Disclosures Leo Semes, OD, FAAO BLOOD FLOW IN GLAUCOMA ... - Blood Flow in Glaucoma.pdf · “OCT-A...
Transcript of Disclosures Leo Semes, OD, FAAO BLOOD FLOW IN GLAUCOMA ... - Blood Flow in Glaucoma.pdf · “OCT-A...
9/1/18
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BLOOD FLOW IN GLAUCOMA – INSIGHTS AND PERSPECTIVES
Leo Semes, OD Professor Emeritus of Optometry and Vision Science, UAB
California Optometric
Association Monterey 2018
Disclosures–LeoSemes,OD,FAAOCommercial Interest
Nature of Relevant Financial Relationship
Maculogix Honorarium Speaker Science Based Health Honorarium Speaker OptoVue Honorarium Speaker B&L Honorarium Advisor Allergan
Regneneron
Shire
ZeaVision
Reichert/Ametek
HPO
Honorarium
Honorarium
Honorarium
Honorarium
Honorarium
Stock options
Advisor
Speaker
Speaker
Advisor
Speaker
Advisor
DavidSackett,MD[1934-2015]
• Widelyregardedasthefatherofevidence-basedmedicine.
Halfofwhatyou'lllearnduringtrainingwillbeshowntobeeitherdeadwrongorout-of-datewithin5years...;…thetroubleisthatnobodycantellyouwhichhalf.
OcularBloodFlowandglaucoma?Stateofthescience2009
“Atthepresenttime,noSINGLEbloodflowimagingdeviceiscapableofevaluatingocularbloodflowrelevanttoglaucoma.
“Acomprehensiveapproach,utilizingmultipleimagingtechnologiesisrequiredformeaningfulinsightintothemultiplevascularbedsoftheeye.”
Consensusstatement
oftheWGA2009
Howmanystateshaveonlyfourletters?
• Clue:Ohioisnotone
Seriously...
POAGisaprogressive,chronicopticneuropathyinadultsinwhichintraocularpressure(IOP)andothercurrentlyunknownfactorscontributetodamageandinwhichthereisacharacteristicacquiredatrophyoftheopticnerveandlossofretinalganglioncellsandtheiraxons.Thisconditionisassociatedwithananteriorchamberanglethatisopenbygonioscopicappearance.–alaAAOPPP
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Seriously...POAGisaprogressive,chronicopticneuropathyinadultsinwhichintraocularpressure(IOP)andothercurrentlyunknownfactorscontributetodamageandinwhichthereisacharacteristicacquiredatrophyoftheopticnerveandlossofretinalganglioncellsandtheiraxons.Thisconditionisassociatedwithananteriorchamberanglethatisopenbygonioscopicappearance.–alaAAOPPP“Canglaucomatousopticneuropathybeinducedbyaprimarynon-IOP-relatedinsult...alone??”-ClaudeBurgoyne DX: POAG, ??? Is there a blood-flow problem here???
Maybeagoodintroduction
Whendoyouthinkthiseditorialappeared?
Maybeagoodintroduction
2009
OcularBloodFlowandglaucoma?Stateofthescience2009
“Atthepresenttime,noSINGLEbloodflowimagingdeviceiscapableofevaluatingocularbloodflowrelevanttoglaucoma.
“Acomprehensiveapproach,utilizingmultipleimagingtechnologiesisrequiredformeaningfulinsightintothemultiplevascularbedsoftheeye.”
ConsensusstatementoftheWGA2009
40o3DEnFaceReference
WideFieldEnfaceOCTTM
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OptovueWidefield-EnfaceOCT
WidefieldVS6mmx6mm3D
Multi-layerassessmentofpathology–evenintheperiphery
OptovueWidefield-EnfaceOCT SLO/LSLO2DImage
Choroidenface ChoroidTopographicalview
Widefield3DOCTVSWidefieldSLO
ILMenface ILMTopographicalview
Multi-layerassessmentofpathology–evenintheperiphery
IPLenface IPLTopographicalviewRPEenfaceRPETopographicalview
OCTwillrevolutionizethediagnosis,management&understandingofglaucoma…
• Higherresolution• Differentialdepthscans• O/Rapplications• Smartphoneapp• OCTangiography!!!
