Glaucoma risk factors, patient compliance can be improved

At Glaucoma Day and throughout the ASCRS meeting, physicians and industry alike emphasized early disease detection and patient compliance.

SAN FRANCISCO — While studies have pinpointed key glaucoma risk assessment factors, the subject still needs further research, according to Kuldev Singh, MD.

Age, IOP and certain visual field parameters have been shown to be factors for glaucoma, but other potential risk factors such as race, have not been, Dr. Singh said here at the American Society of Cataract and Refractive Surgery’s Glaucoma Day.

As an example, he compared two patients with similar backgrounds: Both patients were 40 years old, both had the same IOP and the same family history. One patient was white, the other black.

“Is that black patient more likely than the white patient to develop glaucoma?” he said. “And the answer is — we don’t know.”

Research such as the Ocular Hypertension Treatment Study proved that visual field and optic nerves are important factors that “define” the disease, Dr. Singh said. But glaucoma studies do not have as much data on what happens when those factors go untreated, he said.

“We have far less knowledge when it comes to detectable disease leading to visual impairment,” Dr. Singh said.

He said the reason might be because few subjects in glaucoma studies go blind, although that may be attributed to the treatment course they received while in the study. More presentations from ASCRS are highlighted in the remainder of this article. Many of these items appeared first on OSNSuperSite.com as daily reports from the meeting.

Optic nerve exam essential

The essentials of optic nerve examination have five basic tenets: Systemic examination, optic disc size, neuroetinal rim, peripapillary region, disc hemorrhage and nerve fiber layer, Robert D. Fechtner, MD, said.

He called examining the optic nerve a “fundamental” of glaucoma care. Using the “ISNT rule,” for “Inferiorly, then Superiorly, Nasally, and thinnest Temporally,” which describes a typically healthy optic nerve, is a key to effective examination, he said. Clinicians should concentrate on the neuroretinal rim instead of the cup, he added.

“It’s (the cup) not what an optic nerve looks like,” he said.

Another essential of optic nerve examination is disc hemorrhage, which can precede visual field loss. He said at every examination of a glaucoma patient, he examines the optic nerve through the dilated pupil.

“There is no reason most glaucoma patients should not have their optic nerve observed at each examination,” he said. “You might find a disc hemorrhage.”

Quality, not speed, improves glaucoma surgery

Concentrating on efficiency, rather than speed, is most important in performing glaucoma surgery, according to Bradford J. Shingleton, MD, who detailed the “11 habits of highly effective surgeons.”

Bradford J. Shingleton

His tips included not rushing surgery to avoid reduction in quality. He suggested that surgeons should “go slow to be fast,” resulting in improved, more efficient surgeries.

“The goal is not to be fast, the goal is to be effective,” he said. “Speed is a part of that.”

The other habits that Dr. Shingleton outlined included safety, standardization of practice, purposeful action, effecting positive change, compassion, personal best, and enthusiasm and positive attitude. By enacting these habits in practice, surgeries will proceed more smoothly and safely, he said.

He also recommended surgeons use a template for equipment placement in their operating rooms, with the microscope stand, scrub table, phacoemulsification and anesthesia units in the same position, reducing set-up time by establishing a time-saving routine. He said when he enters the operating room, he does not touch any equipment until he begins surgery.

“I’m only thinking about the surgery,” Dr. Shingleton said. “It makes me a much better surgeon as a result.”

After Glaucoma Day, the following presentations were given throughout the rest of the ASCRS meeting.

Pseudophakic eyes at risk of iris bombé

Pseudophakic patients with deep anterior chambers should be observed carefully for possible symptoms of iris bombé, according to a poster presentation.

Ryoji Yamakawa, MD, sought to understand the risk factors associated with this disease, which leads to uncontrolled IOP if left untreated.

“Iris bombé is often seen in phakic eyes, but in pseudophakic eyes has been rarely reported,” Dr. Yamakawa said.

The noncomparative case series looked at iris bombé in eight pseudophakic eyes of seven patients at Kurume University Hospital and Tobata Kyoritz Hospital between August 2002 and September 2005.

The study included two men and five women, with an average age of 62.5 years. One eye had uveitis, one had chronic angle-closure glaucoma, and six had proliferative diabetic retinopathy.

The study found that iris bombé developed in one uveitic eye and one eye with chronic angle-closure glaucoma after phacoemulsification with IOL implantation and vitrectomy. All eyes had ongoing inflammation, small continuous curvilinear capsulorrhexis (CCC) and poor pupillary dilation. High IOP was observed in four eyes and was lowered by laser iridotomy.

