Dermatologic Therapy-Topical

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Using New Technology to Improve Quality of Care
Profit
John A. McGreal Jr., O.D. Missouri Eye
Associates McGreal Educational Institute
Excellence in Optometric Education
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John A. McGreal Jr., O.D.

• Missouri Eye Associates
• 11710 Old Ballas Rd.
• St. Louis, MO. 63141
• 314.569.2020
• 314.569.1596 FAX
• jamod1_at_aol.com

JAM
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Autologous Serum for PED

• Tears contain EGF, vitamin A, TGF-B, fibronectin
  and other cytokines..all found in serum
• 40ml of blood from venipuncture centrifuged for 5
  min
• diluted to 20 by physiologic saline (empiric)/UV
  bottle
• Dosed at 6-10 X/D with additional AFTs
• Results
• 43 healed within 2 wks, all within several
  months
• Serum accelerates migration of corneal epithelial
  cells
• Serum upregulates mucin expression of corneal
  epithelium

4
Amniotic Membrane Transplantation (AMT)

• Ocular surface reconstruction in SJS, severe dry
  eye, and severe chemical burns
• Human amniotic membrane prepared from placenta of
  elective cesarean section in seronegative (HIV,
  HepB C, syphilis)
• Facilitates epithelialization, reduces
  inflammation, vascularization and scarring
• Limbal stem cell transplantation is needed in
  concert with AMT in the most severe chemical burns

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RPS Adeno Detector
Test Procedure

• Assembling the Detector
• Locate the Test Cassette
• Assemble the detector by gently placing the
  sampling pad of the Sample Collector into the
  sample transfer window of the Test Cassette body.
  
• Press firmly where indicated until the detector
  is secure.

Transfer Window
Note A double auditable click means the detector
is properly assembled, transferring the sample
to the test strip.
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RPS Adeno Detector
Test Procedure

• Running the Test
• Open the buffer vial. Remove the Protective Cap
  from the Test Cassette. Do not allow any portion
  of the detector besides the absorbent tip to
  touch the buffer vial.
• Immerse the Assembled Detectors Absorbent Tip
  into the buffer vial for 15 seconds.

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RPS Adeno Detector
Reading Interpreting the Results
Positive Results The Results Line and Control
Line are RED in the result window, indicating
that Adenovirus antigen is present.
Results Line
Control Line
Control Line
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RPS Adeno Detector
Reading Interpreting the Results
Positive Results
Note An uneven or incomplete test line is due to
an uneven distribution of eye fluid on the sample
pad. Even if the test line is faint in color,
incomplete over the width of the test strip, or
uneven in color, it must be interpreted as
positive.
Results Line
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RPS Adeno Detector
Reading Interpreting the Results
Invalid Results If the Control Line does not
appear, the test must be interpreted as invalid
and discarded.
Note The Patient should be re-tested with a new
RPS Adeno Detector kit.
NO Control Line
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Antiviral Therapy - Oral

• Acyclovir (Zovirax 200/400/800mg)
• Primary Herpes Simplex 400mg- 5x/D x10D
• Chronic Suppressive 400mg bid qd
• Varicella 20mg/kg- 4x/D x 5D
• Herpes Zoster 800mg- 5x/D x 10D
• Famciclovir (Famvir 500mg tid x 7D)
• Valacyclovir (Valtrex 1000mg tid x 7D)
• Vaccine for Zoster prevention
• Zoster Vaccine Live (Zostavax)

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Levofloxacin

• Fluoroquinolone
• Indications
• Conjunctivitis, injuries, pre and post operative
  care, pneumonia, sinus, skin and skin structure,
  GI, GU
• Action DNA gyrase
• Prevents bacterial replication
• Broadest spectrum, low toxicity, low resistance
• Left stereoisomer of ofloxacin, therefore similar
  solubility and actions
• Side effects taste perversion
• Available as
• Quixin 0.5/1.5 (topical) q2h x 4 days, then
  q4h for conjunctivitis
• Levaquin 500mg, Leva-pak 750mg, 25mg/ml q24h

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Ophthalmic Azithromycin AzaSite?

• AzaSite pairs DuraSite drug delivery technology
  with azithromycin (1.0)
• Azithromycin has not been previously used in
  ophthalmology
• A stable aqueous formulation is difficult
• AzaSite A stable, easily delivered formulation
  of azithromycin
• All the advantages of topical ophthalmic delivery

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Glaucoma Evolution
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Glaucoma Evaluation is Transforming

• In the past, detection management relied on
  functional assessment
• Visual fields (white-on-white)
• Insensititve for detecting early POAG
• High degree of variability
• Recently, structural change over time
  longitudinal studies have validated the role of
  structural imaging
• Are structural defects with normal functional
  tests false positives or POAG?