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XRAvantiMCTwithOCTA1
OCTEnfaceimageSSADA/OCTAImagingSSADA/OCTAImaging
Flowratedirectlyrelatestoappearance(brightness)ofvesselintheimage2
*ImagescourtesyofDavidHuang,M.D.OHSU.
1OCTA(SSADA)isnotyetcommerciallyavailable.
Detailedvasculatureofthefovea
withoutanydyeorcontrast
enhancementinjection
Most anterior slab
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X-sect through macula-ONH axis
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note area above ONH with demonstrable RPE loss and prominence of choroidal vasculature. AND, absence of superficial as well as deep retinal capillary plexuses Compare with OCT X-section showing thinned retina.
2014
2014
Glaucoma
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Generalizedandlocaleffects....
CAPILLARY DENSITY AND RNFL THICKNESS COMPARISON
33 POAG pts. with VF depressions unilaterally *MD = -3.91 +/- 3.09 and normal fellow eye (MD = -0.2 +/- 0.9)
• whole image vessel density (wiVD),
• circumpapillary vessel density (cpVD), and
• parafoveal vessel density (pfVD) Mean wiVD in unaffected eyes of patients with POAG was higher than in their fellow affected eyes but lower than in healthy eyes (P < 0.001). Mean circumpapillary RNFL (cpRNFL) thickness, mGCC thickness were also higher than those measurements in fellow eyes. “OCT-A measures detect changes in retinal microvasculature before VF damage is detectable in patients with POAG, and these changes may reflect damage to tissues relevant to the pathophysiology of glaucoma.”
Yarmohammadi A, et al. Peripapillary and Macular Vessel Density in Patients with Primary Open-Angle Glaucoma and Unilateral Visual Field Loss. Ophthalmology. Volume 125, Issue 4, April 2018, Pages 578-587
CHOROIDAL MICROVASCULAR DROPOUT (FOCAL SECTORAL CAPILLARY DROPOUT WITH NO VISIBLE MICROVASCULAR NETWORK IDENTIFIED IN THE CHOROIDAL LAYER)
32 Patients with an initial parafoveal scotoma (IPFS) within a 10° radius in 1 hemifield and, 42 POAG patients with an initial nasal step (INS) within the nasal periphery outside 10° of fixation in 1 hemifield. Microvasculature dropout (MvD) was observed in 25 of 32 eyes (78.1%) in the IPFS group, but in only 1 of 42
eyes (2.4%) in the INS group (P < 0.001). “The presence of MvD in the parapapillary choroid was a strong predictor for IPFS.”
Lee EJ, et al. Central Visual Field Damage and Parapapillary Choroidal Microvasculature Dropout in Primary Open-Angle Glaucoma Ophthalmology Volume 125, Issue 4, April 2018, Pages 588-596.
ANGIOANALYTICS APPROVED JUNE 2018
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2014
Maybethishelpsexplaintheasymmetrythatissoprevalentinglaucoma.Think:VF,rimtissue,PPA....
2012
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Proposedmechanisms
ReducedbloodflowcouldbeaconsequenceofneuraltissuelossarisingfromelevatedIOP
Proposedmechanism
ReducedbloodflowandelevatedIOPcouldbothleadtoneuralstructureloss
Proposedmechanism
ReducedbloodflowcouldbeanindependentcauseofVFloss
Andmoreevidence…
• AstudyfromaregistryinEnglandsuggestedanassociationbetweenglaucoma*andvasculardementia*butnotbetweenglaucomaandAlzheimerdisease*.
• [*Alzheimerandvasculardementiaarebothneurodegenerativediseasesandglaucomaisnowbeinglumpedintothatbucket,too.]
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KeenanTD,GoldacreR,GoldacreMJ.Associationsbetweenprimaryopenangleglaucoma,Alzheimer'sdiseaseandvasculardementia:recordlinkagestudy.BrJOphthalmol.2015Apr;99(4):524-7.
