Sep 24, 2021 Conference

AM Session - Glaucoma Evaluation and Management in Eyes with Coexistent Ocular Diseases and Intraocular Surgery

Welcome remarks - 785th Meeting
Jay Duker

Introduction of Session
Sarwat Salim

The Glaucoma Patient with Ocular Surface Disease
Laura Voicu

Ocular surface disease in glaucoma patients may lead to poor outcomes, and reduced quality of life. Topical glaucoma medications can lead to the development of limbal stem cell deficiency as well as other ocular surface complications. Management strategies including use of preservative free medications, topical anti-inflammatory agents and others can be helpful in such cases. Drop burden may be reduced through the use of sustained-release medication delivery, selective laser trabeculoplasty and minimally invasive glaucoma surgery.

IOL Selection in Patients with Glaucoma
Eric Steffen

The glaucoma patient presents some challenges when picking an IOL for cataract surgery.  Consideration needs to be taken for the stage of the disease, the age of the patient and their life expectancy.  The type of glaucoma the patient has can influence what lens is chosen.  When planning a combined procedure the type of IOL used is important.  Choose the lens that best fits the patients desired visual outcome, but does not compromise their visual potential.  Aspheric monofocal and toric IOL’s can be very beneficial.  Multifocal IOL’s need to be used with caution in patients with early disease and are contraindicated in patients with advanced disease.

Glaucoma in Patients with Corneal Pathology
Lucy Shen

Many patients with corneal pathology undergo partial-thickness or full-thickness corneal transplantation. Unfortunately, 10-20% of the patients develop glaucoma or experience glaucoma progression within 1 year after corneal surgery. Risk factors for glaucoma or progression include older age, preoperative glaucoma, intraoperative IOL removal and postoperative IOP elevation. Patient selection, particularly for KPro and DSEK patients, may also affect the risk of glaucoma. These risk factors should be considered before corneal surgery, and prompt referral to a glaucoma specialist should be made when the patient develops IOP elevation after corneal surgery. The management of glaucoma in patients with corneal pathology is considerably tailored to the individual eye. Medications may not be effective and have potential side effects affecting the corneal graft. Surgical options include cyclodestructive procedures, trabeculectomy and tube shunts, with tube shunts being the most common. However, risk of graft failure and additional challenges for future corneal surgeries need to be considered when performing glaucoma surgery in these patients. A patient example will be used to illustrate these points.

Patient with Uveitis
Rebecca Hunter

It is reported that up to 20% of patients with uveitis will develop glaucoma. Inflammatory ocular hypertension (IOHS)/uveitic glaucoma (UG) is a very challenging condition to manage for ophthalmologists as two issues must be simultaneously addressed. The initial approach to managing IOHS/UG starts with early diagnosis of both the cause of inflammation and the cause of intraocular pressure increase. Promptly starting treatment for ocular inflammation is paramount. The management of ocular hypertension should be initiated simultaneously through aggressive medical management. These patients require close monitoring due to the progressive nature of their disease. Many patients with UG develop recalcitrant elevations in IOP and will require surgical intervention. The benefits and complications of current medical and surgical treatment options for patients with UG will be discussed (1-3).

Glaucoma Evaluation and Management in Patients with Retinal Pathology
Geoffrey Emerick

Intraocular pressure elevation and glaucoma may occur following vitreoretinal surgery, especially pars plana vitrectomy with gas or silicone oil. Extremely high IOP in the early postoperative period can cause optic nerve ischemia. Glaucoma may also develop, through angle-closure or open-angle mechanisms. Risk factors include a personal or family history of glaucoma, ocular trauma, vitreous hemorrhage, and ocular ischemia. Management strategies include medical treatment and surgical interventions such as glaucoma drainage devices.

NEOS Business Meeting
Jay Duker

Introduction of Guest of Honor
Sarwat Salim

Millenial Glaucoma Care
Kuldev Singh

Glaucoma care has has seen an explosion of technology developed to improve care over the past quarter century. Advances in perimetry and imaging, new pharmacologic agents, the evolution of cataract surgery into a glaucoma procedure and the introduction of novel surgical  procedures utilizing microincisional techniques has created tremendous excitement, drawing the best and brightest to our field. With the introduction of so many more options for care, evidence in support of relative benefits of various approaches has not always kept pace with technological innovation.  Numerous treatment approaches and little evidence comparing them have led to widely varying treatment algorithms amongst practitioners. What is easiest and most attractive for the physician may not always correspond with what is best for the patient. Adding more complexity to decision making is the fact that most patients with glaucoma are destined to do well and that major randomized clinical trials have repeatedly shown that one to two thirds of subjects receiving no treatment or placebo for apparent glaucoma do not show progression of disease during the studies. Slow rates of progression make it all the more difficult to show incremental benefits of novel therapies. While medicine historically employed a provider led decision making approach, patients have been increasingly empowered with greater information than ever before and the science of the patient perspective has emerged leading to the introduction of patient related outcome measurement as well as other tools.  Such patient outcome measures are being increasingly used to justify the acceptance of novel therapies.  A patient centered approach should and will prevail in the coming decade.

Why Trabeculectomy Must Survive in the Era of MIGS
Kuldev Singh

We live in an era where there have been a tremendous number of novel glaucoma surgical procedures introduced into clinical practice. Despite many having predicted the demise of trabeculectomy, it remains the preferred go-to procedure for a subset of patients with advanced or rapidly progressing disease who need very low intraocular pressures.  Unfortunately, as novel less invasive procedures become increasingly popular, there has been a substantial reduction in the number of trabeculectomy procedures performed in residency and fellowship training programs throughout the world.  The MIGS revolution has clearly advanced the treatment of patients with mild to moderate glaucomatous disease. Trabeculectomy, however, remains an important option for the subset of patients who need lower IOPs than can be achieved with MIGS procedures, even those that are bleb forming.  As our glaucoma population ages, the absolute number of glaucoma patients requiring very low IOPs to prevent blindness will likely increase in each successive generation, and there is no novel operation on the near horizon that will allow us to titrate IOPs in a manner that is possible with trabeculectomy.

