Volume 14, Number 1
April 2005
Wills Glaucoma Specialists Share Their
Expertise at Annual Glaucoma Conference
Drs. L. Jay Katz, Jonathan Myers, Courtland Schmidt, and George
Spaeth spoke about the newest glaucoma medications and diagnostic
technologies as well as advances in the management and surgical
treatment of glaucoma to comprehensive ophthalmologists and glaucoma
specialists gathered for the 26th Annual Wills Eye Glaucoma Conference,
“Glaucoma 2005: Meeting the Challenges,” held in St.
John, U.S. Virgin Islands, February 2–5.
Also presenting were former Glaucoma Service fellow Dr. Steven
Simmons, now Assistant Professor of Ophthalmology at Albany Medical
College, Dr. Ralph Eagle, Director of the Wills Pathology Service,
Dr. Jeffrey Liebmann, Clinical Professor of Ophthalmology and
Director of Glaucoma Services, Manhattan Eye, Ear & Throat
Hospital, and Dr. George Cioffi, Chief of Ophthalmology and Director
of Glaucoma Services at Legacy Portland Hospital, Portland, Oregon.
Drs. Spaeth, Schmidt, Myers, and Katz covered the following topics:
Dr. Spaeth:
• How Does One Decide When and How to Treat Patients?
• How One Chooses Medications for the Treatment of Glaucoma
• Objective Grading and Evaluation of the
Angle/Optic Nerve/Visual Field
Dr. Schmidt:
• Setting and Re-Evaluating a Target Pressure
• Bleb Headaches (Hypotony, Leaks, Infections): Guidelines
Dr. Myers:
• Perimetry — What’s New? What’s Still
Important?
• Electronic Medical Records 2005 — Time to Take the
Plunge?
• Changing Indications for Combined Cataract/Glaucoma Surgery
Dr. Katz:
• Objective Evaluation of the Visual Field with Electrophysiology
• Selective Laser Trabeculoplasty — Trends and Tips
• Releasable Sutures for Trabeculectomy Microstents
Dr. Liebmann gave the Barnshaw Lecture: What Does Intraocular
Pressure Really Mean? Reflections on Diurnal Variation, Central
Corneal Thickness, and Perfusion Pressure. Dr. Simmons gave the
Benjamin Lecture: “What Guidelines Should We Use for Medication
Use in Glaucoma?” Finally, Dr. Cioffi gave the Sivalingam
Lecture: “What is the Best Primary Operation for Glaucoma
Surgery? — Trabeculectomy? Tube Shunt? Non-Penetrating Surgery?
Stents?
Drs. L. Jay Katz (left), George Spaeth, and Douglas
Rhee (right), representing Wills Eye Hospital, received a trophy
for their participation in a “debate” with Bascom
Palmer Eye Institute glaucoma specialists at the Glaucoma MidWinter
Symposium sponsored by Bascom Palmer in Key Biscayne, Florida
January 28–29. The discussions were wide-ranging —
covering diagnostic issues, such as imaging, as well as treatment
topics including medicinal, laser, and surgical approaches to
glaucoma. The idea, according to Dr. Francisco Fantes, from Bascom
Palmer, Co- Director of the course along with Dr. Richard Parrish
II, was “to present highly clinically relevant teaching
‘pearls’ of the Wills and Bascom Palmer specialists
and throw key concepts on the floor for open discussion among
these world experts.”
Photo by Jack Scully
Dr. Rhee and Former Fellow Dr.
Leslie Jones Receive American Glaucoma Society Clinician-Physician
Awards
Glaucoma Service physician Dr. Douglas Rhee and
former Glaucoma Service fellow Dr. Leslie Jones (2000–2001)
each received one of the five prestigious Clinician-Scientist
Awards awarded this year by the American Glaucoma Society.
Dr. Rhee received the Award for the second year in a row, an especially
unusual distinction. The announcements were made at the annual
meeting of the Society in Snowbird, Utah, March 4–6.