Perfusion
Pressure Blood Pressure
IOP
Lower Diastolic, Systolic, or
Mean Pressure Reduces Perfusion
Pressure
Higher IOP
Negatively Impacts Perfusion Pressure
Perfusion Pressure Is a Result of
A Delicate Balance Between IOP
and Blood Pressure
Lower Perfusion Pressure Is Associated with Increased Risk for
Open Angle Glaucoma Leske MC, et al. Ophthalmology 2007; 114,: 1965-72 Leske MC, et al. Ophthalmology 2008;115, 65-93. Hayreh SS. Trans Am Acad Ophthalmol 1974;78:240-54
OcularPerfusionPressure&GlaucomaProgression–emergingparadigms
DX: POAG, ??? Is there a blood-flow problem here???
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OpticNerveHEADanatomy–bloodflowconsiderations
HayrehSS.Ischemicopticneuropathy.ProgRetEyeRes.2009;28:34–62
Structural evaluation - Diagnosis enhanced depth imaging [choroid] • Choroidal thickness and perfusion/flow evaluation
• Age, axial length, CCT, and diastolic ocular perfusion pressure are significantly associated with choroidal thickness in glaucoma suspects and glaucoma patients.
• Degree of glaucoma damage was not consistently associated with choroidal thickness.
� Maul EA, Friedman DS, Chang DS, Boland MV, Ramulu PY, Jampel HD, Quigley HA. Choroidal thickness measured by spectral domain optical coherence tomography: factors affecting thickness in glaucoma patients. Ophthalmology. 2011 Aug;118(8):1571-9. 44
Hey! Maybe its choroidal blood flow after all Choroidal blood flow (arbitrary units)
Hey! Maybe its choroidal blood flow. After all that seems to be the case in AMD
ImplicationsofBFalterationswithÛÛIOP
Note: increased IOP induces • posterior rotation of the peripapillary sclera • flattening of the cup floor • thinning of the lamina cribrosa and the prepapillary neural tissue and • anterior movement of the central optic nerve relative to the LC
Which may be complementary to reduced blood flow OR a result of same
Sigal I, Ethier CR. Biomechanics of the optic nerve head. Exp Eye Res. 2009; 88,799-807 .
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Structuralevaluation–diagnosisenhanceddepthimaging
• Laminacribrosaevaluation
• Emerginginvestigations:CSFpressure(see:later)
ParkHY,JeonSH,ParkCK.Enhanceddepthimagingdetectslaminacribrosathicknessdifferencesinnormaltensionglaucomaandprimaryopen-angleglaucoma.Ophthalmology.2012Jan;119(1):10-20.ParkSC,DeMoraesCG,TengCC,TelloC,LiebmannJM,RitchR.Enhanceddepthimagingopticalcoherencetomographyofdeepopticnervecomplexstructuresinglaucoma.Ophthalmology.2012Jan;119(1):3-9. 49
Bloodsupplysummary• Interindividualvariation*• Retinalnervefiberlayer
– CRA/CRV
• Opticnervehead– SPCaa– choroidalplexus– bloodsupplyissegmental
v UltimatebloodsupplytoRNFLandONHisfromtheophthalmicartery,abranchoftheinternalcarotidartery
VascularTheoryofGlaucomaChangesinocularbloodflow(OBF)
• Reducedperfusionpressure(beyondautoregulatorycapacity)leadingto...– Secondaryvasculardegenerationfollowingganglioncell/RNFLloss
VascularTheoryofGlaucomaChangesinocularbloodflow(OBF)
• Peripheralvasculardysregulation-PVD– whichcanresultinreperfusioninjury(RI)
• AllcanbeIOPindependentandmayinvolveboththeretinalandchoroidalcirculatorysystems.
Distribution of IOP in a general population*
N=nonglaucoma;G=glaucoma.*Dottedlinesrepresentareasofuncertainty.ShieldsMB.TextbookofGlaucoma.1998.
ImplyinganIOP-independentcomponentinglaucoma(“NTG”???)
