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Inside this issue: Issue 1 2018

 

Special Focus: An overview of the state of play on glaucoma, where we are in glaucoma and where we are going

Author: Robert Stamper MD, PhD
Department of Ophthalmology, University of California in San Francisco, USA

Core Concepts

  • Genetics, oxidative stress, inflammation, glial activation and dysfunction, ageing all play an interactive role in ganglion cell degeneration and death
  • Stiffening inside and outside the trabecular meshwork cells lead to reduced trabecular outflow
  • IOP elevation and fluctuation still most important risk factors for glaucoma
  • Ethnicity, genetics, diet, low blood flow, corneal hysteresis and sleep apnea are other risk factors
  • Up to 60% of peak IOP occurs outside of office hours
  • Virtual reality visual field testing shows promise to improve detection of progression.

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What’s New: Importance of early glaucoma diagnosis and possible options                                                                                           

Author: Luca Rossetti MD, PhD
Department of Ophthalmology, Ospedale San Paolo, Milano and University of Milano, Italy

Core Concepts

  • Early diagnosis is “key” for best glaucoma management
  • Perimetry still represents the “gold standard” for glaucoma diagnosis and monitoring
  • Testing central 10° of the field with increased point density can improve early glaucoma detection
  • Electrophysiology may objectively reveal some reversible glaucoma dysfunction
  • Combining information from different structural measurements can improve diagnostic performance of OCT

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Clinical Issues: Current gold standard in monitoring glaucoma progression, including HRT, OCT, GDx, PERG/VEP 

Authors: J Mohamed-Noriega¹ and DF Garway-Heath²
1 NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
2 Department of Ophthalmology, Faculty of Medicine and University Hospital, Universidad Autónoma de Nuevo León, Monterrey, México.

Core Concepts for Structural Imaging

Pros

  • Imaging enables physicians to obtain an accurate, repeatable record of structure.
  • Longitudinal measurements may be used to estimate a ‘rate of change’, which can help patient management, but normal ageing should be taken into account.
  • The speed of new imaging devices makes it possible to acquire images that allow an objective assessment of progression for patients who are unable to perform perimetry (e.g. young children, dementia).
  • The most studied and best-established OCT parameter to monitor progression is cpRNFL. However, alternatives such as GCL/IPL, lamina cribosa, BMO-MRW, and OCT angiography have been used in longitudinal studies and are becoming commercially available.
  • Some OCT parameters might be more clinically useful at different stages of the disease.

Cons

  • The temporal relationship between optic disc deformation, cpRNFL thinning and GCL loss is variable and poorly understood and for that reason there is no gold standard parameter to monitor changes in structure..
  • A definition of ‘clinically significant’ change for measurements of structure progression has not yet been established.
  • Continued development means that some devices or software versions may become obsolete rapidly.
  • The ability of imaging devices to measure multiple structures simultaneously (cpRNFL, GCL/IPL, BMO-MRW, lamina cribosa, others) increases the risk of more false positives due to artifact and multiple testing.
  • No imaging technology can replace the judgement of the clinician as to whether clinically significant progression that requires intensification of treatment is present for an individual patient. 

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Practical Tips: Management of glaucoma in pregnancy and lactation

Author: John Thygesen, M.D.
Associate Professor, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark, Chair of European Glaucoma Society Training Support Committee


Core Concepts

  • All anti-glaucoma medications are categorized as class C (a risk cannot be ruled out) by the US Food and Drug Administration (FDA), except alpha-agonists (brimonidine) which belong to class B.
  • Alpha-agonists may cause respiratory and central nervous system depression and therefore should generally be stopped during month 9.
  • Glaucoma laser procedures, such as laser peripheral iridotomy and laser trabeculoplasty, have been employed without identifiable teratogenic effects or increased risk of side effects for pregnant women.
  • In pregnant women needing surgery, most local anesthetics may be used safely because they have not been shown to be teratogenic in humans.
  • Antifibrotic agents used adjunctively in trabeculectomy, should be avoided!

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About Glaucoma Now

Our goal is to educate and update general ophthalmologists, glaucoma specialists and ophthalmology residents. Learn more about our publication, guidelines for authors and our editorial board.

Editorial Board

Ivan Goldberg MD, FRANZCO, FRACS, Sydney Eye Hospital, Sydney, NSW, Australia

Remo Susanna Jr MD, Department of Ophthalmology, University of São Paulo, São Paulo, Brazil


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