World Glaucoma Congress, 28 June – 1 July, Helsinki

There was much to celebrate at the 7th World Glaucoma Congress 2017 is the hundredth year of Finnish independence from Russia and the 20th anniversary of the founding of the Finnish Glaucoma Society.

Since the first WGC in Vienna in 2005, both the second-yearly Congress and the Association have thrived. Australian input has been, and continues to be strong the Australian and New Zealand Glaucoma Society was a founding regional member, Prof. Paul Healey is the current Treasurer and I was President 2006 – 2008. Our glaucoma sub-specialists populate several WGA Committees, including the Board of Governors, the Council, the General Assembly, the Patients’ Committee, the Finance Committee, the Associate Advisory Board and the WGA Foundation Board.

Major Association projects include its Consensus Statements, its International Glaucoma Review publication, its Africa Project and the World Glaucoma Week each March. It truly is the umbrella organisation for the global glaucoma community.

There was much to celebrate at the 7th World Glaucoma Congress

While under the auspices of Executive Vice President Prof. Robert Fechtner, (New York) and President Prof. Tin Aung (Singapore), Prof. Jonathon Crowston, (Centre for Eye Research Australia, Melbourne), headed the meeting’s Program Committee which assembled an impressive array of plenary sessions, lively debates, courses, workshops and wet labs. As 2017 also marked the centenary of Lindberg’s original description of exfoliation syndrome, the commonest identifiable cause of glaucoma globally, it was fitting that there were four sessions devoted to this topic, including the President’s Symposium that constituted the opening session.

Also highlighted in both presentations and wet labs, were the new Minimally Invasive Glaucoma Surgeries. Increasing global experience with these procedures is allowing gradual, meaningful assessment of each for effectiveness and safety. Their placement in the spectrum of glaucoma treatment is slowly becoming clearer.

With the World Health Organization’s recent declaration about the centrality of patient-oriented care to all medical management, most welcome was the meeting’s focus on the patient perspective; this was through several patient-outcome symposia. In one of these, Glaucoma Australia’s Geoff Pollard spoke to “What an ophthalmologist should do in developed countries”, complementing Nigeria’s Dr. Sola Olawoye “What an ophthalmologist should do in the developing world”, and San Francisco’s Dr. August Colenbrander’s exquisite presentation on glaucoma’s effects on a patient’s visual perception and subsequent abilities, with practical steps to help (“Scotoma awareness and low vision assistance”). Dr. Pradeep Ramulu, Wilmer Institute presented his team’s work quantifying glaucoma patient challenges in everyday living as visual function deteriorated.

Neuroprotection, neuro-enhancement and neuro-regeneration featured, marrying laboratory science with clinical medicine and discussing methods of assessing efficacy of various proposed protective mechanisms clinically in a feasibly abbreviated time frame. Genetic advances were addressed across the spectrum of primary and secondary glaucomas, with wonderful contributions including Australia’s Profs. David Mackey and Jamie Craig and Dr. Alex Hewitt.

The many posters on display generated much informal discussion, as did the film festival. Industry was well represented.

Another session in which I was involved tackled current practical strategies to optimise glaucoma management for individual patients. Profs. Remo Susanna (Sao Paulo), Prin Rojanapongpun (Bangkok) and Jose Maria Martinez de la Casa (Spain) and I tackled unmet needs in glaucoma: why do patients still go blind? What are the most important parameters in assessment of the risks posed by intraocular pressure (IOP) – average, fluctuations, peak?, how to optimise the balance between potential benefit against possible risks, and how to address non-adherence with medical therapy.

The answers we attempted: people still go blind from glaucoma because late diagnosis means more irreversible visual damage has been sustained before treatment begins; because of insufficient reduction of IOP; because of unreliable adherence and non-persistence with medical therapy. Better opportunistic screening by eye health practitioners and more realistic target pressures, better software to demonstrate progressive damage structurally and/or functionally (so that treatment can be accelerated) and new drug delivery systems to ‘take the patient out of the treatment strategy’ were all addressed, along with the earlier use of surgical techniques such as the newer MIGS procedures undergoing extensive assessment.

