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8th Congress of the European Glaucoma Society Berlin,…
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8th Congress
of the European
Glaucoma Society
Berlin, Germany, 1st 6th June 2008
Courses
Courses 1 Courses 2
C1.19a C2.22
GONIOSCOPY SAFE TRABECULECTOMY
J.F. Salmon T. Zeyen1, P.T. Khaw2
Ophthalmic Surgeon, Oxford Eye Hospital, United Kingdom 1
Middelheim Hospital, Antwerp, Belgium; 2 Glaucoma Unit and
Ocular Repair and Regeneration Biology, National Institute for
Gonioscopy is a demanding skill and an essential part of the ex- Health Research Biomedical Research Centre, Moorfields Eye
amination of a glaucoma patient. It is only by undertaking go- Hospital and UCL Institute of Ophthalmology, London, United
nioscopy on every glaucoma patient that the clinician will be- Kingdom
come familiar with the variety of normal and abnormal findings
that may be present. The most common cause of an incorrect This course will describe techniques for successful perform-
diagnosis is the omission of gonioscopy by the clinician who rea- ance of trabeculectomy. The following steps will be reviewed
sons that if the slit-lamp examination does not suggest a nar- in detail: atraumatic dissection of conjunctiva and scleral flap,
row angle, ocular inflammation, new vessel formation or signs adjustable and releasable flap-sutures, handling anti-fibrotic
of previous trauma, the patient must have an open angle mech- agents, maintaining the anterior chamber well formed during
anism. Chronic angle-closure glaucoma and many other forms the entire surgery, tight wound closure, and postoperative
of glaucoma can therefore be overlooked. Once the exact cause management of the failing filter. At the end of this course, at-
of the glaucoma is known specific therapy can be instituted. tendees will understand the available techniques for safer and
more efficient trabeculectomy and will comprehend postoper-
C1.11b ative adjuncts for dealing with failing filtration characterized
by either high IOP or low IOP.
PIGMENT DISPERSION SYNDROME
D. Broadway
Norfolk & Norwich University Hospital, United Kingdom C2.21
VISUAL FIELD TESTING THROUGHOUT THE GLAUCOMA
Pigment Dispersion Syndrome and Pigmentary Glaucoma typ-
CONTINUUM: A GUIDE TO SELECT BEST METHODS AND
ically affect young myopic individuals. Irido-zonular contact
STRATEGIES
causes dispersion of iris pigment epithelium melanin granules
F.J. Goņi
that become deposited throughout the anterior segment and
Hospital of Granollers I Mollet, Barcelona, Spain
in particular within the trabecular meshwork. The condition is
associated with a number of characteristic clinical features,
which will be described and demonstrated. Accumulation of Determination of visual function in ocular hypertensives, glau-
pigment within the outflow channels may result in transient coma suspects and early, moderate and advanced glaucoma
elevation in intraocular pressure or irreparable damage and patients strongly differs in terms of frequency of testing and
significant chronic glaucoma. methodology. The aim of this course is to provide a guidance
The aim of this course is to present a comprehensive about the What, When, Why and How of visual field testing
overview of Pigment Dispersion Syndrome and Pigmentary throughout the Glaucoma continuum. Non-standard perimetry,
Glaucoma for both the general ophthalmologist and specialist standard achromatic perimetry and use of non-standard pa-
with an interest in Glaucoma. rameters will be reviewed, to obtain the highest performance
The course will cover history, definitions, demography, clinical from the different tools available in our automated perimeters.
features, differential diagnosis and aetiological theories. The
course will also cover management with a discussion on the
C2.03
evidence for laser iridotomy as a useful therapeutic modality.
