welcome to all our participants today’s topic is glaucoma sneak eve of sac the objectives of today’s webinar are number one to be able to define the former number two to understand the key differences between Catherine de palma number 31 understand the basic pathophysiology of the coma number 4 to identify the risk factors for glaucoma number 5 to recognize the signs and symptoms of glaucoma number six identify the major types of glaucoma number seven to identify the key diagnostic procedures needed to diagnose well coma and number eight to identify the options available the management of lip balm today’s speaker is dr. Maria Imelda yeah bellossom she is a magna laude graduate of biology at you Bill de Lima she finished her medical school and residency training in the homology the University of the Philippines College of Medicine Philippine General Hospital she completed her glaucoma calico fellowship at the harvard medical school Massachusetts Eye and Ear Infirmary Boston Massachusetts ophthalmic consultants of Boston this was followed by a post-doctoral research fellowship at the Harvard Medical School shipments I Research Institute dr. bill also is a past president of the flipping welcome society and she is the director of the Welcome service at the Asian I Institute party city philippines she is a clinical associate professor at the University of the Philippines college of medicine and consultant of the glucometer this seller of Don Maloney co of sailing sila Philippine General Hospital a present she’s chief of the local service of the South medical center without further ado we will now call out on the floor on pillows thank you so much magma that kind introduction and for this afternoon i’ll be talking about glaucoma a sneak thief or say romo is a group what diseases that damages the optic nerve were increasing in chocolate pressure or iop is a major diss factor now this damage to the optic nerve leads to irreversible visual field defects and eventually blindness even control now the main structure that’s damaged in the coma is cranial nerve two or the optic nerve the optic nerve serves as a cable that transmits the images we see to the brain now there are two major theories and how your coma causes damage to the optic nerve from the high instructor pressure and the first theory is the mechanical theory were there a compression of the nerve tissue from the high pressure results in depth of the ganglion cells the other theory the vascular theory postulates that the intramural ischemia results from the key results resulting from the crease optic nerve perfusion is a fleece equally of the compromise blood supply due to high pressure now this damage to the optic nerve causes blind spots or visual field defects and what is unique about glaucoma is it does not affect X central vision first it affects the peripheral vision and that’s why it’s actually dr. sleep deep of sight because it can go undetected until the optic nerve and the visual fields are significantly damaged now this is just an example of a visual field print out from normal to an advanced age of obama just to show you what happens to the visual field in the coma so first you start out with a normal field em on top and then you are the next photo you are develop a subtle peripheral visual field defects and this becomes deeper and denser encroaching on the mid peripheral field and in the advanced stage you’re left with essential tunnel vision and this may eventually lead to blindness or total darkness in its uncontrolled now nobody nakoma effects 60 to 70 million people worldwide it is responsible for twelve percent of global blameless and it is currently the leading cause of irreversible blindness yes unfortunately in the Philippines we don’t have local statistics yet and we are currently working on this care of the Philippine become a society now to understand what happens in before all you have to first know how the normal drainage system in the eye works and

just to orient you ah this the front part is the pointer the front part the cursor is the cornea and the lens is in the middle and the scenery body of the I produces a fluid and this is actually the access you more which continually beats the eye and this drains to a space which is actually the elbow I was just looking for a closer so I can show it yeah there and that space is actually the angle formed by the cornea and the iris here and after it passes to the angle it didn’t sell to the trabecular meshwork or the vast endovascular channels now to see it once again in another diagram let’s trace it let’s follow the the red arrow so from the ciliary body it also on to the pupil fastest to this space which is anterior chamber angle this is important because this space the angle is how the water access the drainage system which is a trabecular meshwork and outward to emerge the vascular channels so if we were to make an analogy of the normal drainage system in the eye you can look at the open faucet with the water flowing through the sea and if the drainage canal is open it was clearly out so this is how a normal drainage system in the I should also be now there are actually two major types of your