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223 Cards in this Set

  • Front
  • Back
(T/F) Glutamate antagonists is being studied to see if they can prevent glaucoma
F - Glutamate agonists
(T/F) Neurotrophins may be an effective neuroprotector for glaucoma.
T
(T/F) Nitraseoxide sensatase can block the production of nitrous oxide, which is a free radical that can damage the eye.
T
What is the only proven method to stop/slow down glaucoma?
IOP control
Does structural or functional damage occur first in early glaucoma? What is the clinical relevance?
Structural damage. But this is often hard to see.
(T/F) The OHTS study found that when patients with ocular hypertension converted to glaucoma, ___ of the time, the first sign was VF loss. The European Glaucoma Prevention Study found that the percent was ___.
40%, 60%
What picks up defects earlier? FDT or White-On-White (WOW)/
FDT
(T/F) The best way to monitor glaucoma damage in (early/middle/late) stage glaucoma is with perimetry.
Late
What perimetry type is the standard of care for glaucoma? Why?
White-On-White (WOW) Standard Automated Perimetry (SAP) Threshold. Because it has progression analysis software.
Is the FDT good for early detection or management of glaucoma? Why?
Early detection b/c it picks up glaucoma ??% of the time. Also, there is no progression software to track changes.
If we were to use the Humphrey to screen for glaucoma, what is better (C40/C80)?
C80
FTD screening for glaucoma is best done with the (C20-5/N30-5)
N30-5
(T/F) White-On-White threshold testing picks up glaucoma better than an FDT
F
What kind of defect does fixation errors cause in perimetry?
They smear out true visual field defects.
(T/F) Early glaucoma damage evidence in VF is often inconsistent.
T
(T/F) IOPs do not fluctuate in early glaucoma.
F
What criteria does the patient have to meet to have a threshold test done for glaucoma?
Done for all glaucoma suspects.
(T/F) A patient with everything normal but signs of structural damage should be treated for glaucoma.
T
Name 7 high risk factors for glaucoma.
Large CDs, asymmetric CDs, nerve fiber layer defects, notches, higher IOPs, asymmetric IOPs, family history.
What is Short Wavelength Automated Perimetry (SWAP)? Advantages? Disadvantages?
Blue stimulus on yellow background. Detects glaucoma damage and progression earlier, but lots of variability.
(T/F) The Matrix has VF loss progression software
F
Name 4 factors that cause generalized depression on VFs.
Tiny pupils (<3 mm), Things that mess up the cornea (previous gonio, pachymetry), cataracts, tiredness.
(T/F) If a patient changes from a .1 CD to a .2 CD, but everything else is normal, they have glaucoma.
T
What tools are recommended to detect and treat glaucoma in your practice?
Detect with FDT. Treat with White-On-White perimetry.
What is the working distance for FDT, Octopus, Matrix, Humphry? What kind of adds do we add for the ones that aren’t at infinity?
Infinity, 30 cm, Infinity, 30 cm. +3.00D
What phenomenon might cause a pt to do better on their second threshold test?
The learning effect.
How often should we get VFs when treating an early/advanced glaucoma pt?
3 per year. 3-6 per year.
What test should we do with advanced glaucoma patients? What extra thing do we need to do in this case?
10-2 VF because it tests central 10 degrees. Foveal threshold MUST be on.
What is the difference between EVENT and TREND analysis that is built into our Humphreys?
Event is snapshot. Trend tracks change.
What is the likely culprit of doing a Humphrey test and finding that the patient doesn’t have a blind spot?
They don’t have their other eye patched.
What are the 3 phases of glaucomatous VF loss?
Elevated IOP but no VF change. 2) Unstable VF defects 3) Paracentral scotoma/nasal step.
What is baring of the blindspot?
Vertical enlargement of the blind spot that happens with glaucoma.
What other 6 things might cause an artifactuous baring of the blind spot?
Small pupil, blur (wrong lens), media opacity, wrong age entered, learning curve, fatigue
What are the 3 classic VF defects in early glaucoma?
Paracentral scotoma, nasal step, temporal sector defect
What is a paracentral scotoma? How big is it? How far from fixation is it?
Small scotoma (5-20 degrees) in arcuate region of VF. Can be as close as 1 degree away from fixation.
What VF defect is often found with paracentral scotomas?
Nasal Step.
(T/F) Nasal steps are the #1 most common isolated single defect in glaucoma
F – Paracentral scotoma.
(T/F) Fixation is often affected first in early glaucoma.
F
Nasal steps occur with a paracentral scotoma ___% of the time.
75%
Nasal steps are the #___ most common VF defect. It is found first ___% of the time.