JAM
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Glaucoma Suspect

• CPT / ICD
• 99214 / Glaucoma Suspect (365.01) 80.00
• 92020 / (365.01) 25.00
• 76514 / (365.01) 15.00
• 92250 / (365.01) 70.00
• 92083 / (365.01) 70.00
• CPT / ICD
• 99213 or 92012 / (365.01) 50.00 or 63.00
• 92235-RT, 92235-LT / (365.01) 90.00
• Total 400.00 or 413.00
• Rx Initiate or continue treatment or observe
• Use V58.69 in addition to ICD code when changing
  medications in a glaucoma patient

JAM
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Gonioscopy 92020

• Bilateral
• Requires documentation
• describe visible angle structures
• No limitations to diagnostic groups in most
  states
• Fee 25.71-

JAM
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Digital Gonioscopy 92020

• SL-OCT (Heidelberg)
• Integrated Slit lamp digital gonioscopy system
• Haag-Streit BD 900 slit lamp, OCT scanning unit
• High resolution grey scale or false color reports
• Fast, easy, non-contact OCT at any position
• Stores data
• Measures angle, angle opening distance, angle
  recess area, trabecular iris contact length,
  trabecular iris space area
• Measures pachymetry and biometry

JAM
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SL-OCTTM Hardware Features

• Non-contact
• Fast and easy to use
• Simultaneous
• optical and OCT exam
• Color or gray-scale images

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Limitations of Manual Gonioscopy

• Patient discomfort full globe contact
• Time consuming
• Subjective
• Requires considerable skill and experience

Statement of Assoc. of International Glaucoma
Societies (AIGS) 3rd Global Consensus Meeting,
May 2006
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Pachymetry 76514

• Bilateral
• Measurement of central corneal thickness (CCT)
  proven by Ocular Hypertension Treatment Study
  (OHTS) to be standard of care in diagnosis and
  management of glaucoma, glaucoma suspect and
  ocular hypertension
• Also billable for keratoconus, corneal
  transplants, cataracts with corneal dystrophies,
  guttata, edema
• Requires Interpretation Report
• Fee 11.92

JAM
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CCT Assessment

• Has become standard
• Equipment widely available
• DGH was used in OHTS
• Low cost
• Consider potential effect of LASIK on IOP
  findings
• Also billable for non-glaucoma ICD-9 codes
• Corneal edema, keratoconus

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Reichert IOPac

• Portable, battery op.
• Stores up to 1000 pats.
• USB and infrared interface
• Down load to PC and printer
• Detachable probe
• Easily replaced if necessary
• Download PDR into Palm

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Pachymetry

• IOP correction by correlation to corneal
  thickness is NOT POSSIBLE!
• A linear relationship does not exist!
• Careful examination of regression analysis
  (scatter graph of IOP relative to CCT)
  demonstrates huge bandwidth
• Adjusting IOP by CCT instills a degree of
  accuracy into an inaccurate measurement
• It is possible to adjust the IOP in the WRONG
  direction
• Barbados study of black patients shows no
  correlation of CCT/IOP
• Trying to be more precise than this is not
  supported by the data and may be harmful to
  patient care Jamie Brandt, MD Dir Glauc Src, UCD
  / OHTS investigator

JAM
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Serial Tonometry 92100

• Bilateral
• Requires Interpretation Report
• Example Angle closure glaucoma
• multiple measurements over time
• Fee 55.91-

JAM
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PASCAL at work

• Slit lamp mounted
• Technique similar to GAT but
• Constant light pressure
• No fluorescein
• Self-calibrating
• Battery operated

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Pascal DCT

• Measures
• Ocular Pulse Amplitude
• (OPA)
• IOP
• Quality (Q)
• Heart Pulse (H)
• Stores data

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The PASCAL SensorTip

• Contour-matched concave tip surface (7mm)
• Accurate for corneal radius 5.5-9.2mm and CCT
  300-700
• built-in pressure sensor (1.2mm)
• transparent tip permits view of cornea interface
  for centering and control

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Comparison of DCT With the GAT

• Univ. Of Zurich
• 228 eyes measure with DCT and GAT
• Compared IOP measurements
• Looked at effects of
• CCT
• Corneal curvature
• Astigmatism
• AC Depth
• Axial length
• Intra-observer and Inter-observer variability

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DCT vs. GAT

• DCT median difference DCT 1.7mm higher than GAT
• GAT Affected by CCT, curvature, astigmatism, AC
  depth and axial length
• DCT NO EFFECT with any parameters

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DCT vs. GAT

• Intra-observer variability
• GAT 1.1mm
• DCT 0.65mm
• Inter-observer variability
• GAT 1.28mm
• DCT 0.44mm

Kaufman et. al. IOVS 2004 453118-3121
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IOP Measurements Using DCT After LASIK

• Corneal ablation of 90.0/-49.18microns reduced
  IOP as measured by GAT by 3.0/-mm. ..no
  significant change in IOP was recorded by
  DCT(-0.2MM)

Kaufmann C, et al IOVS 2003 4493790-3794
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Biomechanical Properties in Tonometry

• Flatter corneas lower IOP
• Thinner corneas Lower IOP
• Softer corneas lower IOP
• Stiffer IOP higher IOP
• How accurate is Goldmann in thick, soft cornea?
• How accurate is Goldmann in thin, stiff cornea?
• Pascal DCT removes biomechanical properties from
  measurements
• Cannot correct IOP using thickness alone!
• Linear correction factors of GAT will not
  accurately correct IOP

