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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
Lectures
2003 (Florence) Elke Lutjen Drecoll & Paul Kaufman; Paul Mitchell
Report on WGA consensus 2004 (Vienna) Aiko Iwase; Claude Burgoyne
topics: diagnosis, surgery, 2005 (Chennai) Simon John; Hiroshi Sakai
2006 (Singapore) Terete Borras; Neeru Gupta & Yeni Yucel
intraocular pressure, angle
closure, screening, reporting
WGA CONSENSUS SESSION Main Session 1
E. Greve
World Glaucoma Association, Graveland, The Netherlands NEW UNDERSTANDING IN GLAUCOMA:
NEURONAL MECHANISMS AND
Extensive review of the 2008 5th WGA Consensus on Screening PROCESSES
for Glaucoma & updates of the Consensus reports on:
Structure and Function in Glaucoma Management, Surgery
1.1
Open Angle Glaucoma (OAG), Angle Closure Glaucoma (ACG),
Intraocular Pressure, Screening OAG and ACG. MORPHOLOGIC CHANGES IN GLAUCOMA EYES
The unique Consensus program of the World Glaucoma E. Tamm
Association has now covered five topics of the planned list Institute of Human Anatomy & Embryology, University of
that includes virtually every important topic of glaucoma. All Regensburg, Regensburg, Germany
consensus reports are the result of months long discussions
by over 100 glaucoma experts from all over the world. The Extracellular matrix changes in glaucoma eyes.
reports have passed through all the worlds glaucoma soci- Intraocular pressure, the most critical risk factor for primary
eties for additional input. Each consensus report has been or open-angle glaucoma (POAG), is generated in the trabecular
will be published in a separate book. Each consensus report meshwork outflow pathways which provide resistance to
will be regularly updated. Summary reports can be found at aqueous humor (AH) outflow. The resistance is increased in
www.worldglaucoma.org (tab: The WGA Consensus). The POAG, and changes in the quality and amount of the extracel-
World Glaucoma Association is actively promoting the promul- lular matrix (ECM) in the juxtacanalicular region (JCT) of the
gation of the consensus outcomes a.o. through consensus trabecular meshwork appear to be causatively involved. The
sessions at meetings of member Glaucoma Societies. ECM changes are very likely under control of transforming
growth factor-ß2 (TGF-ß2), which is found at high concentra-
WGA-AWARD CEREMONY 2008 tions in the AH of patients with POAG. Additional factors are
E. Greve thrombospondin-1, which activates TGF-ß2 in vivo, and con-
World Glaucoma Association, Graveland, The Netherlands nective tissue growth factor, which is an important down-
stream mediator of the effects of TGF-ß2 on TM ECM
During the WGA-Award ceremony 2008 (with an attractive au- turnover. In contrast, bone morphogenetic protein-7 (BMP-7)
diovisual introduction) the two best publications from the glau- strongly antagonizes fibrogenic actions of TGF-ß2 on human
coma literature of 2007 will be awarded. The WGA-Award is an TM cells. Growth factors control the homoeostatic balance of
a unique and prestigious award for the glaucoma specialty ECM turnover in the normal TM, a process that appears to fail
since 1999. There will be three two award categories per year in the TM of patients with POAG.
for the purpose of stimulating creativity and originality and re-
warding daring and breakthrough research in the field of glau- 1.2
coma, to help protect the research time of junior researchers
for the benefit of glaucoma patients. 1. "The Classic" for long- NEURAL NETWORKS
term impact 2. "The Present" for present impact 3. "The J. Morgan
Promise" for potential future impact. The nomination process School of Optometry and Vision Sciences, Cardiff University,
consists of two phases. The first phase involves over 70 world- Wales, United Kingdom
wide experts who and together with the regional glaucoma so-
cieties will result in choose a top-ten of nominated papers Retinal ganglion cell death is the key pathological event in
(there is no other global research award that is supported by glaucoma that underlies loss of visual field. Recent work has
the worlds glaucoma societies). The second phase comprises now revealed that retinal ganglion cells undergo changes in
the choice by a selection committee which, from these 10 both structure and function prior to cell death generating
nominated papers, the selection committee it selects the two large populations of "sick" cells. These cells demonstrate
winning papers. The WGA-Awards "The Classic" and "The pruning and shrinkage of the dendritic tree with a reduction
Present" consists of a USD 25.000, a crystal bowl and a diplo- in cell soma volume. Studies in other neural systems suggest
ma. Up to two papers can be selected for these awards. "The that it may be possible to reverse these changes with return
Promise" consists of a crystal bowl and a diploma. The number in neural function. Strategies for the in vivo detection of these
of papers selected for "The Promise" may vary. The awards cells and the recovery of neural integrity will be discussed.
haves been made possible by an unrestricted educational
grant from Pfizer to the WGA.