We spoke to the importance of peak IOP rather than ad hoc clinic-generated random levels, and the value of the water drinking provocative test to detect this peak in a practical fashion while we await technologies that measure real-time 24/7 IOP levels. Every decision in management, from initiation of therapy to its possible acceleration, depends on the expected benefits from any change versus the risks associated with it. The greater the visual damage, the higher the risk of visual disability, the greater the tolerance for adverse possibilities in any recommended change.

Non-adherence remains a major hurdle for patients on long-term medical therapy. We made the point: knowing just two facts, that glaucoma could blind them and that IOP reduction (with their drops) could protect them, doubled measured adherence and persistence rates. Ophthalmologists need to work with individual patients to help them to find and to apply specific strategies to adhere and to employ the assistance of allied professionals such as pharmacists, general practitioners and optometrists. This is precisely one of the tacks Glaucoma Australia is pursuing.

We look forward with great anticipation to the 8th World Glaucoma Congress scheduled for March 27 – 30, 2019 – in Melbourne! Visit www.worldglaucoma.org/

Clinical Associate Professor Ivan Goldberg is Director of Eye Associates in Sydney, Head of the Glaucoma Unit and Visiting Ophthalmologist at the Sydney Eye Hospital, as well as Clinical Associate Professor at the University of Sydney. He is Vice President of Glaucoma Australia.

Dr. Simon Skalicky

Glaucomatous optic neuropathy, especially early in the disease course, is often asymptomatic. However, patients can perceive symptoms related to the treatment (eg. side effects from eye drops) or concerns about the risk of future blindness, loss of independence and driving, and the burden of ongoing treatment and monitoring. Unfortunately such dimensions are easily glossed over, with clinical focus on the IOP, signs of progression and/or glaucoma treatment.

Much quality of life (QoL) research in glaucoma has focused on visual disability related to glaucomatous optic neuropathy, despite the irreversible nature of glaucomatous visual loss. More research is required to evaluate the influence of co-morbidities and other factors on QoL in glaucoma, some of which may be treatable and/or reversible, potentially leading to tangible functional improvements for patients.

I presented five clinical studies that I have undertaken with colleagues to evaluate the influence of ocular comorbidities and other factors on QoL in glaucoma.

Ocular Surface Disease

Ocular Surface Disease (OSD) affects 20–59 per cent of glaucoma patients, and is exacerbated by preserved (and to a lesser extent preservative-free) topical medications. The influence of OSD on QoL was evaluated in 101 glaucoma patients and 23 controls.1 OSD worsened with increasing glaucoma severity; patients with OSD had poorer QoL than those without OSD but similar glaucoma severity. Increased daily exposure to preservative worsened QoL related to glaucoma.

Cataracts

Cataracts are common among glaucoma patients and can exacerbate their visual compromise. A study of 242 glaucoma patients and controls evaluated the influence of cataract on QoL.2 Cataract worsened activity limitation for all glaucoma severity levels; including those with very advanced glaucoma, for whom cataract surgery might still improve their visual function. Objective density of cataract more strongly predicted visual morbidity than visual acuity.

Age-related Macular Degeneration (AMD)

AMD is highly prevalent among elderly glaucoma patients. We evaluated the influence of AMD on QoL among 200 glaucoma patients, 73 of whom also had AMD.3 Patients with AMD and glaucoma had greater difficulty with using steps, judging the distance to the curb, and had a higher self-perceived falls risk than those with glaucoma alone.

Depression and Anxiety

All chronic disabling diseases, including glaucoma, are associated with increased depression +/- anxiety. A cross-sectional study of 131 elderly glaucoma patients and 34 controls measured the influence of depression on QoL in glaucoma.4 Depression worsened with increasing glaucoma severity, and predicted poorer glaucoma-related QoL.