There is variable expertise in trabeculectomy technique amongst recently trained glaucoma specialists. Decreased experience in the performance of the procedure as well as the art of postoperative manipulation to optimize IOP lowering while minimizing the likelihood of the devastating complications that can occur with this procedure, there is a potential for a downward spiral where less trabeculectomy training results in poor outcomes, followed by further reduction in procedures performed, leading to further decrease in training.  Such a sequence of events could create a public health problem where increasing numbers of patients requiring trabeculectomy to prevent blindness will be unable to find practitioners who are adequately trained to perform the procedure.

Panel Discussion
Sarwat Salim

PM - Hot Topics in Pediatric Ophthalmology: How do I Counsel my Patient for These Common Scenarios?

Introduction of Session
Eric Gaier

New Therapies for Amblyopia
Vicki Chen

The past decade has seen tremendous strides forward in amblyopia research, with a focus on new therapies. Novel approaches have arisen from extensive scientific discovery in the field. Some of these treatments have reached the market with limited evidence to support their use. Others have been discussed heavily in the technology and research sectors, but are not yet commercially available. I am excited to share my perspective on the cutting-edge of amblyopia research. Ophthalmologists, parents, and patients want to know what's on the horizon- here is the evidence-based update on new therapies for amblyopia. Moreover, there are new twists on old therapies that could help them today.

Atropine for Myopia Progression
Melissa Wong

Myopia and high myopia are projected to continue to increase in prevalence worldwide (1). The ocular sequelae of myopia will be lifelong and can lead to severe visual impairment. The study of atropine in slowing the progression of myopia has been ongoing (2,3,4,5). While it has been shown to be effective at slowing the progression of myopia as compared to conventional myopia treatment, there are many facets of atropine in myopia that are yet unknown. Awareness of upcoming trials along with facility with current ongoing studies can aide the ophthalmologist in the discussions of myopia that undoubtedly come up both in clinic and outside of clinic.

Blue Light Filtering Glasses for Screens
Jennifer Galvin

Benjamin Jastrzembski

The COVID-19 pandemic necessitated an abrupt shift towards telehealth in ophthalmology and across medicine. A year and a half later, our collective experience with synchronous audiovideo tele-ophthalmology have shown us the advantages and disadvantages of this care platform including its ability to both reduce or exacerbate the challenges in accessing care.

Ophthalmic Care of Children with Dyslexia/Learning Disability
Aparna Raghuram

Dyslexia is a complex neurodevelopmental disorder that can cause life long impairment and an estimated prevalence of up to 10% in the general population.  Neuroimaging and behavioral studies have led to a consensus that the primary deficit is in the language centers of the brain responsible for phonological processing. Although reading is also a visual task, the potential role of vision in dyslexia has been controversial. We will review pertinent current literature and what we can gather as eye care professionals to help provide patient-centered recommendations.

Impact of Traumatic Brain Injury on Vision
Ankoor Shah

Concussion is a common form of injury in the adolescent population.  Although the vast majority of adolescents recover, a cohort proceeds to have significant symptomatology months beyond the initial injury.  Ophthalmologists are often called to see patients with chronic post-concussion symptoms due to the high prevalence of vision-related problems.  However, ophthalmic training the field of post-concussion symptoms and management is lacking.  This talk will give practicing ophthalmologists an overview of the symptoms that a patient may experience and an overview of how to approach the situation with testing and appropriate referral.

Cerebral Visual Impairment
Lofti Merabet

Cerebral (cortical) visual impairment (CVI) is the leading cause of pediatric visual impairment in developed countries. Despite this clear public health concern, our understanding of the functional visual profile and underlying neurophysiology of this condition remain poorly understood. In the setting of early neurological injury, children with CVI typically show deficits associated with higher order visuospatial processing such as finding a target of interest within a complex scene. Beyond standard ophthalmic testing, it remains unknown how manipulating task demands and other environmental factors influence visual search performance in this population. To address this gap, we have developed a series of novel and naturalistic virtual reality (VR) based search tasks combined with eye tracking. We find that CVI is associated with decreased search efficiency and worsening performance with increased visual task demands when compared to neurotypical controls. Finally, neuroimaging using diffusion based techniques has shown that CVI is associated with a dramatic alteration in white matter connectivity, particularly with respect to visual pathways implicated with the dorsal (i.e. spatial) visual processing stream. This novel VR based approach allows for the assessment of visuospatial abilities in CVI with a high degree of behavioral relevance, ecological validity, and participant engagement, and may also have important clinical applications in assessing environmental factors that affect functional visual processing in CVI.

Pediatric Low Vision
Wendy Chen

Children with vision impairments can be one of the most challenging subsets of patients to care for. Families of children with vision impairment often seek more information about their child’s ability to function with the level of vision that they have. Providers should guide families through the process of low vision evaluation and visual rehabilitation. This process can be daunting, both for families and providers. The objective of this talk is to review common scenarios in which providers can assist families through the process of low vision evaluation and the subsequent implementation of recommendations into their daily lives, day care, or school.

Introduction of Guest of Honor
Eric Gaier

Information Technology for Eye Care: Promises, Challenges, Solutions
Michael Chiang

Computing and information technologies have potential to improve quality and delivery of eye care. However, there are significant challenges such as efficiency, the quality and nature of clinical documentation, and impact on patient communication. This talk will discuss those challenges, as well as potential solutions such as data analytics and artificial intelligence.

Panel Discussion
Eric Gaier