, it is important to
distinguish between patients who
have progressive vs. non-progressive
disease. In cases of mild NTG,
consider monitoring until progres-
sion is confirmed. However, factors
that weigh more heavily for treat-
ment are female gender, history of
migraine and disc hemorrhage at
diagnosis.
When you suspect progression,
be sure to confirm that it is actual
REVIEW OF OPTOMETRY JULY 15, 2014 54
OPTOMETRI C STUDY CENTER
progression and not testing variabil-
ity. This may require multiple visual
fields to prevent over-diagnosing
progression.
Once the decision is made to
begin treatment, set a goal (at least
30% IOP reduction) and be diligent
in attaining it. The large arsenal of
IOP-lowering medications available
today makes this goal much more
achievable without surgery.
LoGTS
Have you ever been faced with
a chronic open-angle glaucoma
patient with visual field loss, optic
nerve/retinal nerve fiber layer loss
and normal intraocular pressure?
Have you wondered which hypo-
tensive drop would best preserve the
patients visual field?
The Low-Pressure Glaucoma
Treatment Study (LoGTS) attempted
to answer this question.
15
The study,
published in 2011, compared twice-
daily brimonidine 0.2% vs. twice-
daily timolol 0.5% to determine if
either was better at preserving visual
function.
Results showed a similar IOP
reduction for each medication. Not
surprisingly, 28 of the 99 patients
in the brimonidine arm of the study
dropped out due to drug-related
adverse events, compared with only
nine of the 79 timolol patients.
What was surprising was that
patients on brimonidine had less
visual field loss (9.1%) compared
with patients on timolol (39.2%)
during an average of 30 months.
Why did this happen? Was it due
to a beneficial effect of brimonidine
or a negative effect of timolol? Glau-
coma experts cannot seem to agree,
and questions abound.
Supporters of brimonidine point
to the laboratory data indicating
that alpha-2 agonists may be neu-
roprotective. However, patients
tended to stop using brimonidine
due to adverse reactions such as
burning and irritation, leading to
poor adherence.
15
Detractors of brimonidine say
that the results in this study may
be due to unique properties found
in this group of patients only. Data
may have been skewed due to the
high number of patients dropping
out of the brimonidine group.
Also, the IOP-lowering effect of
each medication was not to the
level believed to be the standard of
care. No therapeutic goal for either
medication had been set. Patients
simply had to have their IOP remain
below 21mm Hg. Baseline untreated
IOP was just over 15mm Hg and
the mean treated IOP was around
14mm Hg. Additionally, timolol,
used to treat glaucoma since 1978,
has been shown to preserve vision
compared to no treatment as long
as the IOP is lowered sufficiently.
16
Timolol was also shown to be
effective in the Ocular Hyperten-
sion Treatment Study and the Early
Manifest Glaucoma Trial. Finally,
diurnal IOP analysis was not done.
Conclusion: LoGTS found that
low-pressure glaucoma patients
treated with brimonidine are less
likely to have field progression than
patients treated with timolol. But,
before jumping on the possible
neuroprotective bandwagon of bri-
monidine, or abandoning timolol
as a treatment for normal-tension
glaucoma patients, it may be best
Our patients visual field results showed a full inferior arcuate defect OD and an early inferior arcuate defect OS. Is it time to begin
medication? Not just yet. Repeat visual field testing is in order first.
REVIEW OF OPTOMETRY JULY 15, 2014 55
to wait and see if these results are
repeatable in future studies.
Clinical implications:
For now, optometrists should
use the therapy that reduces IOP in
normal-tension patients to signifi-
cant levels (minimum 30%), and
modify treatment if the optic nerve,
retinal nerve fiber layer or visual
field changes.
Prostaglandins have superb
efficacy and less effect than other
agents in lowering heart rate. These
should be used as a first-line treat-
ment whenever possible.
Remember to check blood pres-
sure and heart rate before initiating
treatment with a beta-blocker such
as timolol. Also, check if the patient
is already taking a systemic beta-
blocker.
Be sure that patients use timolol
earlier in the evening rather than
before bedtime to avoid the hypo-
tensive effect that might compro-
mise ocular blood flow and induce
systemic hypotension.
Laser Treatment: First-line
Therapy?