Recently an Australia-wide randomised control trial evaluated the influence of counselling provided by Glaucoma Australia to 101 newly diagnosed glaucoma patients.5 The counselling focused on glaucoma facts, treatment and monitoring requirements, as well as answering common concerns and questions. Early counselling reduced anxiety levels at six weeks following glaucoma diagnosis.

In conclusion, despite the challenges of busy clinical practice, we must remember to think broadly about our patients, to understand the psychosocial dimensions to their health care and aim for high quality clinician/patient relationships that optimise healthcare delivery.

Dr. Simon Skalicky, FRANZCO, PhD, BSc (Med), MPhil, MMed, MBBS (Hons 1) is a glaucoma subspecialist in Melbourne. He is a Clinical Senior Lecturer at the University of Sydney and University of Melbourne. He is a federal Councillor for Glaucoma Australia and Associate Advisory Board member for the World Glaucoma Association. Dr. Skalicky specialises in glaucoma and cataract surgery.

References
1. Skalicky SE, Goldberg I, McCluskey P. Ocular surface disease and quality of life in patients with glaucoma. Am J Ophthalmol. 2012; 153: 1-9.
2. Skalicky SE, Martin KR, Fenwick E, Crowston JG, Goldberg I, McCluskey P. Cataract and Quality of Life in patients with Glaucoma. Clin Exp Ophthalmol 2015;43(4):335-41
3. Skalicky SE, Fenwick E, Martin KR, Crowston JG, Goldberg I, McCluskey P. The impact of age-related macular degeneration in patients with glaucoma: understanding the patients’ perspective. Clin Exp Ophthalmol 2016;44(5):377-87
4. Skalicky SE, Goldberg I Depression and quality of life in patients with glaucoma-related visual field impairment: a cross-sectional analysis using the Geriatric Depression Scale-15 and the Glaucoma Quality of Life-15. Journal of Glaucoma 2008;17(7):546-51
5. Skalicky SE, D’Mellow G, House P, Fenwick E, The Glaucoma Australia Educational Impact Study Contributors. The Glaucoma Australia Educational Impact Study: A randomized clinical trial evaluating the association between glaucoma education and patient knowledge, anxiety and treatment satisfaction. Clin Exp Ophthalmol. 2017 Jul [epub ahead of print]

Dr. Ashish Agar

Minimally Invasive Glaucoma Surgery (MIGS) is changing how glaucoma surgeons operate. We now have several devices that allow us to offer surgical control of glaucoma in a far broader range of indications. This is because these procedures, generally involving the implantation of a microstent, are far safer and less traumatic, in terms of the surgery as well as recovery, than conventional trabeculectomy or tube surgery.

This was evident at WGC in Helsinki, where MIGS was for the first time presented and debated at the highest levels. No longer an outlier, this is now mainstream treatment. Data from the US presented by Ike Ahmed (Universities of Toronto and Utah) show that MIGS is the fastest growing procedure in ophthalmology today. Industry has invested literally billions in this field, so they are pushing hard. But as clinicians, how do we navigate through the hype?

Our approach here in Sydney has been to rigorously audit our experience with these devices from the very beginning. This allows us to assess safety and outcomes, informing both surgeons and the profession. The Sydney Multicentre Hydrus study represents Australia’s largest ‘real world’ analysis of the role of MIGS, and was presented at WGC. We documented our experience with the Hydrus microstent (Ivantis), the only device approved for use as a standalone operation, as well as combined with cataract surgery.

The results confirm a high level of safety, with no significant device related complications in over 200 cases, comparable to modern cataract surgery. When the Hydrus microstent was combined with cataract surgery, there was a moderate 25 per cent reduction in intraocular pressure (IOP) after two years. The need for glaucoma drops also dropped by 35 per cent, a factor many patients appreciate. With standalone surgery, the results are even more encouraging. In a smaller cohort of the most challenging cases, after three years of Hydrus-only surgery IOP was reduced by 40 per cent.