2. 20%
A nasal step should be at least ___ degrees big.
10
What is the best technique/tools to use when examining the ONH?
Slit lamp and fundus lens.
What is the best mag when looking at the ONH head with a slit lamp and fundus lens? What beam thickness?
16x is best. Can do optic section to look at contour of cup.
(T/F) Glaucoma produces pallor outside of the cup.
F
(T/F) Nerve fiber layer defects and VF defects are very specific to glaucoma
F
What is the characteristic pattern of glaucomatous ONH damage?
Cup increases and is filled with pallor.
What kind of people have large cups?
People with large nerves (Myopes, African Americans).
What kind of people have small cups?
Hyperopes.
On the Welsch Allen ophthalmoscope, which aperture is the size of a normal ONH?
Middle one.
What makes up the rim tissue?
Axons
What part of the ONH is the rim tissue?
The stuff outside of the cup.
What is the ISNT rule?
The inferior rim tissue is thicker than the Superior. The Nasal is thicker than superior/inferior.
What area of the rim tissue is it most difficult to see pallor? Why?
Temporal because this rim tissue is very variable!
(T/F) It is best to judge CDs by contour, not color.
T
Which part of the ONH rim tissue is rarely affected by glaucoma?
Nasal
(T/F) Peripapillary atrophy is a specific sign of glaucoma
F
What are the 2 zones of peripapillary atrophy? (Alpha, beta)
Alpha is thin, irregular, blotchy line of pigment that gets thicker with more glaucomatous ONH damage on the outside. Beta is on the inside and contains choroidal vessels.
What is the Laminar Dot Sign?
When a person who did not have laminar dots gets them.
If you see laminar dots in a patient’s eye, do they have the Laminar Dot Sign?
No, because it could be congenital. Except if you see it at the inferior and superior rim tissues, then that is characteristic of glaucoma.
What is saucerization of the ONH?
When there are multiple levels of cupping. (Like stairs)
What is a circumlinear vessel and how is it relevant to CD ratio estimation?
A vessel that rides the edge of the cup. If we continue to see it right on the edge of the cup, then we know the cup didn’t change.
A cup asymmetry of .1 will be found in ___% of patients. An asymmetry of .2 will be found in ___% of patients.
8%, 1%
What is the most common cause of peripapillary atrophy?
Age
When cupping occurs on the ONH via glaucoma, what area(s) cup first?
Superior/Inferior areas.
How can we determine if peripapillary atrophy is a cause of glaucoma?
Compare its location to visual field losses.
(T/F) A papillary atrophy width change precedes glaucomatous damage by years.
T
Laminar dots start as (round/oval) and then progress to (round/oval)
Round, Oval.
(T/F) Drance hemes are dot blot hemorrhages.
F – Flame hemorrhages
(T/F) Drance hemes do not always need to be near the ONH.
F
(T/F) Drance hemes are often found found in photos more then through clinical observation.
T
Why are drance hemes significant?
They can precede glaucomatous damage by months, years to 6 years.
(T/F) Seeing a drance heme is reason enough to start glaucoma therapy.
T
What 8 things could cause a flame heme on the ONH?
Low tensions, chronic open angle glaucoma, aspirin, warfarin/Coumadin, fish oil, Anemia, migranes, drusen.
(T/F) We see flame hemes in diabetics.
F – Dot blot hemes
(T/F) HBP can cause flame hemes with no other symptoms.
F – By this point, we’ll probably have swollen ONH and other signs.
(T/F) A PVD where the Weiss ring pulls away from the retina often leads to flame hemes.
F – Dot blot hemes
(T/F) An AION will likely produce a single flame heme that looks like a drance heme.
F – It will make lots of big hemes.
___% of flame hemes will cause a visual defect
60%
What might happen in the place where a drance heme is?
Focal nothch, NFL loss and VF loss.
What 3 things should we think about if we see a drance heme in a pt we’re managing?
Compliant? 2) IOP spike we don’t know about? 3) Need to lower target IOP?
What is meant by baring of the circumlinear vessel?
Cupping progressed beyond a circumlinear vessel.
What is an acquired pit?
Focal excavation of rim tissue near the edge of the disc.
In literature, acquired pits happen in ___% of patients. Dr. Comer sees them in ___% of patients.
20%. 1%
___% to ___% of nerve fiber layer loss must occur for us to see it clinically.
30-50%
Imaging can pick up ___% of nerve fiber layer loss.
10-20%
What 3 things could preceed glaucomatous ONH damage?
Drance hemes, peripapillary atrophy, nerve fiber loss.
(T/F) Generalized NFL loss is easier to detect than focal.