coma if you base it on the angle status open angle which is the more common an angle closure glaucoma which is less common but more urgent so in opener angle glaucoma this is what happens the water passes through the from the sillier value to the pupil and it’s able to access the drainage system because that space or the axis angle to the drainage system is open however the block actually occurs in the drainage system itself so the flow is still not efficient out of the eye and if you use the same enough allergy again the water loads from the faucet to the same and actually is able to reach the drainage pipes because the access space or angle is open but the clog is actually in the drainage system itself so that to open angle glaucoma now in angle closure what happens is the fluid or a consumer can’t even reached the drainage system because the angle or the space that where you have access to the drainage system is actually completely closed so water doesn’t flow at all so if you use the same analogy once again the water flows from the faucet to the same but it isn’t able to reach the drainage site because of that mechanical obstruction from the clothes at angle now these are the two major types open angle and angle closure glaucoma but McCormick can be classified in many ways most of the glaucoma’s we will see become and adulthood usually after the age of 40 but there are some their forms like congenital glaucoma that comes in the early years of life and babies are born with a defective drainage canal and because the eyeballs tissues are still elastic at this age the increase in intraocular pressures touches the sclera enlarging the eyeball and even the cornea as you can see in this particular picture the left hand picture you have a large left eyeball this is a example of unilateral congenital glaucoma the left side now the next picture decided it is a patient with bilateral congenital glaucoma is ugly takes a longer time for the parents to refer this case because in the beginning all they see are unusually large attractive eyes in their child it’s only when other symptoms like peeling or hotel phobia and decreased vision develop that they begin they begin to note that there’s something wrong with your child now juvenile lipoma is also another type of lymphoma but it comes in a later childhood years to truly after three but before twenty years of age now we also have secondary forms of glaucoma I just want to give you some examples of this one is steroid-induced lipoma this is after the intake of steroids either already or after topical application and these are

very dependent on the dose as well as the duration of steroid usage there’s also traumatic mukoma which is a secondary form of lymphoma that comes after injuries I either blood traumas or penetrating eye injuries and you also have lens induced coma which are Yoko must have come from problems in the lens status like in hyper mature cataracts you can develop a secondary glaucoma or anticipated lenses you can also lead to secondary performers now the serving special mention it’s a type of lymphoma that some experts believe are a subtype open-angle glaucoma and this is normal tension glaucoma what makes normal tension before my you need is you deteriorate from glaucoma and there is progressive of optic nerve damage from pressure what the pressure is in the normal range so this is something that is actually different from the other types of lymphoma you will encounter now who are at risk for glaucoma so let’s talk about the risk factors now in me this earlier that the major diss factor is high intraocular pressure aside from this important this factor versus include age after the age of 40 the risk for glaucoma increases this more and more a family history of glaucoma African and Chinese ancestry nearsightedness farsightedness the use of steroids I trauma or surgery pinporn us and other systemic diseases now for the symptoms generally there are none and let me explain this in the open angle glaucoma mutually there are no symptoms in the early and moderate stages because there is a gradual increase in the pressure inside I so the eye is able to adapt to this increasing pressure now in angle closure glaucoma however especially in the pew forum there’s a sudden block 420 sure of the angle so that I cannot adjust to this high pressure that comes suddenly so there is blurring of vision I pain headache nausea and vomiting and because of a swollen corner from high pressure rainbow colored pillows around lights now this is just an example of a patient that descends with acute angle closure glaucoma here you have a red pimple I and as I took this because the foreign is I’m swollen from the high pressure it’s hazy and you also have a mid related few bill because of a damaged I stinker from the high pressure now lucuma regular and complete I exam is recommended and it should be stressed the lipoma was cleaning the only checks pressure is not sufficient to the techno coma we’ve already mentioned that there is a special type of local muffled normal tension diploma or the pressure may be normal but patient deteriorates from laguna and this is the reason behind this particular