The Education Committee carefully selects presentations from the WGC-2019 for your benefit. This month Marcelo Hatanaka introduces the sessions: Collaborative care symposium and Lasers in glaucoma: a critical review.
Collaborative Care Symposium
In this session, the panelists present a great discussion on how to better manage the increasing glaucoma burden on health services. While collaboration may reduce patient waiting time and improve diagnosis, there are issues to be addressed, such as the elaboration of protocols, referral criteria, education, training, communication, data safety, among others.
Education, demographics, burden of disease, preparedness of the future, what is adequate training
To better understand the rationale of collaborative care in the management of glaucoma, Dr. Sharon Bentley presented some data regarding the number of ophthalmologists, health care providers and/or optometrists, as well as their distribution in Australia. She also called the attention to the fact that there is an increasing number of patients with ocular hypertension and glaucoma in need for immediate diagnosis and treatment, in a scenario of fewer resources. While thinking in a team-based care approach, education and adequate training must be taken into account.
The published experience of collaborative care
Dr. Verona Botha shared her experience on a collaborative care glaucoma clinic in New Zealand. Despite the increase in patients and visits over 5 years, in a scenario of collaborative care among ophthalmologists and optometrists, there was a significant reduction in uncontrolled IOP patients, as well as progression rate. A reduction in follow up delays and in waiting times was demonstrated. Another benefit was the detection of other pathologies.
Real world issue in optometry
Murray Smith, Optometrist from Melbourne, Australia, stated that, while this may not be the case in the worldwide scenario, optometry workforce is available in Australia to take part of a glaucoma collaborative care. However, challenges were pointed out by the speaker: training, qualification, variability of activities performed by the optometrist around the World, loss of commitment to shared plan, among others.
Real world issues
Dr. Brain Ang addressed the risks of collaborative care in glaucoma management. Dr. Ang pointed out that patients may have a perception of poorer quality care, lack of continuity of care and even extra cost to receiving care. An administrative burden may also exist, with extra cost, time and effort for training other practitioners, e.g., optometrists. Information loss along the chain may lead to loss of follow-up. In his presentation, Dr. Ang also mentioned that inadequate training may cause incorrect diagnosis and progression detection. The need of special equipment, training, administration, adequate backup systems and ideal IT environment will also increase costs. Finally, medico-legal risks must be taken into account, said Dr. Ang.
Real world issue in a rural optometry setting
In order to improve glaucoma care in a rural setting, Dr Richard Lenne presented arguments to get local optometrists to help monitor and assist glaucoma patients. In this setting, according to Dr. Lenne, good communication among professionals is essential to ensure glaucoma treatment is continued and monitored.
A future state
Dr. Catherine Green presented a wrap-up lecture about collaborative care and glaucoma assessment. In her presentation, it was emphasized that in a patient-centered care, “work is done by the least expensive, qualified caregiver or multidisciplinary team at the location most accessible to the patient”. The concept of collaborative care was also revisited: “The inter-professional process for communication and decision-making that enables the separate and shared knowledge of care providers to synergistically influence the patient care provided”. With that in mind, Dr. Green discussed the guidelines for the collaborative care of glaucoma patients by ophthalmologists and optometrist in Australia, presenting the roles of each professional in the management of glaucoma.
Lasers in glaucoma: a critical review
Laser iridotomy in PACS – ANALIS results
Dr. Mani Baskaran, from Singapore, initiated this session with a nice review of the ANALIS results. He called the attention to the fact that the economic burden of treating all PACS with LPI may be high. Also, he emphasized that there is no clear consensus on the indication for prophylactic LPI in asymptomatic PACS. In a RCT with 5 years follow-up time, prophylactic LPI in one eye and no treatment in the fellow eye was performed in bilateral asymptomatic narrow angle subjects with > 50 years of age. Non-LPI eyes had a 1.92 times higher risk of progression in 5 years, compared to LPI eyes. Prophylactic LPI in 21 patients was able to prevent progression in 1 patient over 5 years. The majority of asymptomatic PACS patients did not progress. From those who progressed, the majority developed PAC with or without PAS. Prophylactic LPI was able to retard progression in a group of patients with PACS, he concluded. Also, as stated by Dr. Baskaran, NNT analysis supports prophylactic LPI for asymptomatic PACS.
Laser iridotomy in PACS – ZAP Trial
The next video, on the other hand, presented the results of the ZAP Trial. Dr. Mingguang He. Dr. He reminded that in a population-based study (He et al., Ophthalmology 2007), 20% of angles remained closed immediately after LPI. He also pointed out that there are about 28 million PACS in China, and that nearly 50,000 LPI are performed annually in the USA. In this scenario, the results of the ZAP trial were presented. In summary, the risk on developing PAC was reduced by half (LPI-treated eyes had a 47% reduction in the risk of reaching an endpoint). In a context of a very low event rate, an overall annual risk reduction of 0.38% would lead to a need to treat 44 to prevent 1 case of new PAC over 6 years. Based on these numbers, said Dr. He, community-based screening to identify PACS and perform LPI is not recommended.
LiGHT Trial results
Another trial was discussed in this session. This time, Dr. Gus Gazzard revisited the LiGHT Trial. This study was performed to determine whether primary SLT delivers better health-related quality of life at 3 years than medicine first in POAG or OHT. Clinical outcomes from six centers, at three years were presented. After analyzing all data and results, Dr. Gazzard concluded that beginning with laser, drop-free disease control was achieved with lower surgery rates, less glaucoma progression and lower cost in ¾ of patients. SLT was safe with no sight threatening side effects, and SLT should be considered for all newly diagnosied patients with POAG or OHT, said Dr. Gazzard.
Recent findings in ECP including endocycloplasty
Dr. Francisco Lima presented the last lecture in this session. First, he presented data from Arora et al. (Ophthalmology 2015), who demonstrated that total cyclophotocoagulation procedures increased 253% from 1994 to 2012, while there was a decrease of various glaucoma surgeries and procedures during the same period. In this scenario, Dr. Lima presented various studies that suggest the efficacy of endocyclophotocoagulation in uncontrolled glaucoma. In this lecture, the results of endocycloplasty for the management of ACG secondary to plateau iris syndrome were also discussed.