GENETICS OF POAG
F. Topouzis1, A.C. Viswanathan2
C1.26
II Department of Ophthalmology, Aristotle University of
AQUEOUS SHUNT IMPLANTATION Thessaloniki, Thessaloniki, Greece; 2 Moorfields Eye Hospital
K. Barton and Institute of Ophthalmology, London, United Kingdom
Moorfields Eye Hospital, London, United Kingdom
Synopsis and objective: This course will provide information
This course will cover a number of practical issues, including: on background and evolution of glaucoma genetics. Genes
1) the basic principles of aqueous shunt function; and loci found so far will be reviewed in the first part of the
2) the changing indications for aqueous shunt implantation in course. In a second part, there will be a complex studies
the light of recent trials; presentation which will include commingling analysis and ini-
3) basic implantation technique step by step and possible tiation in Quantitative Trait Locus (QTL) analysis concept. The
variations; importance of detailed and standardized phenotyping in QTL
4) practical management of specific challenges in implant sur- analyses will be stressed in a third part and there will be a
gery. These include modifications in technique required to reference to ongoing as well as future work. At the end of the
deal with preoperative impediments such as scleral buckles, course, participants will (1) have information on up-to-date
thin sclera, drainage blebs, anterior synechiae, shallow cham- complex genetics research and applications, (2) be aware of
bers and silicone oil; methodology principles, difficulties and practical issues when
5) postoperative problems such as high pressure, low pres- conducting such studies, (3) be informed on current glauco-
sure, occlusion, retraction and erosion. ma genetics research such as the glaucoma component of the
Objective: To illustrate the range of methods that can be used Wellcome Trust Case Control Consortium (WTCCC) and the
in implanting drainage devices in response to various difficult EGS-GlaucoGENE Project, a pan-European Genetic
situations or unexpected circumstances, with a particular em- Epidemiology Study of Glaucoma involving among others very
phasis on preventing and dealing with complications. detailed and standardized phenotyping.
www.eugs.org 74
C2.01 flow pathways in patients with glaucoma, and the structural
and physiological aspects of those surgical procedures that di-
HEALTH ECONOMICS IN GLAUCOMA CARE (DETECTION
rectly target the trabecular meshwork outflow pathways.
AND MANAGEMENT): DEFINITIONS AND METHODS
A. Azuara-Blanco1, A. Tuulonen2, J. Burr3
1
Aberdeen Royal Infirmary, 3 HSRU, University of Aberdeen, C3.30
Scotland, United Kingdom; 2 Department of Ophthalmology,
ANGLE SURGERY: HOW TO GET RID OF THE BLEB
University of Oulu, Finland
S. Gandolfi1, C.E. Traverso2
1
Eye Clinic, University of Parma, Parma, Italy; 2 Dinog-Eye
The main concepts (efficacy, effectiveness and efficiency) and
Clinic, University of Genova, Genoa, Italy
methods of economic evaluation (cost minimization, cost-ef-
fectiveness, cost-utility and cost-benefit analysis as well deci-
The course will focus on the basic techniques of modern angle
sion analytical modeling) will be introduced. The summary of
surgery. In particular, the following procedures will be dis-
utility measures published in published in glaucoma literature
cussed: (a) the trabecular micro bypass i-Stent, (b) the Solx
will be reviewed during the course, with an emphasis on "How
"gold-shunt", (c) the canaloplasty. The surgical steps of each
to use utility measures in clinical practice". The results of two
technique will be presented, as well as the possible complica-
studies evaluating the cost-effectiveness of screening for
tions. The available results from controlled clinical trials will
glaucoma will be presented.
be discussed, together with the present evidence(s) for pres-
ent indications in clinical practice.
Courses 3 C3.18
DISC PHOTOGRAPHS FOR DIAGNOSIS
C3.02 J. Morgan
PREVALENCE / INCIDENCE OF GLAUCOMA School of Optometry and Vision Sciences, Cardiff University,
A. Tuulonen Wales, United Kingdom
Department of Ophthalmology, University of Oulu, Finland
The analysis of stereoscopic optic disc images remains for many
The prevalences and incidences of glaucoma and suspected studies the gold standard by which methods for the digital
will be reviewed based on systematic evaluation of the litera- analysis of he optic disc are assessed. Surprisingly, stereoscopic
ture in addition to the prevalence of glaucoma induced visual optic disc images are infrequently used in clinical practice. In
disability. Due to different definitions of the disease, studies this session I will discuss methods for the acquisition, analysis
show different estimates for prevalences and incidences of and display of stereoscopic optic disc images in the diagnosis of
glaucoma in different age groups and racies. High quality glaucoma and the detection of progressive optic nerve damage.
