GLAUCOMA 2008
Greek Glaucoma Society
Athens, March 28 - 29, 2008
Ledra Marriott Hotel

CONGRESS ABSTRACTS

GLAUCOMA PROGRESSION - NATURAL HISTORY AND CLINICAL OUTCOMES

Anders Heijl, MD
Professor - Director
Department of Ophthalmology
Lund University
Sweden
2008 Award

Abstract: The knowledge about the natural history of glaucoma has been very scarce, and really only available in patients with normal tension glaucoma from CNTGS plus some data from a mainly black population in St Lucia. The amount of good long-term data on clinical outcomes in glaucoma management has also been limited with the studies of Hattenhauer and Cheng emerging as some of the most important.

This presentation will report natural history data from the Early Manifest Glaucoma Trial, which includes patients with POAG, NTG and pseudoexfoliation glaucoma. The data shows differences between glaucoma diagnoses, but also confirm the very large inter-patient variation of rate-of-progression, and is of value e.g. when designing strategies for case finding and population screening.

Data will also be reported from a large retrospective study of 600 patients at our institution, that have been followed long and frequently enough to determine rates of progression under ordinary clinical management. The results show large variability, but often higher progression rates than one would hope. A considerable minority of glaucoma patients developed visual impairment during their lifetime, and the results suggest that there is room for improvement of clinical management.


HOW GLAUCOMA PRACTICE COULD CHANGE - LEARNING FROM THE LARGE RCTS

Anders Heijl, MD
Professor - Director
Department of Ophthalmology
Lund University
Sweden
2008 Award

Abstract: TIn the past decade very important results have been published from a large number of randomized clinical trials. Four of these studies had untreated control arms: CNGTS, EMGT, OHTS and EGPS. Other important studies were AGIS and CIGTS. Results from these trials have given us considerable and important new knowledge that can help us improve glaucoma practice. We now know, e.g., that IOP reduction works even at statistically normal levels and that the magnitude of the effect on progression rates is large. We have a good knowledge about risk factors, and pseudoexfoliation syndrome and corneal thickness have emerged as new important parameters. Other alleged risk factors have not been confirmed, e.g. migraine and IOP fluctuations.

Importantly, we have found that target pressures have to be lower than previously anticipated, but also that even at statistically normal pressure levels, progression is common, and that we are unable to predict safe IOP levels for individual patients.

With our new knowledge we now have the opportunity to change and improve glaucoma management. Initial management could be based on IOP and other risk factors, but with frequent measurements of visual function it is possible to establish of each individual patient's rate of progression after just a few years. Management


THERAPY OF THE VARIOUS FORMS OF SECONDARY GLAUCOMA

Franz Grehn, MD
Professor - Director
Department of Ophthalmology
Julius-Maximilians-University
Wuertzburg

Abstract: The therapeutic approach of secondary glaucomas should cosider the pathogenesis - not so much on the etiology - of intraocular pressure elevation. Neovascular mechanisms, inflammatory mechanisms and trabecular obstructive mechanisms should be separately considered for preselecting the intervention.
In neovascular glaucoma (of different etiology), the therapeutic principle is the treatment of the VEGF producing ischemic retina by photocoagularion or retinal kryoablation and Anti VEGF intravitreal injection. Filtering procedures including tube systems can be added when neovasculaization is under control.
Inflammatory IOP elevations can be separated in those with known pathogen agents such as Herpes viruses and in immunogenic inflammations. When the pathogen is known, specific nonsurgical therapy is indicated. In far advanced uveitic glaucoma, tube shunts can be considered.
Secondary glaucomas following trabecular obstruction (PEX, Pigmentary glaucoma, traumatic glaucoma) are treated according to the rules of Primary Open Angle Glaucoma.
Endothelization in ICE Syndrom can be controlled by filtering surgery but often will need tube implants as a second approach.
Secondary childhood glaucomas, particularly aphakic secondary glaucoma after early congenital cataract surgery or uveitis are the most challenging cases and are subject to a high risk profile.
An individually tailored decision is the key to successful glaucoma treatment in many of the complicated cases of secondary glaucoma.