In all eyes, iris bombé was resolved with laser iridotomy. However, patients with proliferative diabetic retinopathy required several treatments because of repeated closure of iridotomies.

“It must be recognized that persistent inflammation, small CCC and poor pupillary dilation are risk factors for iris bombé,” Dr. Yamakawa said.

Positive attitude improves compliance

Glaucoma patient compliance and overall attitude toward the disease is greatly improved when physicians have a more positive attitude toward treatment, according to Reay H. Brown, MD.

Dr. Brown said glaucoma patients fear blindness and listen carefully to anything their physician says – or does not say – about their illness.

“Our words are very powerful and, in a sense, we control the discussion about glaucoma,” Dr. Brown said. “It’s important that we project a positive attitude to our patients.”

He said doctors should never tell their patients “Nothing is working;” “I’ve tried everything;” “I don’t know what else to do,” or “I give up.” Glaucoma treatment has many options, he said, and if a doctor cannot think of another therapy, the patient should be referred elsewhere.

Physicians should have an open dialogue with patients about their disease, de-emphasizing a target IOP and focusing instead on the improvements in the patient’s glaucoma treatment.

“We all have patients who aren’t doing as well as we think they could do,” Dr. Brown said. “By discussing it, we show that we’re in control, we have a plan. This is very reassuring for patients.”

Educate glaucoma patients before refractive surgery

Education and a lifelong follow-up are strongly urged for patients with glaucoma who want to undergo refractive surgery, according to a poster presentation.

Seung Hyuck Lee, MD, and colleagues examined the clinical course of 10 eyes of 12 patients with glaucoma who had undergone refractive surgery, including LASIK for myopia, LASEK and Artisan/Verisyse lens (Ophtec/Advanced Medical Optics) implantation.

Dr. Lee compared preoperative and postoperative IOP, refractive error, visual acuity and endothelial cell counts. He said both endothelial and keratocyte cell density remained the same. Mean cup-to-disc ratio was 0.7, he said. A mean IOP decrease of 4.7 mm Hg was observed, and there was no progression in visual field loss over the course of the 1-year follow-up.

Dr. Lee said glaucoma patients may be viable candidates for refractive surgery, but the physician should monitor the patient for the rest of his/her life, and should ensure a high level of patient education preoperatively as well.

Beta-blockers still important in management

Beta-blockers still play an important role in glaucoma treatment because of their cost-effectiveness and once-a-day dosing schedule, according to a speaker here.

Speaking at a function sponsored by Ista Pharmaceuticals, Ehsan Sadri, MD, said that Istalol (timolol, Ista) was “a Godsend in my practice.” He cited the affordability of the beta-blocking drug for his patients who cannot afford prostaglandin therapy. He also noted that the once-daily instillation aids patient compliance.

The lower systemic absorption that is characteristic of Istalol also means a reduction in cardiovascular effect, he said.

There is also enhanced patient acceptability because the formulation of Istalol causes less blurred vision than other solutions, Dr. Sadri said.

Retaane may help treat steroid-induced glaucoma

The anterior juxtascleral depot administration of anecortave acetate, in conjunction with other glaucoma medications, appears effective in lowering IOP in eyes with steroid-induced glaucoma, according to a presentation made here at the American Society of Cataract and Refractive Surgery meeting.

Alan L. Robin

The study, presented by Alan L. Robin, MD, examined the IOP increase that is a frequent complication of treatment with intravitreal triamcinolone acetate (Kenalog, Bristol-Myers Squibb).

“The increase in IOP with triamcinolone is a problem that has become an epidemic,” Dr. Robin said.

The IOP spike associated with triamcinolone may in part be a result of changes in the trabecular meshwork, including a significant induction of myocillin. Anecortave acetate is a cortisene, and lacks the usual anti-inflammatory and immonosuppressive properties of glucocortisoids, Dr. Robin said. The drug is marketed as Retaane by Alcon; it is not yet approved for marketing in the United States.

In Dr. Robin’s study, one anterior juxtascleral depot of 24 mg of anecortave acetate was made into the sub-tenon’s space of four eyes of three patients. These patients all suffered from glaucoma due to intravitreal triamcinolone, and were on an average of 3.8 glaucoma medications. Mean pre-treatment IOP was 41 mm Hg. The subjects were followed weekly for 1 month, and then once a month thereafter.

At follow-up points ranging from seven months to a year, IOP lowering seemed significant by 1 month and ranged from 32% to 54%. This IOP reduction was in addition to that produced by prior glaucoma medications. The average decrease was 48%, the effect lasted 6 months and prevented glaucoma surgery in 75% of the patients; none had any adverse events.