1.3
WGA-Award winners 1999-2006
1999 (London) Francesca Cordeiro & Peng Khaw; Ronald IMAGING APOPTOSIS IN VIVO
Harwerth F. Cordeiro
2000 (Seoul) Paul Palmberg & Doug Gaasterland; Harry Head Glaucoma & Retinal Neurodegeneration Research
Quigley Group, UCL Institute of Ophthalmology, London, United
2001 (Orlando) Michal Schwartz; Crawford, Yeni Yucel, Robert Kingdom; Hon Consultant Western Eye Hospital, London,
N. Weinreb United Kingdom
2002 (Tokyo) Michael Kass & Mae Gordon; Anders Heijl
(Special Recognition: Douglas Anderson, Stephen Drance, Recent developments in imaging technologies offer great po-
Dunbar Hoskins) tential for the assessment of RGC disorders, with particular
www.eugs.org 66
relevance to glaucoma. In particular advances in this field In several studies we could demonstrate consistent up- and
have allowed unprecedented access to the retinal layers. down-regulations of immune reactivities against ocular anti-
Most promising technologies use the established confocal gens in glaucoma patients. These are furthermore consistent
scanning laser ophthalmoscope (cSLO) combined with other between different study populations e.g. from the U.S. and
methodologies to improve RGC visualization. Direct assess- Germany.
ment and the successful evaluation of healthy RGCs has been These findings could lead to a better understanding of the
possible in transgenic and disease models. Ideally, method- pathomechanisms involved in glaucoma, but could also lead
ologies enabling the visualization of healthy and "sick" RGCs to new innovative ways of early detection of the disease.
would provide a comprehensive assessment of glaucomatous
changes and disease states
1.6
DARC (Detection of Apoptosing Retinal Cells) is a recently
devised, non-invasive real-time imaging technique using GLAUCOMA DAMAGE AT THE LGN LEVEL
cSLO to visualise single RGC apoptosis in vivo. This allows N. Gupta
longitudinal study of disease processes, which has not pre- Department of Ophthalmology & Vision Sciences, University
viously been possible. Using DARC, we recently showed evi- of Toronto, Toronto, Canada
dence that implicates thee same mechanisms in the blind-
ing disease glaucoma with Alzheimer's. The Alzheimer pro- In glaucoma, the pathological correlate of vision loss is ac-
tein Aß we showed to be closely associated with the devel- cepted as loss of retinal ganglion cells (RGCs). The degenera-
opment of RGC apoptosis in glaucomatous neurodegenera- tion of RGCs and their axons in glaucoma extends into the
tion. brain to target neurons of the lateral geniculate nucleus
Results of RGC imaging and DARC studies to date and future (LGN). In the LGN, there is evidence that all 3 major vision
implications of these technologies will be discussed. channels, namely the magno, parvo and koniocellular path-
ways are injured in the primate model of glaucoma. Ex-vivo
and in vivo human studies of the LGN in glaucoma will be dis-
1.4 cussed and point to the LGN as integral in considering human
glaucomatous neural degeneration and disease progression.
STEM CELLS AND RETINAL GANGLION CELL REPAIR
K. Martin
Cambridge University Centre for Brain Repair and
Addenbrooke's Hospital, Cambridge, United Kingdom
Main Session 2
Stem cell transplantation could theoretically be beneficial in
glaucoma either by replacing retinal ganglion cells (RGC) HEALTH ECONOMICS
lost to the disease or by a neuroprotective effect of trans-
planted cells on surviving RGC. As re-establishing functional 2.1
connections between transplanted cells and the appropriate
target fields in the brain presents formidable challenges, INTRODUCTION: WHY DO WE NEED TO CONSIDER
demonstration of a neuroprotective effect of transplanted COSTS IN GLAUCOMA CARE?
cells may be a more realistic initial goal. Such a protective A. Tuulonen
effect would require transplanted cells to survive, function Department of Ophthalmology, University of Oulu, Finland
and presumably integrate within the host retina without
Today, it is not anymore enough that an intervention is effec-
compromising its function. Several promising candidate cell
tive, it should also be cost-effective. All new interventions (di-
types for transplantation exist, including adult retina-de-
agnostic devices, controlled trials, comparative studies either
rived cells and mesenchymal stem cells. These cells can sur-
medical or surgical) should have a health economic assess-
vive and differentiate in animal models of glaucoma, and
ment. The symposium will survey why we need to consider
modulation of the host environment seems to facilitate inte-
costs in glaucoma care. By definition, every cost-effective in-
gration.
tervention is also clinically effective. In addition to critical eval-
Successful stem cell transplantation for glaucoma will require
uation of clinical literature, clinicians and researchers have to
control of the survival, migration, differentiation and integra-
gain education and understanding on health economics. The
tion of transplanted cells. The mechanisms involved in these
symposium draws an overview of health economics and its
processes are gradually being elucidated and their modulation
methodology as well our challenges in combining it with glau-
can be explored in retinal explant cultures with the most
coma care and research. The methodology will be discussed in
promising approaches then taken forward into animal models
more detail during the afternoon course after the symposium.
of glaucoma.
