Transcript To Screen or Not to Screen: That is the Question?

To Screen or Not to
Screen: That is the
Question?
J. James Thimons, OD, FAAO
Chairman, National Glaucoma
Society
To Screen or Not to Screen!
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Annuals of Internal Medicine 2/19/1013
US Preventative Services Task Force (USPSTF)
Albert Siu, et al
75 Randomized, controlled trials (laser, Medicine,
surgery)
24 observational studies
Available evidence is too sparse and inconclusive
to be certain
Independent panel of non federal experts in IM,
GP, nurses and Health specialists
OSD in Glaucoma
Incidence Rates in Americans
Age
40+
Eye Disease Prevalence and Projections
(Adults 40 Years and Older)
30.1
35
47%
30
25
38%
28.5
20.5
20.7
Cataracts
Dry Eye
20
15
In Millions
10
5
61%
1.8
2.9
75%7.2
50%
2.2
4.1
3.3
0
Advanced AMD
(1)
Glaucoma
Diabetic
Retinopathy
2004
Est. 2020
(1) An additional 7.3 million are at substantial risk for vision loss from AMD.
Source: AMD, Glaucoma, Diabetic Retinopathy, Cataracts: National Eye Institute, 2004 Study.
Dry Eye: US Census Projections and Johns Hopkins University-Wilmer Eye Institute - International Task Force.M
McDonald
DESPERATE HOUSEWIVES
Connecticut
of
Ocular Surface Disease
Prevalence Study
 Purpose:
To Determine The
Prevalence of OSD Symptoms in
Glaucoma Patients
 Methods:
– 10 Sites
– 630 Glaucoma Patients On IOP Lowering
Medication:
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Patients Completed an OSDI Survey While
in The Office
Fechtner R, Budenz D, Godfrey D. Prevalence of ocular surface disease symptoms in glaucoma patients on IOP-lowering
medications. Poster presented at: annual meeting of the American Glaucoma Society; March 8, 2008; Washington DC.
Dry Eye Prevalence May be Understated
Types of Treatment Used To Relieve Dry Eye Symptoms
– Summary –
(n=388)
I do not treat it
8%
68%
I use NON-PRESCRIPTION eye drops
I use PRESCRIPTION eye drops
27%
I use eye compresses
4%
I use “other” techniques
Don't know
6%
1%
0%
100%
% responding
OCULAR SURFACE DISEASE INDEX
Please Answer The Following Questions by Checking The Box That Best Represents Your Answer
Have you experienced any of the following during the last week:
1
Eyes that are sensitive to light?
2
Eyes that feel gritty?
3
Painful or sore eyes?
4
Blurred vision?
All of the
time
Most of the
time
Half of the
time
Some of
the time
None of the
time
4
3
2
1
0
5
Poor vision?
Have problems with your eyes limited you in performing any of the following during the last week:
All of the
time
6
Reading?
7
Driving at night?
8
Working with a computer or bank
machine (ATM)?
Most of the
time
Half of
the time
Some of
the time
None of
the time
N/A
9
Watching TV?
Have your eyes felt uncomfortable in any of the following situations during the last week:
All of the
time
10
Windy conditions?
11
Placed or areas with low humidity
(very dry)?
12
Areas that are air conditioned?
Most of the
time
Half of
the time
Some of
the time
None of
the time
N/A
OSDI Severity Grading
Severe
00 -12
0
10
13 -22 23 -32
20
30
Normal
33 -100
40
50
Score
Mild
60
Moderate
70
80
90
100
Severe
Total OSDI Score=
(Sum of Score for All Questions
Answered) X (25)
(Total # of Questions Answered)
Miller KL, Mink DR, Mathias SD, & Walt JG. Estimating the minimal clinical important difference of the Ocular Surface Disease Index®: Preliminary
findings [Abstract]. Abstract obtained from www.isoqol.org/2006AbstractsBook.pdf.
OSD Prevalence Study:
Results
OSDI Scores in Glaucoma Patients
Ranking
Patients
Percentag
e
Normal
Mild
Moderate
Severe
325
134
84
87
51.6%
21.3%
13.3%
13.8%
48.4%
OSD Prevalence Study
Multiple Medication Impact
Number of
Meds Taken
N
Average
OSDI Score
P-Values
1
Medication
2
Medications
1
2
3
253
12.9 ±
13.1
227
16.7 ±
17.0
114
19.4 ±
18.1
2 Medications 3 Medications
0.007
0.001
0.19
Schirmer Strips
Tear Film Breakup Time (TBUT)
0 seconds
1 second
2 seconds
3 seconds
4 seconds
5 seconds
6 seconds
16 seconds
Tear film break up is indicated by the
dark areas that appear on the cornea.