WhatarethepossibilitiesintheabsenceofelevatedIOP?
• Primary/Peripheralvasculardysregulation
• InadequateONHperfusion
Let’stryandconnectthedots
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Relationshipofperfusiontoglaucoma
• LowdiastolicocularperfusionpressuremaybeassociatedwithincreasedriskforPOAG.
• Thisassociationwasconfirmedinsubjectstreatedforsystemichypertensioninsubgroupanalysis.Thismaysupportthehypothesisthattheconceptofocularperfusionpressurestatusmaybemorerelevanttoglaucomapathogenesisthanocularperfusionpressurealone.
Consultthepatient’sbeta-blockerprescriberinthecontextofprogressiveglaucomadamagewith“good”IOPcontrol.AmJOphthalmol2013;155:843–851.
PrimaryOBFcomponent• Riskfactors(RF)for
atherosclerosisarelargelyparalleltoincreasedIOP– age– smoking– dyslipidemia– systemichypertension– malesex– obesity
Flammer J, Mozaffariaeh M. What is the present pathogenetic concept of glaucomatous optic neuropathy? 2007. Surv Ohthalmol 52: S162-173.
PrimaryOBFcomponent• Riskfactors(RF)for
atherosclerosisarelargelyparalleltoincreasedIOP– age– smoking– dyslipidemia– systemichypertension– malesex– obesity
• ThereforereducingtheseRFreducesIOP(slightly)– physicalexercise– weightloss– treatmentofdyslipidemia
• AndmayincreasebloodflowandaqueousoutflowthroughtheTM
Flammer J, Mozaffariaeh M. What is the present pathogenetic concept of glaucomatous optic neuropathy? 2007. Surv Ohthalmol 52: S162-173.
• GlaucomatousdiscandfieldchangeswithIOPconsistently<22
20%ofnewlydiagnosedglaucomapatientshaveIOP<21mmHgatpresentation
• CAUSE??Decreasedperfusionofdisc(arteriosclerosis,lowBP)
‘NormalTensionGlaucoma?’
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Recentevidence...
‘NormalTensionGlaucoma’
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Recentevidence...
‘NormalTensionGlaucoma’
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Perfusion
Pressure Blood Pressure
IOP
Lower Diastolic, Systolic, or
Mean Pressure Reduces Perfusion
Pressure
Higher IOP
Negatively Impacts Perfusion Pressure
Perfusion Pressure Is a Result of
A Delicate Balance Between IOP
and Blood Pressure
Lower Perfusion Pressure Is Associated with Increased Risk for
Open Angle Glaucoma Leske MC, et al. Ophthalmology 2007; 114,: 1965-72 Leske MC, et al. Ophthalmology 2008;115, 65-93. Hayreh SS. Trans Am Acad Ophthalmol 1974;78:240-54
OcularPerfusionPressure&GlaucomaProgression POAG Risk Factors 9-year BES
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Leske MC, Wu SY, Hennis A, Honkanen R, Nemesure B; BESs Study Group. Risk factors for incident open-angle glaucoma: the Barbados Eye Studies. Ophthalmology. 2008 ; 115: 85-93.
mean perfusion pressure = 2/3(mean arterial pressure) - IOP Where mean arterial pressure = diastolic BP + 1/3 (systolic BP – diastolic BP)
PerfusiontotheONH• DOPP(Diastolicocularperfusionpressure) =DBP–IOP
(Whatisthenumber?)
<40issignificant*-talktothePCP)
– ReducedinPOAG
Alternatively,meanperfusionpressure
*LeskeMC,WuSY,HennisA,HonkanenR,NemesureB;BESsStudyGroup.Riskfactorsforincidentopen-angleglaucoma:theBarbadosEyeStudies.Ophthalmology.2008;115:85-93.
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PerfusiontotheONH
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ExamplecomparingDOPPandmeanOPP120/80IOP=20;DOPP=60[80-20]WhatIOPdowemeasure?diastolic
Significantdifference Whichtouse???
