EyeWorld Asia-Pacific September 2014 Issue

21 EWAP GLAUCOMA September 2014 Dr. Samuels speaks with a patient about the diagnosis of glaucoma and the tests that will be completed during the clinic visit. Source: Nik Layman Confounding the issue is that while seeing abnormalities in the retinal nerve fiber layer and correlating those to visual fields to make a diagnosis is one thing, “telling when that retinal nerve fiber layer is getting thinner and is progressing and correlating that with the rest of the examination is very difficult,” said Louis B. Cantor, MD , chair and professor of ophthalmology, Jay C. and Lucile L. Kahn professor, and director of the glaucoma service, Indiana University School of Medicine, Indianapolis, Ind., U.S. Further, that assessment may be somewhat subjective as “trying to see if there is progressive change is difficult,” he said, calling that one of the biggest challenges glaucoma specialists face. “Establishing the diagnosis of glaucoma, while often challenging, is not nearly as difficult as determining when the glaucoma is getting worse.” As every ophthalmologist knows, visual fields (VFs) “require an alert and cooperative patient,” said Brian Samuels, MD, PhD, assistant professor of ophthalmology, University of Alabama at Birmingham, Ala., U.S. “Additionally, studies have shown that a relatively large percentage of the retinal ganglion cells have to be lost before a visual field defect is apparent.” The key to successfully managing POAG patients is to identify early disease and begin treatment “when they’re having nerve fiber layer loss to prevent visual field loss. If field loss is present, you want to treat them to prevent or delay functional POAG is becoming an individualized disease No single test is best for diagnosing the disease or progression, experts say. It all depends on the patient D etecting glaucoma—and its progression—is a combination of multiple tests, and no one single test is best for any one individual patient. Regardless of where a patient is (ocular hypertension, early glaucoma, advanced glaucoma), the primary tests used for evaluation remain stereo-optic disc photography, visual field analysis, and optical coherence tomography (OCT). “Developing a glaucoma care plan is a form of personalized medicine. We want to assess the individual risk of disease onset and disease progression, try to tailor the testing (structural, functional, and frequency of testing) and visits to the individual patient,” said Jeffrey Liebmann, MD , clinical professor of ophthalmology, New York University School of Medicine, and director of the glaucoma services, Manhattan Eye, AT A GLANCE • Individualized assessment and evaluation are necessary. • Visual fields are the most used method to detect progression, but are still too patient- dependent. • OCT technology is advancing so quickly that it should not be the sole diagnostic. • Stereo disc photography remains mandatory for baseline assessment. by Michelle Dalton EyeWorld Contributing Writer Ear and Throat Hospital, New York, NY, U.S. Dr. Liebmann suggested physicians should be less concerned about determining if progression has occurred and more concerned about the rate of that progression. “We need to pay attention to the rates of change over time—this will allow us to determine the likelihood of visual impairment due to glaucoma over the lifetime of the patient.” The “most important” thing to look for is progression, said Robert J. Noecker, MD , in private practice, Ophthalmic Consultants of Connecticut, Fairfield, Conn., U.S., because “everyone can’t be ‘average’ in terms of progression. The main thing is if that person is changing on our watch.” continued on page 22