The Clinician-Scientist awards are given to encourage
those rare glaucoma specialists who are able to combine a busy
clinical practice with groundbreaking research. Dr. Rhee, who
in addition to being a Glaucoma Service physician is Director
of the Laboratory for Molecular Ophthalmology at Wills, received
the award for continuation of his work to discover the molecular
biological aspects of intraocular pressure regulation in the eye.
Dr. Jones, currently Assistant Professor of Ophthalmology at Howard
University College of Medicine in Washington, DC, received the
award for her proposed project, “Genetic Risk Factors for
Primary Open-Angle  Glaucoma
in an Urban African- American Population.”
Commenting on her project, Dr. Jones noted:
“I believe insights into why glaucoma is the leading causeof
blindness among individuals of black African descent and tends
to be more severe in these individuals will help all glaucoma
patients by increasing our understanding of the basic causes of
the disease, leading to the development of better therapies.”
Seven Glaucoma Studies to be Presented
at National Meeting
Seven studies by Glaucoma Service physicians, fellows, Glaucoma
Research Center personnel, and researchers at the Wills Laboratory
for Molecular Ophthalmology have been accepted for presentation
as posters at the Annual Meeting of the Association for Research
in Vision & Ophthalmology (ARVO), the premier national association
for ophthalmic research, the first week of May.
In a note to the authors Dr. Spaeth said: “The ARVO Program
Committee showed good sense. These are good projects. Congratulations
to all who made them possible.”
- Comparison of Intraocular
Pressure Lowering Efficacy of Fixed Combination Timolol- Dorzolamide
versus an Unfixed combination of Timolol and Latanoprost
Grace Lee, MD, L. Jay Katz, MD, Jeanne Molineaux, Joann
Fontanarosa, PhD, William Steinmann, MD, MSc
Combining two different types of glaucoma medications in a single
formulation is convenient for patients, who, if they require both
medications, would have to instill only one rather than two different
drops. Also it is possible that the combined medication could
be more effective in reducing intraocular pressure than the single
medications taken separately. This study found that glaucoma patients
treated with a fixed combination of timolol-dorzolamide and an
unfixed combination of timolol and latanoprost had equivalent
decreases in intraocular pressure.
- Effect of Mitomycin C on Intraocular
Pressure
Chandrasekharan (Dru) Krishnan, MD, Jonathan Myers, MD,
Carol Shields, MD, Jerry Shields, MD
Mitomycin C is an anti-scarring agent used in glaucoma surgery
(trabeculectomy) to keep the surgically created bleb open and
functioning rather than naturally healing over. Theoretically,
this agent can be toxic to the ciliary body (which produces the
aqueous fluid), decreasing intraocular pressure. The records of
20 patients treated by the Wills Eye Hospital Oncology Service
with topical mitomycin C for conjunctival and corneal tumors were
reviewed. None of these patients had a history of glaucoma and
none were on topical glaucoma medications. The primary objective
was to compare intraocular pressure before and after treatment
with topical mitomycin C to determine whether treatment with mitomycin
C was a factor in intraocular pressure changes. This study found
that topical mitomycin C showed no statistically significant acute
effect on intraocular pressure.
- Color Vision Improvement Following
Successful Trabeculectomy
Dara Lankaranian, MD, Leopoldo Magacho, MD, Jeffrey Henderer,
MD, William Steinmann, MD, MSc, George Spaeth, MD, João
Lopes, MD, Undraa Altangerel, MD
The purpose of this study was to determine if color vision improves
following reduction of intraocular pressure after trabeculectomy.
The percentage of intraocular pressure reduction was compared
with changes in a variety of color-vision parameters. The authors
found that an intraocular pressure reduction of 20% following
trabeculectomy was associated with an improvement in color vision,
and that such an improvement can serve as a useful marker to assess
the effect of treatment.
- Healon 5® Subtenon Under
the Bleb in Trabeculectomy Surgery: A Randomized Clinical Trial
Undraa Altangerel, MD, Marlene Moster, MD, João
Lopes, MD, Melissa Tong, Heryberto Alvim, MD, Joann Fontanarosa,
PhD
Healon® (Advanced Medical Optics, Inc.) is a viscoelastic
substance used as a surgical aid in
cataract extraction, intraocular lens implantation, corneal transplant,
glaucoma filtration (trabeculectomy), and retinal attachment surgery.