studies using severe visual impairment as an endpoint are
lacking. The variabilities in different reports and their impacts C3.13a
in every day practice and in research will be discussed with a
special emphasis on the significance of specificity and sensi- NEUROPROTECTION
tivity of diagnostics tests. Establishing a gold standard for the F. Cordeiro
definition of glaucoma would be essential. Institute of Ophthalmology, University College London and
Western Eye Hospital, London, United Kingdom
C3.04 This course will discuss current and potential targets for neu-
roprotection in glaucoma, and include topics covering NMDA
TRABECULAR MESHWORK CHANGES IN POAG antagonists, alpha-2-agonists, naturally occurring agents - eg
E. Tamm1, Ian Grierson2 Coenzyme Q10, and Alzheimer protein abeta.
1
Institute of Human Anatomy & Embryology, University of
Regensburg, Regensburg, Germany; 2 University of Liverpool,
Liverpool, United Kingdom C 3.23A
NON PENETRATING GLAUCOMA SURGERY
Intraocular pressure (IOP), the main risk factor for primary
T. Shaarawy
open-angle glaucoma (POAG) is determined by the production,
Department of Ophthalmology, Geneva University Hospitals,
circulation and drainage of aqueous humor. The major drainage
Switzerland
region are the conventional or trabecular outflow pathways,
which are comprised of the trabecular meshwork (made up by A course for surgeons wishing to begin practicing non pene-
the uveal and corneoscleral meshworks), the juxtacanalicular trating glaucoma surgery.
connective tissue (JCT), the endothelial lining of Schlemm's This will cover: history, instrumentation, technique, mecha-
canal, the collecting channels and aqueous veins. The trabecu- nisms of function, results.
lar meshwork outflow pathways provide a resistance to aque-
ous humor outflow and IOP builds up in response to this resist-
ance until it is high enough to drive aqueous humor across the
trabecular meshwork into Schlemm's canal. In POAG, IOP is el- Courses 4
evated because the resistance to aqueous humor outflow in the
trabecular meshwork is abnormally high. Outflow resistance is
C4.31
increased in POAG, ocular hypertension, and exfoliation and
pigment dispersion syndromes with accompanying ocular hy- USING PERIDATA
pertension. When IOP is normal in these syndromes, outflow T. Zeyen
resistance is normal. The course will focus on the functional Middelheim Hospital, Antwerp, Belgium
morphology, biochemistry, physiology, and molecular biology of
the trabecular meshwork outflow pathways. In addition, it will Peridata is a software program to archive and interpret auto-
review the changes that occur in the trabecular meshwork out- mated perimetries (Octopus, Humphrey, Oculus, and Medmont).
75 www.eugs.org
After a tour of the program, 14 case reports will be presented to
explain the basics for the interpretation of visual field defects
Courses 5
and to help discriminating progression from fluctuation. At the
end of this interactive course the participant will feel confident C5.15
using this software.
METHODS TO DESIGN, CONDUCT AND ANALYZE RCTS
IN GLAUCOMA
C4.24 L.M. Rossetti
Eye Clinic, Dept. of Medicine, San Paolo Hospital, University
INNOVATION IN PAEDIATRIC GLAUCOMA SURGERY
of Milan, Italy
M. Papadopoulos, J. Brookes
Glaucoma Unit, Moorfields Eye Hospital, London, United
The course (basic, medium level) will consider the different
Kingdom
types of design for conducting clinical trials in the field of
glaucoma. The difference between statistical and clinical sig-
Surgery remains the principal modality of treatment to con-
nificance will be one of the key issue of the course. How to
trol intraocular pressure in paediatric glaucoma. Surgery in
estimate the sample size, when to consider double masking
children with glaucoma differs in several ways from that in
and how to handle withdrawals will be part of the study.
adults. Firstly, it is more challenging and unforgiving, prone
Different ways for collecting and analyzing data will be also
to complications, largely due to anatomical factors related to
discussed, with some particular interest in the "clinical mean-
ocular enlargement. These factors include: thin sclera with
ing" of the outcomes. The role of surrogate endpoints and
low scleral rigidity; deep anterior chambers with lens sublux-
what they will potentially represent in the next future will be
ation from stretched zonules that do not provide normal lens
also discussed.
suspension nor vitreous support; late fibrosis of the trabecu-
lar meshwork and disappearance of Schlemm's canal.