MOPP=2/3[DBP=1/3(SBP-DBP)-IOP2/3[80+1/3(40)]–20resultsin42
2014(monkeys)
RecentassociationbetweenBP/OPPandstructuralglaucomaprogression
• Twogreatestriskfactors– Olderage– LowerdiastolicBP
• Structuralelementsassessed–ONH(rimtissue),RNFLthickness.
McGlynnMM,ErlichJR,MarlowED,etal.Associationofbloodandocularperfusionpressurewithstructuralglaucomatousprogressiionbyflickerchronoscopy.BrJOphthalmol2013.PublishedonlineSeptember24,2013
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EmergingimportanceofdiastolicBP
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• LowmeandiastolicBPisconsistentlyassociatedwithstructuralglaucomaprogression(Rimtissue,RNFL)
McGlynnMM,ErlichJR,MarlowED,etal.Associationofbloodandocularperfusionpressurewithstructuralprogressioninglaucomaasmeasuredbyflickerchronoscopy.BrJOphthalmol.2013.
*Significantlylowerdiastolicperfusionpressurewasobservedinthosetakingoralhypotensivemedications(asinbeta-blockers)
2013,
CurrentOpinioninPharmacology2013,13:36–42www.sciencedirect
2013,
Modelofprimary&secondaryinsultsinglaucomaduetolowOPP
Influencesofabnormalautoregulationinglaucoma(proposedscheme)
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Contributingfactorstoabnormalneurovascularcouplinginglaucoma Conclusionsfromprevious
2014
So,whichismoreimportant,loweredBPorelevatedIOP?
Conclusions• Theresultsshowthatopticnerveheadbloodflowismoresusceptibletoanocularperfusionpressuredecreaseinducedbyloweringthebloodpressurecomparedwiththatinducedbyincreasingtheintraocularpressure.
• Thisbloodflowautoregulationcapacityvulnerabilitytolowbloodpressuremayprovideexperimentalevidencerelatedtothehemodynamicpathophysiologyinglaucoma.
2014
NOCTURNALHYPOPERFUSIONASAGLAUCOMARISKFACTOR
2014
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Conclusionsandguidance
• Inconclusion,themagnitudeanddurationofnocturnalhypotensionidentifypatientswithNTGwhohaveVFprogression.
• AmbulatorymonitoringofsystemicBPshouldbecomepartofroutineassessmentofpatientswithNTG,particularlyamongthosewhocontinuetoprogressdespiteIOPlowering.
Conclusionsandguidance
• NocturnalBPshouldbeconsideredamodifiableriskfactorinNTG.
• RandomizedtrialswillberequiredtoassesstheefficacyofdifferentinterventionsdesignedtoavoidnocturnalhypotensiontopreventVFlossinpatientswithNTG,aswellastotesttheeffectofmoreaggressiveIOP-loweringtherapyinthesecases.
ConclusionsandGuidance
• BloodflowmeasurementscouldguidechangesintreatmentprotocolwithemphasisonnormalizationofcirculatoryalterationratherthanjustIOP.
*RecentassociationbetweennocturnalBPdipsandODHinNTG
KwonJ,LeeJ,ChoiJ,JeongD,KookMS.AssociationBetweenNocturnalBloodPressureDipsandOpticDiscHemorrhageinPatientsWithNormal-TensionGlaucoma.AmJOphthalmol.2017Apr;176:87-101.doi:10.1016/j.ajo.2017.01.002.Epub2017Jan12.
over-dippers=progressors
*RecentassociationbetweennocturnalBPdipsandODHinNTG
KwonJ,LeeJ,ChoiJ,JeongD,KookMS.AssociationBetweenNocturnalBloodPressureDipsandOpticDiscHemorrhageinPatientsWithNormal-TensionGlaucoma.AmJOphthalmol.2017Apr;176:87-101.doi:10.1016/j.ajo.2017.01.002.Epub2017Jan12.