In surgical procedures in the anterior segment of the eye, as
in trabeculectomy, instillation of Healon serves to create and
maintain a deep anterior chamber, which facilitates manipulation
inside the eye, with reduced trauma to the corneal endothelium
and other ocular tissues. The purpose of this study was to investigate
the effect of applying the most recent formulation of Healon,
Healon 5, under the sub-Tenon’s capsule (the layer of tissue
that envelops the eyeball from the edge of the cornea to the optic
nerve) following glaucoma surgery. The study found that application
of Healon 5 in this way following glaucoma surgery was associated
with more diffuse blebs. However, the success rate and the IOP-lowering
effect were not statistically different between these eyes and
controls one year after trabeculectomy.
- ExPRESS™ Shunt Implantation
with Scleral Flap Technique for Complicated Glaucoma
João Lopes, MD, Marlene Moster, MD, Sophia Wamsley,
MD, Lior Haim, Undraa Altangerel, MD, Dara Lankaranian,
MD, Joann Fontanarosa, PhD, William Steinmann, MD, MSc
Glaucoma drainage devices, also known as tube
shunts, are implanted devices that are designed to maintain an
artificial drainage pathway for patients with glaucoma, thereby
lowering intraocular pressure. This procedure is often chosen
for patients at high risk of failure with a traditional glaucoma
filter procedure (trabeculectomy). The ExPRESS™ (Optonol,
Israel) shunt is a new such device. We found in an earlier study
that implanting this shunt under the conjunctiva was associated
with a high rate of postoperative complications. Implanting the
device instead under a scleral flap has been proposed to decrease
the risk of postoperative hypotony (intraocular pressure too low)
and conjunctival erosion. This study found that this technique
of implanting the ExPRESS shunt controlled IOP in more than 75%
of patients with complicated glaucoma, with no need for medications
or additional surgery.
- Effect of Written Instructions
on Accuracy of Self- Reporting Medications in Glaucoma Patients
Bhairavi Kharod, MD, Paul B. Johnson, Heather Nesti, MD,
Douglas Rhee, MD
The purposes of this study were to evaluate
the accuracy of self-reporting ophthalmic medications
in a glaucoma population, identify factors contributing to patient
accuracy, and assess the effect of written instructions on the
accuracy of self-reporting medications. The study found that if
patients are, indeed, reporting medications as they administer
them, there is significant improvement in administration of medications
after written instructions.
- Comprehensive Survey of Tissue
Inhibitors of Matrix Metalloproteinase Enzymes and Their Transcriptional
Response to Latanoprost Incubation in Human Trabecular Meshwork
and Ciliary Body
From the Laboratory for Molecular Ophthalmology: Jonathan
L. Martin, Rachel Peck, Dong-Jin Oh, PhD, Douglas Rhee,
MD, Director
In this study Dr. Rhee and colleagues continue the Laboratory
for Molecular Ophthalmology’s groundbreaking work to discover
the molecular biological aspects of intraocular pressure (IOP)
regulation in the eye. Why, at the most fundamental level, is
the pressure exerted by the fluid in the eye (the aqueous humor)
on the optic nerve cells in certain eyes too high for the optic
nerve cells in those particular eyes to withstand? The physiological
controls that seem to prevent this damaging effect in most eyes,
in these eyes seem somehow to be out of adjustment.
Their studies over the past 4 years have revealed many similarities
and some important differences between the cell signaling systems
for the two pathways or tracts by which the fluid in the eye drains
out of the eye — the conventional pathway (ie, the trabecular
meshwork) and the uveoscleral pathway (ie, the face of the structure
that produces the fluid in the eye, the ciliary body). Importantly,
they have shown evidence that three enzymes, among a family of
21, may be the key effectors of IOP regulation.
The results of the study Dr. Rhee and colleagues are presenting
at the ARVO meeting represent an especially important step forward
in their work. Comments Dr. Rhee, “Our most recent efforts
have investigated the natural inhibitors of these enzymes to understand
how the interplay of enzyme to inhibitor may regulate IOP. In
future studies, we will be testing methods to manipulate the balance
of these enzymes and inhibitors to a ratio that correlates with
improved drainage, thus reducing IOP to a level that will no longer
damage the optic nerve.”