33
DCT in Ectatic Corneas

• Study of 53 eyes at Wills by Ozbek Cohen
• Included eyes with keratoconus, Pellucid Marginal
  Degeneration and penetrating keratoplasty
• Topography 54.7 X 43.6
• CCT 482
• DCT 16.1 / GAT 14.3 / TP 13.8
• DCT were not different between PMD, KC, PK
• DCT were not affected by corneal steepening

34
Conclusions

• IOP measurements by DCT are highly concordant
  with IOP readings obtained by GAT but do not vary
  in CCT and have a lower intra- and inter-observer
  variability. DCT seems to be an appropriate
  method of tonometry for routine clinical use

35
James Brandt, MD Director Glaucoma Services UC
Davis

• Assuming that CCT can be used as a correction
  factor for GAT is a misinterpretation of the
  results of OHTS that couldnt be further from
  the truth. Adjusting IOP based on CCT is
  attempting to instill a degree of precision into
  a flawed measurement. You may actually correct in
  the wrong direction. The issues related to the
  most accurate tonometry need to include the
  material properties of the cornea

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Ocular Pulse Amplitude (OPA)

• Amplitude and shape of OPA are easily observed
  with DCT
• OPA is a function of
• Vascular geometry flexibility
• Ocular rigidity
• Systemic blood pressure
• Can be used to assess ocular perfusion
• Data now suggests a correlation between OPA
  Ocular rigidityand hence between OPA risk of
  glaucoma progression
• A. Harris, PhD (Indiana University)

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Latino Eye Study

• How often is GAT significantly low?
• Median difference between DCT GAT studied
• gt4.5mmHg 10.6
• gt5.5mmHg 4.4
• gt6.5mmHg 2.5
• Increased IOP still most common factor in
  optometric practice converting normals to
  glaucoma suspects

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IOP Measurements By DCT After LASIK

• Corneal ablation of 90.0 /- 49.18u reduced IOP
  as measured by GAT by 3.0mm...no significant
  change in IOP was recorded by DCT (-0.2MM)
• Clinically validated by manometric studies of
  true intracameral pressure
• LASIK case volume in US is 7,401,400
• GAT DOES NOT WORK!

Kaufmann C, et al IOVS 2003 4493790-3794
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Case of I Have A Peculiar Nerve

• 45yowm CC OD wants R/O Papilledema,
  Indistinct optic discs, IOP 20-25 range, pach 637
• PH Hodgkins disease, R hip replacement, 3
  vessel CABG, HTN, Hyperlipidemia
• FH POAG paternal aunt
• Meds Darvocet,Amitryptilline, nitrate,
  isosorbide, norvasc,toprol, plavix, lipitor, ASA
• VA 20/20 OU PERRL-APD
• IOP 26/23 Pach 639
• SLE Nl OU Fundus As shown

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What is the diagnosis?

• 1. Normal optic nerves
• 2. Papilledema
• 3. Optic nerve drusen
• 4. Ocular histoplasmosis
• 5. Choroidal nevus

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What tests are indicated?

• 1. VF / Pach / SCODI / Stereo disc photos
• 2. MRI
• 3. MRI / VF
• 4. Histoplasmosis titres
• 5. IVFA / VF

42
Case of I Have A Peculiar Nerve

• 45yowm CC OD wants R/O Papilledema,
• DCT OD 24.9 / OPA 4.4 / Q3
• DCT OS 23.1 / OPA 3.8 / Q3
• SLE Nl OU Fundus As prev
• VF OD Superior and inferior nasal defects
• VF OS minor changes
• SCODI Confirms disc elevation limited to disc
  itself

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Visual Field 9208x

• Bilateral
• Requires Interpretation
• separate report form
• narrative in body of medical record, on date of
  service
• Fee 43.88- (-81) 57.37 (-82) 65.92- (-83)

JAM
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Oculus Easy Field Perimeter

• Screening AND Threshold fields
• Color LCD-Display
• Fixation monitoring
• CCD camera
• Stores up to 40,000 exams
• Built-in printer

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FDT Perimetry Abnormalities as Predictors of
Glaucomatous VF Loss

• 105 eyes of 105 glaucoma suspects
• IOP 23mm or disc damage on photos
• SAP VF normal
• Baseline FDT obtained
• Mean follow-up 41 months

Medeiros FA, et al AJO 137863-871, 2004
46
FDT as Predictor of VF Loss

• 16 (17 pats.) converted on SAP VF
• In pats. with abnl. FDT at baseline
• Probability of developing abnl. SAP
• 30
• Pats. With NL FDT at baseline
• Probability of developing abnl. SAP
• 4

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FDT as Predictor of VF Loss

• Location of the FDT and SAP defects corresponded
  in 14 of 17 patients
• FDT defects in 59 of the converters occurred as
  much as 4 years before SAP
• Mean 21 months

48
However..

• Only 59 of SAP defects were previously
  identified by abnl. FDT
• 24 had SAP defects BEFORE FDT
• 18 of converters NEVER developed FDT defect
• 24 of normal SAPs showed abnl. FDT but never
  developed abnl. SAP
• False positives?

