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Editorial IGR 8-3

Dear Reader,

WGA

When this issue of IGR reaches the reader, the book on the 3rd WGA Consensus on Angle Closure Glaucoma will be out (click here for details). Preparations for the 4th Consensus on IOP have started. The Ceremony for the 7th WGA-Award presentation will be held at the occasion of the combined SEAGIG/GSI meeting in Chennai, India, December 2006. The Awardees are Hiroshi Sakai from Japan and Simon John from the US (click here for details)

WGC

The final announcement for the World Glaucoma Congress in Singapore, July 18-21, 2007 is out. Many of you will receive it through the services of our Glaucoma Industry Members. Everyone can view the announcement on the website: www.worldglaucoma.org/WGC2007. Registration and submission of poster abstracts opens December 1, 2006. The Program Committee has created all sorts of opportunities to participate at a reduced cost level. The poster presentation will receive maximal attention through organized in loco discussion and special poster discussion symposia.
Special features are:

• Largest Glaucoma Congress
• Highly appreciated didactic program
• Top quality glaucoma experts
• 84 courses at all levels
• Extensive poster program
• Basic and Clinical Science Sessions
• Special topic discussion symposia
• Glaucoma Patient Symposia
• Grants for economically underprivileged colleagues
• Special Participation Packages

Editors Selection

The Editors Selection is interesting as usual by its very nature of being a selection: more POAG than PACG in China, familial glaucoma more severe, timolol and death, genes and IOP, microglia and astrocytes, IOP and CSF, SAP as good as SWAP, optic disc and blood pressure, PERG and OCT, additional Risk Factors from the OHTS, latanoprost after ALT, phaco after GDD. The Editors Selection also comments on the economics of selective laser trabeculoplasty as primary therapy for glaucoma. The IGR reviewer highlights the shortcomings of the study while stressing that the subject - comparison laser vs medical therapy - is of major importance to the management of glaucoma. An editorial in the Canadian Journal of Ophthalmology (vol. 41, p. 419) also discusses the article and concludes that "the evidence as presented does not justify changing the current treatment paradigm for POAG." A prospective randomized clinical trial is under way and will hopefully provide an acceptable answer to this important management issue. At present there is one advantage of laser treatment: compliance. With the upcoming trend in medical therapy to change from drops to patient administration-independent delivery systems, this compliance advantage may disappear. A future comparative study will subsequently need to include these delivery systems. That study may take a while to start though.

IOP 100 years

The Schiotz tonometer was introduced one hundred years ago and it served the ophthalmic community for over fifty years (see also the editorial in the Arch Ophthalmol 124: 1337). Its indentation principle was replaced by the Goldmann applanation principle in 1954. Since then and particularly since the OHTS factors influencing Goldmann tonometry have received great attention. The fact that the measured IOP values in practice may not be always as representative as we would hope is food for thought (click here). Such thoughts will be extensively addressed in the upcoming consensus on IOP .

Epidemiology of medical treatment

The increased attention to OHT and glaucoma is expressed in a paper in the BJO (abstract 849) which showed that the prevalence of being treated for OHT or glaucoma increased in 10 years from 1.7% to 2.3%. Of course the over-eighty were much more likely to be treated than younger patients. Social status came up again as influencing participation in the treatment process (see also editorial in the AJO 2006, p. 1185). In 2003 prostaglandins took over betablocker-only treatment in this UK-based study. A further increase of treatment prevalence is expected because of the introduction of risk calculators for OHT, better understanding of structure and function diagnostic measurements, better detection of glaucoma, reduced social status difference, and aging population.

Compassion

Comparison is a word rarely used in our medical world. Evidence has won the race for the doctor's attention. Nevertheless, compassion is at the heart of all spiritual theory and without compassion it would be impossible to be a good doctor. So we will have to be both evidence based and compassionate doctors. Is this mere idle philosophical talking? I hope not; I am sure it is not, as 'evidenced' by a discussion in the 'controversies' series of Arch Ophthalmol 124: 1032. The question is discussed whether promising treatment modalities should be provided 'compassionately' to patients before the hard evidence of randomized clinical trials is available. The idea prevails that it is non-compassionate to withhold promising medication. However, should we, following Hippocrates (do no harm) treat patients with drugs for which there is sufficient evidence? As the series is named 'controversies' it will be clear to the reader that there is no uniform opinion on the practice of compassion. This matter deserves consensus: compassionate consensus.

Glaucoma more than the eye

In the introduction of IGR 8-2 we commented on 'Glaucoma, a brainy disease'. A recent review in the J Français d'Ophtalmol 29: 847 also highlighted the involvement of various parts of the brain in glaucoma. They added reductions of retinal projection to the suprachiasmatic nucleus. Glaucomatous ganglioncell-degeneration may lead to lesions of the retino-hypothalamic tract which is involved in synchronisation of circadian rhythms. There is more in the eye and brain, Horatio, than we can detect with the ophthalmoscope and perimeter (free after Shakespeare, Hamlet).

The future of glaucoma

This issue of IGR has a supplement that reports on a meeting that was dedicated to future development in glaucoma. The report covers such interesting topics as aging and glaucoma, biomarkers in prevention, future of function and structure, drug delivery, and neurodegeneration. Everyone interested on current ideas on future developments in glaucoma should have a look at this report; the key-points after each section will allow a quick overview. Some of them are printed here:

• With the information available, it is currently not possible to predict disease evolution in many patients: there is a need for better risk assessment approaches and biomarkers for progression rate;

• Improvements of imaging techniques will allow a more sensitive detection of optic disc damage and an assessment of disease progression rate;

• Effective glaucoma management requires a better understanding of patient susceptibility to glaucoma due to both IOP- and non-IOP-related factors;

• In addition to IOP-lowering, therapeutic intervention may be required at the level of multiple degenerative pathways - possibly at the level of the axon, synapse/dendrite and soma.

Erik L. Greve
Robert N. Weinreb