GLT and SLT/Med Studies
The Glaucoma Laser Trial (GLT)
and the GLT Follow-up Study
compared newly-diagnosed POAG
patients treated with medical thera-
py vs. those treated with argon laser
trabeculoplasty (ALT).
17,18
Patients
were followed 2.5 to 5.5 years.
Two-year results showed that
patients treated initially with ALT
had lower IOP (1.2mm Hg lower
on average) compared to patients
who were initially medicated. Eyes
that had initial ALT had a better
visual field and better ONH status
during the 5.5 years than fellow
eyes treated initially with topical
medications.
Keep in mind that this was prior
to the advent of prostaglandins,
CAIs or alpha-agonists. So, upon
completion of the study, 56% of the
laser patients and 70% of the medi-
cation patients needed additional
treatment (more medication, laser
or surgery) to reduce the IOP.
The GLT Follow-up Study
evaluated 203 of the original 271
patients of the GLT for six to nine
years. Seven-year results showed
that IOP, visual fields and ONH
status were all similar between ALT-
first and medication-first groups.
Critics of the GLT study have
pointed out that timolol used in one
eye of the study may have had a
crossover effect on the contralateral
eye that was treated with ALT, thus
introducing bias for the ALT-treated
eyes. Also, they note that the effects
of ALT have been shown to wear
off over time.
18
Several years later, the SLT/Med
Study compared 360 selective laser
trabeculoplasty (SLT) to drug thera-
py (prostaglandin analog) as initial
treatment for open-angle glaucoma
or ocular hypertension.
19
Target
intraocular pressure was set for
each group according to the CIGTS
formula. Fifty-four patients (29 SLT,
25 medical) reached the nine- to
12-month follow-up. Baseline IOPs
as well as the IOP at the last follow-
up were similar between the groups
(24.5mm Hg reduced to 18.2mm
Hg for SLT vs. 24.7mm Hg reduced
to 17.7mm Hg for medicine). Addi-
tional treatment was necessary in
11% of the SLT group vs. 27% in
the medicated group. Unfortunately,
the SLT/Med Study was only for a
year, so long-term data is unknown.
Conclusion: These studies found
that initial treatment with laser tra-
beculoplasty is at least as efficacious
as initial treatment with topical
medication for patients with open-
angle glaucoma.
Clinical implications:
When choosing an initial treat-
ment, offer your patient the option
of starting with either medication or
laser trabeculoplasty (now SLT).
Be sure to discuss the pros and
cons of each treatment. All of our
topical medications have potential
side effects; discuss the most com-
mon for the medication you would
prescribe. Likewise, laser trabecu-
loplasty is not without risk, and
patients should be made aware that
they could have a spike in pressure
after the procedure that may require
medication or surgery to lower the
pressure as well as possible inflam-
mation leading to pain, redness and
transient blurred vision.
Should the patient choose medi-
cation, the optometrist should begin
treatment. If the patient chooses
SLT, refer the patient to someone
who has the experience and capabil-
ity to perform the procedure. (If you
practice in Oklahoma, Kentucky or
Louisiana, this may be you.) Make
sure the patient understands that the
treatment may not work, may wear
off, and that additional laser or
drops may be necessary if progres-
sion occurs.
Surgical Intervention: Dont
Let Glaucoma Rob You Blind
AGIS
While there is no cure for glau-
coma, our current therapies are
all aimed toward a simple goal: to
preserve visual functionthat is,
visual field and visual acuity. How-
ever, determining the best path to
reaching this seemingly simple goal
can be frustratingly complex. Even
when patients are compliant, medi-
cal therapies can fail, and glaucoma
can progress to advanced stages
despite our best efforts.
The Advanced Glaucoma Inter-
vention Study (AGIS) was designed
to determine the best sequence of
surgical interventions in patients
when medical therapies had failed.
20
Some 789 eyes were randomly
assigned to one of two intervention
sequences. One sequence began with
argon laser trabeculoplasty (ALT)
REVIEW OF OPTOMETRY JULY 15, 2014 56
OPTOMETRI C STUDY CENTER
and the other began with trabecu-
lectomy. If ALT failed in the first
sequence, trabeculectomy was per-
formed as the second procedure in
that sequence. In the other sequence
that began with trabeculectomy,
failure dictated that ALT would
next be performed.
In both sequences, if needed,
another trabeculectomy was done
as the third intervention.