Replacement of RGC is the long-term goal, but in the short
term it is important to establish if cellular transplantation 2.2
therapy has neuroprotective potential without unacceptable
side effects. OVERVIEW OF HEALTH ECONOMICS (MAIN
PRINCIPLES): WHAT ARE THE METHODS TO EVALUTATE
COST-EFFECTIVENESS OF GLAUCOMA CARE
1.5 R.A. Hernandez
Health Economics Research Unit, University of Aberdeen,
IMMUNOLOGIC ASPECTS OF GLAUCOMA Aberdeen, Scotland
F.H. Grus
Department of Ophthalmology, University of Augenklinik, This presentation will start with the underlying economic prin-
Mainz, Germany ciples in economic evaluation: scarce resources and opportu-
nity costs. Secondly, the different types of economic evalua-
Although an elevated intraocular pressure represents the tions will be explained. Next, it will focus on modelling based
main risk factor, it cannot explain the glaucoma disease in all economic evaluations and when to use them. It will briefly
patients. Previous studies could provide hints for an involve- address different types of models. Finally, it will discuss how
ment of autoantibodies in the pathogenesis of the disease. to present and read results.
67 www.eugs.org
2.4 extent that the use of fundus photography has been proposed
as an alternative to finger printing for personal identification.
EVIDENCE BASED HEALTH ECONOMICS (WHAT DO WE
Bearing in mind the wide interindividual variations in disk and
CURRENTLY KNOW). WHAT IS CURRENT STAGE OF
physiological cup sizes, the absolute value of the C/D ratio
EVIDENCE BASED HEALTH ECONOMICS IN GLAUCOMA
has no diagnostic significance. A C/D ratio of 0.3 in a small
CARE?
disk may be pathological and of 0.8 in a large disk may be
J. Burr
physiological. The diameter of the optic disk can in fact be ac-
HSRU University of Aberdeen, Aberdeen, Scotland, United
curately measured at most slit lamps, whether the examina-
Kingdom
tion technique is indirect with a Volk-type lens or by direct
observation with a contact lens.
Current evidence on the cost effectiveness of interventions
for the detection and management of glaucoma will be de-
scribed. In addition, the results of a systematic review of the 3.3
impact of glaucoma on patient reported health status will be
ARE THERE DIFFERENCES BETWEEN TYPES OF
presented.
PERIMETRY TO DETECT EARLY GLAUCOMATOUS FIELD
DEFECTS?
2.5 A. Azuara-Blanco
Department of Ophthalmology, University of Aberdeen,
THE PROBLEMS IN HEALTH ECONOMIC STUDIES (RE: Scotland, United Kingdom
CURRENT CLINICAL AND COST DATA). WHAT KIND OF
INFORMATION DO WE NEED FOR ECONOMIC The current gold standard to detect glaucomatous visual field
EVALUATION? loss is the white-on-white perimetry. Fast strategies (e.g., SI-
A. Azuara-Blanco TA, TOP) have gained wide acceptance among clinicians.
Department of Ophthalmology, University of Aberdeen, There are other types of perimetry that have been proposed
Scotland, United Kingdom as potentially useful to detect visual field abnormalities (e.g.,
FDT, SWAP). In this lecture we will review how the different
There are several types of economic analysis, which would ob- types of perimetry work, their diagnostic performance, practi-
viously influence the type of data needed. In cost-effective- cal issues such as time of examination, and whether selective
ness analysis, for example, we would try to answer what is the perimetry or early diagnosis have any advantage in the man-
most cost-effective method to prevent significant loss in quali- agement of glaucoma.
ty of life due to glaucomatous loss of visual function. Data
needed to answer such question would include the natural his-
3.5
tory glaucoma, the effect of the intervention on disease pro-
gression, cost and potential harms of the intervention(s), and HALF OF ALL GLAUCOMA PATIENTS ARE UNDETECTED -
the impact of glaucoma on quality of life. Practical examples in WHAT CAN WE DO?
the context of interventions for glaucoma will be provided. T. Zeyen
Middelheim Hospital, Antwerp, Belgium
Glaucoma is the leading cause of preventable blindness and
half of all glaucoma patients are undetected. Is there an ap-
Main Session 3 propriate screening test? Optimal screening test criteria are
unknown and there is no single test or group of tests that is
DETECTING GLAUCOMA DAMAGE WITH the best. Advanced glaucoma can be diagnosed more easily
OPHTHALMOSCOPY, IMAGING AND and at lower cost than early disease. The sensitivity and speci-
PERIMETRY ficity of all diagnostic tests for population based screening are
unknown since most have been tested on selected groups, not
3.1 on populations. Screening tests for case finding are probably
the most cost-effective, provided they have a high sensitivity.