è
over-dippers=progressors
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Reducedperfusion-MoreRiskfactors
• Autoregulationdisturbances• VasospasticDisorder• Migraine• Increasedresistance
• ✔Reducedbloodflow(20lowBP)→Nocturnalhypoperfusion
• Sleepapneasyndrome85
SASandNormalTensionGlaucoma• 50sleepapneapatientswerecomparedwith40normals
• PrevalenceofNTGamongSASptswas5.9%(and0%amongthecontrols)
• SeverityofSASwascorrelatedpositivelywith[structuralandfunctionalelements]– IOP– MD– C/D– meanNFLthickness(HRTII)
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Sergi M, Salerno DE, Rizzi M, et al.. Prevalence of Normal Tension Glaucoma in Obstructive Sleep Apnea
Syndrome Patients. J Glaucoma. 2007; 16: 42-46.
SAS–Glaucomaconnection(additionalevidence)
� Theprevalenceofglaucomainpatientswithobstructivesleepapneaisanestimated27%!
BendelRE,etal.Prevalenceofglaucomainpatientswithobstructivesleepapnoea-across-
sectionalcase-series.Eye.2007.
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OcularbloodflowandObstructiveSleepApneaSyndrome(OSAS)
• 31patientswithprovenOSAS/25controls
• 12.4%ofOSASandnoneofthecontrolswerediagnosedwithglaucoma
• NodifferencesinretinalcirculationmeasuresorIOP(implyingIOP-independentrisks)
• PositivecorrelationbetweenMDandLV&retinalcirculatorymeasures
Karakucuk S, et al. Ocular blood flow in patients with obstructive sleep apnea. Graefes Arch Clin Exp Ophthalmol. 2008; 246: 129-134.
SAS–Glaucomaconnection(furtherevidence)
� InpatientswithOSAS,ahighprevalenceofglaucomawasfound.
� VisualfielddefectsmaybeduetoopticnerveperfusiondefectsandthesefielddefectsalsoincreaseastheRI(resistanceindex)increases.
KarakucukS,etal.Ocularbloodflowinpatientswithobstructivesleepapneasyndrome(OSAS).GraefesArchClinExpOphthalmol.2008Jan;246:129-34.
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And,morerecentlyraisedquestions...
• ShouldOSAHSbeincludedintheDDxofglaucoma?
• IsOSAHSanotherglaucomaoracontributor?
• DoesloweringIOPinOSAHSarresttheprogressionofopticneuropathy?
LinPW,FriedmanM,LinHC,ChangHW,PulverTM,ChinCH.Decreasedretinalnervefiberlayerthicknessinpatientswithobstructivesleepapnea/hypopneasyndrome.GraefesArchClinExpOphthalmol.2011Apr;249(4):585-93.Epub2010Oct19.
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Glaucoma - Glaucoma + Total Apnea - 64,825
(95.0%) 3,410 (5.0%) 68,236
Apnea + 2,497 (91.6%) 228
(8.4%) 2725
Total 67,322 3,638 70,960 Limitations and confounders * Boyle-WalkerM,SemesLP,ClayOJ,FuhrP,LiuL.SleepApneaSyndromeRepresentsaRiskforGlaucomainaVeterans’AffairsPopulation.ISRNOphthalmology.Volume2011,doi:10.5402/2011/920767.
“Fairandbalanced”
• FoundthatthereISarelationshipbetweenIIHandAIONandthoseusingaC-PAPbutnotbetweenglaucomaandC-PAPuse.
SteinJD,etal.TheAssociationbetweenGlaucomatousandOtherCausesofOpticNeuropathyandSleepApnea.AmJOphthalmol.2011Aug17.[Epubaheadofprint]
2013,
And,theverylatest!
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And,theverylatest! Howshouldglaucomabemanagedcomprehensively?
• First,lowerIOP
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Newdirectionsinglaucomatreatment
• Yes,treatment• BeyondIOPreduction,regulationofbloodflow...– Systemically(regulatingbloodpressureandmonitoringperfusionpressure)
– Locally–endothelial-cellactivitybymodulatingNitricOxide(NO)ThisistheNEXTBIGTHING!