F
What 2 techniques are good for picking up NFL loss?
DO, Fundus lens
What is the danger of going too high mag for NFL loss evaluation with a fundus lens? What mage is best?
10-16x is best. If too high, will mistake normal NFL spread as damage.
What parts of the ONH is it easiest to see the NFL?
Superior/Inferior.
(T/F) Increasing visibility of medium sized vessels indicate possible NFL loss.
T
(T/F) It is acceptable to compare the superior and inferior portions of the ONH to compare for NFL loss.
F – You should compare eye to eyes!
How big should a possible slit defect be so we know it’s real?
The size of a vessel or larger up to 2-3x.
How do wedge defects form?
Slit defects coalesce together.
(T/F) Wedge and slit defects are lighter bands of area.
F – Darker.
(T/F) If you see lots of striations, then you have NFL loss.
F. That’s good!
How does the presence of a wedge defect and a drance heme tell us different things about glaucomatous damage?
Wedge defect shows past damage. Drance heme indicates current damage.
How do we know we have a real RNFL slit defect?
It runs to the ONH and is the same size or 2-3x larger than vessels.
What are 2 advantages of using imaging technology?
1) Glaucoma identification 2) Tracking of glaucoma change
What do you get with an HRT? Advantages? Disadvantages?
ONH image and RNFL image. Good picture of ONH. Bad picture of RNFL.
What is the GDX good for?
Imaging the RNFL
What 3 things does Optivue RT give us?
NFL image. Nerve head topography. Paramacular retinal ganglion cell layer.
What generation is the OCT Zeiss?
3rd gen. Not as good as 4th.
(T/F) Imaging is covered by Medicare for late stage glaucoma. Why?
False. Because VF damage is a better way to see how late stage glaucoma is changing.
What is the difference between 4th gen OCTs and 3rd gen OCTs?
65x faster and 2x better resolution. Therefore, you can compare better and pt movement isn't an issue.
What is an A Scan?
Coherent light is shot into the eye along the long axis and the reflectance from various layers of the retina come back to the instrument.
What is the difference between A and B scan?
B scans are a series of A scans along one line.
What is the best thing about the HRT?
It gives good optic nerve topography.
What is the best thing about the GDX?
It gives a good look at the NFL.
What does the Optivue RT give in addition to the HRT and GDX?
Paramacular ganglion cells scan.
(T/F) Proper imaging can replace our clinical exam.
F
(T/F) Thicker corneas can prevent meds from reaching the back of the eye.
T
If a patient has a ___ nm cornea, then meds won't reach the back of the eye. Therefor, _____ should be considered.
625+ nm. Laser trabeculoplasty.
Name the conditions we need to do a prone dark room provocation test.
Lights off. Head down so facing floor. Eyes open or closed. No sleeping. Hour.
How do we reverse angle closure from a dark room provocation test?
Turn on the lights -> Pupil shrinks -> pupillary block stops -> Iris pulled away from TM
If a dark room provocation test brings an ___mmHg or greater rise in IOP, then the patient is at risk for a pupillary angle closure.
8
What is the formula for ocular blood flow?
Ocular blood flow = BP - IOP
Does BP rise or lower at night?
Lower
Does IOP rise or lower at night?
Rise
Why are the BP and IOP changes at night when sleeping supine a possible cause of glaucoma?
BP lowers. IOP rises. Less ocular blood flow -> decreased profusion -> ONH damage
(T/F) Beta Blockers are good for lowering IOP but keeping BP high at night?
F - Prostaglandis and CAIs are better. BBs lower BP.
(T/F) Timolol is a good choice to keep IOPs low at night.
F - All BBs don't lower BP when sleeping
(T/F) Alphagan is a good choice to keep IOPs low at night.
F - They work minimally.
Why are prostaglandings preferred over CAIs for keeping IOPs low at night?
B/c you take them once per day. CAIs should be taken TID. But they can be used together if you need to.
What tool gives an indication of ocular blood flow? How?
Pascal tonometer because it gives ocular pulse amplitude which is the difference between diastolic and systolic eye pressure.
(T/F) There are no symptoms in open angle glaucoma
T
(T/F) It is acceptable to treat an ocular hypertensive for glaucoma.
T - especially if other strong risk factors.
What is the average corneal thickness?
575 nm
(T/F) It is appropriate to give an ocular hypertensive with 25/25 IOPs glaucoma treatment if their cornea is 575 nm?
F - It is better to see them in 6 months or 1 year.
(T/F) There is no acute risk with open angle glaucoma.
F - A patient with prior central or branch vein obstruction. We want to prevent another one.
