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Pearls and insights from the experts at Moorfields International Glaucoma Symposium, part 1
Many of the presentations focused on patient-centered approaches to treatment, challenging cases and surgical tips.
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Regent’s Park in London was the destination for the 8th Moorfields International Glaucoma Symposium, organized by local faculty Keith Barton, Winnie Nolan and Nick Strouthidis. Multiple international experts shared their personal experiences and tips for managing difficult glaucoma cases — a unique learning experience that just cannot be emulated with textbooks or journals.
Patients first
A continuing theme throughout the symposium was the importance of a patient-centered approach to our management of and research into glaucoma.
Pradeep Ramulu gave us insight into how glaucoma affects the daily lives of our patients and how we may not always be asking the correct questions. While glaucoma patients may not have impaired short duration reading, asking about reading ability for longer durations may uncover difficulties. Ramulu also discussed the association between reduced physical activity and degree of visual field loss; a mediation analysis conducted by his research group suggests that this may be a causal relationship of less physical activity resulting in worse glaucoma.
Russell Young, chief executive of the International Glaucoma Association, discussed driving issues for glaucoma patients and shared results from a UK survey. He said that while the ability to drive is one of the top concerns of glaucoma patients, 45% of survey respondents had never had a discussion about driving with their physician. Encouragingly for patients, 95% of group 1 drivers with bilateral glaucoma retained their license after testing. However, a significant proportion of patients reported poor conditions at test centers, including noisy environments and inadequate explanations of the field test.
Richard Wormald asked us the question: Who really benefits from glaucoma research? Is it the researcher for his career, or the patent holder, or pharmaceutical companies, or patients and their carers? Wormald encouraged us to involve patients in our study planning and process to ensure the research we do truly benefits our patients.
Romesh Angunawela reminded us that 60% of glaucoma patients have ocular surface disease symptoms compared with 10% of a similarly aged general population. He advised we need to consider how we prescribe BAK-containing drops in the long-term management of patients because BAK builds up in ocular surface cells cumulatively and remains even after cessation of the BAK-containing drops.
Challenging cases
No matter how experienced we become, rare situations or unexpected outcomes still challenge us in the management of glaucoma, and experts sharing what they have learned from such cases is always informative and engaging.
Leon Au shared a case of a patient with ocular cicatricial pemphigoid and glaucoma who developed a corneal melt following transscleral cyclophotocoagulation therapy due to a neurotrophic defect. In retrospect, he suggested newer angle procedures as a good option, and tube surgery is also a reasonable option despite the conjunctival disorder if patients are adequately immunosuppressed.
Gus Gazzard shared his tips for managing patients with cyclodialysis clefts. He explained that assessing patients is often difficult due to a soft eye and advised visco-assisted gonioscopy with pilocarpine administration if necessary, with the utility of 360° swept-source OCT for delineation of the cleft. While some cases may resolve spontaneously, surgery is sometimes necessary, and Gazzard recommended the use of an intraoperative endoscope, if available, for direct visualization.
Jonathan Clarke shared a case of Schwartz-Matsuo syndrome, stressing that the “cells” seen in the anterior chamber are larger than true cells and are in fact photoreceptor end-plates that have a route into the anterior chamber, potentially via a retinal dialysis. The syndrome is cured by retinal surgery and is not the explanation for increased IOP frequently seen following retinal detachment surgery.
Mark Sherwood and Poornima Rai discussed cases requiring multiple tube surgeries. Sherwood shared his local outcomes for second tube insertion (50% failure at 5 years) and suggested that some patients may require a third tube. Rai identified risk factors for patients requiring multiple tubes in her practice; these included young age, only eye affected, steroid responders, preservative intolerance, acetazolamide intolerance and failed trabeculectomy.
Surgical tips
Winnie Nolan gave tips for the surgical management of angle-closure. She advised initial transscleral cyclophotocoagulation in refractory acute angle closure and then lens extraction once the IOP has settled, especially if the patient is unsuitable for a general anesthetic. Nolan said she aims for +1 D postop refraction in very high hypermetropia, as the final outcome is often significantly more myopic than predicted. The role of trabeculectomy was discussed in angle-closure, and she advised very careful patient counseling, especially regarding the risk of aqueous misdirection. There was further discussion regarding the management of primary angle-closure suspects. The panel advised undertaking laser peripheral iridotomy (LPI) in white patients but observing black patients, who do not respond as well to LPI and may develop adverse effects. It was also stressed that patients undergoing clear lens extraction for angle-closure should have a clear discussion explaining that their vision may be worse following the procedure.
There was a panel discussion regarding which eye to operate on first in patients with bilateral progressive open-angle glaucoma — the better or worse eye first? In general, the panel felt it was best to operate on the worse eye first because the experience and outcome of surgery will better inform both the patient and the surgeon about the individual response to surgery. However, situations were highlighted when it may be appropriate for the better eye to be operated on first, such as when a patient only wants one operation or when a patient may not have access to medical care for a long enough period to have both eyes operated.
Part 2 of our coverage of the Moorfields International Glaucoma Symposium will be in next month’s issue of OSN Europe Edition and includes a discussion of minimally invasive glaucoma surgery and glaucoma management in patients with comorbidities.
- For more information:
- Anthony P. Khawaja, MB BS, MA(Cantab), MPhil, FRCOphth, OSN Europe Edition Board Member, can be reached at Moorfields Eye Hospital, 162 City Road, London EC1V 2PD, UK; email: anthony.khawaja@gmail.com.
Disclosure: Khawaja reports no relevant financial disclosures.