International News

HIGHLIGHTS 3RD WORLD GLAUCOMA CONGRESS :

8 – 11 JULY 2009 , BOSTON, USA



• In Africa Glaucoma patients present late, 29% are blind in both eyes, 53% in one eye at the first visit. The treatment option in Africa is surgery. (A Ouertani, Tunis)

• Frequency Doubling Technology is a valuable tool for early detection in mass screening.      K BenAmur, Tunis)

• The cons of optic nerve head imaging: it is difficult to see disc hemorrhages,to distinguish pigments (PPA), impossible to identify pallor, and OCT and GDx do not tell us progression, do not evaluate the cup or neuro-retinal tissue status. (E Ancker, Cape Town)

• Glaucoma Management needs to establish a target pressure, individual risk factors, and the rate of progression of each glaucomatous eye. (E Ancker, Cape Town)

• 95% of blind glaucoma patients are in Africa and Asia, surgery is compliance free.
(T Shaarawy, Switzerland)

• 86% visual field assessments are not confirmed on retesting. (R Weinreb, USA)

• OHTS conversion to glaucoma 65% optic disc (OD)/45% visual field defect (VF), EGPS 40%OD/60% VF, EMGT 14% OD/99% VF. The different structure/function changes depend on the disease stage.

• Use imaging devices to assist in the diagnosis and documentation of the disease stage. Prostaglandins are most effective in lowering IOP in angle-closure glaucoma, a negative provocative test does not exclude angle closure.(www.gonioscopy.org) (H Lemij, Netherlands)

• Beta-peri-papillary atrophy in 62% of glaucoma eyes / 20% in normal eyes. A larger beta zone at thinner rim, location associated with largest loss, disc hem mean VF loss in 6/12 – 12years, 50% greater progression with a disc hemorrhage. (C de Moraes, USA)

• RNFL thickness measured with GDx and OCT give insufficient evidence that RNFL atrophy is predictive of progression. (D Greenfield, USA)

• FDT, SWAP, Flicker Perimetry are no gold standard for detecting progression of VF loss. (CA Johnson, USA)

• HRT c/d ratio is similar to a disc photo, there is good agreement between 5year risk estimates. (L Zangwill, USA)

• Event analysis tells us whether progression has occurred. It is very useful for early detection versus trend analysis which provides the rate of progression. (A Heijl, Sweden)

• AGIS revealed that after 10 years 16% of patients are unilateral blind / 10% in both eyes. 34% of blind patients had visual defects at baseline.( J Crowston, USA)

• 50% or more with POAG have normal IOP. IOP interacts with BP, BPP, PP is related to progression in high IOP. ( H Quigley, USA)

• After 5 years 40% of our glaucoma patients will progress! Dorzolomide reduced RoP in 85% from 40% to 17%. (A Garcia, Spain)

• BAK has a detergent and a toxic effect, glaucoma drugs have an affect on the ocular surface causing inflammatory changes, tear film alteration and conjunctival shrinkage, but with BAK better corneal penetration. Stopping one drug will improve the ocular surface, use one drop, not two! The most important test for dry eyes is to use one drop of fluorescein to assess the tear film break up time, stain the cornea, and look at the conjunctiva esp. nasally. (C Baudouin, France)

• Acute ange-closure glaucoma needs either

  1. ALPI sine systemic medication, or
  2. stat paracentesis, rotate and twist knife or
  3. central corneal indentation for 30 seconds. 58% of AAC develop CACG. (D Lam, China)

• Best long term trabeculectomy outcome can be achieved by

  1. pre-op inflammatory treatment,
  2. at surgery proper technique and tissue handling,
  3. post-op care with Avastin, 5FU, needling with 5FU. (F Grehn, Germany)

• How to choose a drainage device?: factors influencing the success:

  1. surface area,
  2. non-restrictive or restrictive device,
  3. plate material,
  4. cost. (V Costas, Brazil)

• Complications with drainage device implantation:

  1. elevated IOP,
  2. hypotony,
  3. tube exposure or migration.

All complications can be prevented or corrected. (P Netland, USA)

 

IGS ATHENS 2007 HIGHLIGHTS


∙IOP is the only modifiable RF
∙Risk calculators provide quality medication
∙Risk factor of OHT: CCT, PSD, c/d ratio, age, IOP
∙OD stereo-photograph is not replaced by digital imaging
∙Why do we use PGs as first choice: better compliance and persistency, no side effects
∙No threshold IOP for onset of POAG
∙Level of IOP affects course of disease
∙A single IOP measurement is a snapshot in a dynamic process
∙CCT is most powerful prediction for conversion from OHT to POAG
∙IOP is ignored for diagnosis but vital to establish baselines and target pressures
∙Use time intelligently to find TP, establish non-IOP RFs : age, genetics, BP, DM, sleep apnoe, lipids, vasospasm
∙Changes of ocular perfusion pressure have a greater effect than IOP increases
∙Statins influence nerve cell regeneration, increase OBF, exhibit anti-inflammatory effect, anti-ageing, are neuroprotective
∙RFs for progression : baseline IOP, severity of damage, age, PEX, disc hem, gender
∙Easy rules for glaucoma management: individualize treatment, change with FU, where is patient in age/function diagram?, look at RFs, TP, PEX, FU patients and see!, after 3-5 years where is patient on diagram?, any ROP?, if rapid progress or change Rx 


SINGAPORE WGC 2007 HIGHLIGHTS


∙Physician – patient communication: educate your patients (hand outs, reprints,
instruction sheets), treat blepharitis, dry eye, tell how to instill drops (www.glaucoma.net) do not let your ego get involved with your work, be honest about diagnosis, listen to patient, second opinion
∙Changes of BP have a stronger influence on perfusion pressure than IOP changes, mean ocular perfusion pressure is a predictive risk factor for rate of progression
∙Is it defensible to spend lots of resources on patients who are either healthy or with mild disease and are we under managing patients with potentially serious glaucoma?
∙None of the scanning techniques replace stereo-photography, they are missing disc haemorrhage, disc pallor, peripapillary atrophy; imaging technology supplements but does not replace clinical examination
∙Supine IOP is higher in glaucoma patients regardless of time of day, 67% of peak IOP in glaucoma patients occurs during sleep period
∙Very scant evidence that IOP fluctuation is an independent risk factor
∙An increased mean IOP is a significant risk factor for rate of progression
∙Visual field can show better rate of progression than HRT, it is hard to translate optic disc imaging into function, once OD damage is established FU is better with VFs than imaging techniques
∙Target pressure is not a magic number! It can only be established after a certain period of time, TP is based on amount of glaucoma damage, life expectancy, family history and fellow eye, TP requires periodic re-evaluation


∙7 “sins” of glaucoma:

  1. limitation of IOP measurements,
  2. severity of damage is underestimated
  3. IOP reduction is not enough
  4. IOP spikes are not detected
  5. glaucoma progression is not dedected
  6. rate of progression is not assessed
  7. compliance is not addressed.

∙Low diastolic perfusion pressure (<50mmHg) is high risk factor in POAG, systemic
diuretics given for high BP are a high risk factor to develop POAG
∙Surgery is still cheapest way to treat glaucoma
∙It is best not to prescribe 2 medications (combos) until you are certain that one is not enough