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Other Important VF Studies

• Paczka (2001) - found FDT better overall
  performance in detecting damage than RNFL
  photographs
• Kondo (1998), Wu (2001) - In patients with SAP
  VFDs restricted to 1 hemifield, FDT has shown to
  be able to detect functional losses in the other
  hemifield
• Medeiros (2004) functional defects in FDT
  predict future defects on SAP

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Other Important VF Studies

• Kim (2007/AAO) when SAP is normal, some
  patients with VFD detected by FDT showed
  decreased NFL thickness (OCT)
• Provide evidence that coincident FDT OCT
  abnormalities may be an early sign of glaucoma

51
Visual Field Testing for Specific Functions

• Short wavelength autoperimetry (SWAP)
• Bistratified ganglion cell (9) short-wavelength
  cones
• Frequency doubling technology (FDT)
• Magnocellular ganglion cells
• Motion automated perimetry (MAP)
• Magnocellular ganglion cells (3)
• High pass resolution perimetry (HPRP)
• Parvocellular ganglion cells

52
Visual Field Testing for Specific Functions

• Standard Autoperimetry (SAP)
• Achromatic perimetry
• Non-specific for ganglion cell type
• Appreciable portion of nerve fibers lost before
  defect measured
• Short wavelength autoperimetry (SWAP)
• 440nm, 1.6degree tartget _at_ 200ms yellow
  background
• More sensitive by 3-5 years to early loss
• UCD studied for over decade
• Disadvantages time consuming, variable, not
  bright enough to threshold in advanced POAG

53
Visual Field Testing for Specific Functions

• Frequency doubling technology (FDT)
• 0.25 cycle/sec sinusoidal grating with 25Hz
  counterphase flicker
• View grating at low spatial frequency and high
  temporal rate
• Percept is double frequency illusion attributable
  to subset of magnocellular ganglion cells
• Portable, fast, reproducible

54
Visual Field Testing for Specific Functions

• Motion automated perimetry (MAP)
• Tests Magnocellular ganglion cells (3)
• Present random dot kinematogram with coherent
  motion on uniform grey background in 14 locations
• Computer controlled stimulus (1024x768), 30degree
  field, 7 frames in rapid succession (420ms), 20
  dots/frame, in circular 7.3 degree angle, moving
  at 8 degree/sec
• Superior to SAP in early detection, but time
  consuming and high variability

55
Visual Field Testing for Specific Functions

• High pass resolution perimetry (HPRP)
• Parvocellular ganglion cells system detection
• Test presents spatially filtered rings, 50 test
  locations in 30degree field, 14 different ring
  sizes used _at_165 ms
• 6 minutes, easy
• Very useful in following progression
• Lacks standardization

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A Comparison of Humphrey SITA-Standard Perimetry
With Both Screening Oculus Easyfield Perimetry
And With Screening FDT

• Seitzman,G.D., Robin,A.L., et al
• Dept. of Oph., Johns Hopkins University

57
Objective

• To determine the sensitivity and specificity of
  the screening modes of the Oculus Easyfield
  Perimeter and Frequency Doubling Testing when
  compared with SITA standard threshold perimetry.

58
Methods

• One hundred one subjects had the following
  perimetric testing Frequency Doubling
  Technology (screening mode), Oculus Easyfield
  Perimetry (suprathreshold mode), and Zeiss
  Humphrey SITA Standard C-24-2 threshold
  perimetry.

59
Results

• The sensitivity and specificity of detecting any
  glaucomatous visual field defect using an
  abnormal Glaucoma Hemifield Testing criterion was
  76 and 89 for the FDT and 86 and 98 of the
  Oculus Perimeter, respectively.

60
Conclusions

• Both smaller screening perimeters were relatively
  quick. Although the Oculus was just 30 seconds
  slower than the FDT, its increased sensitivity
  and specificity could be much more cost effective
  in the treatment of glaucoma.

61
Octopus 301 Perimeter

• Motorized auto eye tracking
• 100 fixation control
• Blazing fast speed
• Ergonomic design patient friendly
• Blue yellow testing in 3 min/eye
• Critical fusion testing
• One min screen
• Three min full threshold
• PeriTrend Analysis
• LAN ethernet
• 800.787.5426
• www.haag-streit.com

62
Closing Statements

• Advances in perimetry are continuing
• Faster third generation algorithms reduce test
  time by 50
• Customization for specific needs
• Early detection / established glaucoma /
  screening
• Early VF loss is often selective, with specific
  types of axons disturbed
• SWAP allows early recognition, HPRP follows
  progression
• SAP perimetry will continue to be preferred for
  established glaucoma with VFDs
• Considerably improved methods of
  computer-assisted interpretations of serial VFs
• Screening methods will sacrifice sensitivity for
  specificity and ease of use to detect the half of
  glaucoma patients who have undiagnosed disease
• Deployed in non-professional environments