21
Keep in
mind, this study began recruitment
in the late 1980s so SLT and tube-
shunt procedures had not yet been
introduced.
Conclusion: Although not origi-
nally predicted, racial differences in
treatment outcomes became appar-
ent upon analysis of the AGIS
data.
22
The treatment sequence that
began with trabeculectomy did show
a greater decrease in IOP regardless
of race. However, black patients in
the treatment sequence who began
with ALT had greater preservation
of visual field and visual acuity
than those who
began with tra-
beculectomy. In
contrast, white
patients in the
sequence who
began with
trabeculectomy
had greater pres-
ervation of
visual field on
long-term follow-
up than those
who began with
ALT.
21
Therefore,
researchers con-
cluded that visual
function was best
preserved when
black patients
began with ALT
and when white
patients began
with trabeculec-
tomy.
21
Effects of IOP
on visual field progression were also
specifically evaluated from AGIS
data, and it was found that patients
with an average IOP of greater than
17.5mm Hg had greater worsening
of their visual fields than those with
an average IOP of less than 14mm
Hg.
23
AGIS was one of the first
studies to show that lower mean
IOP results in a decreased risk of
visual field progression.
Clinical implications:
Each patient requires individu-
alized care. AGIS demonstrated that
race is an important consideration
for surgical intervention in advanced
glaucoma. This is not to say, for
instance, that a white patient with
medically-uncontrolled glaucoma
should only be offered the option of
trabeculectomy. Potential operative
complications associated with the
more invasive surgery may sway the
patient toward laser intervention as
a first option. Conversely, a black
patient presented with the option of
laser intervention should be warned
of the likely future need for both
additional medications and addi-
tional glaucoma surgery after the
laser procedure is completed.
21
There is no magic number for
target IOP. Patients in the AGIS
group who consistently maintained
IOP less than 18mm Hg at every
visit over six years, with mean
IOP of 12.3mm Hg as a group,
had good preservation of visual
fieldyet a number of patients in
this group still showed progressive
visual field loss.
23
TVT Study
When medical and laser therapy
fail in glaucoma, we are left with
several surgical options. Trabecu-
lectomy and tube-shunt implanta-
tion are the two most common
glaucoma surgeries worldwide.
24
When patients have already under-
gone previous intraocular surgery,
which procedure should glaucoma
surgeons choose?
Until 1995, glaucoma surgeons
generally preferred trabeculectomy
to the newer tube-shunt procedure,
primarily used at that time only for
high-risk eyes. However, Medicare
claims data between 1995 and 2004
showed a 184% increase in tube-
shunt surgery, revealing a paradigm
shift in the approach to glaucoma
surgical intervention.
25
The Tube Versus Trabeculectomy
(TVT) study was introduced as an
evidence-based approach to either
support or invalidate this para-
digm shift and to observe whether
tube-shunt implantation offered
advantages over trabeculectomy in
patients who had undergone previ-
ous ocular surgery (specifically
cataract extraction and/or previous
failed trabeculectomy).
In eyes randomized to the tube
group, surgeons placed a Baerveldt
glaucoma implant in the superotem-
poral quadrant, while all eyes in the
When our patient returned for repeat field testing of the left eye,
it now showed marked improvement. Still, given the patients
relatively young age, her large cup-to-disc ratios, her thin cor-
neas and elevated IOP readings, we decided to begin medication
after discussing the options with her.
REVIEW OF OPTOMETRY JULY 15, 2014 57
trabeculectomy group underwent
trabeculectomy with adjunctive use
of mitomycin C.
26
Conclusion: While both pro-
cedures generally produced a sig-
nificant and sustained reduction in
IOP and both procedures showed
reduced postoperative dependence
on glaucoma medications, the
trabeculectomy group had a sig-
nificantly higher failure rate after
five years of follow-up.
24
The most
common reason for failure was
inadequate IOP reduction (IOP
>21mm Hg or not reduced by 20%
below baseline). Significantly higher
failure rates remained in the trab-
eculectomy group even when more
stringent IOP criteria were applied
(upper IOP limit of 17mm or 14mm
Hg). Additionally, glaucoma reop-
eration was needed more frequently
in the trabeculectomy group.
