EyeWorld Asia-Pacific March 2020 Issue

GLAUCOMA EWAP MARCH 2020 49 A close look at the glaucoma suspect by Liz Hillman EyeWorld Editorial Co-Director Contact information Richter: Grace.Richter@med.usc.edu Sheybani: sheybaniar@wustl.edu This article originally appeared in the November 2019 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. W ith glaucoma, once the damage is done, it’s irreversible, which is why identifying—and following— glaucoma suspects before they even have an optic nerve defect is vital to protecting their vision. What is considered suspect? How often should these patients be assessed? Arsham Sheybani, MD, and Grace Richter, MD, shared their thoughts on how to navigate identification and monitoring of glaucoma suspects. “Unfortunately, there is no hard science on who is a true glaucoma suspect, and we can never know which of these patients will actually develop glaucoma in the future,” Dr. Richter said in an email to EyeWorld. Red flags on an exam that put a patient in glaucoma suspect category, according to Dr. Richter, include: an enlarged cup-disc ratio (CDR), CDR asymmetry, focal thinning of the neuroretinal rim, disc hemorrhage, or retinal nerve fiber layer defect. Elevated IOP and a glaucomatous visual field are other factors that would lead Dr. Richter to monitor a patient over time for the progressive condition. Factors such as a family history of glaucoma, thin central corneal thickness, myopia, older age, and African or Latino ancestry are associated with an increased risk for glaucoma and should be taken into consideration with exam findings as well, Dr. Richter said. The most important thing to do with glaucoma suspects, Dr. Sheybani said, is serial follow-ups. First, you can catch something that you just missed the first time, he said. And, second, they allow you to assess whether it’s a person who might progress rapidly or not. “Sometimes you’ll do a field every 6–9 months for a couple of years. You get 3–4 visual fields as baselines, and if things are steady and there is no change, then you feel a little better about it,” he said, adding that, generally, yearly follow-ups of glaucoma suspects are handled by referring doctors or optometrists in his practice. In addition to establishing a baseline with a series of visual field tests and monitoring that over time, Dr. Sheybani sees a value in using OCT. “Sometimes there is variability between scans and sometimes it’s kind of burdensome, but if you’re really trying to do it right, you want to get a couple of scans at the start, the first visit. Then follow those scans over time with