63
Closing Statements

• Perimetry is a robust method of examination, a
  cornerstone of glaucoma management and will
  remain so
• It will become more user and patient friendly
• VF testing is easy to administer (technician)
• VF instruments are not expensive
• VF testing can still be performed in cataract
  patients
• Computer-assisted analysis (ie Glaucoma Hemifield
  Test) performs as well as trained observers and
  are extremely specific
• Asman Arch Ophthalmol 1992

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Closing Statements

• Standard SAP testing is not optimal
• Combination testing of 2 or more modalities
  improves detection
• Glaucomatous optic atrophy may precede currently
  measurable functional loss in some
• Functional loss with specific tests may precede
  detection of glaucoma disc changes on stereo
  photograph review
• Most sensitive test may be different for each
  stage of the disease

65
Fundus Photography 92250

• Bilateral
• Not Bundled
• Stereo disc photography
• Requires Interpretation
• Fee 73.67

JAM
66
Fundus Retinal Photos ROI

• Synemed (Canon)
• Cost 24,500.00
• Lease 543.90
• Breakeven 2 photos / wk
• 6 MP digital non-mydriatic
• 10 images / wk lease 22,273.20 annual revenue

67
Extended Ophthalmoscopy 92225 / 92226

• Unilateral
• Initial (-225) vs. Subsequent (-226)
• Implies detailed, extra ophthalmoscopy
• document fundus lenses used
• Modifiers RT /LT
• Requires retinal drawings interpretation
• sizes, colors and dimensions carrier specific
• Fee 92225 (22.23) 92226 (20.01)

JAM
68
Scanning Computerized Ophthalmic Diagnostic
Imaging 92135

• Unilateral
• Applies to glaucoma and retinal evaluations
• Retinal Thickness Analyzer (RTA)
• Heidelberg Retinal Topography (HRT3)
• Humphrey Optical Coherence Tomography (OCT)
• Laser Diagnostic Technology (GDX VCC)
• Requires Interpretation report
• Fee 45.59-

JAM
69
Scanning Laser Covered Diagnosis List

• 362.85 retinal nerve fiber bundle defects
  377.00-377.04
• 364.22 glaucomatocyclitic crisis Papilledema
• 364.53 pigmentary iris degeneration
• 364.73 goniosynechiae
• 364.74 pupillary membranes
• 364.77 recession of the angle
• 365.00-365.9 glaucoma
• 368.40-368.45 visual field defects
• 377.9 unspecified disorder of optic nerve or
  pathways

JAM
70
Scanning Laser 92135

• Moderate Damage - payable once or twice per year,
  not with a field
• Visual field examples
• moderate reduction in retinal sensitivity
• temporal wedge
• Optic Nerve examples
• enlarged cup with sloped or pale rim
• focal notch
• rim/disc gt0.1 but lt0.2
• prominent lamina cribrosa

JAM
71
Scanning Laser 92135

• Advanced Damage - rarely payable, fields more
  valuable
• Visual field examples
• loss of central vision
• temporal island remains
• severe reduction in retinal sensitivity
• absolute defects to within 3 degrees of fixation
• Optic Nerve examples
• rim destroyed
• rim/disc ratiolt0.1

JAM
72
GDx VCC

• Image acquisition in less than 1 second
• Uses internal fixation device
• Compact, table-top design
• Portable
• Easiest to use
• Comfortable, objective test for patients
• Easy interpretation

73
Whats NEW in the HRT3

• OHTS Ancillary Study Results
• GPS Glaucoma Probability Score
• Enhanced Glaucoma Analysis
• Enhanced Progression Software
• Portable Design
• More operator friendly
• Choose from four packages

74
Top 5 Stereometric Parameters

• Rim Area
• Rim Volume
• Cup Shape Measure
• Height Variation Contour
• Mean RNFL Thickness

75
DIAGNOSE CUP, RIM RNFL

• Optic disc size measure and small, average
  and large
• Parameters adjusted for disc size
• Largest normative database
• Ethnic-selectable
• OU asymmetry
• RNFL normative data
• Quality Indicator
• Conclusion
• Complete Assessment

76
Monitor Change Over Time

• Baseline compared to follow-up images
• Absolute change calculated
• Progression Change Probability Analysis
• Pixel by pixel comparison
• Independent of reference plane
• No contour line is needed
• Progression Trend Report
• Normalized stereometric parameters graphically
  displayed

77
How Predictive is the HRT?

• Moorfields Regression Analysis measures rim
  area adjusts for disc size
• 40 of patients flagged at baseline as outside
  of normal limits by Moorfields Temporal Superior
  sector analysis developed glaucoma.
• 26 of patients flagged at baseline as outside
  normal limits by Moorfields Global analysis
  developed glaucoma
• 90 of those with normal HRTs did not develop
  glaucomatous damage over the next 5 years

78
Glaucoma Probability Score (GPS)

• What if we could take the worlds leading
  glaucoma experts and use their combined knowledge
  to help you diagnose your patients?
• The Glaucoma Probability Score takes the first
  step in this direction by applying machine
  learning to glaucoma diagnostics.

