Education Committee Highlights WGC-2019 – part 10

The Education Committee carefully selects presentations from the WGC-2019 for your benefit. This month Ingrida Januleviciene introduces the sessions: Dilemmas in glaucoma surgery and Genetics for the non-geneticist.

Dilemmas in glaucoma surgery

When I do trab and when I do MIGS?

Dr.Julian Garcia Feijoo discussed the role for MIGS devices and Trab based on the clinical experience and existing scientific evidence. The target IOP range, stage of disease, rate of progression, age, topical treatment regime, number of drops are different among glaucoma patients. Surgeon’s choices are affecting patient’s quality of life. Patients have expectations for safe surgery, low complication rate, efficacy. He suggested to think about ocular features, type of glaucoma, patient’s life expectancy. Safer surgeries are not risk free surgeries.

When I do trab and when I do tube?

Dr. Esther Hoffman discussed difficult choices and started with the main points for the surgeon first of all to be right in your diagnosis, to be sure if this is really glaucoma. She also described the results of clinical studies proving that both methods are effective in IOP lowering, no clear superiority, but tube shunt surgery showed lower failure rates.  Surgeon’s skills and experience are important factors. She provided her personal decisions for trab or tube.

Preventing bleb failure and optimizing outcomes.

Dr Tina Wong Tzee Ling talked about problems related to the use of antimetabolites and factors influencing inflammation in the eye and scarring. Conjunctival health is important for the trabeculectomy results. She discussed the use of steroids and non-steroidal anti-inflammatory drops.

Preventing and managing Hypotony

Dr.Chungkwon Yoo talked about risks of postoperative hypotony and which eyes have higher risk for it.  He gave suggestions how to prevent hypotony and how to manage it if happens in different types of surgery based on most recent publications.

Will MIGS replace non-penetrating surgery

Dr Gordana Sunaric Megevand unfortunately could not come, so topic was presented by dr.Alain Bron. He pointed the idea that there is a good surgery for the patient and a good surgery for the surgeon and our task is to make a mixture. He discussed the problems with non-penetrating surgery leading to its relative unpopularity and compared them to the problems with MIGS. He expressed the view that new evolving techniques will help us to understand how glaucoma surgery works.

Measuring outcome in glaucoma surgery

Dr Ecosse Lamoureux talked about clinical endpoints that are IOP, visual field, but it rarely matters in patient’s perspective. Patients may better understand such an outcome as e.g. reading speed, text messaging, etc. It means that we need to look beyond clinical outcomes to the patient reported outcomes. He mentioned that we need to look at more sophisticated and sensitive things, at all the items and domains affected by disease.

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Genetics for the non-geneticist

How can you tell that genetics are involved in a disease and traits- Introduction to heritability

Dr.Alex Hewitt talked about possibilities to evaluate evidence for high heritability,  genetic factors, environmental factors evaluating homozygotic twins, giving examples of tight correlation in identical twins as compared to non identical. Also he mentioned possible pedigree studies, investigations of glaucoma endophenotypes  – measurements that are abnormal in glaucoma e.g. IOP, Optic nerve. He mentioned that electronic health records passively capture a wide range of clinically relevant data and provide a resource for studying the heritability of traits that are not typically accessible.

Importance of families/pedigrees in genetic studies

Dr.David Mackey discussed that after finding random glaucoma cases in the population we should think about genetics and think about heritability.  He talked about problems finding genes using linkage and association studies (“mutation” carriers are distantly related).  He mentioned testing penetrance, cascade screening – clinical and genetic and family strategies for implementing treatment.

Complex inheritance patterns

Dr.John Fingert overviewed the potential benefits of genetic studies, diagnostic utility, early detection confirming clinical evidence of disease. He talked about prognostic utility and ability to predict the course of disease and possible response to therapy. Family counseling helps to evaluate the risk for offspring.  He also discussed gene directed therapies – medications that target a gene defect and gene therapy (viral delivery of normal genes). The future ideas of genome editing (in vivo gene repair) and regenerative therapies as stem cell therapy (replacement of tissue).

Labwork & genetics- what is involved

Dr.Monica Melo talked about requirements for genetic tests in both clinical and research context. She stressed that it is a multidisciplinary team work involving clinicians, nurses, technicians and researchers. Genetic tests results might show unexpected results and not always answer all the questions.

What is a GWAS?

Dr.Ching-Yu Cheng talked about Genome-Wide Association Studies. He mentioned association studies evaluating direct association between risk factors and disease, providing examples of association between family history, genetic factors and glaucoma.

Why would you even bother mapping genes? Translation of GWAS results

Dr. Stuart MacGregor talked about translation of Genome-Wide Association Studies results and why would we need genes mapping. He discussed causal Inference, new drug targets, genetic risk prediction examples. He stated that GWAS has identified many glaucoma risk loci, is useful for causal inference. It helps identifying new drug targets. He talked about genetic risk prediction and mentioned that good risk stratification in general population may help identifying disease progression in early disease or need for surgery in advanced disease.

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