The study concluded that in combination with other glaucoma medications, “this administration of anecortave acetate was safe and effective in lowering IOP in patients with steroid-induced glaucoma,” Dr. Robin said. The delivery of this treatment does not require patient compliance.

“In summary, this is a new class of medicine, and a new way of delivery,” Dr. Robin said. “It lowers IOP in six out of seven eyes, and may have some potential advantage in the treatment of primary open-angle glaucoma.”

New compliance device for glaucoma patients unveiled

A device that helps ophthalmologists and patients measure glaucoma medication compliance is now available for users of Travatan, said Ronald L. Gross, MD, here at an evening symposium held in conjunction with the meeting.

According to Dr. Gross, patients put their Travatan (travoprost, Alcon) drops into a holder that can automatically tell how many drops are dispensed, and at what intervals. When the patient returns to the office, the physician can easily monitor compliance.

Dr. Gross said the device is Food and Drug Administration approved and is available at no cost to physicians.

“Right now, 95% of the patients are reporting positive experiences with the Travatan Dosing Aid, and 85% of the physicians are happy with it as well,” he said.

Dr. Gross described the device during an Alcon-sponsored symposium on “Innovations in Ophthalmology.”

Purse-string suture effective surgical technique

A technique dubbed the purse-string suture seems to be an effective surgical intervention in the treatment of neovascular glaucoma, according to a poster presentation.

Wan-Soo Kim, MD, and colleagues retrospectively reviewed six eyes of six patients who had an incidence of IOP spikes between 42 mm Hg and 60 mm Hg during the course of their neovascular glaucoma. The patients were unresponsive to medical and laser treatment. The patients’ visual acuity ranged from finger counting to 30/200. They had closing angles and neovascularization of the angle was noted. All eyes underwent purse-string sutures with a PC-7 needle, Dr. Kim noted.

IOP was stabilized within 2 weeks; stabilization in these cases was defined as 22 mm Hg or less. Anterior chamber angles were open after surgery; hyphema was noted in all cases.

Aqueous humor flow essential to non-penetrating glaucoma surgery

Adequate aqueous humor flow from the trabecular meshwork and Descemet’s membrane are “crucial” to successful non-penetrating glaucoma surgery, Kurt Von Wolff, MD, said.

He said changes in egress of aqueous humor from surgically exposed trabecular meshwork and Descemet’s window were apparent in about 900 cases he studied of viscocanulostomy performed to treat primary open-angle glaucoma. Surgeons can significantly increase aqueous flow after enlarging Descemet’s window by detaching Schwabe’s line with a Weck cell, he said. Surgeons can also increase aqueous flow by stripping the juxtacanicular tissue, Dr. Von Wolff said.

“Very seldom, even after stripping, the flow is not adequate,” he said. “At this time, we do radial perforation of the trabecular meshwork.”

He said the adequate exit of aqueous humor from the surgically exposed trabecular meshwork is crucial to successful non-penetrating glaucoma surgery. Surgical techniques should be applied to ensure sufficient flow, the study found.

Collagen device useful for refractory glaucoma

A collagen device designed to treat glaucoma may be an effective alternative to surgical treatment of refractory glaucoma, according to a presentation made here.

Svetlana Y. Anisimova, MD, discussed potential applications for a new, elastic porous implant of xeno-collagen (type 1) with sulfated glycosaminoglycanes she said can exist in the intrascleral space for several years. In her study, Dr. Anisimova examined 72 eyes of 62 patients with refractory glaucoma. One group had undergone non-penetrating surgery and the other group had undergone angle-uveal insertion of the collagen device. The mean IOP for both groups was 28.5 mm Hg and the patients averaged two medications a day before surgery. A total of 32 eyes had previously undergone different filtering and laser procedures.

None of the patients in either group had postop inflammatory responses, Dr. Anisimova said. Postoperatively, after 3 years of follow-up, 85% of the patients had IOP no higher than 21 mm Hg, with the mean being 16.7 mm Hg. The average amount of medication 21 patients was on dropped to an average of one to two. In 17 cases, YAG laser was performed between 1 and 3 years after initial surgery.

“There was no fibrosis around the implant, and good poral structure,” Dr. Anisimova said. “The effect was very good in all cases.”

Dr. Anisimova also said the implant can be used during penetrating procedures as inert and effective drainage.

“The aim is not only to open Schlemm’s canal, but to keep the intrascleral space for years after surgery,” Dr. Anisomova said.