New Technologies in Glaucoma Management

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arl Zeiss Meditec, Inc Cirrus 6.0 Speaker Slide Set CIR.3992 Rev B 01/20127Carl Zeiss Meditec, Inc Cirrus 6.0 Speaker Slide Set CIR.3992 Rev B 01/20128EFC#;3C(!$0C3C(G8&A83440&2(52#"6404(H!G5IJ(3%4")5) 3%4")6)*5GKLM(E+KN*9.5+KO+!(.PN(QG.O7(+N*=N(O+(!-5E7QR5(9*5GKS(NSF#2C3C(G$F0"(K0#A2&4;0%4(*3"#;0T3(5::3832;(G$F0""#86(K3:3%;(•! Relative•! Afferent•! Pupillary•! Defect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ounis AA, Eggenberger ER. Correlation of Relative Afferent Pupillary Defect and Retinal Nerve Fiber Layer Loss in Unilateral orAsymmetric Demyelinating Optic Neuropathy. Investigative Ophthalmology and Visual Science. August 2010, Vol. 51: 4013-4016.2

9/22/13((N63(K043#434(;/#;('#6("3#C(;&(#(*5GK(!! 89%:+,7%]'VI"-'()/%1)'12#%+/0#'#W"+($'D/()'"3"$J'*.'()"'4*$"#$"'*$'0/&"'$"I"&"'*-'/-"'"3"J''''''#'FM=O'0#3'D"'4"("+("4)!! ;"$&'%9)

9/22/13((*5GKS(G$F0""#86(.34;02A()(-#;32%6(( !&"C'#22(5FF"#2#;0&2(!! L)"'8/24'$(#-4#&4'*-'#"..:#")-:")$,)&'+#"%."-)+"'$#%9)+,#'"%9)$B&+C'"../)8&#"."$'M&+)'92*-'V65'Q5)()#20/2E'B```'!#&e?Zf7Z>]??@Ng'd! gC'QRLG'$%DX"+($'N'A`?;PNZ`'d! bZ'5#(*"-($'K*()'=QM8'AZb;PNZg'd! B@b'-/&0#2'$%DX"+($'AgA;PNZZ'd! ';"9%$&,'.B&>)D"$E""')+,#'"%9)$B&+C'"..)%'-)7"%.:#"-)&'$#%,+:9%#)>#"..:#")&')%)4"'"#%9),>B$B%97,9,4()+9&'&+/'Q5)()#20/2/13E'B```'G/IeB@b7BB>]?BAgNb@'d! ?Z?'QRLG'$%DX"+($'c'Af`EA'd! ZZA'5#(*"-($'K*()'=QM8'AA@EB'd! ?ZA'-/&0#2'$%DX"+($'AgA;PNZZ'd! A?'G/&0#2N("-$*/-'12#%+/0#'ABg'Mean CCT 573.0 +/- 39.0 !m24% had a central corneal thickness > 600 µmCCT for African Americans subjects(555.7 +/- 40.0) was 23 !m thinner than for whitesubjects (579.0 +/- 37.0) - P < 0.0001Other factors associated with greater mean centralcorneal thickness were younger age, femalegender, and diabetes.77.(#4(#(8041(:#%;&8(02(F#;032;4(

9/22/13ORA Signal AnalysisThe ORA optical system records400 data samples of reflected IRlight intensity during the rapid(30 ms) in/out cornealdeformation.The optical signal (red curve) isa dynamic map of the corneaduring the rapid in/outdeformation.The signal provides additional information about cornealbiomechanical properties, revealing signature characteristics ofthe eye being measured.Applanation Detection IIR Light EmitterUndisturbedCorneaAir tubeIR Light DetectorApplanation Detection IIApplanation Detection IIIApplanatedCorneaAir-JetAir-JetCorneal ConcavityApplanation Detection IVApplanation Signal Plot! Signal PlotApplanatedCorneaAir-Jet5