Of course, trabeculectomy and tube devices remain the mainstay of glaucoma surgery, with decades of experience to back them up. However technological innovation is offering us new options to control IOP. In select cases they can be transformational, and offer the surgeon safer alternatives to conventional procedures. The role of MIGS is still being defined and we must remain cautious, particularly from a health economics perspective. But 50 years after the development of the trabeculectomy, as Ike says, maybe it’s time to “make glaucoma surgery great again”!

Dr. Ashish Agar is a glaucoma specialist at Prince of Wales and Sydney Eye Hospitals, and a partner at Marsden Eye Specialists, Sydney. A conjoint Senior Lecturer at the University of New South Wales, he is engaged in clinical studies as well as laboratory research into glaucoma. Dr. Agar is the Director of the Ophthalmology service in Broken Hill Hospital and provides outreach care through the Outback Eye Service to far western NSW. He is also the Chair of the RANZCO Indigenous Committee, and the Secretary / Treasurer of the Australian Society of Ophthalmologists.

Professor Allison McKendrick

Traditionally, it is considered that the macular area is relatively spared in early glaucoma, hence that higher spatial resolution testing of the macula is only necessary with advanced damage that encroaches on fixation. Recent advances in understanding of the early stages of the disease, assisted by OCT imaging of the macula, now clearly demonstrate that macular damage can occur early in the disease. Detecting vision loss close to fixation is important not only for disease monitoring but also because this area of vision is key to visual function in natural environments (for example reading, face recognition, visual search). A limitation of most regular grid patterns used to assess visual fields (for example, the 24-2 or 30-2 test patterns) is that very few visual field locations are sampled in the central area. Research from my lab, and others internationally, provides evidence for adding additional test points to these patterns. There is support from major perimetric manufacturers to incorporate these test locations into new test patterns in upcoming perimetric software.

Advanced Functional Assessment in Glaucoma

An overview of advances in functional testing reveals that visual field testing in the future may be directly linked to ophthalmic imaging. Additionally, visual field testing may be made more engaging to patients through the novel use of virtual reality or gamification. Portable visual field assessment may be feasible via the use of tablet technology, or accessible eye-tracking technology, and there is potential for remote monitoring via telemedicine platforms.

This session, co-chaired with Professor Vittorio Porciatti (Miami, United States), also included an update on electrophysiology for glaucoma (Dr. Brad Fortune, Portland, OR, USA; and Prof. Porciatti) and a detailed look at a potential new method for visual field assessment that involves patients simply looking from one stimulus to the next rather than manual button pressing (Prof. David Crabb, City University, London). Testing of visual performance in glaucoma is critically important for disease detection and monitoring, and is of key concern to patients. There is a large amount of international research in this area at the moment, assisted by more powerful and less expensive computer technology.

Professor Allison McKendrick is Head of the Department of Optometry and Vision Sciences at the University of Melbourne.

Associate Professor Bang Bui

It is widely accepted that glaucoma is associated with elevated intraocular pressure (IOP) elevation. However, there are some patients who develop glaucoma without IOP elevation (normal tension glaucoma) and in many patients, vision loss can progress despite successful IOP reduction. Recent studies suggest that non-IOP factors contribute to glaucoma risk, such as blood pressure, diabetes, myopia and intracranial pressure.

The optic nerve head is the primary site of injury in glaucoma. It is biomechanically the most susceptible part of the eye to stress, being the thinnest part of a pressurised chamber; hence it is prone to displacement when subjected to changes in the pressure gradient across the lamina cribrosa. Two key forces exert their effects at the optic nerve head; intraocular pressure from inside the eye and intracranial pressure (ICP) from the retro-laminar subarachnoid space just outside of the eye. Elevated IOP has been well established to cause backward bowing of the lamina cribrosa, which is consistent with the increased cupping seen in glaucoma. Conversely an increase in retro-laminar pressure will cause the nerve to move forward. For example, intracranial hypertension can manifest in the eye as papilloedema, which is associated with forward displacement of the optic nerve. As such, ganglion cell health depends on the balance between IOP and ICP.