 Dr.
Stuart Fine, Chair of the Department of Ophthalmology, University
of Pennsylvania Health System, and Director of the Scheie Eye
Institute of Philadelphia, presented the Edmund B. Spaeth Oration
at the College of Physicians of Philadelphia Wednesday March 9th.
Dr. Fine (left) spoke on “Clinical Trials: Good for the
Patient, Good for the Doctor, Good for Society.” The lecture,
along with dinner, is presented annually under the auspices of
the Edmund Benjamin Spaeth Clinical Research Foundation, founded
in 1978 to honor Dr. George Spaeth’s father, Edmund B. Spaeth,
a prominent ophthalmologist. All ophthalmology residents and fellows
in the Philadelphia area were invited to attend the lecture and
dinner as guests of Alcon Laboratories.
In addition to Dr. Fine, pictured are (left to right) Dr. Louis
Schwartz of the Wills Eye Glaucoma Service, Dr. Spaeth, and Dr.
William Frayer, Professor Emeritus, Scheie Eye Institute.
Photo by Ken Parker, PhD
People Making A Difference
All of us at the Glaucoma Service Foundation
to Prevent Blindness would like to express our sincere thanks
to our many friends and supporters — both those who sustain
us financially and those who donate their valuable time to our
cause.
With Special Thanks to
Our lead donors, Mr. and Mrs. Raymond G. Perelman, for
their continued support of glaucoma research and education.
Alcon Laboratories, Inc.
Allergan
Mr. and Mrs. James Kim
Pfizer, Inc.
The Scholler Foundation
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Mr. and Mrs. Raymond G. Perelman
Since he and his wife were our major financial benefactors in
2004, we asked Mr. Perelman about the inspiration for their gift.
“Having glaucoma personally, I know it is important that
we develop a cure for this disease, and therefore I think we should
support research and education towards this goal. All of us who
are unfortunate enough to have this disease should generously
support research and education that will help find a cure which
will benefit us and future generations.”
Mr. Stanley Tuttleman
As a major donor of his valuable time and energy, we asked Foundation
Board member Mr. Stanley Tuttleman why he expended so much effort
advising and supporting the Glaucoma Service Foundation. “The
extremely important work being done by the physicians and researchers
through the Glaucoma Service Foundation is already having a significant
effect on the health of glaucoma patients around the world. Their
work will make an even greater impact on peoples’ lives
in the years to come. I feel privileged to be able to make some
small contribution to this effort. I hope my example may inspire
others to join us as we work to meet the challenge of glaucoma.”
2004 — A Fundraising Success!
Nearly 2,000 individuals, foundations, corporations, and estates
donated a total of $795,937 to support our efforts to meet the
challenge of glaucoma — cutting edge research, community
screenings, patient support, physician education, and patient
education. Our Annual Fund total was $163,016. An additional $508,523
was restricted to glaucoma research, and $124,398 was earmarked
specifically for screenings, the Foundation newsletter and website,
educational programs, and salary support. With your continued
help, our goal — to end blindness from glaucoma —
is within our reach!
To all of our donors,
THANK YOU FOR YOUR EXTRAORDINARY GENEROSITY.
We could not do it without YOU!
Donor List (PDF
format)
From the “Chat Highlights”
of the Glaucoma Service Website
Is Glaucoma Loss
of Peripheral Vision?
Participant: Can glaucoma be equated with loss
of peripheral vision?
Dr. George Spaeth: It is a misconception that
patients with glaucoma lose peripheral vision. “Peripheral
vision” for most people means vision off to the side. That
is, when a person is looking straight ahead, peripheral vision
means vision way off to the right side and way off to the left
side. But that kind of “side” vision is, in fact,
the last part of the vision to be lost in people with glaucoma.
P: Perhaps part of the confusion comes from a
misunderstanding of what “peripheral” vision means.