Secondly it is more likely to fail because of a more rapid and C5.13b
aggressive healing response associated with a thicker infan-
NEUROPROTECTION
tile Tenon's capsule. Thirdly, angle surgery is more successful,
F. Cordeiro
especially in children with primary congenital glaucoma.
Institute of Ophthalmology, University College London and
Consequently, highly specialised surgical procedures have
Western Eye Hospital, London, United Kingdom
evolved for paediatric glaucoma. This course will cover recent
advances in angle surgery along with modifications to tra-
This course will discuss mechanisms of cell death with rele-
beculectomy and aqueous shunt surgery that aim to minimise
vance to modes of action of current and potential neuropro-
complications and improve success rates.
tective agents in glaucoma, and include topics covering mito-
chondrial activity, axonal/dendritic pathology, growth factor
C4.13c and cellular apoptotic activity.
NEUROPROTECTION
S. Gandolfi C5.19b
Eye Clinic, University of Parma, Parma, Italy
GONIOSCOPY
T. Zeyen1, A. Hommer2
The course will focus on (a) the basic mechanisms leading to 1
Middelheim Hospital, Antwerp, Belgium; 2 Department of
neurodegeneration in glaucoma, (b) the potential therapeutic
Ophthalmology and Optometry, University of Wien, Austria
strategies that are being investigated and (c) the possible
tools to evaluate the impact of a neuroprotectant in the indi-
The goal of this course is to introduce gonioscopy and to illus-
vidual patient. The attendees should leave the course with
trate gonioscopic and slitlamp findings, normal and abnormal.
the information to dissect those glaucoma patients whose
In the first part the anatomic structures are described step by
damage is more likely to be less IOP-related.
step. The different examinations methods as well as grading
systems for the angle configurations are discussed.
C4.20 The most common pathologies will be covered and the partic-
ipants will be able to test their knowledge using an interactive
IDENTIFYING GLAUCOMATOUS VISUAL FIELD voting system.
PROGRESSION IN CLINICAL PRACTICE
F.J. Goņi1, A. A. Lopez2
1
Hospital of Granollers I Mollet, Barcelona, Spain; 2 Glaucoma C5.08a
Department Institute Catalá de Retina, Barcelona and
MEDICAL MANAGEMENT OF POAG/FLOW CHARTS
Glaucoma Unit Hospital Esperanza Mar. IMAS, Barcelona,
J. Thygesen
Spain
Copenhagen University Glaucoma Clinic, Denmark
Detection and interpretation of Visual Field Progression (VFP)
Management of glaucoma, particularly of Primary Open Angle
is of paramount importance for clinical decision making in
Glaucoma is often based on assumptions or personal experi-
Glaucoma management. Main objectives of this course are to
ences more than on real facts.
better understand and learn more about:
The ultimate goal medical management of POAG is to prevent
- customizing appropriate frequencies of visual field testing;
visual impairment due to glaucoma. Low impact disease should
- methodology currently available to detect VFP;
have low impact treatment. Glaucoma is a chronic and often
- calculating individual rates of VFP.
asymptomatic eye disorder. Intervention should therefore be
The course will focus on day to day clinical practice, through
individualised according to age, disease stage and disease
practical examples.
severity. Relevant outcomes in glaucoma management are
long-term and comprise the preservation of optic nerve struc-
ture and function, the prevention of further visual field loss
and maintenance of the patient's quality of life. Intraocular
www.eugs.org 76
pressure is currently the only parameter that can be modified it really? Which factors influence the conversion and the de-
as a means of achieving these outcomes and a comprehensive velopment of XFG? What predisposing factors influence this
perspective is recommended. Other parameters like ocular he- conversion? When should we initiate IOP lowering therapy?
modynamics and neuroprotection are still under investigation. These clinically important issues will be dealt with in the talk.