25
While TVT answered its intended
inquiry, the results have spurred
follow-up questions. Are the advan-
tages seen with tube-shunt place-
ment maintained when the patient
has not undergone any previous
ocular surgery? In other words,
should tube-shunt placement be
considered as a primary surgery
option for glaucoma? A new study,
the Primary Tube Versus Trabecu-
lectomy Study, hopes to answer
these questions; results are expected
in April 2016.
27
Clinical implications:
The researchers maintain that
the TVT study does not dem-
onstrate clear superiority of one
glaucoma operation over the other,
but that both surgeries are viable
options.
24
Potential pitfalls exist with
the use of tube shunts. Subsequent
surgical options after failure of
tube-shunt devices become lim-
itedsurgeons are left with the
choice of a second, inferiorly placed
tube or cyclophotocoagulation.
28
Also, some patients are not com-
fortable with the idea of a tube-
shunt device or what they perceive
as hardware in their eye, says
Brian Francis, MD, a contributing
investigator in the TVT study.
28
Trabeculectomy is not without
its travails. It requires the surgeon
to tailor the procedure to each
patient (i.e., number of scleral flap
sutures and dosage of an antifi-
brotic agent) whereas tube-shunt
surgery is a more standardized
procedure according to TVT lead
author Steven Gedde, MD.
28
Also,
trabeculectomies require more fre-
quent and more vigilant postopera-
tive care than tube shunts.
Glaucoma has taken the stand.
We have heard its testimony. Now,
it is time to render our verdict.
In our patients case, the decision
to treat or not to treat was influ-
enced by the OHTS findings. An
argument could be made to monitor
our patient because she is relatively
young, had full visual fields and
normal OCT findings. However,
our patient also had large cup-to-
disc ratios, elevated IOP readings
and very thin pachymetry measure-
ments. OHTS has shown us how
significant corneal thickness is in
the development of glaucoma.
Based on all of the findings and
after discussion with our patient,
we made the decision to begin med-
ical treatment with a prostaglandin.
Now, six years later, her IOP
remains well controlled and her
optic nerves and visual fields are
stable. Would she have been the
same had we not treated her? Pos-
sibly, but we cant know. Ultimately,
treatment decisions, while guided
by information learned from the
landmark glaucoma studies, must
be based on each individual patient
and their optometrists best clinical
judgment.
Drs. Lynne, Mandese and Walker
are on staff at the Orlando VA
Medical Center in Florida.
Thanks to John Spalding, OD,
also at the Orlando VA Medical
Center, for contributing to this
article.
1. Chew EY. The value of randomized clinical trials in ophthalmology.
Am J Ophthalmol. 2011 Apr;151(4):575-8.
2. Heijl A, Leske MC, Bengtsson B, et al; Early Manifest Glaucoma
Trial Group. Reduction of intraocular pressure and glaucoma
progression: results from the Early Manifest Glaucoma Trial. Arch
Ophthalmol. 2002 Oct;120(10):1268-79.
3. Stuart A. Landmark glaucoma studies: Key findings and treatment
lessons. EyeNet. 2012 Mar 22;16(3):49-55.
4. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hyperten-
sion Treatment Study: A randomized trial determines that topical ocu-
lar hypotensive medication delays or prevents the onset of primary
open-angle glaucoma. Arch Ophthalmol. 2002 Jun;120(6):701-13.
5. Gordon MO, Beiser JA, Brandt JD, et al. The Ocular Hypertension
Treatment Study: baseline factors that predict the onset of primary
open-angle glaucoma. Arch Ophthalmol. 2002 Jun;120(6):714-20;
discussion 829-30.
6. Lichter PR, Musch DC, Gillespie BW, et al. CIGTS Study Group.
Interim clinical outcomes in the Collaborative Initial Glaucoma Treat-
ment Study comparing initial treatment randomized to medications or
surgery. Ophthalmology. 2001 Nov;108(11):1943-53.
7. Janz NK, Wren PA, Lichter PR, et al; CIGTS Study Group. The
Collaborative Initial Glaucoma Treatment Study: interim quality of
life findings after initial medical or surgical treatment of glaucoma.
Ophthalmology. 2001 Nov;108(11):1954-65.
8. Musch DC, Gillespie BW, Lichter PR, et al.; CIGTS Study Group.
Visual field progression in the Collaborative Initial Glaucoma
Treatment Study the impact of treatment and other baseline factors.
