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Top X of the Snogeholm Castle Glaucoma Meeting
September 15-17, 2000, Snogeholm, Sweden
Anders Heijl
The Castle Glaucoma Meeting had an unusual and interesting format; it was almost exclusively devoted to structured discussions. During the whole symposium only two specific glaucoma topics were addressed, permitting discussions that at least partly achieved considerable depth while at the same time permitting a very open exchange of thoughts.
Sixty invited glaucoma specialists participated in the meeting that had been organised by Professor Anders Heijl and Dr Boel Bengtsson of the Malmö University Hospital in Sweden, and totally sponsored by Merck.
The two topics of the meeting were:
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The Optic Disc in Glaucoma Management, with discussions introduced by Erik Greve, Amsterdam and Joe Caprioli, Los Angeles and chaired by Juhani Airaksinen, Oulu and Jost Jonas, Mannheim. The discussions were in purpose concentrated on the optic disc, excluding as much as possible the RNFL to allow a more thorough exchange if thoughts.
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Clinical Trials in Glaucoma, introduced and chaired by Mae Gordon, St Louis, Stefano Miglior, Milan, and Jim Tielsch, Baltimore.
Many of the conclusions from the meeting, below, were thus results of discussions specifically aimed at reaching consensus:
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There is presently no morphological proof for vasogenic glaucoma damage. On the other hand, there is also certainly no proof that vasogenic mechanisms are without importance for the development of glaucoma damage.
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The three most important risk factors for glaucoma progression related to the optic disc are probably (in order of importance): 1. optic disc haemorrhages, 2. neuroretinal rim notches, 3, parapapillary atrophy - this factor possibly may be of marginal importance.
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If only one device is allowed for the diagnosis of glaucoma would you prefer a topographic 3-dimensional optic disc scanner or a perimeter? Almost all discussion groups agreed that both are desirable. Quantitative optic disc analysis needs to be further developed and tested, however, presently the usage and interpretation of perimetry is more mature. Visual function testing has a further advantage of giving a better understanding of the impact of the disease on the patients visual function and quality of life.
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Is it sensible, cost-effective or necessary to try to diagnose glaucoma and start treatment at a stage when visual field defects cannot be demonstrated with standard automated static white-on-white perimetry? All discussion groups agreed that if such a diagnosis could be made the answer was still not automatically a positive one, but depending on patient age, general health and social conditions.
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It is desirable that a staging of glaucomatous disc damage is developed - similar to that available for glaucomatous visual field damage.
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The goal of the Vision 2020 project of the WHO is to eliminate avoidable blindess; the target is blindness - not disease.
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We still have very deficient knowledge of the effect of IOP reduction on glaucoma progression or reduction of glaucoma incidence in ocular hypertension. On-going studies: the Early Manifest Glaucoma Trial (EMGT), the Ocular Hypertensive Treatment Study (OHTS), and the European Glaucoma Prevention Study are well under way, however, and their results have great potential to increase such knowledge tremendously.
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Primary prevention of glaucoma is presently out of reach because of the unknown etiology of the disease.
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Secondary prevention of glaucoma will depend on better screening and on proof of treatment efficacy. There is now good reasons for optimism regarding development of practicable mass screening methods, and ongoing studies should give much needed answers on treatment effects.
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Can a "large, simple trial" approach work for glaucoma? - a trial characterised by a very large sample size, one initial simple recruitment and examination, no or few and simple follow-up examinations, and a simple outcome definition, e.g., legal low vision status or blindness. Such studies would be highly desirable and their results could be particularly relevant for the effects that could be expected in the community of any treatment modality studied in this way.