SHARING BEST PRACTICES IN EYE CARE - PowerPoint Presentation

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SHARING BEST PRACTICES IN EYE CARE BETWEEN UGANDA AND THE UK

A FOCUS ON

GLAUCOMA

BY: TINDYEBWA

LUDOVICA K

AN OVERVIEW OF GLAUCOMA MANAGEMENT IN UGANDA.

INTRODUCTION

Glaucoma is the 3

rd

cause of blindness in Uganda contributing approx. 6 %.

In Uganda, Glaucoma is managed by General

Ophthalmolgists

who are distributed in 20 hospitals (10

G

overnment,

10

private )

, 12 of which are located in Kampala. We also have OCOs who help us with screening both at District hospitals and in specialized eye clinics. They times initiate RX before referring to ophthalmologists.

-We do not have Glaucoma subspecialists.

- We do not have glaucoma specialized nurses.

In terms of Equipment, most hospitals can do

slitlamp

biomicroscopy,

applanation

tonometry, a few hospitals use Pulse air and some still use

schiotz

tonometers

.

Very few hospitals have Visual field machines, OCT and fundus cameras.

Case finding

Most patients walk in hospitals because of poor vision, loss of vision , pain or looking for reading glasses.

Very few people are found during routine eye checks.

Referrals from units run by OCOs and optometrists .

Referrals from eye care community outreach

programs

.

Referrals from fellow ophthalmologists.

2.TYPES OF GLUCOMA IN UGANDA and the common presentation.

1 . CONGENITAL

GLAUCOMA ( both with and without anterior segment abnormalities ) These usually present in

infancy .

Pts

are brought in by caretakers/ parents for a bupthalmos or cloudy corneas and photophobia.

2 . OPEN

ANGLE GLAUCOMA

:

Primary OAG: This is the commonest type of glaucoma we see. They present with poor vision, loss of vision or difficulties in

reading . Some times found accidentally during fundoscopy.

Secondary OAG ( commonly due to trauma, uveitis,

pseudoexfoliation

and corticosteroids

).

Pts

present with poor vision with or without painful red eyes depending on the cause.

3 .ANGLE

CLOSURE GLAUCOMA :

--Primary

acute angle closure is rare. They come in

with headache, severe eye

pain and

bLurring

or

rapid loss

of vision

. Eye exam findings are very high IOP, Corneal edema with mid

dialated

pupils and normal optic discs .

-

chronic angle closure is commoner and they present H/O of haloes around light and blurring of vision at night and early in the morning ( awake in dim light) and then diminishing vision

. Usually you find optic disc cupping with normal IOP and

Gonioscopy

shows a shallow angle and areas of evidence of

synechia

--Secondary angle closure commonly to dislocated natural lens esp. after eye trauma .

4 . NEOVASCULAR

GLAUCOMA

usually

associated with retinal

neovascular

diseases like

PDR, and Retinal vein occlusions.

Case finding

Walk ins to hospitals because of pain, poor , loss of vision or difficulties in reading or replacement of glasses

.

Cases found on routine fundoscopy during eye exams.

Referrals by OCOs or medical ophthalmologists, optometrists.

Screened cases from community outreach

programmes

.

Babies are brought in by parents for abnormal eyes.

Patient management

Diagnosis

History-

pt

complaints sometimes give a clue to the type of glaucoma

Exam :- visual acuity (VA)

-Intraocular pressure (IOP

). May or may not be raised in OAG, but always very high in acute angle closure.

-slit lamp biomicroscopy for both anterior and posterior segments

. Corneal edema is common in acute Angle closure and NVG due to very high IOP.

-Optic Nerve disc changes are usually not present in acute angle glaucoma but disc cupping is diagnostic in OAG

- Documentation of

the optic nerve usually by vertical C:D > 0.5 ,ratio, cup depth, visible lamina

cribrosa,notches

, disc hemorrhages,

bayonating

vessels, and inequalities in the C:D of the two eyes.

ct

Open angle glaucoma and chronic angle closure are diagnosed on optic nerve damage

(cupping)

Other glaucoma investigations/documentation methods now available in few facilities :

-visual field tests in cases where the optic disc appearance is inconclusive but also to serve as a baseline for monitoring glaucoma progression.

-OCT of the optic nerve. We take the vertical C: D

. > 0.5.

- Fundus photography

A high IOP is a very important

finding

and may be the cause of the optic nerve damage.

Gonioscopy

to determine the angle

c

haracteristics

and distinguish between OAG and Chronic angle closure.

Open Angle Glaucoma Treatment .

The

degree of optic damage (cupping ) determines the TARGET) IOP, which is presumed safe in minimizing further damage.

A

s

a

guideline

C:D 0.8 TO 1.0 , we target 15mmhg and less,

C:D

0.6 to 0.7 target 18 and less,

0.5 and better 18-21

mmhg

.

Then go back to the IOP, because it’s the only treatable factor. Depending on how high the IOP is , we choose the drugs / drug combinations that will push the IOP to the target.( using the IOP lowering effect, and C/Indications.)

Surgery here is not attractive to patients, so we initially start with medical Rx , do cancelling ,

and

finally most

patients accept and

get glaucoma

surgery,

especially those who fail to reach targeted IOP, defaulters on follow ups, those who find drugs expensive and co existing cataracts.

Currently available drugs are the : alpha agonists, beta adrenergic blockers, prostaglandin analogues and carbonic anhydrase inhibitors.

GLAUCOMA SURGICAL PROCEDURE depend on the choice of the surgeon as per individual success rates. The commonest procedure

here

is a

trabeculectomy

with 5 FU or

mitomycin

C.

Some

people do them with multiple scleral flaps. Also combined procedure with cataract operations are

commonly

done.

Some units are

doing laser

trabeculoplasty

.

Treatment of angle closure Glaucoma

Rx of Acute cases with high IOP depend on what is available to the Doctor. we IV

mannitol

if available to rapidly reduce the IOP. If not available, then Acetazolamide orally. When the IOP is reduced, we use 2 %

pilocarpine

eye drops to open the angle and later do a PERIPHERAL IRIDECTOMY ( YAG or surgical) depending on the facility.

If the high IOP was due to lens displacement, then arrange for lens removal ( cataract surgery).

If chronic angle closure without peripheral

synechia

, do PI, but if there is

synechia

, do

trabeculectomy

.

Treatment of Neovascular glaucoma

Usually the IOP is very high

We initially use Acetazolamide to reduce the IOP and topical

antiglaucomas

which suppress aqueous production. Where

avastin

is available , its given to reduce

Rubeiosis

and ultimately do a

trabeculectomy

or glaucoma drainage implant( few cases).

Where possible PRP is done to induce regression of

rubeiosis

.

The long term results of a

trabeculectomy

are not good esp. if

rubeiosis

is not handled.

Management of Congenital glaucoma

We do Exam under General

anaesthesia

(EUA)

Take IOP using

schiotz

or

tonopens

Measure corneal diameters

Do fundoscopy

Documentation.

Post EUA, we control IOP with topical

antiglaucoma

, usually beta blockers and plan for glaucoma surgery.

Common surgery here is

trabeculectomy

. Some people do

goniotomy

IOP monitoring is done regularly and for long .

In some cases even after surgery

antiglaucoma

are

ctd

depending on the IOP AND at times,

trabs

are repeated.

CTDIn summary Glaucoma management is controlling the Intraocular pressure to the level of minimizing or preventing visual loss.

Although , there are general principles of management ,the clinician makes intervention decisions as per individual case.

THANK YOU FOR YOUR PARTICIPATION.