Early diagnosis, treatment urged to combat glaucoma

FLORENCE – Many of the world’s leading experts in glaucoma gathered here recently to share the latest information and technological advances in glaucoma diagnosis and treatment. The 7th Congress of the European Glaucoma Society attracted more than 1,700 delegates with its program of free papers, poster presentations, educational courses and symposia.

The common theme in presentations at the congress was that early diagnosis and treatment, as well as attention to the patient’s quality of life, are essential to the goal of maintaining visual function for life in patients with glaucoma. Because vision loss does not occur until significant nerve damage has already occurred in glaucoma, it is essential to educate the public on the importance of glaucoma screenings, said Prof. Roger Hitchings, FCOphth, president of the EGS and senior glaucoma specialist at Moorfields Eye Hospital in London.

“We know that in Europe, over half of those with glaucoma don’t know they have it and are likely to present only once they have advanced disease and have begun to experience a deterioration in vision,” Prof. Hitchings said in a press release distributed at the meeting.

“To prevent blindness in the future, we have to act now by identifying and treating as many people with the condition as possible, as early in the disease course as possible,” Prof. Hitchings said in the press release.

Prof. Hitchings said the purpose of the EGS meeting was also to put glaucoma into context regarding numbers, cost to the patient, cost to society and the worldwide nature of the disease. While the technology exists to detect glaucoma early, more must be done to make people aware of the disease, he said.

Prof. Carlo Traverso, an EGS executive committee member, added, “People are going blind from glaucoma unnecessarily. If glaucoma is diagnosed and treatment begun before the damage is at an advanced stage, then we can reasonably expect to maintain visual function for life.”

This article recaps some of the important presentations at the EGS meeting. Many of these items appeared first on the OSN SuperSite as live coverage from the meeting by our editorial staff.

Needling for failed blebs

Bleb needling revision can lower IOP in eyes with failed filtering blebs, according to a study presented by David Goh, MD.

Dr. Goh discussed a retrospective review of 30 eyes with follow-up of 1 year after bleb needling and injection of 5-fluorouracil. Bleb needling was performed using a 27-gauge to 30-gauge needle inserted 10 mm from the flap. A sweeping motion was used to break adhesions.

According to Dr. Goh, mean IOP decreased from 25 mm Hg before needling to 15.6 mm Hg after needling. Eight eyes (27%) achieved an IOP of 20 mm Hg or less without additional medication and were considered total successes. Another 14 eyes (47%) that required additional glaucoma medications to achieve similar IOPs were considered partially successful. Seven eyes (23%) had IOPs greater than 20 mm Hg and were considered medication failures. Dr. Goh said his study results were similar to other retrospective studies. He said prospective studies evaluating the use of antimetabolites in needling procedures are in progress.

Antimetabolites equally effective

Both mitomycin-C (MMC) and 5-fluorouracil (5-FU) appear to be equally effective as adjuncts to primary trabeculectomy, according to interim results of the Primary Trabeculectomy Antimetabolite Study.

Kuldev Singh, MD, presented approximately 3-year follow-up data from the ongoing prospective, randomized study.

The study includes 119 eyes of patients with a range of forms of glaucoma, including primary open-angle, pigmentary, exfoliation and chronic angle-closure glaucomas. All patients in the study were more than 40 years of age and were considered to have low-risk eyes. Sixty eyes were assigned to treatment with adjunctive 5-FU and 59 eyes to MMC.

Dr. Singh said surgeons participating in the study could choose their own method for applying the antimetabolites but were required to remain consistent in their surgical techniques. The study required that the drugs be applied in specific concentrations for specific durations: 0.4 mg/mL of MMC for 2 minutes, or 50 mg/mL of 5-FU for 5 minutes.

The mean follow-up reported by Dr. Singh was 36 months for MMC patients and 33 months for 5-FU patients. The mean IOP in both groups was 12.5 mm Hg, reduced from preoperative means of 26.3 mm Hg for the 5-FU patients and 24.1 mm Hg for the MMC patients.