(T/F) There is a cure for glaucoma
T
(T/F) You cannot go blind because of glaucoma
F
A ___ nm decrease in central corneal thickness equates to a ___% risk increase of glaucoma
40 nm, 70%
What is the average CD ration for an African American?
.5 to .6
A pt has "borderline" IOPs one week. The next week, they are "normal". Should we treat?
Yes - because the drastic change in IOPs shouldn't occur.
If angles are .12, is there a risk of open angle glaucoma?
No because the angle is still open. Open angle glaucoma is when the aqueous reaches the TM but can't leave.
We do a one eyed therapeutic trial of a drug on a patient. The next week, the IOPs for both eyes are lower. Keep using the drug?
No. The lowering of IOP is due to another factor, not the drug.
Do we need to do one-eyed therapeutic trials every time we introduce a new drug?
Yes.
What is the first line med for glaucoma?
Prostaglandins.
Which eye do we choose for the one-eyed therapeutic trial?
The eye with the higher IOP.
What 3 things do we look for to get a good response to a drug during a one-eyed trial?
Only 1 IOP reduced by the percent we expect. Pt was compliant. Side effects are tolerable.
How much should the IOP lower for a prostaglandin? BB?
20-30%
Why would we use BBs over prostaglandins when they have more systemic side effects?
Cheaper. ($4 per bottle)
Why is it important to check the pulse when giving BBs?
Systemic side effects can cause cardiac risk
When should we follow up on a prostaglandin? BB?
4 weeks. 3 weeks.
A person uses BBs says they now get winded more easily. Discontinue?
Yes - Pulmonary side effect is bad.
When is the best time to take a prostaglandin?
Before sleep.
One eyed patients. Glaucoma management change?
Yes. Treat more aggressively because they only have 1 eye!
A person has unilateral glaucoma. How treat?
Ease them into therapy with one eye. Eventually, will need to bring in both eyes in a month to a year because glaucoma is often bilateral.
How does target pressure change with severity of glaucoma damage?
Greater damage -> lower target pressure.
(T/F) The lower the pressure, the harder it is to lower it even more.
T
(T/F) If optic nerve damage is noted, but no VF loss, we should treat for glaucoma.
True.
What is the maximal tolerable medical therapy for a pt?
The most medications that a pt can take.
What is the main goal of glaucoma treatment?
VA preservation.
What is the 2nd goal of glaucoma treatment?
Keep compliance
(T/F) Lowering IOPs is the only proven way to slow the progression of glaucoma
T
(T/F) A 20% risk of getting glaucoma in 5 years is significant enough to start treatment.
T
CD ratios for Latino pts is ___ to ___
.4 to .5
If you can see VF loss with confrontations, is glaucoma damage bad?
Yes.
What drug that we use in clinic all the time could cause IOP increase? How?
Relaxes ciliary muscle fibers, so IOP can increase.
We give tropicamide to a pt and their IOP shoots up. What drug do we give to bring them down?
Alpha 2 agonists
What is a target pressure for glaucoma management?
Whatever I estimate the IOP to be to slow/stop glaucomatous change.
What is the minimal IOP reduction we want with a patient with minimal damage or just high risk?
25-30%
What is our target IOP when glaucomatous VF loss in central 5 degrees, spittling fixation, or double acuates?
10 mmHg
Is it harder to get an IOP from 30 -> 20 or 12 -> 10?
12 -> 10.
What did the Collaborative Normal Tension Glaucoma Study (CNTGS) find?
Normal tension glaucoma pts (never > 21) had 60% glaucoma progression without treatment.
(T/F) A patient can have a non-progressive form of low tension glaucoma.
F - It must be progressive.
What is the target IOP reduction for low tension glaucoma?
30%
What did the Advanced Glaucoma Intervention Study (AGIS) find about African Americans vs. Caucasians?
African Americans like ATT and Caucasians like TAT. T = Trabeculectomy surgery. A = Argon laser trabeculoplasty
What percent of pressure reduction did the Advanced Glaucoma Intervention Study (AGIS) find to prevent glaucoma progression? Exact parameters?
50%. Near 10 mmHg and minimal variation to always keep it < 18 mmHg
What is the average IOP lowering with surgery and drugs?
40% and 37%
What did the Collaborative Initial Glaucoma Treatment Study (CIGTS) find was better at preventing VF loss? Surgery or Drugs?
Same.
Do we prefer surgery or drugs to prevent glaucomatous damage?
Drugs because less side effects (1/2 line VA loss, 3x more cataracts, dry eyes, red eyes, irritated eyes, etc.)
(T/F) Meds are an acceptable first line treatment for glaucoma.
T
If one eye IOP is 27 and the other is 18, do we want both to be 18?
