Volume 15, Number 3

December 2006

• The 1st Annual Glaucoma Service Foundation CARES Conference
• Letter from the Executive Director
• Glaucoma Service Announces New Director
• FROM THE “CHAT HIGHLIGHTS” OF THE GLAUCOMA SERVICE WEBSITE 
• The Optic Disc: That Which Must be Understood in Glaucoma
• New Research Fellows Join the Glaucoma Service
• Understanding the Trabectome: A New Device for Glaucoma Surgery
• Glaucoma Service Physicians - Sharing Their Knowledge
• The Foundation Welcomes Two New Board Members
• Assessment of Disability Related to Vision

The 1st Annual Glaucoma Service Foundation CARES Conference

Glaucoma is the most common cause of irreversible blindness in the world and yet if detected and treated early, glaucoma-induced blindness can almost always be prevented.

That is why the Glaucoma Service Foundation to Prevent Blindness will host the 1st Annual Glaucoma Service Foundation CARES* Conference (*Committed to Awareness through Research, Education and Support) on Saturday, January 20, 2007, at Wills Eye Institute from 9:00 AM to 2:30 PM - to further educate those suffering from glaucoma and those at risk. January is the perfect time for the CARES Conference as it is Glaucoma Awareness Month.

Glaucoma is known as the “sneak thief” of sight – unwittingly affecting patients often without any early warning signs. This stark reality makes awareness of primary importance! It alone can make a difference for the 1.2 million Americans who are suffering from glaucoma and do not even know it.

If you are a glaucoma patient, your family members are at risk for developing glaucoma. That is why we are offering free glaucoma screenings for family members of glaucoma patients at this conference. In addition, the CARES Conference will provide information sessions and lectures by physicians on the Wills Eye Glaucoma Service, as well as resources available to patients living with glaucoma.

Representatives from pharmaceutical companies with patient assistance programs, Low Vision Services, Associated Services for the Blind, the Glaucoma Research Center and Sunrise of Dresher, an assisted living facility with low vision services, will all be on hand. Lecture topics and speakers are listed on the following page.

Each session will end with questions and answers. A patient panel discussion will close the conference.

The CARES Conferenceis FREE but space is limited, so please register now!

We look forward to seeing you there! If you have any questions, please call the Foundation office at 215-928-3283.

Register by:

• Calling: 215-928-3283
• E-mailing: Kathy Kuzmanich at kkuzmanich@willseye.org
• Mailing your information to:

Kathy Kuzmanich
Program Director
Glaucoma Service Foundation
840 Walnut Street, Suite 1130
Philadelphia, PA 19107

Please include your name, address, phone number, and number of attendees.

Please click here for schedule of events.

Letter from the Executive Director

Dear Friends,

Season’s Greetings! This is a busy time of year for everyone including those of us at the Glaucoma Service Foundation to Prevent Blindness. We are excited to be preparing for our 1st Annual CARES Conference being held in January and I am happy to report that the responses to this event have been wonderful. We hope that you plan to join us for this informative patient conference and remind you to please call our office to register early, as space is limited.

You have probably received our 2006 Annual Fund appeal and if you have made a donation to the Foundation, thank you very much! If you have not yet made your contribution, please take a moment to consider the progress the Foundation and the physicians of the Glaucoma Service continue to make, with your help, in the fight against blindness from glaucoma.

The Glaucoma Service Foundation brings together the Glaucoma Service physicians, patients, researchers and administrators with a common goal to eliminate blindness from glaucoma. With your help, the Foundation supports essential programs to accomplish this goal. Through the Foundation’s programs, glaucoma patients around the world receive valuable sight-saving information, support services and improved treatments.

There are many ways to support the Glaucoma Service Foundation and the important work being done on the Glaucoma Service. Gifts of cash, checks, or stocks are very much appreciated. Making a donation to the Foundation is a wonderful way to remember a loved one or honor someone at a special time. If you would like to make a donation in memory or honor of someone, please include the name of the individual you would like to remember or honor and the name and address of the person you would like us to notify about your gift. If you have any questions, please contact the Foundation office at 215-928-3283.

This may also be a good time to consider long-term support of the Foundation’s activities - and longterm tax savings. By remembering the Glaucoma Service Foundation to Prevent Blindness in your will, you will insure the future success of our important glaucoma related programs. In addition, if you are over the age of 70-1/2, and have an IRA, you may benefit from giving a “qualified charitable distribution.” Please contact the Foundation office for more information.

