As many glaucomas as there are patients

The experience and preferences of the ophthalmologist and the risk factors of the patient, such as myopia or even playing sports or one's race, essential in determining treatment
The experience and preferences of the ophthalmologist and the risk factors of the patient, such as myopia or even playing sports or one's race, essential in determining treatment

Over 250 ophthalmologists specialising in glaucoma met this weekend at Trends in Glaucoma, an international congress organised by IMO Foundation on the disease, the main cause of irreversible blindness in the world. The meeting was attended by a large number of the main experts both at home and abroad, all of whom highlighted its great success for the sharing and updating of knowledge on the handling of this multi-factorial condition with many therapeutic options.

Personalised treatment

One of the main conclusions of the congress was the wide variety of surgical and non-surgical techniques and strategies that exist for the treatment of glaucoma, as Dr Elena Arrondo, IMO glaucoma specialist and co-director of the congress, explained. If you add the characteristics of the eye and the specific risk factors of each patient to this, the result is that, beyond the protocols, “the surgeon's experience is essential when effectively treating glaucoma patients, and this has been the great success of the meeting, in which some of the most expert glaucomatologists from around the world have shared their ‘tips’ for obtaining the best results with patients,” Dr Carolina Pallás, co-director of the course, added.

According to the glaucomatologists, in general, when deciding on a treatment for a glaucoma patient, many other factors must be taken into account, as well as intraocular pressure, such as family history or myopia. More particularly, one of the round tables discussed the case of myopic patients, who are at greater risk of glaucoma, particularly those with over six diopters, who are two to three times more likely to suffer the disease.

Types of glaucoma and therapeutic options

Another issue of interest was glaucoma at paediatric age, which is relatively infrequent, but can lead to irreversible sight deficit in children, and secondary glaucomas that affect a large number of patients who, as well as this condition, suffer from others, such as uveitis or diabetes, or who have suffered traumas or have been subjected to certain eye surgery procedures, such as cornea transplant or vitrectomy (surgery to treat retina conditions). Along these lines, some specialists referred to neovascular glaucoma (one of the secondary glaucomas) as a “public health problem,” as it affects diabetic patients, an increasingly large population.

The relationship between sports and glaucoma was also covered during the meeting by Dr José Luis Urcelay, a glaucoma specialist and marathon runner, who warned that certain sports, such as scuba diving, or specific sports accessories, such as swimming goggles, could affect intraocular pressure, the main risk factor of glaucoma. “This does not mean that glaucoma patients cannot enjoy sports, but it is something that must be considered by the ophthalmologist.”

Urcelay also explained that there are certain treatments that could decrease sports performance. According to the specialist, some beta-blocker drugs used to lower intraocular pressure could affect the heart rate and have an impact on anti-doping tests in the case of elite sportspeople.

With regard to the possible adverse effects of the drug treatment for glaucoma, IMO cornea specialist, Dr Óscar Gris, also advised on the use of preservative-free eye drops, especially in elderly patients and in treatments with multiple eye drops, given their harmful effect on the eye surface.

Maintenance treatments and future treatments

The congress also discussed maintenance treatments after glaucoma surgery, such as injections of antifibrotic drugs, an extremely important aspect if it is considered that many surgeries require maintenance injections or further surgery several years later, especially due to scarring problems. While some experts defended the fact that good post-surgical drug modulation is necessary to prevent the surgery from being a failure, others referred to the benefits of using certain surgical techniques that “agree with scarring,” such as the implanting of drainage tubes or the canaloplast.

In terms of future treatments, neuroprotection was considered a possible new therapeutic weapon for the foreseeable future, as is already the case with other neuro-degenerative conditions, such as Alzheimer's or Parkinson's.

Variety of surgical techniques

Case studies using the different surgical techniques were seen during the meeting, without avoiding the controversy among surgeons preferring trabeculectomy to sclerectomy or one of the more recent surgical options, such as the canaloplast, the ExPRESS implant or the so-called MIGS, which are minimally invasive and very non-aggressive surgeries, although questioned by some surgeons because of their limited effectiveness in advanced glaucomas.

Cataract surgery as a strategy to treat primary closed-angle glaucoma patients was also covered, as removing the crystalline lens and replacing it for a much thinner one increases the angle of the eye's anterior chamber and reduces intraocular pressure.

Ophthalmologists expounded their experience with the use of new SLT and PLT lasers, which were generally defined as being more user-friendly, faster, less aggressive and with fewer long-term complications. The advantages of the new diagnosis devices were also highlighted, such as ultrasound biomicroscopy, a high-resolution ultrasound that provides extremely useful information.

Beyond intraocular pressure

The specialists also debated on how to treat glaucoma in patients with normal intraocular pressure, considering that high intraocular pressure is the main risk factor for glaucoma and that all current treatments are aimed at its reduction. Along these lines, certain studies were also referred to that show, however, the suitability of reducing pressure by at least 30% in patients with normal-tension glaucoma to prevent a worsening of the condition. However, as well as this measure, other factors must be considered that could be associated with this type of glaucoma, such as low blood pressure, migraines, vascular problems or Raynaud's phenomenon (alteration of the peripheral circulation), according to Dr Sílvia Freixes, co-director of the congress.

The ophthalmologist explained that “the patient can improve by treating these associated problems, and, therefore, the ophthalmologist should be familiar with them, assess them and, where necessary, send them to the GP to determine the suitability of taking measures, such as reducing blood pressure pills or recommending coffee or salt in patients with low blood pressure.”