9/22/137&823#"(P64;383404(Corneal HysteresisIdentified by David Luce, Ph.D., CornealHysteresis is the difference in the inward andoutward pressure values obtained during thedynamic bi-directional applanation processemployed in the Ocular Response Analyzer, as aresult of viscous damping in the cornea.CH: P1 - P2Corneal Resistance FactorAn indicator of the overall resistance of the cornea,including both the viscous and elastic properties. It issignificantly correlated with Central Corneal Thickness(CCT) and GAT, as one might expect, but not with IOPCC.•!CRF = P1-(0.7*P2)Corneal-Compensated IOP (IOPCC)CCT vs. CH - 184 normal eyes- An Intraocular Pressure measurement that is less affected bycorneal properties than other methods of tonometery, such asGoldmann (GAT). IOPCC has essentially zero correlation withCCT in normal eyes and stays relatively constant post-LASIK.- IOPcc = P2 - (0.43*P1)Data courtesy New England College of Optometry!"#$%#&'()*+,-"+.%-+/&0)112)!"#$%#&'()*+,-"+.%-+/&0)112)60%60%50%50%40%40%30%30%20%20%10%10%0%400 480 560 640 7200%400 480 560 640 720CCT (Normal)CCT (Normal) CCT (HTG) CCT (NTG)C. E. Fraser, et al. ARVO, 2010.C. E. Fraser, et al. ARVO, 2010.6

9/22/13%;G=@?E?L>;@$H=;$A>9L@?8 visual fields,followed for > 5 years6=?H?LC9O=$!! Progressing eyes (n=25) had lower CCT (525 vs542, P=0.04) and lower CH (7.5 mmHg vs 9.0mmHg), P9L@?;@$H=;$A>9L@?@L$)9$/3$&??^$573$*C;;@_;EM$A,$9@M$-M`9@G;M$+:9L>@L$>@$*E9FG?:9$,HFMI$*C?FO8$%=;$+:O9GH$?N$5;H9CM9@G;$69P;C@$a9C>9R>E>HI$?@$!;C`;$B>R;C$)9I;C$/;9H=$a9C>9RE;$9@M$"@=9@G;M$&?C@;9E$&?:O;@?QR>?:;M>G9EQ>@HC9?GFE9CgOC;

9/22/138%;G=@?E?L>;@$H=;$A>9L@?HL;R3$58$-8$[WTSW\3$';9CHgR;9HgO=90$ST8STTWQJR>?8WTSWTTTWV$=NG(02(!"#$%&'#(69P;C@$"E;GHC?C;D@?LC9:$Q$a>M;:>?E8$WTTS$A;GcX[Z\0WVkgUTk8$%;G=@?E?L>;@$H=;$A>9L@?p:9@$%3$6FE>9_H?$&-3$BFJ>:?H?$7*3$,]9@

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9/22/13Visante OCT Anterior Segment Imaging andBiometryProblems with traditional Gel& Shell examination method•! Worry about probe tip hittingthe cornea•! Probe sterility issues•! Methodology concerns–! Patient must recline–! Gel often required–! Shell must be inserted under thelids and (uncomfortable)–! Likelihood of corneal abrasionsfrom shell as posteriorstructures are examinedMethodology!! Fill bag ! with tap waterMethodology (Preferred)Patient can be examined sitting (ocular structures &dynamics same when viewed with slit lamp)!! Add water slowly tominimize air bubbles!! LIN50 – USE DISTILLEDWATERClinical ApplicationsGlaucoma(lights off exam)Occluded angleGlaucoma© Dr T. C. Prager, University of Texas, Houston, USA1 0

9/22/13PhakomorphicPhakomorphicBulky ciliary body in phakomorphic angle closure© Dr P. Good, Midland Eye Center, Birmingham, UK© Dr P. Good, Midland Eye Center, Birmingham, UKConvex irisin pupil blockPupil Blockbefore and after YAG laser© Dr P. Good, Midland Eye Center, Birmingham, UK© Dr P. Good, Midland Eye Center, Birmingham, UKBefore© Dr P. Good, Midland Eye Center, Birmingham, UKAfterPlateau irisCyst© Dr Satger, Grenoble Hospital, Grenoble, Fr© Dr Pegourié, Grenoble Hospital, Grenoble, Fr1 1

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