AN EXAMPLE OF GLAUCOMA DETECTION IN INDIAN OPTOMETRY CLINIC_rajesh wad

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Indian optometry clinics have a great scope in early detection of glaucoma. This resource should be well utilized.

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AN EXAMPLE OF GLAUCOMA DETECTION IN INDIAN OPTOMETRY CLINIC:

AN EXAMPLE OF GLAUCOMA DETECTION IN INDIAN OPTOMETRY CLINIC -Rajesh Wadhwa M.Optom B.Sc.Hons.(Ophth.Tech.)(AIIMS) B.Sc.Hons.(DU); FIACLE;PGDHRM

Glaucoma-India-Optometrist “link”:

Glaucoma-India-Optometrist “link” Without gonioscopy With or Without a perimeter/ OCT/ HRT Is there a link ? Yes ! Rajesh Wadhwa Golden because of great out-reach at very low cost

We found the link:

We found the link We worked towards it We succeeded in preventing several more eyes from blindness What is the “Key to Success” Rajesh Wadhwa

Why did we look for the key to success: a confession :

Why did we look for the key to success: a confession Way back in the year 2000 We analyzed our available clinic data Over 50,000 patients seen in 20 years (1979 to 1999 ) Total positive glaucoma cases detected= 6 Rajesh Wadhwa

Was that good enough? WHO score:

Was that good enough? WHO score Indian population has over 2% incidence of glaucoma We should have detected at least 1000 positive glaucoma cases We had missed many: Disheartening and added to the feeling of guilt Many clinics are making this mistake inadvertently all over the world Rajesh Wadhwa

This needed an immediate intervention: Identified the limitations:

This needed an immediate intervention: Identified the limitations Rajesh Wadhwa Clinical attitude towards detection of glaucoma No tonometry Legislation Space & time How much is glaucoma detection dependent on these?

How dependent is glaucoma detection on these?:

How dependent is glaucoma detection on these? Most important screening tests are: IOP: for over a century Optic Nerve head analysis Visual fields Need the trio together Though today’s science is way beyond this--but doing this much can save several eyes (as it did for centuries). Rajesh Wadhwa 6

Why are we asking for trio together?:

Why are we asking for trio together? IOP: alone is not a stand alone indicator (over 40% of Px have normal IOP at the time of diagnosis) Optic nerve cupping: it's common for some people to have optic nerve cups that are larger than “normal” Visual fields: even the visual fields can change back and forth and can sometimes be influenced by medication. (may not be available) We can add other details (to be discussed in later slides). Rajesh Wadhwa 4

2 instrumental limitations (1=Tonometry):

2 instrumental limitations (1=Tonometry) No S/L initially Lack of space for Schiotz Applanation after acquiring slit lamp Sterilization of Appln. very difficult Needs topical anesthetic. Rajesh Wadhwa 5

2 instrumental limitations (2= gonioscopy):

Not practiced at optometry school Also needs topical anaesthetic Rajesh Wadhwa 2 instrumental limitations (2= gonioscopy) 2

With inward compulsion to save more eyes We broke the barrier: tonometry & gonioscopy:

With inward compulsion to save more eyes We broke the barrier: tonometry & gonioscopy Tonometry: We invested into an expensive non-contact tonometer Gonioscopy: Fletcher in his book says:”The Van Hericks grading of peripheral AC depth is so accurate that I did not feel the need to learn the skills of gonioscopy” Rajesh Wadhwa

Limitation that remained was of “clinical attitude”:

In routine-refraction, we became more attentive to following: Symptoms Family history IOP assessment Optic nerve head assessment High-risk categories Details……….(cont.). Rajesh Wadhwa Limitation that remained was of “clinical attitude” 7

Symptoms:

Symptoms Most often: Reported for routine refraction but rarely (On close probing) Headache/ Eye-pain/Colored halos Transient blackouts/ Heaviness in eyes Nyctalopia Frequent change of glasses . Rajesh Wadhwa 5

Categories encouraged for tonometry::

Categories encouraged for tonometry: Age above 40years Diabetics /Hypertensives Hypermetropes Family history of glaucoma or Diabetes H/o previous eye injury/ disease or surgery Cataract / Iritis Relevant drugs being taken (systemic/topical). Rajesh Wadhwa 5

What tests do we perform in optometric set-up:

What tests do we perform in optometric set-up VA assessment Refraction Cover-test Direct ophthalmoscopy S/L exam if needed Tonometry (filter exists) Among these what will hint towards “glaucoma suspect” ? . Rajesh Wadhwa 7

Noteworthy findings that add to suspicion of glaucoma :

Noteworthy findings that add to suspicion of glaucoma Accepts for near an "Add" value higher than what usually corresponds with age Frequent change in refractive error Rajesh Wadhwa 2

Lens & Iris: :

Lens & Iris: Lens intumescent Rajesh Wadhwa intumescent cataract a mature cataract that progresses; the lens becomes swollen from the osmotic effect of degenerated lens protein, and this may lead to secondary angle closure (acute) glaucoma.