Monotherapy is certainly the optimal treatment with regard to What is new in the medical treatment of XFG?
compliance, safety, and tolerability. Yet, if target IOPs are not Once medical therapy is needed in XFG, the choice and effica-
met with monotherapy, the decision to switch or add medica- cy of initial and stepwise therapy are of paramount impor-
tions should be made. Replacement therapy is advantageous tance. Since XFG is different from POAG optimal medical ther-
because it eliminates medications that are no longer effective, apy may also differ in XFG. What do we know of the 24-hour
while keeping the patient on a single agent. Combination ther- IOP efficacy of available medications in XFG? What is the role
apy should be considered if the target IOP has not been of fixed combinations in the management of XFG? This pres-
reached. Laser trabeculoplasty (ALT or SLT), an intermediate entation will briefly review these topics.
step between medication and filter surgery, often reduces IOP What is new in the surgical treatment of XFG?
in both previously untreated and treated eyes with pigmented In XFG surgery is often required to decrease IOP within the
trabecular meshwork or pseudoexfoliation, although most pa- target range, and to reduce 24-hour IOP fluctuation. What is
tients still will need medical treatment to reduce IOP. Incisional the bets choice of surgery? Is trabeculectomy the only evi-
surgery is an option for glaucoma patients who are still pro- dence-based type of filtering surgery in XFG? Should we use
gressing. Success rates with trabeculectomy have risen dra- MMC? How does non-penetrating filtering surgery fit in our
matically with antifibrotic agents, though postoperative prob- choices? These topics will be critically reviewed.
lems include hypotony, hyphema, choroidal effusion, and hem-
orrhage. Guarded filtering surgeries, such as deep sclerotomy
C6.07
and viscocanalostomy, are safer alternatives to trabeculecto-
my, although they are less successful in reducing IOP. Shunts DISABILITY FROM GLAUCOMA
are useful when inflammation or excessive scarring arises from A.C. Viswanathan1, D. Crabb2, A. Kotecha1, P. Artes3
previous glaucoma surgery. 1
Moorfields Eye Hospital and Institute of Ophthalmology,
London, United Kingdom; 2 Nottingham Trent University,
United Kingdom; 3 Dalhousie University, Halifax, Nova Scotia,
Canada
Courses 6 Given the chronic progressive nature of glaucoma, the rise in
prevalence with age and the growing longevity of the popula-
C6.10 tion, the impact of the disease is substantial and rising, repre-
senting a serious public health dilemma for the elderly popula-
EXFOLIATION tion. Despite the importance of the clinical measurements
A.G.P. Konstas1, G. Holló2 used to manage the condition (visual fields), little is actually
1
Glaucoma Unit, University Department of Ophthalmology, known about how the severity of visual field defects at differ-
AHEPA Hospital, Thessaliniki, Greece; 2 1st Dept. of ent stages of the disease impact on patients' 'everyday' visual
Ophthalmology, Budapest, Hungary functioning. The main research 'instruments' for assessing pa-
tients 'everyday' visual disability are questionnaires: these are
What is new in genetics of XFG? useful and have provided some evidence, for example, that
The understanding of the genetic background of XFS and XFG patients are more likely to be at risk of falls, accidents and im-
has increased recently by the discovery of LOXL1 gene poly- paired quality of life. However, the concept of 'self reported
morphism in patients with XFS/XFG. In less than one year dif- disability' is somewhat flawed because it is reliant on patients'
ferent populations were investigated with generally similar own retrospective perception of what they can and cannot do.
genetic results. The significance and the recent data on This course will focus on very recent research attempts to re-
LOXL1 gene polymorphism in XFS/XFG will be discussed. late patient's visual field defect severity to what they can and
What is new in basic science of XFG? cannot actually do in terms of functioning and everyday skills.
Oxidative stress and disturbed metabolism of extracellular The course will start with a focus on relating visual field de-
material have been proposed to play important roles in the fects with fitness to drive and then extend this theme to other
development of XFS, and in the conversion from XFS to XFG. everyday tasks such as reaching and grasping objects, search
New laboratory data and their connection to genetic changes tasks, viewing natural scenes and also exploring the eye
in XFS/XFG will be presented. movements that patients make to 'compensate' for their visu-
What is new on systemic cardiovascular changes in XFG? al field defects. At the end of the course delegates will have a
Systemic associations between exfoliation and systemic car- clear idea of the latest research in this area allowing them to
diovascular diseases have been the focus of interest for more include this evidence in the management and understanding
than a decade. Recently, using human pathophysiological and of the disease.