Dr. Singh noted that there were no significant differences between groups in the rates of adverse events or postoperative interventions such as bleb needling.

Combined surgery complications

Combined surgery for glaucoma and cataract was associated with a higher incidence of postoperative complications among monocular patients than binocular patients, according to a poster presentation.

Tarek Eid, MD, and colleagues at the El-Maghraby Eye Hospital in Jidda, Saudi Arabia, conducted the study, which compared 60 monocular patients with both glaucoma and cataract to 60 binocular age- and sex-matched controls. According to the poster authors, the monocular patients had more severe glaucoma and more ocular comorbidities. No significant differences were seen between groups in best corrected visual acuity or IOP control.

Monocular patients had significantly higher rates of postop complications (P = .02), which the authors said was probably due to the higher level of ocular comorbidity and severity of glaucoma.

Valve for pediatric implantation

The Ahmed glaucoma valve can be efficaciously implanted in pediatric glaucoma patients, according to another poster.

Banu Satana, MD, and colleagues reviewed the records of 18 eyes of 18 consecutive pediatric patients implanted with the Ahmed glaucoma valve (New World Medical). The mean age of the patients was 10.9 years. Mean follow-up was 35.8 months.

According to the study authors, mean IOP decreased from 38.3 mm Hg at baseline to 18.3 mm Hg at 3 months follow-up. Mean IOP was 17.8 mm Hg at 6 months, 19.6 mm Hg at 1 year, 16.8 mm Hg at 2 years and 18.2 mm Hg at 3 years follow-up.

Filter for ICE syndrome

Filtering surgery can help preserve vision in patients with iridocorneal endothelial (ICE) syndrome, according to a poster by Heidar Amini, MD, and colleagues in Iran.

The researchers retrospectively evaluated 11 patients with ICE syndrome who underwent at least one trabeculectomy for uncontrolled IOP. Eight of the patients included in the study also had progressive iris atrophy, two had iris nevus syndrome, and one had Chandler syndrome. Mean age was 39.4 ± 11.2 years.

According to the study authors, IOP was reduced from a mean of 32.5 mm Hg preoperatively with an average of 2.8 glaucoma medications to a mean of 18.9 mm Hg postoperatively with an average of one glaucoma medication. Mean follow-up was 22 months.

SLT vs. meds

Selective laser trabeculoplasty (SLT) was as effective as topical medication in controlling primary open-angle glaucoma or ocular hypertension in a study presented by H. Ferdinand A. Dujim, MD.

Dr. Dujim described a study that compared SLT to medical therapy in 19 patients with primary open-angle glaucoma and seven with ocular hypertension. Patients were at first treated with topical antiglaucoma medications. After 3 months, patients who achieved the target pressure — a 25% reduction from baseline — had their medications discontinued. After a washout period, the patients were bilaterally treated with SLT.

According to the study, mean IOP for the 47 eyes included in the data analysis declined from 27 mm Hg at baseline to 11.5 mm Hg at 3 months follow-up. Dr. Dujim said the results suggest SLT could be used as a first-line treatment.

Poor compliance

Patients prescribed prostaglandins for the control of IOP have poor compliance rates, according to a pharmacy claims study presented by Gail F. Schwartz, MD.

Drug records from 2,503 patients were included for analysis, said Dr. Schwartz. Of these, 477 (19%) had discontinued and restarted their initial drug by day 180, the final follow-up day. An additional 40 patients (2%) had discontinued use of their initial drug and later restarted on prostaglandin, Dr. Schwartz said.

Of the 1,986 remaining patients, 879 (35%) persisted with treatment to the end, 280 (11%) discontinued use of the prostaglandin and switched to another class of drug and 827 (33%) failed to restart any treatment.

Single-use tonometer

Single-use tonometers can provide IOP measurements comparable to Goldmann applanation tonometers, according to a British study.

The study, conducted by Anna Maino, MD, and colleagues at Manchester Royal Eye Hospital, compared two single-use tonometers, the Tonosafe from Clement Clarke and the TonoJet from Luneau, to Goldmann tonometry in 56 consecutive patients.