statement now in the comprehensive eye examination we have to pay special attention to certain points in the examination that will help us diagnose lymphoma these are optic nerve examination which you can do to oakland lost puppy i pressure measurement that we is actually called anomaly and angle evaluation or the internal driven drainage evaluation which is called vinyasa p if any of these specific points in the examination are positive for the suspicion of glaucoma ancillary does like an optic nerve scan which is like a CT scan of the nerve tissue and visual fields which measure the peripheral vision should be done to confirm the diagnosis so we’ll be going to this dish one by one so for the optic nerve assessment we can either use our graph thermal scope to assess the optic nerve but most of homologous use the sleep lab with a 90 dr. lense to get the more serious topic view of the optic nerve now what we’re actually looking for an optic nerve assessment is the cup to this trade show and just to give you a diagram the cup is the pale area in the center of the disc and it’s also deleted by the bending of the blood vessels and patients are leave people to the former suspects when their top this ratios are point five or more the photograph on your right shoe of copying of about point 62.7 which makes this patient a glaucoma suspect it is another example the left-hand photo shows a normal optic nerve in the copying of about point three and photo on the right shows you an optic nerve compensation of about point seven listen I will look on already now this just tracks what

happens the optic nerve over time when the glaucoma is uncontrolled so first you start with a normal optic nerve be the caucus ratio of a point and three and over time it gets larger up especially the vertical cavity show and the third and fourth go to see I don’t have you can see the disk hemorrhage on the inferior nasal side these are actually warning this is actually a warning sign that the performance worsening if you see this hemorrhage and over time this enlarges and can sometimes literally the newer technology meeting so the other important thing localized anonymity here we measure the intraocular pressure and if you don’t have the diagnostic economic ters available an estimate of the pressure would be to do finger a location where we ask the patient to look down and using the second finger both hands yes I’m all danish navy press downwards if it’s soft that’s normal pressure usually and it’s like the tip of the nose and if it’s firm and it will be similar to like touching your forehead that’s high pressure lucky you now have the Phenom eaters available which are more accurate and actually the gold standard is the one that’s been shown here the golden echinacea thermometer where we have this conical instrument that condense the cornea and the force needed to indent the corner reflects the pressure inside I now the normal pressure ranges from 10 to the 21 and anything about 21 is considered abnormal now it has to be also emphasized that high pressure is the only table this fact we’re up to this point in time all current treatments are designed to lower eye pressure now who knows could be examines the internal drainage canal so it tells us whether we are dealing with an open angle or angle closure glaucoma just to give you an idea this is what we see in an eye angle that I using that lens in the lower court is the pew build iris and in the upper section is the cornea and if you look at the left hand side of the photo we have the ciliary body band and the trabecular meshwork the second pigmented band those are the angles structures with the skittles / that white van in between if you see those structures during your gallos copy then the angles are open as you move from left to right you see that is it’s appearing to the angle structures and you actually lose angle structures in the right hand side of the photograph this tells you that the angle is closes the right hand side of the photo now if one of your desert I mentioned a while ago is suspicious or glaucoma then we have to do some ancillary tests to confirm the diagnosis and one is the Oct nerd scan which measures the thickness of the nerve tissue this is the printout of the right hand side sorry go to the pointer but the left hand photo shows some red the red areas in the upper and lower quadrant of this circular print out and this denotes that there’s thinning significantly of the optic nerve in the superior and inferior quadrants well the right hand photo of the optic nerve it’s all green that means that the nerve tissue is within normal thickness so near the normal thickness now another important test that we use to confirm the diagnosis of glaucoma is perimetry or the visual field examination so it is a print out from the visual field in the upper right hand photo of this print ouch gives you the grayscale the dark areas correspond to the areas that the patient cannot see if you direct your attention to the right hand lower print out is a clustering of the black points here in the superior field confirms that there’s loss significantly in the superior field optician of the patient so the overall goal of treatment in glaucoma is to reduce eye pressure to target pressure so what is this target better target pressure is the pressure level at which no further glaucoma damage takes place and target pressure is different for patient because it depends on several important factors it depends on the one the baseline pressure of the eye it depends on the severity of your home or the stage if you’re in the severe or advanced stage we are more aggressive and getting a lower pressure also it also depends on other this