Patient CCF
Potential Chronic Changes
 Telangiectasia
 Dislocation
of
meibomian glands/
gland atrophy
 Scarring
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ICD-9
Diagnostic
Codes
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375.15 Tear Film Insufficiency,
Unspecified; Dry Eye Syndrome
370.33 Keratoconjunctivitis sicca,
not specified as Sjögren's
syndrome
710.2 Sicca syndrome,
keratoconjunctivitis sicca
Sjögren's disease
365.11 Primary open angle
glaucoma
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373.12 Meibomian gland infection
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373.71 Hyperemic conjunctiva
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370.23 Filamentary keratitis
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371.42 Recurrent corneal erosion
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375.21 Epiphora excess
lacrimation
375.22 Epiphora insufficient
drainage
374.01 Entropion
Ectropion
374.10
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375.51 Punctal eversion
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375.52 Punctal stenosis
Osmolarity & Tear Film Instability
in DED
Summary Statistics on Tear
Osmolarity
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Normal subject average:
– 296 ± 8 mOsm/L
Dry Eye subject average:
– 323 ± 16 mOsm/L
Normal subject inter-eye difference:
– 7 ± 6 mOsm/L
Dry Eye subject inter-eye difference:
– 17 ± 15 mOsm/L
– Inter-eye difference is the hallmark of DED
( > 8 mOsm/L between eyes)1
1Lemp
MA et al., Am J Ophthalmol. 2011 May;151(5):792-798.e1. Epub 2011 Feb 18.
KEEP IT SIMPLE AND TAKE
ADVANTAGE OF PPV
 MILD
RANGE:
– 300-320 mOsmol/L
 MODERATE
RANGE:
– 320-340
 SEVERE
– > 340
RANGE:
Tear Film Reflection Before
and After Cyclosporine
Before
After
OSDI in Glaucoma before and after treatment
Not a Dry Eye in the House
20 COAG patients 40-82 with OSDI
complaints.
 Stable IOP x 6 months with no medication
changes (ocular/systemic)
 Average meds: 1.12
 VF: 13.5
 ONH:0.82
 RNFL: 71.4
 OSDI: 19.7
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Not a Dry Eye in the House!
 Outcomes:
– Initial Tear Lab: 334/ 318
– Tear Lab: post Tx ( 6 weeks)
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317/306
– OSDI: post Tx 6 weeks (Restasis)
 15.4
– Schrimers: 7.8 mm
Decreased Corneal
Hysteresis in a Chronic
Open Angle Glaucoma
Patient
Patient History
 45
year old, African American female
 POHx: POAG OD x 3 years
 PMHx: Unremarkable
 Medications: None
 Ophthalmic Medications: Combigan
OD, bid; Lumigan, OD, qhs
 Allergy: NKDA
Patient Examination
 VA(cc)
– OD: 20/20– OS: 20/20
 Pupils:
PERRL (-) APD
 EOM: FROM OU
 CVF: OD, OS: see VF
 Refraction:
– OD: -1.75 -1.00 x 092
– OS: -2.00 -0.50 x 105
20/20
20/20
Anterior Segment Evaluation
 Lids/Lashes:
WNL OD, OS
 Cornea: WNL OD, OS
 A/C: WNL OD, OS
 Iris: WNL OD, OS
 Lens: WNL OD, OS
 Vitreous: clear, OD, OS
 Gonioscopy:
– OD: CB in 4 quadrants, (-) PAS
– OS: CB in 4 quadrants, (-) PAS
OD ONH Evaluation
 ONH:
– OD: Rim thinning inferior>superior,
inferior notching, CD?, RNFL drop-out
inferiorly
Inferior notching
RNFL drop-out
OS ONH Evaluation
 ONH:
– OS: pink, distinct margins, CD?
Ocular Response Analyzer
Marked asymmetric corneal hysteresis
OS>OD
In a prospective experimental study, corneal hysteresis was associated with increased
deformation of the optic nerve during episode of elevated IOP1
Wells AP, Garway-Heath DF, Poostchi A, Wong T, Chan KCY, Sachdev N. Corneal hysteresis but not corneal thickness correlates with optic
nerve surface compliance in glaucoma patients. Invest Opthalmol Vis Sci. 2008;49:3262-3268
OD HVF
In an observational study, axial
length of the globe and corneal
hysteresis were associated with
progressive VF loss2.
superior hemifield defect with
clinical correlation to RNFL drop
out and notching of the OD ONH
Congdon N, Broman AT, Bandeen-Roche K, Grover D, Quigley
HA. Central corneal thickness and corneal hysteresis
associated with glaucoma damage. Am J Ophthalmol 2006;
141:868-875.
OS HVF
OD Zeiss OCT- GPA
Marked asymmetric RFNL with
thinning inferior> superior
Glaucomatous state appears stable since 2010
OS Zeiss OCT-GPA