clinical cardiovascular tests decreased cardiovascular regula-
tion, increased arterial rigidity, elevation of plasma homocys-
tein levels and clinically significant cardiac dysfunction were C6.17
demonstrated in patients with XFS. These new findings and IMAGING TECHNOLOGY
their clinical significance will be discussed. H.G. Lemij1, D. Garway-Heath2
Why IOP is increased in XFG? 1
Rotterdam Eye Hospital, Rotterdam, The Netherlands;
Approximately 30% of XFS cases convert to XFG during a 10 year 2
Moorfields Eye Hospital, London, United Kingdom
period. Why does elevated IOP develop in exfoliation patients?
Which are the characteristics of increased IOP in XFG? What are In this course, 3 commonly used glaucoma imaging technolo-
the earlier signs of damage manifested? Is 24-hour IOP fluctua- gies will be introduced: Scanning Laser Tomography (avail-
tion important in the development of optic nerve head damage in able as the Heidelberg Retina Tomograph, HRT), Scanning
XFG? These issues will be highlighted in this presentation. Laser Polarimetry (available in the GDx VCC) and Optical
Conversion of XFS to XFG: recent data Coherence Tomography (OCT, various devices). The working
Conversion from XFS to XFG is common. But how common is principles of each technology will be discussed, as well as
77 www.eugs.org
their clinical applications, both for the diagnosis of glaucoma comfort and vision in the post operative period. Detailed de-
and for the detection of glaucomatous progression. Future scriptions of these techniques will be discussed.
developments will be discussed briefly. This course will cover the surgical technique for the Safer
Surgery System:
1) Position of filtration area. Considerations including lid posi-
Courses 7 tion and previous surgery.
2) Traction suture.
3) Conjunctival incision. Pros and Cons of different incisions
C7.32 and techniques to optimise bleb appearence.
4) Scleral flap. Optimal design to control and adjust flow in
EYE DISEASES IN ART
the post operative period.
T. Zeyen
5) Intraoperative antimetabolite use. Options and reasons for
Middelheim Hospital, Antwerp, Belgium
choice.
Synopsis: This presentation will give an overview of how fa- 6) Type of sponge. Shape, type and reasons for choice.
mous artist depicted eye diseases. Objective: It is known that 7) Antimetabolite treatment duration and washout.
eye diseases have affected the way in which some of the 6) Paracentesis.
world's most famous artists expressed themselves. However, 7) Special Infusion and optimal intraoperative control of flow
eye conditions or ophthalmic devices have also been depicted and IOP.
in works by artists who were not affected by ocular conditions 8) Sclerostomy technique. Small micropunch to maximise
themselves. Art and science can be complementary. At the flow control.
conclusion of this course, the attendee will be able to observe 9) Peripheral iridectomy technique with infusion "third hand"
how meticulously some artists, interested in medicine, depict- assistant.
ed eye diseases in their art work. 10) Scleral flap sutures. Releaseable, fixed and Khaw ad-
justable sutures. Optimising outflow at the time of surgery.
11) Conjunctival closure. Including secure corneal buried su-
C7.12 ture technique to achieve maximal apposition with minimal
chance of leakage and discomfort.
SECONDARY GLAUCOMAS
12) Post operative management. Including loosening of ad-
S. Gandolfi1, K. Barton2
1 justable sutures to gradually reduce intraocular pressure -
Eye Clinic, University of Parma, Parma, Italy; 2 Moorfields
special techniques. Achieving early flow. Post operative an-
Eye Hospital, London, United Kingdom
timetabolites including "viscoelastic wall".
The course will address the clinical management of secondary
glaucomas, in general, and will focus on neovascular and
uveitic glaucomas in particular. A practical approach to identi- Courses 8
fy and treat the individual phenotypes of inflammatory glau-
comas will be offered. The most recent development in terms
of control of anterior chamber neo-vascularization (e.g. the C8.11a
use of anti-VEGF etc.) will be presented an discussed.