Ophthalmology. 2009 Feb;116(2):200-7.
9. Musch DC, Gillespie BW, Niziol LM, et al.; CIGTS Study Group.
Intraocular pressure control and long-term visual field loss in the
Collaborative Initial Glaucoma Treatment Study. Ophthalmology.
2011 Sep;118(9):1766-73.
10. Wishart PK. Interpretation of the glaucoma landmark studies.
Br J Ophthalmol. 2009 May;93(5):561-2.
11. Janz NK, Wren PA, Guire KE, et al.; CIGTS Study Group.
Fear of blindness in the Collaborative Initial Glaucoma Treatment
Study: patterns and correlates over time. Ophthalmology. 2007
Dec;114(12):2213-20.
12. Jampel HD, Frick KD, Janz NK, et al.; CIGTS Study Group.
Depression and mood indicators in newly diagnosed glaucoma
patients. Am J Ophthalmol. 2007 Aug;144(2):238-244.
13. Collaborative Normal-tension Glaucoma Study Group. Compari-
son of glaucomatous progression between untreated patients with
normal-tension glaucoma and patients with therapeutically reduced
intraocular pressures. Am J Ophthalmol. 1998 Oct;126(4):487-97.
14. Anderson DR; Normal Tension Glaucoma Study. Collaborative
Normal-tension Glaucoma Study. Curr Opin Ophthalmol. 2003
Apr;14(2):86-90.
15. Krupin T, Liebmann JM, Greenfield DS, et al; Low-Pressure Glau-
coma Study Group. A randomized trial of brimonidine versus timolol
in preserving visual function: results from the Low-Pressure Glau-
coma Treatment Study. Am J Ophthalmol. 2011 Apr;151(4):671-81.
16. Epstein DL, Krug JH, Hertzmark E, et al. A long-term clinical trial
of timolol therapy versus no treatment in the management of glau-
coma suspects. Ophthalmology. 1989 Oct;96(10):1460-7.
17. Glaucoma Laser Trial Research Group. The Glaucoma Laser Trial
(GLT). 2. Results of argon laser trabeculoplasty versus topical medi-
cines. Ophthalmology. 1990 Nov;97(11):1403-13.
18. Glaucoma Laser Trial Research Group. The Glaucoma Laser Trial
(GLT) and glaucoma laser trial follow-up study: 7. Results. Am J
Ophthalmol. 1995 Dec;120(6):718-31.
19. Katz LJ, Steinmann WC, Kabir A, et al.; SLT/Med Study Group.
Selective laser trabeculoplasty versus medical therapy as initial
treatment of glaucoma: a prospective, randomized trial. J Glaucoma.
2012 Sep;21(7):460-8.
20. The AGIS Investigators. The Advanced Glaucoma Intervention
Study (AGIS): 1. Study design and methods and baseline charac-
teristics of study patients. Control Clin Trials. 1994 Aug; 15(4):
299-325.
REVIEW OF OPTOMETRY JULY 15, 2014 58
OPTOMETRI C STUDY CENTER
Y
ou can obtain transcript-quality
continuing education credit through
the Optometric Study Center. Com-
plete the test form (page 59), and return
it with the $35 fee to: Optometric CE, P.O.
Box 488, Canal Street Station, New York,
NY 10013. To be eligible, please return the
card within one year of publication.
You can also access the test form and
submit your answers and payment via
credit card at Review of Optometry online,
www.revoptom.com.
You must achieve a score of 70 or
higher to receive credit. Allow eight to 10
weeks for processing. For each Optomet ric
Study Center course you pass, you earn
2 hours of transcript-quality credit from
Pennsyl vania College of Optometry and
double credit toward the AOA Optom et ric
Recog nition AwardCate gory 1.
Please check with your state licensing
board to see if this approval counts toward
your CE requirement for relicensure.
1. The Early Manifest Glaucoma Trial
showed intraocular pressure reduction
delayed disease progression in cases of
POAG. Specifically, treatment reduced IOP
by what percentage on average?
a. 20%.
b. 25%.
c. 30%.
d. 40%.
2. Which one of the following was NOT a
limitation of the Early Manifest Glaucoma
trial?
a. Moderate glaucoma patients were
excluded.
b. It included a homogeneous population.
c. Inclusion of patients with high IOP.
d. Exclusion of patients with advanced
visual field loss.