Mean IOP measurements did not differ significantly among the three tonometers. Goldmann tonometry measured a mean IOP of 12.9 mm Hg, the Tonosafe a mean 12.5 mm Hg and the TonoJet a mean 12.4 mm Hg.

A reliability test showed the three systems to yield consistent measurements as well, Dr. Maino said.

These single-use devices could be advantageous for use during emergency situations or in instances when infection or pathogen transmission is a concern, Dr. Maino added.

Iridoplasty for phacomorphic closure

A number of papers and posters at the meeting addressed angle-closure glaucoma, acute angle closure and pupillary block glaucoma.

Argon laser peripheral iridoplasty can be a safe alternative to topical and systemic medications as an immediate treatment for patients with acute phacomorphic angle closure, according to Jonathan Chan, MD.

Dr. Chan said traditional management of the acute condition, in which a hypermature cataract causes angle closure and a subsequent rise in IOP, has been drug therapy. The drug therapy options include systemic acetazolamide, which carries significant risks, he said.

Dr. Chan and colleagues studied the use of argon laser peripheral iridoplasty (ALPI) in 10 consecutive patients with a first attack of phacomorphic angle closure causing an IOP of at least 40 mm Hg. Patients were initially treated with topical atropine, prednisolone and timolol. ALPI was then applied in five to 10 spots per quadrant. Once the acute phase subsided, patients underwent either phacoemulsification or extracapsular cataract extraction. All patients underwent posterior chamber IOL implantation.

The study patients’ mean IOP of 56.1 mm Hg at baseline dropped to 45.3 mm Hg at 15 minutes postop, to 37.7 mm Hg at 30 minutes postop, to 34.2 mm Hg at 60 minutes postop and to 25.6 mm Hg at 120 minutes postop. Mean IOP was 12.3 mm Hg at about 6.5 months postoperatively, Dr. Chan said. No systemic acetazolamide was used in any case, Dr. Chan said, and topical medication was needed in one eye of one patient.

Iridotomy for angle closure

A study in Hong Kong found that prophylactic laser iridotomy in the fellow eyes of patients with monocular angle-closure glaucoma may help prevent development of angle-closure in the fellow eye over the long term.

The study included the records of eight men and 34 women with a mean age of 69.1 years. Patients included in the study had been followed for at least 5 years without undergoing cataract sur-gery during that time. Patients who had existing high IOPs, chronic angle closure or other forms of glaucoma, such as neovascular glaucoma, were also excluded.

Pui Wai Pian Yip, MD, who conducted the study with colleagues at the Tuen Mun Hospital, Hong Kong, noted that the prevalence of angle-closure glaucoma is much higher among people in Hong Kong than in Europe. She said the study was intended to assess the effectiveness of the procedure only in Hong Kong Chinese patients.

All patients were successfully treated with argon laser iridotomy. During the course of follow-up, one patient (2.4%) developed appositional angle closure and was subsequently treated with argon laser peripheral iridoplasty, she said.

Paracentesis for IOP spike

Patients with an acute rise of IOP to more than 50 mm Hg might benefit from undergoing a paracentesis, according to a poster presentation.

Alain Bron, MD, and colleagues prospectively enrolled 13 eyes of 13 patients with acute elevation of IOP to at least 50 mm Hg. Of the patients, one had phacolytic glaucoma, eight cases had secondary angle-closure glaucoma with pupillary block and two cases had secondary angle-closure glaucoma without pupillary block.

Mean IOP decreased from 52.5 mm Hg before undergoing corneal paracentesis to 23.8 mm Hg at 10 minutes after the procedure. After 1 week, mean IOP had fallen to 16 mm Hg.

Improvement of corneal edema was seen in 11 of 13 cases. One case of failure occurred in a patient with posterior block, and two cases required an additional puncture. Nine patients underwent a laser peripheral iridotomy following the paracentesis. No additional treatment was required in 11 eyes.

No complications directly related to the paracentesis were observed, the study authors said.