factors the patients may have it should be noted that target pressure is something that’s dynamic so we adjust it accordingly based on the patient’s response to treatment and on the stability of the patients that’s over time now the treatment of glaucoma follows a stepwise approach where we start with medical treatment first followed by laser treatment and surgical treatment after but just a point of emphasis in patients with angle closure glaucoma because the angles are damaged laser and surgical treatment they need to be done sooner so again for medical treatment this is our cruise line and we’re lucky now because in the last two and a half decades several classes of medications have been developed for glaucoma so we now have a lot of options to choose from and the medications available actually work two ways they may either in peace outflow move it from the eye or decrease the fluid production inside I now if medical treatment they also control glaucoma laser treatment is done and an example for open al google form of the laser we do a selective laser trabeculoplasty or a laser energy is directed to the drainage system will stretch the pores in the trabecular meshwork to allow more fluid to flow out for patients with angle closure glaucoma where are those at risk for angle-closure glaucoma or what we call narrow angles I leave circuited ectomy or bypass canal in the IRS is done and this is not enough sometimes another laser hopefully the plasti will report contraction burns these are the green spots light green spots on the beautiful part of the iris that we apply in order to pull the I days away from the angles it will try to open the angles of the patient now if medical and laser treatment fails and the next step is surgical treatment and the gold standard is cervical at the need for glaucoma field during surgery here we create a conduit that connects and your chamber to the subconjunctival space in order to bypass the damaged drainage system so the water passes from the deer chamber and we make an opening the steerer and then the water gains to under the conjunctiva in the Superior part of the eye now the main cause of failure in trabeculectomy scar tissue formation so if the trabeculectomy fails because scar tissue formation another option would be your glaucoma drainage devices or your tubes where you put an implant that connects the deer chamber with a subconscious level space to a plate where the fluid can drain out this is all also useful in patients that had previous surgeries and have a lot of scar tissue area now at this point I just want you to be more familiar with frequently asked questions from patients and friends and some entities that are currently linked to mukoma so one a common question we get from patients are what would be the major differences between a cataract and glaucoma so just again to review for the cataract the main structure affected is the normal crystalline lens that becomes cloudy well in glaucoma the main structure of affected as you mentioned earlier is the optic nerve or cranial nerve number two now for the vision or symptoms for local OMA although there are no symptoms in the early part of the disease it affects a peripheral vision so what it looks like is something like this when you have moderate to advance your coma you lose your peripheral vision for a patient that has a cataract the description of the visual loss is a generalized cloudy vision because you’re like looking through a window which is cloudy because of the cataract and third for the type of visual loss for the cataract it’s a reversible form of visual loss once you remove it and replace it with the intraocular lens implant you reverse the visual loss in a patient with a cataract in glaucoma however the visual loss is irreversible so you also have to keep in mind it meant Oklahoma is not curious it just controls the progression of the disease now the second entity that’s closely related also to the Obama and many patients also asked about it on the readings is caffeine it has been shown that I’m consuming large quantities of caffeine usually five cups of coffee a day can increase the pressure from one to four millimeters mercury from baseline but overall the studies still show that caffeine intake is not to shake it to the nucleus of glaucoma now