Again, thank you for your support. With your help, we continue to make a difference!

I wish you a wonderful holiday season and a healthy and happy New Year!

Nancy Petrongolo

Glaucoma Service Announces New Director

At a recent Wills Eye Executive Council meeting, Dr. L. Jay Katz was named the new Director of the William and Anna Goldberg Glaucoma Service and Research Laboratories at Wills Eye Institute. Dr. George Spaeth, the Director of the Glaucoma Service for the past 38 years, comments, “He is the kind of person who is right for the job.”

Dr. Spaeth continued, ”When Dr. Katz was finishing his Fellowship Training Program on the Glaucoma Service at Wills, I asked him if he wanted to stay on and work with me. He was a good surgeon, he cared deeply about his patients, he was smart, he worked hard, and he was not interested in putting other people down. Though I had gotten to know him quite well during the fellowship, choosing a partner in a medical practice is important, and the outcome is not always what one thinks it is going to be. Dr. Katz answered by saying that he would like to, but his wife needed to go back to Yale to finish her training in pathology. She had come to Philadelphia so he could take his fellowship, and he thought it was only fair to accompany her back to New Haven so she could finish her training. That answer convinced me that he was the right person. The person who is going to lead a department so it will grow, and so that the people there are happy and productive, must respect those individuals and generally want their well-being. The primary requisite is that the leader like people and be able to manage the other people in the department. I have every confidence that Jay Katz will do that well.

Some of the leaders in academic medicine are encouraging development of “clinician-scientists,” that is, people who are expert in the laboratory and expert in the clinic. True expertise demands constant increase in knowledge, skill and dedication. The idea of the clinician- scientist sounds great, but in my opinion does not work. It takes total commitment to be a truly expert clinician, and it takes total commitment to be a truly expert laboratory researcher. Dr. Katz knows this. He knows the importance of laboratory research, the importance of clinical research, the importance of teaching, the importance of fundraising, and the importance of publishing articles. He also knows that the patient’s well-being always comes before all of those other activities.

A department in which there is not superlative teaching, superlative community outreach, and superlative research, clinical and/or basic, cannot call itself a great department. The leader of such a department must know about those fields and be able to participate in them and establish a department in which those activities are well covered.

The most important thing that a leader does is set the tone, and that means deciding what is most important and acting in a particular style. In my opinion, Dr. Katz believes that at the center of everything that happens in the field of medical practice is the patient. Dr. Katz has the other skills: the knowledge of research, the ability to be a great teacher, the wisdom to raise funds, the talent to administer well, and he will bring those skills to enhance the Glaucoma Service, and in so doing Wills Eye Institute and Jefferson Medical College, also.

I predict that he will set a tone in which it becomes clear to everybody that always at the top of the pyramid is the patient who is to be respected and cared for to the best of one’s ability. I believe that Dr. Katz is the right person to be the new Director of the Glaucoma Service of Wills Eye Institute / Jefferson Medical College.”

When asked about this new appointment, Dr. Katz replied, “I am honored to have been chosen as the Director of the Glaucoma Service at Wills. I am looking forward to maintaining the international reputation Dr. Spaeth developed over the last 38 years and hope to maintain the standard for providing the best, most compassionate patient care for glaucoma.”

All of us on the Glaucoma Service look forward to working with Dr. Katz in this new role and have every confidence that he will continue to move the Glaucoma Service at Wills Eye forward.

Congratulations Dr. Katz!

FROM THE “CHAT HIGHLIGHTS” OF THE GLAUCOMA SERVICE WEBSITE

September 20, 2006
The Routine Eye Examination

Question: What should a routine eye examination include?

Dr. Michael Pro: A complete routine eye examination includes refraction (glasses correction), intraocular pressure check, angle evaluation and a dilation of the pupil to evaluate the structures behind the iris; namely the lens, the vitreous, the optic nerve, and the retina.

Question: How can the shallow-chambered, narrow angle eye be identified by using a flashlight during a routine eye examination?

Dr. Michael Pro: The flashlight test is done by shining light from one side of the eye and looking for a shadow on the other side. It is not performed by any glaucoma specialists as it is not specific. To properly evaluate the angle, the examiner needs to use a gonioprism, which is a special type of mirrored lens.

Question: Why does the doctor look for shallowchambered, narrow angles?

Dr. Michael Pro: A narrow angle can lead to two problems. One problem is a sudden attack of angle-closure glaucoma caused by a sudden obstruction of the angle. The second, much more common problem, is chronic scarring of the drainage angle that eventually leads to poor drainage and secondary glaucoma.

