To Screen or Not to Screen That is

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! u u u u 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+ 47% 50% 75% In Millions 61% 38% (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 Mc. Donald

DESPERATE HOUSEWIVES Connecticut of

Ocular Surface Disease Prevalence Study u Purpose: To Determine The Prevalence of OSD Symptoms in Glaucoma Patients u Methods: – 10 Sites – 630 Glaucoma Patients On IOP Lowering Medication: u 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: All of the time 1 Eyes that are sensitive to light? 2 Some of the time None of the time 4 3 2 1 0 Painful or sore eyes? 4 Half of the time Eyes that feel gritty? 3 Most of the time Blurred vision? 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 Some of the time None of the time N/A Driving at night? 8 Half of the time Reading? 7 Most of the time Working with a computer or bank machine (ATM)? 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 e al m or N 0 -12 0 0 10 ild M t ra de o Severe M 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/2006 Abstracts. Book. 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. 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 u Telangiectasia u Dislocation of meibomian glands/ gland atrophy u Scarring

u ICD-9 Diagnostic Codes 375. 15 Tear Film Insufficiency, Unspecified; Dry Eye Syndrome u 370. 33 Keratoconjunctivitis sicca, not specified as Sjögren's syndrome u 710. 2 Sicca syndrome, keratoconjunctivitis sicca Sjögren's disease u 365. 11 Primary open angle glaucoma u 373. 12 Meibomian gland infection u 373. 71 Hyperemic conjunctiva u 370. 23 Filamentary keratitis u 371. 42 Recurrent corneal erosion u 375. 21 Epiphora excess lacrimation u 375. 22 Epiphora insufficient drainage u 374. 01 Entropion 374. 10 Ectropion u 375. 51 Punctal eversion u 375. 52 Punctal stenosis

Osmolarity & Tear Film Instability in DED

Summary Statistics on Tear Osmolarity u u Normal subject average: – 296 ± 8 m. Osm/L Dry Eye subject average: – 323 ± 16 m. Osm/L Normal subject inter-eye difference: – 7 ± 6 m. Osm/L Dry Eye subject inter-eye difference: – 17 ± 15 m. Osm/L – Inter-eye difference is the hallmark of DED ( > 8 m. Osm/L between eyes)1 1 Lemp MA et al. , Am J Ophthalmol. 2011 May; 151(5): 792 -798. e 1. Epub 2011 Feb 18.

KEEP IT SIMPLE AND TAKE ADVANTAGE OF PPV u MILD RANGE: – 300 -320 m. Osmol/L u MODERATE RANGE: – 320 -340 u 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. u Stable IOP x 6 months with no medication changes (ocular/systemic) u Average meds: 1. 12 u VF: 13. 5 u ONH: 0. 82 u RNFL: 71. 4 u OSDI: 19. 7 u

Not a Dry Eye in the House! u Outcomes: – Initial Tear Lab: 334/ 318 – Tear Lab: post Tx ( 6 weeks) u 317/306 – OSDI: post Tx 6 weeks (Restasis) u 15. 4 – Schrimers: 7. 8 mm

Decreased Corneal Hysteresis in a Chronic Open Angle Glaucoma Patient

Patient History u 45 year old, African American female u POHx: POAG OD x 3 years u PMHx: Unremarkable u Medications: None u Ophthalmic Medications: Combigan OD, bid; Lumigan, OD, qhs u Allergy: NKDA

Patient Examination u VA(cc) – OD: 20/20– OS: 20/20 u Pupils: PERRL (-) APD u EOM: FROM OU u CVF: OD, OS: see VF u Refraction: – OD: -1. 75 -1. 00 x 092 – OS: -2. 00 -0. 50 x 105 20/20

Anterior Segment Evaluation u Lids/Lashes: WNL OD, OS u Cornea: WNL OD, OS u A/C: WNL OD, OS u Iris: WNL OD, OS u Lens: WNL OD, OS u Vitreous: clear, OD, OS u Gonioscopy: – OD: CB in 4 quadrants, (-) PAS – OS: CB in 4 quadrants, (-) PAS

OD ONH Evaluation u ONH: – OD: Rim thinning inferior>superior, inferior notching, CD? , RNFL drop-out inferiorly Inferior notching RNFL drop-out

OS ONH Evaluation u 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 IOP 1 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 loss 2. 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