marijuana is another entity that is currently related to diploma because of the legalization of the use of marijuana in some states in the US and in other countries as well as studies that show that marijuana either taken orally or inhaled can lower the pressure for three to four hours rest in the lot of speculation and its use for glaucoma however the studies to show that there’s lack of evidence that its use can alter the forest of the disease the stand of the American Academy of Ophthalmology on the use of marijuana for glaucoma treatment is it’s not recommended because there are safer options such as medications that are available in faking shoes oh there are also activities that may be linked to an increase in pressure and one is a very popular exercise which is yoga it has been shown that certain positions in you booga unlike headstands and I think this is the downward-facing dog position can increase the pressure significantly so since studies are still ongoing recall all patients to the void his particular activities another philippe’s also weightlifting especially forensic the load is very heavy now to summarize lipoma is a group of eye diseases that damages the optic nerve where the major risk factor is an increased intraocular pressure and it should be emphasized that until this point in time intraocular pressure is the only treatable this factor for glaucoma to comprehensive eye examination with the necessary scenarios are essential in the diagnosis of lymphoma and because of certain forms like normal tension glaucoma there is no single diagnostic tests that can detect lymphoma 3 since we come across is permanent optic nerve damage Vishal loss is permanent but its notes treatment that can recover the vision that the sloths from glaucoma and treatment aims superserver every vision remains for regular follow-ups crucial since this is a lifelong disease and it is not cured but it can be controlled I’d like to end by saying nokomis this sneak deep of sight because it means to feel precious memories from you not of what was but what win is to come so early detection and management is key thank you thank you for that the insightful lecture dr. Yap villa we now have 83 log in to go go to webinar and 15 participants to live streaming we would like to thank today they sponsor Santa in our media partners the philippine daily inquirer and the filipino doctor before we received our Q&A portion let’s have one of our panelists if a reaction may I introduce our reactor dr. Neith dr. Marie Antoinette as an alpha squad dr. ethanol phosphonium is an Internet graduate the new clean College of Medicine she did her residency training in ophthalmology in a fellowship in cornea external diseases at the department of ophthalmology affiliate the film in general hospital and institute of offer more he’s a member of the board of salmon heirs of the Philippine border for homology she was a past chairman of the Department of Ophthalmology tunnel might need medical center and she is a she is a council member of the Philippine Academy watch it council member of the Philippine occasion have you been hadn’t you ophthalmology currently she’s an associate of real lecture the Department of Ophthalmology a fastening do something when you got College effect she is also an ophthalmology consultant at the hospital in Manila asian hospital I referral center and perryman at the character may we call a doctor ethanol SAS one thank you Gary for that kind introduction thank you for inviting me I like to say thank it to the my class and my music class named ricardo martinelli Villa and for being late so that is able to sing reading ok so my reaction basically to your lecture in my mail is just to point out the three key points at you that you also emphasized a senior lecturer first that optic nerve damage due to glaucoma is irreversible so when

the doctor catches you up a certain point whether it’s early middle moderate moderate or severe stage whatever damage has been inflicted on your optic nerve by the disease cannot be reversed anymore you can only at at the best stay the way you are and not get better in other words you the best for us doctors to do is to prevent further progression of the disease there for early detection really is the key in the treatment of glaucoma and that’s dr. Abela sayaka’s also young fellow so has emphasized most Obama is asymptomatic because the central vision that remains is usually good usually stay as 2020 except that the fields are narrow so the feeling louder and louder ok so the field are narrow but so um sometimes you have patients who just keep bumping on the Sun hides or they drive a car and they they keep sideswiping other cars no because the central vision really is maintained and in the vision just keeps contracting and contracting until one day only a tunnel remains then which is why most of the patients really are as symptomatic um this is why when I was past councilor of the Academy we came up with an information poster which we had a printed in several broad broad sheet snow and magazines on the mass knows about proper care and prevention of blindness and number 8 of the 10 is that certain blinding eye diseases like glaucoma have no signs or symptoms there for everyone everyone should consult with an awesome male chest once one reaches the age of 40 okay because again the Obama is mostly asymptomatic and it will take a doctor to look into the inside of your eye take a look at your optic nerve to tell if you are a suspect for glaucoma or not