3. The treatment goal in the Ocular
Hypertension Treatment Study was to
reduce IOP by:
a. 25% and less than 24mm Hg.
b. 20% and less than 24mm Hg.
c. 25% and less than 20mm Hg.
d. 30% and less than 24mm Hg.
4. All of the following factors should be con-
sidered as reasons to lower IOP in ocular
hypertensives EXCEPT:
a. Repeatable Humphrey visual field SITA
standard 24-2 tests showing a superior
arcuate defect.
b. Corneal thickness thinner than 555m.
c. A normal OCT.
d. Significant nerve fiber layer damage of
the neuroretinal rim of the optic nerve.
5. The Collaborative Initial Glaucoma
Treatment Study (CIGTS) evaluated which
glaucoma treatment method?
a. Observation vs. topical medication.
b. Topical medication vs. SLT/ALT.
c. SLT/ALT vs. trabeculectomy.
d. Trabeculectomy vs. topical medication.
6. The primary outcome measure for the
CIGTS was:
a. A 30% reduction in IOP.
b. Progression of visual field loss.
c. Progression of optic nerve head cupping.
d. Treatment effect on patients quality of
life.
7. Based on the outcomes of the CIGTS,
which is NOT true?
a. Both treatment groups had a significant
reduction of IOP.
b. There was no significant difference in
the rate of visual field progression between
treatment groups.
c. There was no significant difference in the
development of cataracts between treat-
ment groups.
d. Over one-third of patients had a fear of
blindness at the diagnosis of glaucoma.
8. The Collaborative Normal Tension
Glaucoma Study (CNTGS) showed that by
decreasing IOP by 30%, glaucoma progres-
sion could be reduced by:
a. 30%.
b. 40%.
c. 50%.
d. 60%.
9. Which treatment method was NOT used
in the CNTGS?
a. Topical pilocarpine.
b. Oral carbonic anhydrase inhibitor.
c. Laser trabeculoplasty.
d. Trabeculectomy.
10. Based on CNTGS, which is NOT a risk
factor for faster progression of normal ten-
sion glaucoma?
a. Presence of disc hemorrhage at diag-
nosis.
b. Female gender.
c. Central corneal thickness.
d. History of migraine.
11. In the Low-Pressure Glaucoma
Treatment Study (LoGTS), which topical
treatment drops were compared to deter-
mine which better preserves a normal ten-
sion patients vision?
a. Timolol and betaxolol.
b. Timolol and brimonidine.
c. Timolol and latanoprost.
d. Timolol and dorzolamide.
12. What was the main limitation of the
LoGTS, which may have skewed the study
results?
a. Timolol caused drug-related adverse
events.
b. Brimonidine caused drug-related adverse
events.
c. Both timolol and brimonidine caused
drug-related adverse events.
d. Neither timolol nor brimonidine caused
drug-related adverse events.
13. Which is true regarding the long-term
results of the Glaucoma Laser Trial and GLT
Follow-up Study?
a. Prostaglandins and alpha-agonists were
used for treatment in the medication group.
b. 56% in the medication group needed
additional treatment to lower IOP.
c. IOP, visual fields and optic nerve head
status were all similar between the medica-
tion and ALT groups.
d. All patients had undergone glaucoma
treatment prior to the start of the GLT Study.
14. What was the duration of the SLT/Med
Study?
a. Seven years.
b. Five and a half years.
c. Ten years.
d. One year.
15. What must you discuss with your
patient when considering laser trabeculo-
plasty?
a. There are no known complications with
laser trabeculoplasty.
b. The effects of laser trabeculoplasty may
wear off over time.
c. They will never need to use drops for
glaucoma again.
d. Medication is always the better option.
OSC QUI Z
21. The AGIS Investigators. The Advanced Glaucoma Intervention
Study (AGIS): 13. Comparison of treatment outcomes within race:
10-year results. Ophthalmology. 2004 Apr; 111(4): 651-64.
22. The AGIS Investigators. The Advanced Glaucoma Intervention
Study (AGIS): 4. Comparison of treatment outcomes within race.
Seven-year results. Ophthalmology. 1998 Jul; 105(7): 1146-64.