HOW TO DETECT GLAUCOMA WITHOUT STRANGE
INSTRUMENTS - CLINICAL ANALYSIS OF THE OPTIC
NERVE HEAD
Y. Lachkar
L'Institut du Glaucome, Hospital St. Joseph, Paris, France Main Session 4
Stereoscopic examination of the optic disk is an essential part FOLLOWING GLAUCOMA WITH IMAGING
of good clinical practice. Dilation of the pupil is preferable AND PERIMETRY
(having verified the irido-corneal angle) in order to achieve a
good stereoscopic view, although this may not be absolutely
4.3
necessary for the seasoned observer.
Cupping is the characteristic sign of injury to the disc in glau- HOW TO ASSESS GLAUCOMA RATE-OF-PROGRESSION
coma, providing that it is progressive. However it may be ac- WITH PERIMETRY
companied by other visible signs such as peripapillary atro- B. Bengtsson
phy, the appearance of a disk haemorrhage or exclusion of a Department of Ophthalmology, Lund University, Malmö
circumlinear vessel. Numerous studies have confirmed the University Hospital, Malmö, Sweden
presence of disk haemorrhages to be a major prognostic indi-
cator for progression of glaucoma. Rate of progression is very important for the management of
In order to recognise the pathological qualities of a cupped glaucoma patients. In perimetry it is usually assessed by re-
disk, a finding mainly confined to glaucoma, it is necessary to gression analysis of the mean deviation (MD) value over time.
first recognise the wide variations in the normal disk. No two A new visual field index (VFI) has been designed for calculation
optic disks are identical, as are no two ocular fundi, to such an of perimetric rate of progression. The new index is presented
www.eugs.org 68
in percent of a full field, less affected by cataract than the tra- elastic fibers of the uvea finally insert either into the scleral
ditional MD, and is scaled according to ganglion cell density. spur, trabecular meshwork or peripheral cornea anteriorly and
VFI has been evaluated in comparison with MD in patients with Bruch's membrane and optic nerve posteriorly. In non-human
no cataract (pseudophakic patients), in patients with increas- primates disinsertion of the anterior insertion of the elastic
ing cataract, and in patients who had cataract surgery during fibers leads to posterior movement of the ciliary muscle and
follow-up. The rates of progression calculated with the new VFI influences accommodation. Schlemm's canal drains aqueous
seem to be less affected by cataract than the traditional MD. humor into 25-30 collector channels which are then drained
into the episcleral veins. This draining system is located di-
rectly adjacent to the cornea without active pumping cells be-
tween the two connective tissue layers. On the other hand the
Main Session 5 basal limbal cells contain enzymes which seem to the involved
in dehydration of the connective tissue of the limbal region. In
SURGERY 1 the limbal sclera and the episclera the arteries and veins are
intensely innervated and the veins are surrounded by a thick
muscle layer. In human eyes there are not only arteriovenous
5.1
anastomoses in the episclera but also anastomoses between
GLAUCOMA SURGERY SUCCESS DEFINITION arterioles and collector channels. In about 20% of the eyes in-
T. Shaarawy vestigated these anastomoses are present directly at the out-
Department of Ophthalmology, Geneva University Hospitals, er wall of Schlemm's canal as connections between the so-
Switzerland called Friedenwald arteries and collector channels. Location of
these arteries has implications for the outcome of glaucoma
This talk will present recently developed guidelines on design and surgery. If only the avascular trabecular meshwork is cut, only
reporting glaucoma surgical trials. This will include guidelines on little or no scarring is observed and the holes stay open. If a
methodology, success definitions, definitions of complications, vessel at the outer wall is opened there is scarring of the
Ethical and economical considerations and statistical analysis. wound region with occlusion of Schlemm's canal.
5.2
THE EFFORTS TOWARDS SAFER TRABECULECTOMY Main Session 6
T. Zeyen
Middelheim Hospital, Antwerp, Belgium SURGERY 2
Trabeculectomy is the most widely used filtration surgery. 6.1
Technical modifications to make trabeculectomy safer and
more efficient include: handling correctly antimetabolites, us- OUTCOMES OF PRESENT ESTABLISHED SURGICAL
ing a combination of adjustable and releasable sutures, main- TECHNIQUES. WHAT DO YOU NEED TO BE BETTER
taining the anterior chamber well formed throughout surgery, THAN TRABECEULECTOMY
closing the conjunctiva watertight, and postoperative man- K. Barton
agement of the failing filter. Moorfields Eye Hospital, London, United Kingdom
Trabeculectomy is only moderately successful, visual recovery
5.4
is slow and complication rates are less than ideal.