USING THE SUPRA-CILIARY SPACE - THE CONCEPT AND PRACTICE OF GOLD MICRO-SHUNT SURGERY

Shlomo Melamed, MD
Professor - Director
Glaucoma Service
Chaim Sheba Medical Center
Tel-Hashomer, Israel
2004 Award

Abstract: The Supraciliary Space participates in the normal uveo-scleral outflow mechanism. Communicating the Anterior Chamber with the Supraciliary Space is associated with enhanced uveo-scleral outflow and IOP reduction.The advantage of this surgical concept is the "Bleb less" operation, with minimal complications compared with other invasive glaucoma procedures.

The Gold Micro Shunt (GMS) is a thin drainage device made of pure gold, with tubules having lumen diameter of 20-60 microns.The surgical procedure will be described, along with results from the pilot study and interim results from a multicenter, randomized comparative study of GMS vs. AGV implant in refractory glaucoma patients.


MANAGEMENT ALTERNATIVES FOR THE PROGRESSING PATIENT

John Thygesen, MD
Director of Glaucoma Service
Copenhagen University Eye Clinic
Denmark

Abstract: New diagnostic tools and drugs have benefited greatly our ability to make clinical decisions and treat patients with progressing glaucoma. Nevertheless, the overall patient profile provides critical information on which we base those decisions.

Disease stage, rate of progression and life expectancy need to be taken into account, as does the patient's compliance potential.

Detection of visual field progression is a crucial component of glaucoma patient management as it guides decisions about whether or not existing treatment is working.

In the progressing patient aggressive, long-term, vision-preserving treatment must be used while trying to minimize the compromising of quality-of-life factors, including recurring cost.

Monotherapy is certainly the optimal treatment with regard to compliance, safety, and tolerability. Yet, if target IOPs are not met with monotherapy, the decision to switch or add medications should be made. Replacement therapy is advantageous because it eliminates medications that are no longer effective, while keeping the patient on a single agent. Combination therapy should be considered if the target IOP has not been reached.

Laser trabeculoplasty (ALT or SLT), an intermediate step between medication and filter surgery, often reduces IOP in both previously untreated and treated eyes with pigmented trabecular meshwork or pseudoexfoliation, although most patients still will need medical treatment to reduce IOP.

Incisional surgery is an option for glaucoma patients who are still progressing. Success rates with trabeculectomy have risen dramatically with antifibrotic agents, though postoperative problems include hypotony, hyphema, choroidal effusion, and hemorrhage. Guarded filtering surgeries, such as deep sclerotomy and viscocanalostomy, are safer alternatives to trabeculectomy, although they are less successful in reducing IOP. Shunts are useful when inflammation or excessive scarring arises from previous glaucoma surgery.


PNEUMATIC TRABECULOPLASTY: AN UPDATE

Nicola Ungaro, MD
Department of Ophthalmology
University Eye Clinic
Italy

Abstract:

Presentation will try to elucidate the key features of pneumatic trabeculoplasty (PNT), an instrument used for the tratment of glaucoma and ocular hypertension: rationale of the use, possible mechanisms of action and results of former studies will be given. Indications and contraindications will be discussed. Preliminary results of an ongoing study on PNT in the tratment of ocular hypertension will be presented, as well as personal experience with the use of the device.


PERSONALITY AND OBJECTIVELY MEASURED ADHERENCE TO ONCE-DAILY PROSTAGLANDIN ANALOGUE MEDICATION

Gabor Hollo, MD, PhD, DSci, Peter Kothy, MD, PhD1 Anna Geczy, PhD2
Department of Ophthalmology, Semmelweis University, Budapest
Department of Psychology, Pazmany Peter Catholic University, Budapest

Abstract: In order to investigate the influence of personality and depression on objectively measured adherence to once-daily PG medication adherence was measured with the Travalert Dosing Aid on consecutive, regularly followed-up glaucoma patients already on self-administered travoprost. Psychological characteristics were measured using the STAI, EPQ, Beck Hopeless Scale and Depression Inventory. Adherence was 77% for the three-month period.
Social desirability was higher than normal (p < 0.0001). 12.1% of the patients showed mild-to-moderate depression, which was not significantly associated with decreased adherence (p=0.071). Severity of glaucoma, number of ocular and systemic medications, satisfaction with the recording device and socio-economic characteristics had no influence on adherence.
Objectively measured adherence to once-daily PG medication was good, and not influenced by treatment characteristics or patient factors including mild-to-moderate depression. The elevated social desirability suggests that self-reported adherence is not a reliable measure of adherence in glaucoma.