Rubeosis iridis:

Rubeosis iridis (especially in diabetics) New vessels appear on the iris.  When this occurs, careful inspection of the anterior chamber angle is essential, as growth of neovascularization in this location can obstruct aqueous fluid outflow and cause neovascular glaucoma. Rajesh Wadhwa

Peripheral anterior chamber depth: Eclipse test:

Peripheral anterior chamber depth: Eclipse test Eclipse Test: Shadow of iris eclipses/ does not eclipse the other side . Rajesh Wadhwa

Peripheral anterior chamber depth:VH Grading:

Peripheral anterior chamber depth:VH Grading Van Herick's Grading under S/L (Grade 1 is shallowest, Grade 4 is widest) Rajesh Wadhwa

Van Herick's Grading under S/L::

Van Herick's Grading under S/L: Corneal thickness:periph. AC ratio (60° illum. angle) <1:1/4= Gr 1 1:1/4 = Gr 2 1:1/4 to 1:1/2= Gr 3 = or > 1:1/2= Gr 4 Rajesh Wadhwa

Optic nerve head assessment:

Optic nerve head assessment Rajesh Wadhwa

ISNT criterion:

ISNT criterion Rajesh Wadhwa T N I S Oval disc Round cup

Cup:Disc Ratio recorded in its widest axis:

Cup:Disc Ratio recorded in its widest axis Diameter of Cupping can be =pallor or Cupping>Pallor Pallor Ratio= Contour Ratio or not Rajesh Wadhwa A B

Considered as Glaucoma suspect:

Considered as Glaucoma suspect ISNT criterion not met C:D ratio >/=0.5:1 Interocular diff. of C:D=/>0.2 IOP > 20mmHg Interocular diff. Of IOP =>4mm Hg Rajesh Wadhwa

Other reasons for suspecting glaucoma:

Other reasons for suspecting glaucoma Cup: Oval along 6-12 o’clock axis Asymmetry between discs of two eyes is present. Asymmetry does occur normally but the possibility of pathological significance is there especially in the absence of marked axial anisometropia Rajesh Wadhwa

Other reasons for suspecting glaucoma:

Other reasons for suspecting glaucoma Site of cup: Superior/ Superior temporal/ Inferior/ Infero-temporal. Inferior location of cup has higher index of suspicion due to the more frequent superior field defects seen in glaucoma Focal disc damage: Pit near 6 o'clock Rajesh Wadhwa

Vessels Continuity::

Vessels Continuity: The blood vessels do not appear continuous at the disc margin Baring of circumlinear vessel Splinter shaped hemorrhage on disc margin Rajesh Wadhwa

Other reasons for suspecting glaucoma:

Other reasons for suspecting glaucoma Vessels Pulsation: NO spontaneous arterial pulsation. (A spontaneous arterial pulse is more likely to be seen if the IOP is high) Rajesh Wadhwa 2

Basis of inference:

Basis of inference All foregoing indicators are kept in mind for referral Fields, WDT, diurnal variation, Gonioscopy ,OCT etc. are to be considered in suspected cases Did we gain anything by doing all this? Results……. Rajesh Wadhwa

Compared to previous 20 years:

Compared to previous 20 years Rajesh Wadhwa This is an amazing improvement over our previous results 6 in 20 years, 22 in 1 year

…Just 3 minutes more:

…Just 3 minutes more

Limitation in statistics::

Limitation in statistics: This is retrospective analysis Population sample is from 1 clinic in north India Extra charges were taken for this checkup (therefore filtered) Actual incidence could be higher Rajesh Wadhwa 4

Do we really need tonometry?:

Do we really need tonometry? All said-and done, tonometery is important in detection of glaucoma If an optometrist is permitted to use that one drop of topical anesthetic then many more eyes can be saved Rajesh Wadhwa

How clear is our knowledge about glaucoma:

How clear is our knowledge about glaucoma ONE EXTREME: elevated IOP is not glaucoma. Elevated IOP is only a risk factor and is not prognostic (no magic figure) OTHER EXTREME: New research suggests that Glaucoma, what we know to be an ‘eye disease’, should instead be characterized as a neurologic disorder similar to what causes nerve cells in the brain to degenerate and die – like what occurs in Parkinson’s and Alzheimer’s diseases. The new research paradigm focuses on the damage that occurs in retinal ganglion cells (RGCs), which connect the eye to the brain through the optic nerve. Rajesh Wadhwa

Where do we stand:

Where do we stand We have treatment “for” glaucoma We do not have treatment “of” glaucoma Rajesh Wadhwa

Take home message:

Take home message IOP measurement is important in detection of glaucoma Optometrist is the first line of defense against blindness & optometrists are eagerly waiting for government’s permission to use diagnostic drugs like topical anesthetics to save more eyes. Aspects other than IOP can also be indicators for “glaucoma suspect” It is better to refer out one extra “glaucoma suspect” than one less Rajesh Wadhwa

PowerPoint Presentation:

Rajesh Wadhwa Thank you! Let us plant a sapling of good practice today…. ..and enjoy the fruits tomorrow My contact: Ph: +91-9868010187 r_wadhwa@yahoo.com Wadhwa Optikos,55,Krishna market, Kalkaji,New Delhi-19,India

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