GLAUCOMA SURGERY WOUND HEALING RESEARCH - Despite these disadvantages, an explosion in new medications,
WHICH TRACK TO FOLLOW IN THE FUTURE? the evolution of non-penetrating surgery as a safer alternative,
G. Schlunck and a renewed interest in aqueous shunt implantation, tra-
University Eye Hospital, Würzburg, Germany beculectomy remains the gold standard IOP-lowering proce-
dure in many countries. Why has trabeculectomy survived?
Postoperative scarring remains a major obstacle to success in Safe IOP-lowering surgery demands a careful balance be-
filtering glaucoma surgery and additional means to modulate tween a higher success rate with a greater risk of complica-
wound healing are desirable. Recent clinical trials may have tions on the one hand, and a safer less successful procedure
raised some reservations concerning the targeting of TGF-be- on the other. In this talk, the speaker will discuss the ideal fil-
ta. However, failed filtering blebs show enhanced expression tration procedure and whether it will ever be possible to
of TGF-beta receptors and extensive TGF-beta-induced extra- achieve this ideal.
cellular matrix alterations which further support the notion of
TGF-beta as a distinct mediator of filtering bleb scarring in vi- 6.2.1
vo. At the same time, biomechanical cues and cell-matrix in-
teractions emerge from studies of basic cell biology as addi- TRABECTOME
tional determinants of scarring responses and may afford new D. Minckler
approaches to wound healing modulation. Professor of Ophthalmology and Pathology UC Irvine, Irvine,
California, USA
5.5
Purpose: To update a retrospective case series including 688
FUNCTIONAL MORPHOLOGY OF THE LIMBAL REGION trabectome-only, 7 trabectome-other, and 320 trabectome-
AND ITS RELATION TO GLAUCOMA SURGERY phacoemulsification procedures.
E. Lütjen-Drecoll Methods: Electro-ablation of 90-120° of nasal meshwork via a
Department of Anatomy, University of Erlangen-Nürnberg, temporal corneal approach under gonioscopic control.
Germany Outcomes include intraocular pressures (IOP), medications,
and complications. Kaplan-Meier curves provide success/fail-
The limbal region contains the sulcus sclerae and the trabecu- ure estimates.
lar meshwork, which are especially rich in elastic fibers. The Results: Among trabectome-only cases, mean preoperative
69 www.eugs.org
IOP of 25.3 ± 7.7 mmHg < to 16.8 ± 4.1 mmHg (n = 46), 6.2.5
(39% 21).
L'Institut du Glaucome, Hospital St. Joseph, Paris, France
Failure led to trabeculectomy in 7.3% (n = 50) and shunt in-
stallation in 1.6% (n = 11). Medications < from 2.95 to 1.2 The main goal in glaucoma surgery is to achieve a low intraoc-
by 24 months. Cumulative success among 81 cases with > 1- ular pressure with a low complication rate. A balance between
year follow-up (IOP < 21 or > 20% below baseline) was the complication profile and the need of a "tailor made target
57.9%. Success among 500 trabectome-only cases with > IOP" is to be considered when selecting a procedure for glauco-
two weeks follow-up, no repeat surgery, IOP < 21 with & ma surgery. Non penetrating glaucoma surgery provides an al-
without medications was 55% at 48 months (n = 15). 78/688 ternative surgical approach to trabeculectomy for lowering IOP.
(11.3%) had prior failed trabeculectomy & 231/688 (34%) Deep sclerectomy and viscocanalostomy were developed 2
had undergone prior ALT or SLT. decades ago to decrease the rate of complications of glauco-
Among combined phaco-trabectome cases base-line IOP of 20 ma surgery. These techniques are more challenging and take
± 6.4 mmHg decreased at 12 months to 15.4 (16%) mmHg longer to perform. Short term complications may be fewer
(n = 35) and medications < from 2.65 to 1.49. Success (< in and less severe because sudden decompression of the eyeball
IOP > 20%, < in medications, no additional surgery) was is avoided. However, the IOP level obtained long term may
78% at 6 months and 64% at 12 months. not be as low as with trabeculectomy.
Conclusions: Trabectome offers an effective minimally inva- Careful post-operative monitoring is crucial to achieve an ac-
sive method of improving IOP control in open-angle glauco- ceptable success rate. Post-operative Nd Yag laser goniopunc-
mas including previously operated eyes at increased risk for ture is an integral part of these non-penetrating procedures.
surgical failure. When antimetabolites are used long term complications (such
as transconjunctival oozing) may be less frequent with deep
6.2.2 sclerectomy than with trabeculectomy.