VASCULAR RISK FACTORS IN GLAUCOMA; FROM EPIDEMIOLOGY TO THE CLINIC

Alon Harris, MD
Letzter Endowed Professor of Ophthalmology
Professor of Physiology and Biophysics
Indiana University School of Medicine

Indianapolis
USA

Abstract: Despite its prevalence, glaucoma remains a multi-factorial optic neuropathy of unknown etiology. Although elevated intraocular pressure (IOP) was identified as a risk factor for the disease over 100 years ago, a meta-analysis showed steady disease progression with persons, at all levels of IOP, equally likely to exhibit deterioration and vision loss. It has to be concluded, therefore that "factors quite independent of intraocular pressure may be responsible for (disease) progression in glaucoma".

According to evidence based medicine, in 1993, the effectiveness of IOP reduction in the treatment of glaucoma still needed to be determined. This realization provoked the execution of large-scale studies, which eventually concluded that the reduction of IOP is beneficial to the glaucoma patient. However, these studies also found that vascular related factors are also important risk factors in glaucoma. Any benefits that could be experienced from both, IOP reduction, or vascular improvement, remain uncertain.

Participants of the Framingham Eye Study with glaucoma were reported to have significantly low BP/IOP ratios. In addition persons with definite glaucomatous visual field defects has lower ratios than those with suspect defects or no defects. Low perfusion pressure (PP) was also a glaucoma risk factor in the Baltimore Eye Survey, Egna-Neumarkt, Proyecto VER, and most recently, the Barbados Incidence Study of the Eye (BISED). Additionally, the Baltimore Eye Study found diastolic PP ((DPP) DPP = diastolic blood pressure (BP) - IOP) of less than 30 mm Hg to be strongly associated with open angle glaucoma (risk factor = 6), whereas systolic PP ((SPP) SPP = systolic BP -IOP), and mean PP ((MPP) MPP = mean BP -IOP) were only mildly associated. In the Egna-Neumarkt study, open angle glaucoma prevalence increased progressively with decreased DPP. The proyecto VER study found similar results at a low DPP. The BISED study found all three factors (DPP, SPP and MPP) to be related to open angle glaucoma.

The only vascular parameter that meets the criteria necessary to be considered clinically, based on evidence-based medicine is diastolic perfusion pressure. The relationship, if any, between perfusion pressure and glaucoma is not known, however, the existence of a relationship begs the question: Are vascular deficits and ischemia involved in the pathogenesis and progression of glaucoma?


GLAUCOMA TUBE IMPLANT SURGERY - EVIDENCE FROM PROSPECTIVE STUDIES

Maria Papadopoulos, MB BS FRACO
Consultant Ophthalmologist
Department of Ophthalmology
Moorfields Eye Hospital
London, UK

Abstract:

Tube implant surgery, as first introduced by Molteno for refractory glaucomas resistant to other forms of medical, laser and surgical treatments, has more recently been increasingly introduced either as a primary procedure or much earlier in patients care. This lowering of our threshold for tube implant surgery is multifactorial.
Firstly, modifications in the surgical technique over the years have resulted in a reduction in complications as has the introduction of flow restricted implants. Furthermore the desire to avoid bleb related complications such as bleb related endophthalmitis has been an enormous incentive for the use of tube implants.
Lastly, poor long term results of cyclodestructive procedures, especially in children, have led to the earlier use of tube implants. Despite the rising use of tube implants there is very little prospective evidence in the literature regarding their comparative success.
This talk presents the evidence from prospective studies of how tube implants compare to each other, and to other procedures such as trabeculectomy with regards success rates. In addition, the variables that determine the success of tube implants along with the available evidence will be covered.


UVEITIC GLAUCOMA

Keith Burton, MD FRCS FRCOphth
Consultant Ophthalmologist
Glaucoma Service Director
Moorfields Eye Hospital
London

Abstract:


COMPLIANCE: A GREEK PROBLEM?

Tarek M. Shaarawy, MD
Head, Glaucoma sector
Ophthalmology Service
Geneva University Hospitals
University of Geneva

Abstract:




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