23. The AGIS Investigators. The Advanced Glaucoma Intervention
Study (AGIS): 7. The relationship between control of intraocular
pressure and visual field deterioration. Am J Ophthalmol. 2000 Oct;
130(4): 429-40.
24. Gedde SJ, Singh K, Schiffman JC, Feuer WJ; Tube Versus Tra-
beculectomy Study Group. The Tube Versus Trabeculectomy Study:
interpretation of results and application to clinical practice. Curr Opin
Ophthalmol. 2012 Mar; 23(2): 118-26.
25. Gedde SJ, Schiffman JC, Feuer WJ, et al; Tube versus Trab-
eculectomy Study Group. Treatment outcomes in the Tube Versus
Trabeculectomy (TVT) Study after five years of follow-up. Am J
Ophthalmol. 2012 May; 153(5): 789-803.e2.
26. Gedde SJ, Schiffman JC, Feuer WJ, et al; Tube Versus Trab-
eculectomy Study Group. The Tube Versus Trabeculectomy Study:
design and baseline characteristics of study patients. Am J Ophthal-
mol. 2005 Aug; 140(2): 275-87.
27. ClinicalTrials.gov. Primary Tube Versus Trabeculectomy Study.
Available at: http://clinicaltrials.gov/show/NCT00666237. Accessed
May 15, 2014.
28. Scheck A. Consider tube shunts for glaucoma surgery. EyeNet.
2012 Sep;16(9):33-34.
REVIEW OF OPTOMETRY JULY 15, 2014 59
16. Which treatment sequence inves-
tigated by the Advanced Glaucoma
Intervention Study was found to provide
the best long-term preservation of visual
function in black patients?
a. Trabeculectomy-ALT-trabeculectomy.
b. ALT-trabeculectomy-trabeculectomy.
c. Trabeculectomy-trabeculectomy-ALT.
d. ALT-ALT-trabeculectomy.
17. What is the target IOP at which a
patient can be guaranteed no further glau-
comatous visual field progression?
a. 12.3mm Hg.
b. 14mm Hg.
c. 18mm Hg.
d.
18. What are the two most common
glaucoma surgeries being performed
worldwide?
a. Trabeculectomy and tube-shunt implan-
tation.
b. ExPress mini shunts and cyclophotoco-
agulation.
c. Trabeculectomy and cyclophotocoagula-
tion.
d. ALT and trabeculectomy.
19. Which result of the Tube Versus
Trabeculectomy Study is true?
a. Failure rates were significantly higher in
the tube group compared to the trabecu-
lectomy group.
b. Glaucoma reoperation was needed
more frequently in the trabeculectomy
group.
c. Tube shunts were found to be superior
to trabeculectomy.
d. None of the eyes in the study had
undergone any previous ocular surgery.
20. Which may be a potential downside
to trabeculectomy surgery compared to
tube-shunt implantation?
a. The patient does not want hardware
placed in the eye.
b. Subsequent surgical options are more
limited after trabeculectomy failure as
compared to options after tube-shunt
failure.
c. Tube shunts were found to be superior
to trabeculectomy.
d. The patient lives far away from the
clinic.
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(travoprost ophthalmic solution) 0.004% is indicated for the reduction of elevated intraocular
pressure in patients with open-angle glaucoma or ocular hypertension.
DOSAGE AND ADMINISTRATION
The recommended dosage is one drop in the affected eye(s) once daily in the evening.
TRAVATAN Z
(travoprost ophthalmic solution) should not be administered more than once daily since it
has been shown that more frequent administration of prostaglandin analogs may decrease the intraocular
pressure lowering effect.
Reduction of the intraocular pressure starts approximately 2 hours after the rst administration with
maximum effect reached after 12 hours.
TRAVATAN Z
Solution may be used concomitantly with other topical ophthalmic drug products to lower
intraocular pressure. If more than one topical ophthalmic drug is being used, the drugs should be
administered at least ve (5) minutes apart.
CONTRAINDICATIONS
None
WARNINGS AND PRECAUTIONS
Pigmentation
Travoprost ophthalmic solution has been reported to cause changes to pigmented tissues. The most
frequently reported changes have been increased pigmentation of the iris, periorbital tissue (eyelid) and
eyelashes. Pigmentation is expected to increase as long as travoprost is administered. The pigmentation
change is due to increased melanin content in the melanocytes rather than to an increase in the number
of melanocytes. After discontinuation of travoprost, pigmentation of the iris is likely to be permanent, while
pigmentation of the periorbital tissue and eyelash changes have been reported to be reversible in some
patients. Patients who receive treatment should be informed of the possibility of increased pigmentation.