No. Reduce both by 30%
(T/F) High IOP fluctuation is linked to glaucomatous damage progression
T
If the rate of VF damage is 3 dbs per year, is that bad? What do we do?
Yes. Treat it more aggressively.
How much will a 1 IOP decrease reduce the risk of glaucoma progression?
10%
What is combigan?
Timoptic and Alphagan
What is Cosopt?
Timoptic and Dorzolamide
What are 3 reasons why we don't want to pile excessive drug combos on?
Compliance, cost, side effects.
When setting the target IOP, do we use the (highest/lowest) IOP. Even if it is from another doctor's office.
Highest.
(T/F) Always start with one medication when initiating chronic open angle glaucoma treatment.
T - But F for angle closure glaucoma!
(T/F) Try to use the lowest concentration of drugs initially.
T
How long should a patient wait between drops?
15 mins
What is the pouch technique?
When we put a drop of drugs in the lower culdesac
What is better to write? q8H or TID?
q8H b/c a patient may take all three drops in the morning.
When changing glaucoma medications, should we substitute first or add another one?
Substitute
(T/F) Travatan -> Lumigan is an acceptable substitution to bring down IOPs.
T
(T/F) Travatan -> Xalatan is an acceptable substitution to bring down IOPs.
F - They are very similar. But T - If managing side effects b/c Xalatan has less side effects.
(T/F) Drug combinations may result in reduced results compared to individual drugs
T
Why are prostaglandins great?
25-30% IOP reduction. Once a day. Works all day. Few systemic side effects.
Why are BBs not a great as prostaglandins?
Don't work at night. List of side effects.
What are the 5 contraindications for prostaglandins?
Pregnancy. History of uveitis, herpes simplex keratitis, cataract surgery, CME
If the pt is using Ca Channel blockers, what glaucoma drug should we avoid?
BBs
If the pt is using MAO inhibitors, what glaucoma drug should we avoid?
Adrenergic Agonists (all - alpha 1, alpha 2, non-selective)
What are the cap colors for prostaglandins? Alphagan? Combigan? CAIs?
Teal, Purple, Blue, Rust
What are the cap colors for .5% BB? .25% BB? Anticholinergics like tropicamide?
Yellow, light blue, red
What are the cap colors for Cholinergics like Pilocarpine? Cosopt?
Green, rust and yellow
After adding a prostaglanding, what drug class do we want to use next? Why? Schedule?
CAIs. Good additive effect. TID.
(T/F) Oral CAIs are a good addition to use with prostaglandins.
F - Topical only!
If we don't reach our target pressure, should we add a new drug or substitute?
Substitute.
What drug should young patient avoid? Why?
Pilo. Because produces ciliary spasm, so always accommodating. So will be massively blurred!
What drug should older patients avoid? Why?
Pilo. Tiny pupils decrease light coming in. Also increases blocking effect of cataracts.
What drug should you avoid if the pt has anterior uveitis? Why?
Pilo. Because it causes ciliary spasm and vasodilation which cause more pain and inflammation, leading to posterior synechiae.
What drug should aphakes and pseudoaphakes avoid? Why?
Epinephrine/Propine b/c increases risk of CME
What drug should be stopped before surgery? What is a good replacement?
Prostaglandin. Alphagan
What drug should people with retinal detachment risks avoid? Why?
Miotics. Can increase risk of tears.
What drug should Corneal Endothelial Disease pts avoid? Why?
CAIs. It will compromise the endothelium.
What drug should you avoid if you have breathing problems?
BBs.
What drug should you avoid if you have kidney problems?
CAIs
What drug should you avoid if you have liver problems?
CAIs
What drug should you avoid if you have heart or lung problems?
BBs
What drug should you avoid if you are pregnant? What should you use?
Prostaglandins. Alphagan.
What drug should you avoid if you have low BP?
BBs
What drug should you avoid if you have diabetes?
BBs
How does Dr. Comer define an angle that is not narrow?
Must see TM in 2 angles.
What 3 drugs should narrow angle pts avoid?
BBs, propine, epinephrine
(T/F) A large bottle should be ordered from the start to save the pt money.
F - First see if it works. Also make sure the pt has a reason to come back. (1-3 refills)
What instructions should a BB installing pt follow?
Do at night so your eyes are closed 3-4 mins afterwards (b/c you're sleeping!)
What 2 drugs/drug classes tend to not work as much when used BID instead of TID?
Alphagan and CAIs
At what point should laser trabeculoplasty be considered? Why?
When patient needs more than 2 meds b/c compliance will be bad.
How much will cataract remove reduce IOP?
2-4 mmHg