PIGMENT DISPERSION SYNDROME
S. Gandolfi
C.7.23b Eye Clinic, University of Parma, Parma, Italy
NON PENETRATING GLAUCOMA SURGERY The course will offer a practical approach to diagnose and
T. Shaarawy monitor patients affected by PDS. The most recent findings
Department of Ophthalmology, Geneva University Hospitals, on the pathogenesis and natural history of the syndrome will
Switzerland be discussed as well as the possible strategies to prevent
conversion to pigmentary glaucoma.
Advanced course on NPGS covering: intra and postoperative
complications, postoperative management, goniopunctures,
controversies. C8.09
MANAGEMENT OF PACG
C7.25a J. Thygesen1, P.J. Foster2, G. Gazzard2
1
Copenhagen University Glaucoma Clinic, Denmark;
GLAUCOMA SURGERY 2
Institute of Ophthalmology, London, United Kingdom
F. Grehn1, P.T. Khaw2
1
University-Eye Clinic, Würzburg, Germany; 2 Glaucoma Unit, All patients presenting with acute angle closure should be
Moorfields Eye Hospital, London, United Kingdom treated immediately with systemic and topical medications to
lower the IOP, followed by laser iridotomy for the affected and
Indication and selection of glaucoma surgical procedures. fellow eyes.
Practical approach to the steps of trabeculectomy, However, some patients who present with acute angle closure
videodemonstration of trabeculectomy. can take longer to respond to medical treatment and may es-
Discussion of results. pecially with plateau iris configuration require additional inter-
Recent changes in technique have markedly improved the ventions such as argon laser peripheral iridoplasty to break
safety and acceptability of trabeculectomy for patients and the acute attack iridotomy. When faced with a patient present-
physicians even with the use of antimetabolites. This course ing with acute symptomatic primary angle closure it is difficult
will outline a simple system of trabeculectomy to maximise to make judgments on how much the lens is contributing to
the safety of trabeculectomy, when antimetabolites such as the disease. Assessment of the contribution of lens opacity to
mitomycin-C are used. This simple system, when implement- poor visual acuity is complicated by the presence of corneal
ed results in a significantly lowered incidence of hypotony and oedema and it is often difficult to obtain a clear gonioscopic
bleb related complications and better maintenance of patient view of the angle. The role of lens extraction in this form of
www.eugs.org 78
the disease is still unclear and there is currently little in the of cataract/lens extraction in post-acute primary angle closure.
way of evidence to guide us. For a patient who has residual This technique has the potential to prevent recurrence of the
appositional angle closure following iridotomy and coexisting condition and progression to chronic angle closure glaucoma.
lens opacity, it is reasonable to have a low threshold for doing With existing and upcoming new data on managing acute pri-
cataract surgery at the earliest sign of visual symptoms. mary angle closure, it is hopeful that a more optimal treat-
Difficulties arise when dealing with cases in which the lens ap- ment algorithm will be established soon.
pears to be making a significant contribution to the residual
angle closure but there is no significant cataract and visual
C8.25b
acuity is good. Does this situation justify a clear lens extrac-
tion and can prophylactic surgery prevent future development GLAUCOMA SURGERY
of PACG in these cases? Some studies suggest that cataract F. Grehn1, P.T. Khaw2
surgery may be as effective as filtering surgery in controlling 1
University-Eye Clinic, Würzburg, Germany; 2 Glaucoma Unit,
IOP in PACG cases. In cases in which there is early optic disc Moorfields Eye Hospital, London, United Kingdom
cupping and mild visual field loss, lens extraction alone may
be enough to achieve adequate IOP control; whereas eyes Indication for various types of glaucoma surgery, depending
with advanced glaucomatous optic neuropathy are more likely on glaucoma type and glaucoma stage. Detailed discussion of
to have poor residual trabecular meshwork function as a result pre-operative, intraoperative and postoperative management.
of PAS or non-synechial damage. In such cases phacotra- Special features of trabeculectomy: conjunctival approach,
beculectomy may be necessary to achieve the degree of IOP adjustable sutures, Mitomycin C application, 5-FU-application.
control required to prevent progression of glaucomatous optic Classification of filtering blebs. Decisions for postoperative in-
neuropathy. Surgical trials are underway to examine the role terventions. The "saver trabeculectomy" concept.
79 www.eugs.org