Clinical studies support a role for lower ICP, and thus a higher pressure gradient, in the development of normal tension and high tension open angle glaucoma. Also consistent with a critical role for trans-laminar pressure, is the finding that those with ocular hypertension (without visual field loss) tended to have higher ICP.

Consistent with these clinical data, using an experimental model, we have shown that small changes to intracranial pressure can produce more substantial effects on the optic nerve structure and function than do equivalent changes in intraocular pressure. Perhaps more importantly, we show in a laboratory model using optical coherence tomography (OCT) that for similar changes in IOP and ICP, older eyes actually show tissue deformation. However, a less compliant tissue is less able to take up strain, thus we saw more retinal nerve fibre layer compression in older eyes. While Doppler OCT imaging revealed that retinal blood flow was very similar between young and older eyes, ganglion cell function in older eyes was worse off with a higher pressure difference between IOP and ICP.

As we age, ICP actually decreases a little, leading to a higher translaminar pressure gradient and potential increased glaucoma risk. This risk could be compounded by less flexible connective tissue support for the optic nerve in aging.

Associate Professor Bang Bui is Deputy Head of the Department of Optometry & Vision Sciences at the University of Melbourne. He holds an Australian Research Council Future Fellowship as well as research grants focusing on understanding the risk factors underlying age-related neurodegeneration and developing novel non-invasive imaging tools for research and clinical applications.

Geoff Pollard

A patient oriented symposium highlighted the need to consider the patient view when treating people with glaucoma.

Australia, like most developed-world countries, is ageing rapidly. The 2011 census highlighted 14 per cent of the population was over 65 years of age and this is expected to reach 22 per cent by 2061, when 85 year olds are expected to make up 5 per cent of the population and those over 100 years old will continue to be the fastest growing segment.

At the same time, Australia is one of the richest countries in the world, with a gross domestic product (GDP) 433 per cent of the world average (US$55,000 per capita). Nothing is perfect of course, but most Australians have ready access to a universal health system, and disability and pension schemes that act as a broad ‘safety net’ for the disadvantaged and ageing in our community. The increased incidence of chronic diseases arising from an ageing population, the increasing taxpayer to welfare shift and the city/country, rich/poor, insured/uninsured inequities all conspire to increase competition for health spend.

In Australia 2–3 per cent of adults have glaucoma but only half know about it. By age 40 years, one in 200 are likely to have it and even more with advancing age (one in eight at age 80). People don’t have routine check-ups but this is likely only part of the reason why rates are so poor, and why late diagnosis remains a major concern for lost vision and eventual blindness. There is also the compounding factor of low compliance, with under 50 per cent of people remaining adherent after one year on medication.

The patient passes through a number of ‘pinch points’ while on their ‘journey’. Making this less of a funnel will help ensure undiagnosed and untreated people with glaucoma will enjoy a more favourable outcome.

Eye healthcare professionals coming together with other stakeholders –representative bodies, patient advocate groups (like Glaucoma Australia) government and service providers – to focus on patient care can make a real difference when we influence all stages of the glaucoma patient journey, not just diagnosis and treatment.

Figure 1: Source: ABS 2011

Figure 2

Table 1

What Can You Do?

Advocate to create effective community messaging across the population; one that achieves a call to action:

• Glaucoma can strike at any age and is a potentially blinding eye disease.
• Regular and comprehensive eye checks are the best protection against vision loss and blindness
• This is especially relevant for the relatives of people already diagnosed with glaucoma
• Glaucoma Australia has many resources to help in that patient journey, visit www.glaucoma.org.au

Patients’ best interests are served when everyone involved works together through leadership, collaboration and showing you care.

Geoff Pollard is the National Executive Officer of Glaucoma Australia.