• Regulationofaqueousdynamicsatthetrabecularmeshworkbyvascularmodulation
• Inaddition,theapplicationofNO-donatingcompoundsfortheloweringofIOPdirectly
AsofNov.2,2017...
Future options for medical management – targeting the site of glaucoma, the TM
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¨ latanoprostene bunod (a nitric oxide-donating compound, NO) Vyzulta (Valeant)
¨ FDA-approved November 2017
¨ MOAs: ¤ relax the cellular matrix of the TM (and perhaps more
distally) ¤ may also act at the endothelium of TM blood vessels to
constrict and therefore further open drainage pathways.
Future options for medical management – targeting the site of glaucoma, the TM
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¨ Rho-kinase inhibitors (Rhopressa and Roclatan, (netarsudil/latanoprost ophthalmic solution) 0.02%/0.005%, Aerie) ¤ FDA-approved December 2017
¨ MOAs ¤ increase fluid outflow through the trabecular meshwork, (10
drainage) ¤ increase fluid outflow through the uveoscleral pathway, (20
drainage) ¤ reduce fluid production in the eye, and ¤ reduce episcleral venous pressure (EVP).
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How should glaucoma be managed comprehensively?
¨ Second, consider increasing perfusion (may be a consequence of lowered IOP) ¤ Topical treatments? (betaxolol, brimonidine, brinzolamide,
¤ Gingko Biloba and other CAM interventions ¤ Exercise, weight loss ¤ Lower cholesterol, blood sugar levels ¤ Treat underlying vascular disorders (HT, SAS, CVD) ¤ Etc.
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Anti-oxidant/Supplement formulation 110
HarrisA,GrossJ,MooreN,etal.Theeffectsofantioxidantsonocularbloodflowinpatientswithglaucoma.ActaOphthalmol.2017Aug3.doi:10.1111/aos.13530.[Epubaheadofprint]
Study design 111
¨ 45 patients with confirmed glaucoma on IOP-lowering treatment (placebo controlled, X-over)
¨ Baseline and post-administration (@ 1 month) measurements ¤ IOP ¤ OPP ¤ Retrobulbar (ultrasound) and retinal capillary (Doppler)
blood flow
Results 112
¨ Increased peak systolic and/or end diastolic velocities among the active group (but not placebo)
¨ Reduced vascular resistance in central retinal and short posterior ciliary arteries
¨ Increased superior and inferior temporal retinal artery mean blood flow
¨ Enhanced retinal capillary density
SO, what were they given? 113
SO, what were they given? 114
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Howshouldglaucomabemanagedcomprehensively?
• Third,reduceoxidativestress(Ca++blockade[BUT,notsystemicβ-blockers],supplements)ANDenhancebloodflow!
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NON-SELECTIVEBeta-blockers:Significantadditionalprecaution
Topicalβ-blockersadministeredatnighttothosetakingsystemicβ-blockersmayreduceperfusiontotheONHplusβ-blockertherapytoreduceIOPisineffectiveatnight.
Whichbringsusto...
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Hayreh SS. Effect of nocturnal blood pressure reduction on retrobulbar hemodynamics in glaucoma. Graefes Arch Clin Exp Ophthalmol. 2002; 240: 867-8.
2013, 2013,
Considerthis:
• IsglaucomaAIONthathappensoveralifetime?•
OR• IsAIONglaucomathathappensovernight?
LiuC-H,etal.ComparisonoftheRetinalMicrovascularDensityBetweenOAGandnAION.IOVS.2017;58:3350–3356.DOI:10.1167/iovs.17-22021
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62WM
• Complainedofvisionlosssuperiorlyinthelefteye(May,2018)
• VA20/20OD,OS;(L)RAPD2+;IOP11,9mmHg.• Seenbyprimary-careOD– Dx=NTG,initiatedonlatanoprostqhs.
_____________________________________• Sentforconsultation/SLTduetosignificantVFdepressions.(June2018)
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CONTINUOUSIOPMEASUREMENT
Theholygrailofglaucomawhetheritisdiagnosisormanagementis...
Closingthoughts
• How can IOP (and BP) be monitored continuously?
• What impact may this have on management?
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