GLAUKOS
6.4
T.S. Dietlein
Department of Ophthalmology, University of Cologne, PEDIATRIC GLAUCOMA SURGERY A CHALLENGING
Cologne, Germany FIELD OF GLAUCOMA SURGERY
F. Grehn
The intracanalicular microshunts (I-stent or Eyepass, Glaukos) Department of Ophthalmology, Würzburg, Germany
are designed to create a microbypass between the anterior
chamber and Schlemm's canal. The angled non-ferromagnetic, Congenital glaucoma and secondary paediatric glaucomas are
implant-grade titanium i-stent is inserted into the trabecular among the most challenging procedures to be performed in
meshwork by an ab-interno approach using a small clear glaucoma surgery. Delicate surgical technique of the newborn,
cornea incision. The Eyepass double tube made of silicone (6 long life expectancy of these babies, and amblyopia are three
mm in length) is implanted by an ab-externo approach after characteristic features that differ from adult glaucoma surgery
identifying Schlemm's canal. First clinical pilot studies have and have to be also addressed scientifically. The results of the
demonstrated the pressure-reducing potential of this surgical two Würzburg retrospective studies on trabeculoromy and go-
concept. However, as yet clinical data on both micro shunts niotomy will be presented and discussed. Although trabeculo-
are extremely limited making a reliable evaluation difficult. tomy and goniotomy are appropriate procedures with a ac-
ceptable high success rate in congenital glaucoma, newer ap-
proches of trabecular surgery were not yet introduced or ade-
6.2.4
quately investigated. For secondary pediatric glaucoma, par-
SOLX M. ticularly aphakic glaucoma after early cataract surgery, con-
M. Nardi ventional precedures have much lower long term success rates
Department of Neurosciences-Ophthalmology, University of and scarring is often a long term problem, resulting in multiple
Pisa, Pisa, Italy repeated cycloablative interventions or tube surgery.
Alternatives to trabeculectomy: internal shunts.
Filtrating procedures are actually the gold standard for surgi-
cal treatment of glaucoma: in this type of surgery, the sub- Main Session 7
conjunctival space is the target for diverting acqueous humor
and the formation of a functioning bleb is necessary for the ANGLE CLOSURE
success of the procedure. Problems with filtrating procedures
(umpredictable wound healing, need of antifibrotic agents, 7.2
failures, bleb rupture, blebitis, endophthalmitis) are common IMAGING IN ANGLE-CLOSURE
and are mainly linked to the bleb. Aiming at a blebless sur- T. Aung
gery the suprachoroidal space is an attractive alternative to Singapore National Eye Centre, National University of
subconjunctival filtration, because hydrostatic pressure in the Singapore, Singapore
suprachoroidal space is lower than IOP. The Gold Micro-
Shunt (Solx), which received CE mark in 2005, is a 24 karat Objective: To review recent advances in imaging for angle
gold sheet 5.2 mm long with multiple channels to allow ac- closure.
queous flow through the shunt; they are implanted with a Methods: Several new instruments have been introduced for
simple procedure through a sclera approach with the tip in angle imaging. Ultrasound biomicroscopy and anterior seg-
the anterior chamber and the tail in the suprachoroidal space. ment optical coherence tomograph (AS-OCT) are new non-
From January 2007, 48 shunts where implanted at the Eye contact instruments that rapidly obtain high-resolution im-
Clinic of the University of Pisa, mainly in refractory glauco- ages of the angle and allow qualitative and quantitative angle
mas, with an high percentage of success and a reduced num- analysis. This talk provides an overview of the use of imaging
ber and seriousness of complications. instruments in angle imaging.
www.eugs.org 70
Results: Instruments such as AS-OCT provides a simple, user lower the IOP, followed by laser iridotomy for the affected and
friendly and objective method of assessing the drainage angle fellow eyes.
that is well tolerated by the patient. The quality of the images However, some patients who present with acute angle closure
allows a dynamic cross-sectional view of the angle, which is can take longer to respond to medical treatment and may es-
very helpful in determining mechanisms and appropriate pecially with plateau iris configuration require additional inter-
management of patients with angle closure. ventions such as argon laser peripheral iridoplasty to break
Conclusions: Several promising new tools for angle imaging the acute attack iridotomy.
have been introduced. When faced with a patient presenting with acute symptomatic
primary angle closure it is difficult to make judgments on how
much the lens is contributing to the disease. Assessment of
7.4
the contribution of lens opacity to poor visual acuity is com-
LASER IRIDOPLASTY plicated by the presence of corneal oedema and it is often dif-
P. RojanaPongpun ficult to obtain a clear gonioscopic view of the angle. The role
Department of Ophthalmology, Faculty of Medicine, of lens extraction in this form of the disease is still unclear
Chulalongkorn University, Bangkok, Thailand and there is currently little in the way of evidence to guide us.