79
GPS Advanced Artificial Intelligence

• "Find a bug in a program, and fix it, and the
  program will work today. Show the program how to
  find and fix a bug, and the program will work
  forever."
• - Oliver G. Selfridge, in AI's Greatest Trends
  and Controversies

80
Glaucoma Probability Score

• A new approach to optic disc analysis
• 6 years in development
• Applies the latest in artificial intelligence to
  glaucoma diagnostics Relevance Vector Machine
• Produces an understandable indicator -
  probability of disease
• Eliminates the need for contour lines or
  reference planes

81
GPS How It Works

• Uses same HRT scan as in the past
• Performs 3-dimensional shape analysis
• Relevance Vector Machine is trained to look for
  glaucoma
• Measures 5 key parameters
• 3 parameters represent cup shape and 2 represent
  RNFL

Healthy
Glaucomatous
82
Case of the Ocular migraine?

• Age 43yowm CC Flashes of light
• HPI 20mins / OU / once / 3L soda/Day / -HA,
  nausea, vomiting / overweight
• Meds synthroid Allergy none
• BVA OU 20/20 Pupils PERRL-APD EOM full
  EXT NL, CA auscultation Nl
• Pach 528/532 SLE Nl OU IOP 24/24,17/17
• VF normal Optic N OD 0.80 OS 0.65
• OcHx Mother brother susp ONH Nl VFs

83
Support Literature

• Heidelberg Engineering website
  www.heidelbergengineering.com
• Complete list of published articles on all
  products
• Abstracts of published articles
• Condensed summary of the supporting literature
  for main topics of interest
• Downloadable tutorials for all HE products

84
Optical Coherence Tomography OCT

• Optical Light-based
• Coherence property of light waves in which the
  oscillations maintain a fixed relationship to
  each other
• Tomography Cross-sectional imagery

85
How OCT works

• Similar to ultrasound but uses light instead of
  sound to image tissue
• Beam of light is directed into tissue and
  reflections coming from different layers of the
  tissue are received by a detector

86
Stratus OCT Software

• Macula Thickness Analysis
• RNFL Analysis
• ONH Analysis

87
RNFL analysis

• Circular scanning around ONH at a radius of 1.
  73mm
• Scan begins temporally
• Three scans are acquired and data is averaged

88
Optic nerve head analysis

• Radial scanning across optic nerve head
• Six 4mm scans are taken

89
Optic Nerve Head Parameters

• Volumetric Information
• Volume of Cup
• Dimensional Information
• Disk Area
• Cup Area
• Rim Area
• Cup Disk Ratios
• Horizontal
• Vertical
• Average

90
Ophthalmic Genetics

• Researchers have identified genes for OAG
• TIGR/Myocilin juvenile OAG
• OPTN (optineurin) Primary OAG (NTG)
• Optineurin may provide neuroprotection to optic N
• CYP1B1 Congenital glaucoma
• Genetic testing will allow clinicians to
  determine if Pt is predisposed to or affected
  with specific type of glaucoma, even before
  symptoms appear
• OcuGene (InSite Vision/Alimeda) simple, in
  office test, 99 accurate detection of TIGR
  (trabecular meshwork inducible glucocorticoid
  response gene)
• Positives may be treated more aggressively,
  earlier

91
Blood Flow Analysis

• Paradigm/Dicon
• TonoPlus Tonograph
• Pulsatile Ocular blood flow analysis
• Identifies ocular ischemic syndromes
• Reimbursable procedure
• Small laptop size

92
Anti-Glaucoma Agents

• Non-Selective B-Adrenergic Antagonists
• Timolol (Timoptic 0.25, 0.50, XE, Istalol/Ista
  Pharmaceuticals)
• Levobunolol (Betagan 0.25, 0.50)
• Metipranolol (Optipranolol 0.3)
• Selective B-Adrenergic Antagonists
• Betaxolol (Betoptic-S 0.25, 0.50)
• Levobetaxolol (Betaxon)
• Carteolol (Ocupress 1.0)

93
Anti-Glaucoma Therapy

• Adrenergic Agonists
• Dipivefrin (Propine 0.1)
• Epinephrine (Epinal,Eppy-N, Epifrin, Glaucon)
• Apraclonidine (Iopidine 0.5, 1.0)
• Brimonidine (Alphagan 0.2, Alphagan P-0.1,
  0.15) / Timolol (Combigan)
• 41 less ocular allergy with Alphagan P vs
  Alphagan over 12 months
• Only ophthalmic glaucoma drug without BAK
• Cholinergic
• Pilocarpine (Pilocar 0.50 - 8.0, Pilogel 4)
• Carbachol (Carbachol 0.75, 1.5, 2.25, 3)
• Echothiophate Iodide (0.03, 0.06, 0.125, 0.25)