and to conduct further tests to definitely say if you have the disease or not so since this is mike in my last webinar i would just like to take the chance to point out the other points in this must knows about proper i care so first if you will allow me doctor barry thank you number one if you are a child bearing age as a woman you need to have yourself vaccinated against rubella before sit at least at least six months before you get pregnant because if you get rubella or German measles within the first Master of pregnancy you will get rubella syndrome here your infant will be born with congenital heart defects hearing defects and congenital cataracts also even sometimes if you’ve had rubella vaccinations as a child sometimes you really need to repeat the dose and because you’re not sure if that vaccine was um if you your body took the knock-back see the second point is children suspected of having errors of refraction those children who need eyeglasses should be brought to the eye doctor for refraction and screening for possible amblyopia so if your child watches TV too closely or squints when he’s looking for or has frequent headaches that might be a sign that the child needs glasses a child a school-age you need to have him or her refracted to prevent functional blindness or unglue yeah release my third point you should wear I’ll ultraviolet protected sunglasses and exposed to the Sun to prevent cataracts and age-related macular degeneration and to redo number four avoid over abuse and overuse of the eyes also don’t do activities like reading at the dark or breathing in a moving vehicle okay and then when you’re on the computer for a prolonged period of time you’re blinking decreases or

your eyes get dry so you need to rest periodically when you’re using the computer this is the number five is very very common sense avoid work and failing to hide injuries do not make your children play with pellet gun pellet guns or if they’re not old enough darts or even very very sharp pencils because we’ve seen or I’ll run around with barbecue steaks at the party because we’ve seen so many many injuries like this if you are a carpenter or you work around the house wear protective goggles because I cannot count the number of times I’ve seen foreign bodies male standard the eye because of carpentry work number six traditional practices like dropping herbal extracts breast milk and murine on the eyes which are still being done up to now may be harmful and must be abandoned if you need to drop something when your eyes to clean it you can wash it with clean water you know or use artificial tears but other than that if your eyes are red if you feel anything if you feel like it’s something’s wrong with your eyes best consultant ophthalmologist number seven if you bunch all black your blood pressure your blood sugar in your blood cholesterol you will have had eliminated at least fifty percent of all I illnesses because hypertensive retinopathy after austerity 30 nathi diabetic identity would have been avoided or prevented so this is also the same for your body just control your blood pressure blood sugar and blood cholesterol and you’ll be okay okay so um as we said as we have been repeating most the form is asymptomatic but in my practice as an ophthalmologist I’m not a dog on my specialism a–the when patients come to me with the following signs and symptoms are history I am very careful and try to look if there are suspects for go home so hey X of unexplained cause migraine not then Sean they just have the head dates at certain times of the day would be that assign that their pressures are increasing iridescent vision which cost which is forced by the corner and becoming getting noticed because of the pressure oh this is a you see it as halos around rainbows and you look at the life there’s a rainbow on it or a halo around it that can be a sign that your eye pressure is going up even if you don’t fit anything else family history of glaucoma I think the Torah my mother will agree if here there’s family history of glaucoma then you have to be really checked for it as well because this is one of the risk factors and then again that television because everything can disappear around now the periphery of the tradition can be contracting but the central is still okay so it’s like a tunnel and you keep bumping into things on the side so that’s a possibility that you have a job on okay so you need to go see an ophthalmologist if this in all of this if you have one of these even before the age of 40 but definitely when you reach the age of 40 and you need to start very reading glasses already anyway then go to an ophthalmologist at least once in your life to make sure you don’t have go home no problem is okay and this is the second part of my reaction this part is aimed for general practitioners and end this out there who are looking to serve them the countryside I study done by a resident of mine dr. Ajay Perez man on the geographic distribution of awesome algae in the Philippines for the year 2014 reviewed the main addresses of ophthalmologists throughout the countries throughout the country and found out that eighty-three percent of ophthalmologists are in Luzon and out of that fifty-three percent are in the national capital region only eight point three eight percent are in the visayas and only eight percent are in the know so you can imagine how mal distributed the ophthalmologists are throughout the country this these are the provinces in the Philippines without ophthalmology so