The long term effects of increased pigmentation are not known.
Iris color change may not be noticeable for several months to years. Typically, the brown pigmentation
around the pupil spreads concentrically towards the periphery of the iris and the entire iris or parts of the
iris become more brownish. Neither nevi nor freckles of the iris appear to be affected by treatment. While
treatment with TRAVATAN Z
Solution may gradually change eyelashes and vellus hair in the treated eye. These changes
include increased length, thickness, and number of lashes. Eyelash changes are usually reversible upon
discontinuation of treatment.
Intraocular Inammation
TRAVATAN Z
Solution should be used with caution in patients with active intraocular inammation
(e.g., uveitis) because the inammation may be exacerbated.
Macular Edema
Macular edema, including cystoid macular edema, has been reported during treatment with travoprost
ophthalmic solution. TRAVATAN Z
Solution has not been evaluated for the treatment of angle-closure, inammatory or
neovascular glaucoma.
Bacterial Keratitis
There have been reports of bacterial keratitis associated with the use of multiple-dose containers of
topical ophthalmic products. These containers had been inadvertently contaminated by patients who,
in most cases, had a concurrent corneal disease or a disruption of the ocular epithelial surface.
Use with Contact Lenses
Contact lenses should be removed prior to instillation of TRAVATAN Z
(travoprost ophthalmic solution) 0.004% was ocular hyperemia which was reported in 30 to
50% of patients. Up to 3% of patients discontinued therapy due to conjunctival hyperemia. Ocular adverse
reactions reported at an incidence of 5 to 10% in these clinical studies included decreased visual acuity, eye
discomfort, foreign body sensation, pain and pruritus. Ocular adverse reactions reported at an incidence of
1 to 4% in clinical studies with TRAVATAN
or TRAVATAN Z
Solution is administered to a
nursing woman.
Pediatric Use
Use in pediatric patients below the age of 16 years is not recommended because of potential safety
concerns related to increased pigmentation following long-term chronic use.
Geriatric Use
No overall clinical differences in safety or effectiveness have been observed between elderly and other
adult patients.
Hepatic and Renal Impairment
Travoprost ophthalmic solution 0.004% has been studied in patients with hepatic impairment and also in
patients with renal impairment. No clinically relevant changes in hematology, blood chemistry, or urinalysis
laboratory data were observed in these patients.
NONCLINICAL TOXICOLOGY
Carcinogenesis, Mutagenesis, Impairment of Fertility
Two-year carcinogenicity studies in mice and rats at subcutaneous doses of 10, 30, or 100 mcg/kg/day
did not show any evidence of carcinogenic potential. However, at 100 mcg/kg/day, male rats were only
treated for 82 weeks, and the maximum tolerated dose (MTD) was not reached in the mouse study. The high
dose (100 mcg/kg) corresponds to exposure levels over 400 times the human exposure at the maximum
recommended human ocular dose (MRHOD) of 0.04 mcg/kg, based on plasma active drug levels. Travoprost
was not mutagenic in the Ames test, mouse micronucleus test or rat chromosome aberration assay.
A slight increase in the mutant frequency was observed in one of two mouse lymphoma assays in the
presence of rat S-9 activation enzymes.
Travoprost did not affect mating or fertility indices in male or female rats at subcutaneous doses up to
10 mcg/kg/day [250 times the maximum recommended human ocular dose of 0.04 mcg/kg/day on a mcg/kg
basis (MRHOD)]. At 10 mcg/kg/day, the mean number of corpora lutea was reduced, and the post-implantation
losses were increased. These effects were not observed at 3 mcg/kg/day (75 times the MRHOD).
PATIENT COUNSELING INFORMATION
Potential for Pigmentation
Patients should be advised about the potential for increased brown pigmentation of the iris, which may be
permanent. Patients should also be informed about the possibility of eyelid skin darkening, which may be
reversible after discontinuation of TRAVATAN Z
Solution.
Use with Contact Lenses
Contact lenses should be removed prior to instillation of TRAVATAN Z