94
Antiglaucoma - CAI

• Topical
• Dorzolamide (Trusopt)
• Dorzolamide-Timolol (Cosopt)
• Brinzolamide (Azopt)
• Oral
• Acetazolamide (Diamox)
• Methazolamide (Neptazane, MZM)
• Dichlorphenamide (Darinide)

95
Anti-Glaucoma Agents

• Prostaglandin Analogue
• Latanoprost (Xalatan 0.005)
• Bimatoprost (Lumigan 0.03)
• Travoprost (Travatan 0.004/ Extravan with
  timolol 0.5)
• Travaprost (Travatan Z 0.004) No BAK
• Unoprostone (Rescula 0.15)
• Pipeline
• DE-085 (Santen) prostaglandin based phase II

96
Low Tension Glaucoma

• Compromised ocular blood flow
• 50 have a cause / find it / fix it
• Past hx transfusions, bleed, hypovolemic
• Medications B-blockers, digoxin, digitalis
• MRI orbits brain
• R/O all cardiovascular causes of LTG
• CBC/anemias, CA doppler, TEE, sleep studies,
  coagulaopathies (PTT), overly fit (low BP)
• Treatment
• Decrease IOP, avoid B blockers, start with PG,
  bromonidine, CAIs last resort
• Ginko biloba 60mg/D inc fluidity without
  affecting platelet aggregation

97
Surgical Glaucoma Therapy

• Argon Laser Trabeculoplasty (ALT, LTP)
• Selective Laser Trabeculoplasty (SLT)
• Q switched NdYAG selectively targets pigmented
  trabecular cells (increasing activity?)
• Increases immune system by increasing monocytes
  macrophages in TM
• Selective because it does not cause appreciable
  damage to TM
• 50 confluent applications to 180 degrees _at_0.06mJ
• No blanching or bubble phase needed
• Addresses greatest roadblock compliance with
  medical therapy

98
Surgical Glaucoma Therapy

• Trabeculectomy
• Trabeculectomy with surgical adjuncts
• 5 FU (lower risk eyes)
• Mitomycin-C (MMC) higher risk eyes
• Indications
• Maximum tolerated medical therapy
• Progression of disease
• Unable to instill medications
• Secondary glaucomas (Neovascular glaucoma)
• Consideration
• Age, HTN, DM, Anticoagulants, Preop IOP, previous
  vitrectomy
• Degree of visual impairment,
• Lens status
• Comorbidities

99
Surgical Glaucoma Therapy

• Future directions
• Newer antifibrinolytics
• CAT-12, a monoclonal antibody to TGF-B2
• Photodynamic therapy
• Novel drug delivery systems
• Collagen implants, bioerodable polymers,
  liposomes microspheres
• Glaucoma drainage implants instead of filtering
  surgery
• Shunts aqueous from AC tube through an episcleral
  plate
• Ocular genetics
• Discover genes, gene therapy, primary prevention
  of glaucoma may become a reality

100
Glaucoma Pipeline

• Extracellular Matrix metalloproteinases
• Oral neuroprotectants - Memantine (Nameda)
• Sustained release formulations
• Anecortave acetate (Retaane/Alcon) ARVO 2006
• Originally studied for ARMD
• Steroid that actually LOWERS IOP
• No cataract formation
• 25 decrease in IOP at six months after 1
  juxtascleral injection

101
Theories on Aging and Eye Disease

• Age related macular degeneration and cataracts
  are associated with age
• Leading causes of blindness worldwide
• Elderly
• Family history, gender, cardiovascular disease
• Smoking nicotine, benzopyrene, nickel, lead and
  arsenic
• Light colored irides and hair
• Exposure to UV radiation
• Diet saturated fat intake increases risk for
  AMD
• Mechanisms free radical damage, UV damage

102
AMD Risk Factors

• Age gt 60
• Race WgtB
• Sex FgtM
• HTN
• Smoking
• Nutrition
• Family History
• Fair complexion
• Cardiovascular disease

103
New Ideas in AMD

• Sub-subspecialty emerging in Retina
• Devices to measure Macular Pigment Optical
  Density
• Macuscope
• QuantifEye (ZeaVision)
• Hyperacuity perimetry
• Forsee PHP (Notal/MSS)
• Zeaxanthin is considered important in
  supplementation
• Combination therapies more common in wet AMD

104
AMD Research on Genetics

• Age related macular degeneration gene located
• Encodes for a protein called Compliment Factor H
• Increases inflammatory proteins
• Increases C-reactive protein
• We now know a genetic component of the disease
  exists!