there’s botanas if you go Northern Samar follow Sulu sector and Annie’s and Wanda I used to go to Rome blowing but I didn’t stay the whole the whole time I would just go three or four days a week and then come back so that was not my main clinical it wasn’t really although I helped a lot of people it wasn’t really enough because if patients have an accident in the middle of the month they would still have to come to Manila and it’s very difficult you had to take a 10 hour boat ride to the Tongass and then take a two hour bus ride too many so they would rather wait five hours for the doctor in the clinic then takes somebody a member of their family their families behind leave but their livelihood and come to Manila okay for a fork and latching pay for the dock will pay for the food um just to be able to see an ophthalmologist know so you can imagine if if we at least serve these areas a lot of people wouldn’t boost their livelihood for that period of time that they’re having their checkup so for example my dog my daughter used to a joke me and tell me Mom why do you have to leave me I’m your daughter why do you have to give me I’m more important to you than your patience and then there was a point in time that I really had to find a way to explain to her so my way to explain is you miss me so much when i leave you imagine 50 mothers being missed by 50 daughters because they have to go with her husband to Manila to have their husbands check after that she was able to understand so so this is the place I used to go to this is the blast from blonde it’s located in the heart of the philippines right in the middle in some laps it’s not given there no it’s not even there it’s very hard to go teens it’s not really small but it is a population of around 200,000 plus um this is their equivalent to Manila Bay okay so and the beaches are so clean in that Bay they do the children use it to play around and they actually swim in it it’s not toxic that all day they really use it for on 44 family bonding spending time and I used to be both visible to the shore with my daughter when when should the rest of time should I could bring her already and she’d wait 10 hours at the clinic just touch this the sunset and we will get fish was made azizul that is a big thing for me at least I gave her memories didna but here’s the thing in that province they do not have cardiologists radiologists in the chronologies orthopedic surgeon we have meant neurosurgeons or gastroenterologist so patients who need dialysis you can just imagine they have to come to Manila every 15 days every week at the very least be able to have their dialysis done they don’t have a 2d echo there are so many patients there were posts Trudeau who do not have any rehab doctors to go to there there is no endoscopy units there so for those family physicians who are looking to serve the countryside and help others as well you can please funky their own blonde it’s also a vacation because the beaches are so beautiful so it’s like a monthly working vacation for you you can bring you can bring your wife it’s like a weekend date can do an endoscopy for all the patients needing it and then come home and you will be able to help the people there well you know it’s it’s like a part of all the more people put their hands in if the bigger it tools because I doctors that need to fulfill our our vocation of services is a being fulfilled so that’s it thank you thank you thank you for sex thank you very much going on for that or the special for the tips that you game about the Darrell I care and of course for highlighting the concerns of the mouth distribution of I care in the Philippines you actually have a comment actually I’m a comment that there’s a doctor that goes to this another moieties that goes to someone i

see cool guy ah when I monthly basis i think for fabrication so we didn’t put the name of the doctor but or graduate that person that’s true but um anyway we have a we both work at question answered so we’ll have there’s a question here are their medications that are contraindicated for glaucoma or contra I suppose they’re also asking there are medications that cause a track in boom okay for the medications that cause cataract and glaucoma steroids are number one of the year because they they both got cataract in tacoma now for medications to treat cataract we don’t usually give medications for cataract is there’s no medication but has been shown to help stop a third or smooth down a catnap so for glaucoma in terms of the complication content occasions for the use of the follow medications we have different classes to choose from but you also have a beta blocker class so just like any big of dr. content occasions would be asthma and heart problems like especially AV block sir paddock area most of the other eye drops though it’s