For a patient who has residual appositional angle closure fol-
Argon laser peripheral iridoplasty (ALPI) creates contracting lowing iridotomy and coexisting lens opacity, it is reasonable
burns placed at the iris periphery in order to pull the iris root to have a low threshold for doing cataract surgery at the ear-
away from the angle. It is effective in acute primary angle liest sign of visual symptoms.
closure, and pure plateau iris by eliminating appositional an- Difficulties arise when dealing with cases in which the lens
gle closure, but has no proven efficacy for CACG. Additionally, appears to be making a significant contribution to the residual
it has been used to temporary relieve appositional angle clo- angle closure but there is no significant cataract and visual
sure secondary to lens-related mechanism, and to widen the acuity is good. Does this situation justify a clear lens extrac-
angle prior to argon laser trabeculoplasty. However, it will not tion and can prophylactic surgery prevent future development
break permanent synechiae. So, if there is residual apposi- of PACG in these cases? Some studies suggest that cataract
tional closure after LPI, ALPI should be performed in an early surgery may be as effective as filtering surgery in controlling
stage before extensive PAS develops. IOP in PACG cases. In cases in which there is early optic disc
cupping and mild visual field loss, lens extraction alone may
References be enough to achieve adequate IOP control; whereas eyes
with advanced glaucomatous optic neuropathy are more likely
Lam DS, Lai JS, et al. Argon laser peripheral iridoplasty versus
to have poor residual trabecular meshwork function as a re-
conventional systemic medical therapy in treatment of acute pri-
mary angle-closure glaucoma: a prospective, randomized, con- sult of PAS or non-synechial damage. In such cases phacotra-
trolled trial. Ophthalmology 2002; 109(9): 1591-6. beculectomy may be necessary to achieve the degree of IOP
Lim AS, Tan A, et al. Laser iridoplasty in the treatment of severe control required to prevent progression of glaucomatous optic
acute angle closure glaucoma. Int Ophthalmo l 993; 17(1): 33-6. neuropathy.
Ritch R., Tham CC, et al. Long-term success of argon laser periph- Surgical trials are underway to examine the role of
eral iridoplasty in the management of plateau iris syndrome. cataract/lens extraction in post-acute primary angle closure.
Ophthalmology 2004; 111(1): 104-8. This technique has the potential to prevent recurrence of the
condition and progression to chronic angle closure glaucoma.
7.5 With existing and upcoming new data on managing acute pri-
mary angle closure, it is hopeful that a more optimal treat-
MEDICAL MANAGEMENT ment algorithm will be established soon.
T. Aung
Singapore National Eye Centre, National University of
Singapore, Singapore
Objective: To review recent advances in medical management Main Session 8
for angle closure.
Methods: Several randomized controlled trials for the medical SECONDARY GLAUCOMA: XGF AND PSG
management of angle closure have recently been completed.
This talk provides an overview of the use of various medica-
8.1
tions for angle closure.
Results: Recent studies have shown that prostaglandin ana- GENETICS OF EXFOLIATION SYNDROME &
logues are efficacious in reducing intraocular pressure in pa- EXFOLIATION GLAUCOMA.
tients with angle closure glaucoma. Such new information on GENE SEARCH LANDS A BIG HIT
medical therapy has allowed us to choose the most appropri- F. Jonasson, deCode Genetics Study Group, Reykjavik Eye
ate management of patients with angle closure. Study Group
Conclusions: Therapeutic options for the medical treatment Ophthalmology, Landspitali University Hospital, Reykjavik,
for angle closure have increased recently leading to improved Iceland; Faculty of Medicine, University of Iceland, Reykjavik,
care for patients with this condition. Iceland
Aim: To summarize the recent discovery of the genetic basis
7.6
for exfoliation syndrome and possible clinical implications.
SURGERY (SURGICAL IRIDECTOMY, LENS EXTRACTION, Methods: A recent study that identified the genetic etiology
TRABECULECTOMY) of exfoliation syndrome will be discussed as well as later
J. Thygesen replications. This landmark study used a whole genome-
Copenaghen University Glaucoma Clinic, Denmark scan much like a case control study, to compare sequence
variants in persons with and persons without exfoliation
All patients presenting with acute angle closure should be glaucoma.
