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Top-Nine of the WGC Presidents Symposium
Hong Kong, June 6, 2015
S. Fabian Lerner
An outstanding symposium co-chaired by Tin Aung, Robert Fechtner, Franz Grehn and Jeffrey Liebmann was presented following the Opening Ceremony of the WGC in Hong Kong. This event, entitled: Glaucoma Innovations and Opportunities, addressed several aspects of the present and future of glaucoma diagnosis and management.
- Adriana Di Polo (Montreal) talked on The RGC and its microenvironment: What we know and what we need to know. The RCGs live within a rich and complex environment, which is a key factor to their survival, and there is an important interaction between ganglion cells and other cells, particularly astrocytes and microglia, in this microenvironment. Glial cells may play a role in the pathophysiology of the disease. Could modulation of glia have an effect in glaucoma? A possible neuro-inflammatory component on glaucoma was suggested.
- Jost Jonas (Mannheim) presented Is the lamina cribrosa the site of glaucoma damage and what can we do about it? The lamina cribrosa is the limit between two pressure compart-ments: the IOP and the cerebrospinal fluid pressure (CSFP) sections. It gets thinner in glaucoma and, thus, the gradient of pressure across the lamina increases. The lamina gets thinner also in high myopia in which there is a stretching of the optic nerve, and this may be a risk factor for the higher prevalence of the disease among high myopes, usually with an axial length of more than 26.5 mm. Dr Jonas also discussed the different zones of parapapillary atrophy and their possible association with glaucoma; as well as the possible role of a low CSFP in the disease.
- Tin Aung (Singapore) presented Glaucoma genetics: recent advances and future directions. Dr Aung presented the list of genes found by GWAS. He also discussed the work of the International Glaucoma Genetic Consortium that looks at quantitative traits in OAG. Genes have been discovered for optic disc size, central corneal thickness and IOP. Using GWAS, genes for ACG were also discovered. Moving into new technologies may allow finding new genes, mecha-nisms of action of the genes, what targets are involved and possibly new therapies.
- Keith Martin (Cambridge) talked on Applying regenerative medicine techniques and tech-nology tomorrow. Dr Martin began his talk by stating that we are living the era of regenerative medicine. Particularly in glaucoma, experiments are trying to replace ganglion cells with its different types and connections, and these are particularly difficult cells to replace. A possible and short to medium-term approach is to use stem cells methods and protective factors to protect the ganglion cells against pressure-induced injury. Axonal regeneration is feasible. However several questions remain including, how to guide axons to the correct place, how are we going to prevent ongoing regeneration, and how much regeneration will we need to get functional recovery. Can we engineer a retina? Regenerative medicine is coming to the eye. Is already happening with RPE cells and photoreceptors may follow. Tissue engineering advances very fast. Work is being done to protect injured cells and regenerate new ones. Function recovery is still a big challenge.
- Kazuhisa Sugiyama (Kanazawa) presented Integrating RGC counts and optic nerve struc-ture and function measures to improve care. Dr. Sugiyama presented simultaneous evalua-tion of structure and function point by point. Correlation between structure and function points is moderate and depends on the stage of the disease. OCT structure analysis is useful in early stages and visual field function in more advanced stages. RGC counts may be important in all stages of the disease.
- Robert N. Weinreb (La Jolla) talked on Personalizing IOP. The concept of measuring 24-hour IOP will transform medical therapy and surgical therapy and reduce glaucomatous blindness. Currently we manage glaucoma with single IOP measurements, however, IOP fluctuates very rapidly and is not consistent from day to day. IOP is highest at night in two thirds of individuals, while aqueous inflow is lowest at the same time, and uveoscleral outflow also decreases at night compensating for the reduce inflow. Together with the increased episcleral venous pres-sure at night, the IOP is increased at night. Drugs may be seen as those that decrease IOP during 24 hours and increase perfusion pressure (PGAs and carbonic anhydrase inhibitor and alpha agonists). Laser trabeculoplasty and trabeculectomy are effective throughout the 24-hour day. Continuous 24-hour IOP measurements may be temporary or permanent. Treatments will be individualized based on an individual’s 24 hour of IOP profile.
- Glaucoma surgery of tomorrow: beyond IOP was presented by Tarek Shaarawy. Current avail-able operations reduce IOP, which is the primary endpoint for glaucoma surgery. We still rely on four mechanisms to do this: filter into the subconjunctival space, enhance filtration through the conventional outflow, use the suprachoroidal space, or reduce production by ciclodestruction. Each of these four strategies can be addressed ab interno or ab externo. There are still unmet needs, including safety, visual outcomes as well as health economics. Safety is not as good as needed yet. New ‘bleb-less’ devices or modalities are being used and also the supracho-roidal space is explored as a new approach for glaucoma surgery. Visual outcomes need to be improved, and health economics taken into consideration.
- Neeru Gupta presented Using technology to mitigate glaucoma disability and improve the lives of our patients today and tomorrow. Electronic Medical Records and Ocular Risk Calculators are available now. New technologies, available in our smartphones, might be able to help us determine progression. There is a need to peer review of new ‘eye apps’ to allow them to become standard. Also this is an opportunity for low-income areas. The future is mobile. Assisted technology is becoming mobile. Some of the technologies going on in the retina field may be transferable to glaucoma. Virtual reality technology may help glaucoma patients with their balance. For every one-dollar invested to prevent blindness there are four dollars in economic benefits generated. The technology exists. We need education and programs. The future of glaucoma is at the palm of our hands.
- Roy Wilson finished the symposium with The consequences of longevity: implications for glaucoma surveillance and management in the 21st century. Increased longevity has some consequences, including the decline of economic growth, and the increase in health care expen-ditures. There is considerable research trying to slow down the aging process at the cellular level. The prevalence of glaucoma increases with increase of age in any population. As life expectancy increases, this has consequences in the actual management of a patient and the possibility of visual disability during lifetime. The increase in glaucoma will be a challenge in developing economy countries. We have to think about adjusting our current treatment strategies. More aggressive IOP lowering may be needed earlier in the disease.