more hypersensitivity more minor a dsi okay so um going back to the steroid it’s a common medication nowadays and does it really matter if it’s a when we say services oral steroids a relational you have any genetic component whether one is worse or both both can false platform I think both pull off post click on it really depends on the load of steroids you received it and also the duration um if it’s given like if it’s a topical application of the skin like just a small area I don’t think it’s going to make much fun put your risk for glaucoma but let’s say you first or I some patients they self medicate such a wonder drug that incident is it something you can use it after that and that’s when it starts when you keep using it in the duration because like more than two weeks there is becomes much more yeah so they’re so steroids by itself they’re not actually they they’re not dangerous but they should be a used appropriately otherwise they can’t post lymphoma and they can’t post katra there are very important medications are for particular diseases we have a question here from the for Athena camera your past made it even anyway is it safe to prescribe glycopyrrolate an anticholinergic that they prescribe for some case of fog of hyperhidrosis if someone has a personal or family history of well I suppose this ISA is this oral probably what I’m not very familiar with the Medicaid shown here so there are many medications but maybe because it’s an anticholinergic and yeah profile yeah counters one of her classes of medication which is a quality urging medication that’s been working so there may be there maybe come to the Contin Contin occasionally but i’m not very familiar and i’m not aware that he said that yeah I evaluated this simulation our continued to medications for the one okay yeah see oh yeah so you know you see their answer satisfied yeah she said there ma in Chicago anyway let’s see there we have any more questions here hi there this is doctored upon I i would like to ask about routine cataract surgery which is more cost effective for more advice and extra action or extraction or an intraocular extraction and what are the indications for each since I’ve music Oracle I supposed to capture we don’t really do that anymore they’re very very little indications in Japan circles maybe you’re talking about phacoemulsification versus an extra pouch in your gutters so extra casually basically you can remove the nucleus as

a pole where as a phacoemulsification of the sound waves will fragment them to you so you need a smaller incision to remove the cataract usually you don’t need sutures anymore so both are safe in the hands of an effective surgeon you just really have to talk about the dangers and pros and cons of each surgery let’s see ok we recognize what’s missing is a professional singer i think is a family member occupational that’s it sorry if there is no more questions feel ok so thank you again for that comprehensive discussion on glaucoma doctor yeah but also in the 411 alpha squad Mary melon taunton to summarize if i define what glaucoma is how it happens and it’s signs and symptoms our speakers have discussed the different types of home authority the diagnostic procedures appropriately diagnose platform over identified and explain such as nerve fiber Oct perimetry and the life that’s been discussed management of local mice personalized and they range from topical medical treatment laser and also to surgery in an effort to lower in chocolate peer pressure now again although glaucoma can post universe about whiteness and incurable disorder with early diagnosis and appropriate management we shall may be preserved for life after this session an email containing a survey link would be sent to you after answering the survey your certificates will be sent you as well please answer the survey so we can assess our web dinner and address more of your preferences and give you materials from this session thank you for joining me you so we would like to thank again our sub sponsor Santa and the philippine daily inquirer and the filipino doctor for their support our media part we hope to see you again in our upcoming webinar on November’s November 3 Wednesday well 1 p.m. manila time with speaker dr. Homer abia on adult vaccination was for her disaster and nimah Papa this environment colleagues to join is continuing medical not be GM webinar skills or optimal for upcoming webinar schedules you may check our facebook page or subscribe or mailing list by visiting the links written on your screen for questions and comments you may e-mail us at UT met Wagner’s 2016 @ gmail.com and if you missed some of our webinars you may subscribe to our YouTube channel on behalf of UPC en paz 1991 and the u.p medical alumni society we also think our collaborator units the UK Medical Information Management Service National Ballet hot senator you’ll be married college of medicine postgraduate institute of medicine and medical informatics units a vos de su I and miss chase or handle on the UPA medicine webinar team penske of the UT plus 90 night one bites you again on November 23 for our next webinar that would be wednesday 12 good manila time