treated immediately with systemic and topical medications to Results: Combined the high risk single nucleotide polymor-
71 www.eugs.org
phisms (SNPs) were present in 99% of the Icelandic and Results: Exfoliation syndrome is a frequent disease worldwide
Swedish exfoliation glaucoma cohorts. Person homozygous with several clinically significant consequences. It is well
for both the highest risk haplotypes were 700 times more known that due to zonular damage the risk for complication
likely than those with the low risk variant to have exfoliation in intraocular surgery, especially in cataract surgery is signifi-
glaucoma. This may in near future lead to genetic testing of cantly increased in exfoliation. Exfoliative glaucoma develops
persons who have family members with exfoliation glaucoma from exfoliative syndrome. This glaucoma is not only the
and may lead to targeting of family members with the high most frequent type of the secondary open-angle glaucomas,
risk haplotype in the glaucoma clinic. but also associated with elevated intraocular pressure, unusu-
Conclusion: This remarkable finding will provide the basis for ally high intraocular pressure fluctuation, severe visual filed
better insight in the pathophysiology of exfoliation syndrome and damage and relatively poor intraocular pressure decrease un-
probably provide insight into the development of new not in- der conventional glaucoma medication. Both exfoliation syn-
traocular pressure lowering medication for exfoliation glaucoma. drome and exfoliative glaucoma are associated with systemic
alterations and diseases. The association between systemic
vascular diseases and exfoliation is well explained by the re-
8.2
sults of those recent human studies in which systemic vascu-
BASIC SCIENCE OF EXFOLIATION SYNDROME AND lar pathophysiology was investigated. In exfoliation syndrome
EXFOLIATIVE GLAUCOMA and glaucoma both microvascular and macrovascular perfu-
U. Schlötzer-Schrehardt sion is damaged, and the damage increases along the dura-
Department of Ophthalmology, University of Erlangen- tion of exfoliation.
Nürnberg, Erlangen, Germany Conclusion: All the above results are of clinical importance,
thus all ophthalmologist need comprehensive information in
Exfoliative glaucoma (XFG) is the most common and most im- the field.
portant secondary open-angle glaucoma comprising the ma-
jority of glaucoma in some countries. The underlying disorder,
8.5
exfoliation syndrome (XFS), is a generalized disease of the
extracellular matrix characterized by the progressive, stable CATARACT SURGERY IN EXFOLIATIVE GLAUCOMA
deposition of abnormal fibrillar aggregates in various intra- M. Teus
and extraocular tissues. Active involvement of trabecular Department of Ophthalmology, University Hospital Alcala de
meshwork cells in this fibrotic process involving the local pro- Henares, Madrid, Spain
duction of exfoliative material in the juxtacanalicular area
may be the primary cause of outflow resistance and chronic The coexistence of cataract an glaucoma is very common in
pressure elevation in XFS patients. Molecular biologic and bio- exfoliative (PEX) eyes. In these eyes, cataract surgery is usu-
chemical data support the pathogenetic concept of XFS as a ally more difficult than in non PEX eyes, due to the poor
type of stress-induced elastosis, associated with the exces- midriasis and weak zonula that theses eyes usually have.
sive production and abnormal aggregation of elastic fiber The clues for the correct diagnosis and management of these
components. Both genetic and environmental factors have potential difficulties will be discussed, and also some videos
been implicated in the pathogenesis of XFS. Recently, a showing our preferred surgical technique in these eyes will be
strong genetic risk factor for XFS/XFG, i.e. polymorphisms in shown.
the lysyl oxidase-like 1 (LOXL1) gene has been identified.
LOXL1, a member of the lysyl oxidase family of enzymes,
which are essential for the formation, stabilization, and main- 8.6
tenance of elastic fibers, has been shown to play a role in XFS
PIGMENT DISPERSION SYNDROME AND PIGMENTARY
material accumulation and in concomitant elastotic processes
GLAUCOMA
in intra- and extraocular tissues of XFS patients. In addition,
M. Irkec
TGF-ß1, increased oxidative and cellular stress, a dysbalance
Department of Ophthalmology, Hacettepe University Faculty
of proteolytic enzymes and their inhibitors, low grade inflam-
of Medicine, Ankara, Turkey
matory processes, and impaired cellular protection mecha-
nisms appear to be key factors in pathogenesis.
The Pigment dispersion syndrome (PDS) and the pigmentary
glaucoma (PG) are characterized by almost always bilateral mid-
peripheral loss of pigment from the posterior surface of the iris.
8.3
Dispersed pigment is deposited on intraocular structures such
CLINICAL SIGNS OF EXFOLIATION SYNDROME AND as the corneal endothelium (Krugenberg spindle), anterior sur-
EXFOLIATIVE GLAUCOMA face of the iris stroma, anterior and posterior lens surface at the
G. Holló zonular attachments, and typically the trabecular meshwork.
1st Department of Ophthalmology, Semmelweis University, Pigmentary glaucoma (and PDS) is more common in men than
Budapest, Hungary women and young myopic men 20 45 years of age typically
affected Krukenberg spindle, iris transillumination defects, tra-
Aims: To summarise the clinical characteristics of exfoliation becular pigmentation, elevated IOP with wide fluctuations are
(pseudoexfoliation) syndrome and exfoliative (plesudoexfolia- findings that aid in clinical diagnosis. Recently, there has been
tive) glaucoma. interest in the genetics of PDS and PG. Treatment comprises
Methods: Clinical and literature based review. both medical and laser/surgical modalities.
www.eugs.org 72