Education Committee Highlights WGC-2017 -part 8

The Education Committee carefully selects presentations from the World Glaucoma Congress 2017 in Helsinki for your benefit. This month Maria Carassco introduces the sessions Angle closure and angle closure glaucoma, Big data and glaucoma and CSF pressure and glaucoma.

Angle closure and angle closure glaucoma (APGS symposium)

Over the last few years, the classification of angle-closure glaucoma has undergone revisions. One common classification is based on the presence of symptoms but fails to identify a large number of asymptomatic patients and people at risk. In addition, it does not help the ophthalmologist who wants to plan an appropriate treatment and predict prognosis. The term “glaucoma” is currently used indiscriminately, regardless of the presence or absence of optic neuropathy and vision loss. The usefulness of the natural history classification is clearly addressed by Paul Foster.

By 2040, 32 million individuals will have angle-closure glaucoma (ACG), and half of those blind from glaucoma will have angle closure. It is important to know the prevalence in your region and to be able to identify at-risk populations of this potentially blinding disease by watching the presentation by Dr. Makoto Araie.

There are several angle-closure mechanisms that play a role in causing anatomical angle-closure. These include pupillary block, iris and ciliary body abnormalities, lens-related causes, as well as causes that are located behind the lens. A classification of the mechanism that identifies the obstructions to aqueous flow at different levels could be widely accepted and could help predict responses to treatment. Advances in imaging have demonstrated that combined mechanisms are present in some patients. Dr. Winifred Nolan shows interesting cases and discusses the relevant findings.

On Diagnosing Angle Closure: Is gonioscopy the gold standard for angle evaluation yet? Why is indentation gonioscopy crucial in angle closure disease? What are the advantages and disadvantages of imaging tools like Anterior Segment OCT or UBM? Which other techniques may help to diagnose an angle closure? Find out by watching Dr. Ho’s presentation.

While laser peripheral iridotomy appears relatively harmless, one cannot be certain of the long-term safety of this procedure. Dr. Yamamoto shows the long-term outcomes of LPI as IOP control, endothelial cell loss and results according to the extension of PAS (peripheral anterior synechiae). He also mentions other treatment options like lens extraction and trabeculectomy.

The management of primary angle closure may be challenging. Do yourself a favor and do not miss the clear and dynamic presentation of Dr. Clement Tham who discusses treatment options in different scenarios. His flow charts will be very helpful in your daily practice. One of the best lectures of the congress!

Acute Angle Closure Crisis is an emergency. Access this video to learn how proceed: First step: lower IOP as soon as possible. Dr. Fang discusses many alternatives. Second step: reverse the mechanism of angle closure: use LPI whenever useful or phacoemulsification. Third step: do not forget to treat the fellow eye. Fourth step: appropriate follow up.

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Big data and glaucoma

Big data is extremely large data sets that may be analyzed computationally to reveal patterns, trends, and associations that relate especially to human behavior and interactions. Do we have the big data about glaucoma?

Detecting glaucoma requires a thorough analysis along with a relevant examination of risk factors and changes in structure and function. Dr. Tatham lectures about the specificity and sensitivity as well as the strengths and limitations of these tests. Access to modern technology in low income countries is challenging but the necessity for diagnosis, documentation and follow-up supersedes these challenges because the rate of blindness and advanced glaucoma are becoming more frequent. Dr. Philippin shows how to use smartphone cameras, low cost ophthalmoscopes as well as how to conduct visual field tests with a laptop in underdeveloped areas.

Open angle glaucoma has a significant genetic component with a relative risk of over 9 in first-degree relatives of affected individuals when compared to relatives of unaffected people. Genome-wide association studies (GWAS) have now successfully identified important genetic variants associated with many human traits and diseases. Dr. Hewitt introduces us to this innovative and groundbreaking topic. After, Dr. Craig addresses interactions between genes and their environments with valuable examples about the upregulation of the myocilin gene with steroids and the increased expression of LOXL1 under UV irradiation in Pseudoexfoliation.

What information enables an analysis of half million of the visual field? David Crabb provides data of VF progression, the initial presentation stage of glaucoma, and the right frequency of testing that may surprise you as well as save costs in the health care system.

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CSF pressure and glaucoma

A message to take home: The Imbalance between IOP and cerebrospinal fluid pressure may influence the risk of normal-tension glaucoma or the susceptibility of the optic nerve to ocular hypertension. Dr. Wang discusses the possible mechanisms at play from optic nerve damage based on the results from animal models with lower Cerebrospinal Fluid Pressure (CSFP). A comprehensive review of the existing clinical data that supports the role of CSFP in normal tension glaucoma, open angle glaucoma and ocular hypertension is discussed in the lecture by Dr. Berdhal.

Will measurements of intracranial pressure be a routine examination in glaucoma? How does one measure ICP non-invasively? Dr. Sit talks over present and future techniques.

Over the last few years, Dr. Jonas has paid considerable attention to the role of lamina cribosa in the pathogenesis of glaucoma. The concept of trans-lamina cribosa pressure difference is addressed, as well as interactions between the “three pressures”: intraocular, blood and intracranial.

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