105
Components of Ocular Supplements

• Vitamins
• Vitamin A as beta carotene
• Vitamin C
• Vitamin E
• Minerals
• Zinc
• Copper
• Selenium
• Macular pigments
• Lutein macular carotinoid
• Zeaxanthin foveal carotenoid
• Bioflavenoids
• Ginko biloba for AMD and glaucoma (blood flow)
  and memory

106
Treatment Modalities

• Dietary Supplements
• TheraLife Eye TheraLife Enhancer (TheraLife)
• Beta carotene, bilberry, chrysanthemum, copper,
  fructus lycii, Vitamin E C, riboflavin (B2),
  selenium, semen cassiae, zinc
• Hydrate Essential (Cynacon/Ocusoft)
• Essential fatty acids - Flaxseed oil and bilberry
  extract encapsulated in hydroxylated lecithin
• HydroEye (Science Based Health)
• Blend of omega fatty acids and nutrients
• TheraTears Nutrition (Advanced Vision Research)
• EPA enriched flaxseed oil omega-3s

107
Nutritionals and OTC Vitamins

• Ocuvite Lutein (BL)
• Ocuvite extra (BL)
• Ocuvite PreserVision (BL)
• AREDS NIH Study
• 2 tabs bid
• ICAPS Lutein Zeaxanthin Formula (Alcon)
• ICAPS AREDS formula
• ICAPS MV
• I-Sense OcuShield (Akorn)
• Maximize
• EyePromise (ZeaVision)

108
Nutritionals

• First degree relatives of ARM pts 2-4 times
  greater risk of ARM compared to controls
• Twin studies show high levels of concordance of
  the disease among monozygotic sibs
• Vitamin E may cause bleeding
• Vitamin D may be of benefit
• Diets high in omega-3 FAs are of benefit
• Control of weight, HTN cholesterol is important
• Diet of green leafy vegetables increase lutein,
  zeaxanthin which increase optical density of
  macular pigment providing protective role

109
Measurement of Macular Pigment

• Objective Techniques
• Modified Fundus Cameras
• Fundus Reflectence
• Raman Spectroscopy
• Autofluorescence Spectroscopy
• Modified SLO
• Subjective Techniques
• HFP (Heterochromatic Flicker Photometry)
  (pschyophysical)
• (Ability to detect a blue flickering light)

110
Is MPOD Related to AMD?

• Three donor eye studies published, all show
  30-50 less pigment in AMD eyes vs controls
• Moran Eye Center (Bernstein) Raman method
• Manchester UK group HFP method found AMD patient
  eyes had 50 lower MPOD
• Germans found 50 lower MPOD in dry AMD patient
  eyes
• Dutch group did cross sectional prospective study
  using reflectance and found no difference on MPOD
  in early AMD

111
The AREDS I II Formulations

• AREDS (Age-Related Eye Disease Study)
• Vitamin C 500 mg
• Vitamin E 400 IU
• Beta-carotene 15 mg (May be listed on the label
  as 25,000 IU vitamin A as beta-carotene)
  (eliminate!)
• Zinc oxide 80 mg (40 mg)
• Copper 2 mg (needed to prevent copper deficiency
  caused by high dosage of zinc)
• Lutein Zeaxanthin 10 mg 2 mg
• Omega-3 fatty acids 1 gram

112
Nutritionals

• EyePromise (ZeaVision)
• Zeaxanthin 6mg
• in the same 11 ratio as found in healthy macula
• Lutein 6mg
• Beta carotene none
• Vitamin C 120mg
• Vitamin E 60 IU
• Zinc 15mg
• Copper none
• Fish oil (omega-3) 250mg
• Alpha Lipoic acid 10mg

113
Visual Field 9208x

• Bilateral
• Requires Interpretation
• separate report form
• narrative in body of medical record, on date of
  service
• Fee 44.77- (-81) / 46.18
• Fee 58.29- (-82) / 59.09
• Fee 66.96- (-83) / 68.17

JAM
114
Why Is Early Diagnosis Important?

• Lesion size was a more significant factor
  affecting treatment benefit than either
• 1. Lesion composition
• 2. Baseline visual acuity
• TAP and VIP Report 1, AJO, Sept., 2003

Earlier Diagnosis Means BetterFinal Visual
Acuity
115
Average CNV Presentation

• Average size
• 3300µ
• Location
• 80 Subfoveal
• 20 Extrafoveal
• Initial Vision
• 20 gt 20/40
• 40 20/50 20/200
• 40 lt 20/200

Olsen, TW Ophthalmology Feb. 2004
116
Inherent Faults of the Amsler Grid

• Completion
• The Amsler Grid does not overcome cortical
  completion
• Fixation
• The Amsler Grid does not force fixation
• Crowding
• Inhibition by neighboring peripheral lines
  reduces detection

117
Foresee PHP Technology Vernier Acuity

• The human ability to perceive minute differences
  in the relative spatial localization of two
  objects in space
• The brain is exceptionally sensitized to the
  detection of small shifts in the co-linear
  arrangement of photoreceptors.

2 sec arc
118
Hyperacuity

• Snellen 20/15 Resolution
• 1minute of arc
• 0.017 degrees
• Vernier Resolution
• Two seconds of arc
• 0.03 minutes of arc
• 0.00051 degrees
• The width of a pencil viewed at 300 m !

119
The Future of AMD Monitoring Foresee PHP

• Easy operation
• Comfortable for patient
• Noninvasive Rapid threshold test 5 min/eye
• Automated results analysis
• Generates visual field map of disturbance
  patterns consistent with the progression of AMD

120
Thank you
McGreal Educational Institute Missouri Eye
Associates
Excellence in Optometric Education