For instance, the visual field tests I’ve taken for years
on Humphrey machines test the central 30 degrees, not peripheral
vision. Why isn’t the full visual field tested? Do doctors
think that the peripheral loss outside the 30 degrees is acceptable
to most of us?
Dr. George Spaeth: The central
30 degrees of vision is straightahead vision. It is the part you
are using when you are reading or watching your computer screen.
Testing outside the 30 degrees is difficult, and that is not where
early field loss develops. Thus, it would be time consuming and
would not tell us anything that we can’t learn from testing
the more central portion.
P: Instead of saying that glaucoma
affects peripheral vision first, shouldn’t that be phrased
in another way?
Dr. Richard Wilson: Yes. It is more correct to say that
glaucoma affects a doughnut of vision around the center, sparing
the center and the periphery till later in the disease.
What are the most important factors
in determining if and how glaucoma damage will progress?
Dr. Richard Wilson: The main factors are intraocular
pressure, genetic susceptibility to pressure, adequate blood pressure
and circulation, and thickness of the cornea. Other factors, such
as race, are important. Nearsightedness and diabetes play a lesser
role.
Moderator: Does the attitude of the patient affect
progression of glaucomatous damage?
Dr. Richard Wilson: Absolutely. A compulsive
person who always instills the eye drops on time has a far better
chance than a recalcitrant or forgetful patient. I also think
that a positive attitude and sense of humor help a great deal.
Participant: Are these differences among ethnic
groups statistically significant? Dr. Richard Wilson:
Yes, very much so. African- Americans are 14 to 17 times
more likely than Caucasians to go blind from glaucoma between
the ages of 45 and 65.
Should you be treated if you have
above-normal pressure, even though the optic nerve is healthy?
Participant: If the pressure is high and drops
won’t lower it, but the optic nerve is healthy, is surgery
still needed?
Dr. George Spaeth: If the nerve is healthy, why
do you need any treatment at all?
P: Don’t data show that treating ocular
hypertensives preserves vision over the long term, as opposed
to not treating?
Dr. George Spaeth: The data are the other way
around. Treating causes cataracts and introduces anxiety. The
only long-term study, by Linner and Stomber, showed that after
25 years of not being treated, ocular hyptensives rarely (5%)
lost enough vision to notice any visual loss. But everybody who
is treated for ocular hypertension has some side effects from
the meds.
New Ways to Prevent Glaucoma?
Dr. Jeffrey Henderer: I have an update on new
research concerning neuroprotection. Researchers treated mice
with radiation and then a bone marrow transplant. Somehow that
prevented glaucoma in the mice. Perhaps there is some immunologic
aspect that is being overcome by giving these mice a new bunch
of blood cells.
Participant: How did the researchers know that
it prevented glaucoma? Did they induce glaucoma in the mice?
Dr. Jeffrey Henderer: The mice were of a strain
that develops glaucoma spontaneously. They didn’t get glaucoma.
There are a number of animal models of glaucoma, especially in
dogs. But mice are easier to work with. This particular lab is
famous for its ouse strain, which looks a lot like pigmentary
glaucoma.
P: What kind of vaccination against glaucoma
are the Israelis working on?
Dr. Richard Wilson: A vaccination that initiates
an immune response that increases the patient’s resistance
to glaucoma
damage.
Do vitamins and minerals help with
primary open-angle glaucoma and normal-tension glaucoma?
Participant: My friends keep suggesting nutritional
supplements. Is there any solid evidence that vitamins and minerals
help with primary open-angle glaucoma and normal-tension glaucoma?
Dr. Elliot Werner: There is some evidence that
gingko biloba helps stabilize the optic nerve. There is no other
good scientific evidence for any other nutritional supplement,
but good nutrition is always a good idea and certainly promotes
good health.
Patient Support Group Meeting
May 15:
Dr. Marc Mydlarski
Glaucoma and the Aging Process
The meeting is from 1:30 to 3:00 pm on Sunday May 15th in the
8th floor auditorium of the “new” Wills Eye Hospital,
southeast corner of 9th and Walnut Streets, with the entrance
on Walnut Street, near 9th Street.
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