Question: How often should an adult in his or her late thirties be screened for glaucoma if both parents had glaucoma?

Dr. Michael Pro: First you need a complete examination, including angle evaluation and corneal thickness measurement. Then the risk factors can be determined. If the examination is unremarkable, I would evaluate that person every one to two years.

Question: What should a glaucoma patient or glaucoma suspect insist upon during an eye examination? Is central corneal thickness measured routinely?

Dr. Michael Pro: Good question. Measurement of central corneal thickness, angle evaluation and baseline imaging of the optic nerve are a must.

Question: Can a physician see the lens and nerve without dilating the pupils of someone who is at risk for an attack of acute angle-closure?

Dr. Michael Pro: Yes, but the view is generally monocular because the pupil is too small. Often, though, a physician can judge the amount of glaucoma from that view.

Question: What do you mean by monocular?

Dr. Michael Pro: Monocular refers to my view using a single eyepiece. The slit lamp in the exam room gives a stereo view of the eye. Both of my eyes need a clear view. When the pupil is small, only one of my eyes can see into the back of the eye.

Question: What is meant by the “amount of” glaucoma? Does that refer to intraocular pressure of the damage to the optic nerve?

Dr. Michael Pro: It is the amount of damage to the optic nerve and visual field loss.

Question: What is the difference between open-angle and closed-angle glaucoma?

Dr. Michael Pro: Those terms refer to the way the angle looks. The angle, between the iris and the cornea, is the part of the eye that drains the fluid (aqueous) from the eye. “Open” means that the angle appears not to have any obstruction of fluid leaving the eye. “Closed” means that the angle is narrow and looks like fluid may be obstructed from exiting the eye. Both lead to the same disease and end result, but treatment is different.

July 19, 2006
Who is at Risk for Glaucoma?

Question: What are some anatomical abnormalities that put people at risk for glaucoma?

Dr. Jeff Henderer: For most people with glaucoma, there is nothing "wrong" with the eye. You can't see any problem, although we believe that the trabecular meshwork is not allowing adequate flow of the aqueous humor. Some people have obvious problems, like pseudoexfoliation or pigment dispersion or ocular inflammation, which can raise the IOP. Others have new blood vessels in the front of the eye that clog the meshwork. But for primary open-angle glaucoma, there is no obvious defect.

Question: Does the typical examination by an optometrist include an examination of the trabecular meshwork?

Dr. Jeff Henderer: In my experience, that is highly variable. I'd say that some younger OD's (Doctor of Optometry) do perform gonioscopy (at least they refer to me for narrow angles), but it is probably not the routine.

Question: Are there certain ethnic groups of people that are at increased risk for glaucoma?

Dr. Jeff Henderer: We know that for open-angle glaucoma, Africans and African-Americans are at higher risk. It appears that Hispanics and Asians are roughly comparable to Caucasians. The general number to remember is that 2% of the U.S. population over the age of 40 has glaucoma and only about half know it. It appears that other populations are more at risk for angle-closure, especially the Chinese.

Question: Does glaucoma “run in the family”?

Dr. Jeff Henderer: Glaucoma does have a genetic component. Five or six genes have been identified for open-angle glaucoma. There is a likely gene for exfoliation and pigment dispersion. Genes have also been found for juvenile and infantile glaucoma. I'm pretty sure we haven't identified most of the genetic defects in glaucoma.

Question: When those medical warnings on over-the-counter medicines say to avoid use if you have glaucoma, does that only apply to POAG?

Dr. Jeff Henderer: It generally applies to narrow-angles and the risk of causing an attack of glaucoma.

Question: Is it true that vigorous walking can help lower IOP?

Dr. Jeff Henderer: Yes.

The Optic Disc: That Which Must be Understood in Glaucoma.

Jeffrey D. Henderer, MD

Consider the following patient referred to the Wills Glaucoma Service for a glaucoma evaluation. These photos are of the optic nerves. Salient features are labeled.

Is glaucoma present? How would you know? What features of these optic nerves suggest an abnormality? This article is designed to help patients understand how and why ophthalmologists examine the nerve. The hope is that patients will become familiar with some of the terms used to describe the nerve and with recent efforts by researchers on the Wills Glaucoma Service to try and improve our current way of classifying glaucomatous damage.

Why is it important to examine the nerve? Simply put, because glaucoma is a disease of the optic nerve. In addition, glaucomatous nerve damage often precedes visual field loss. This is important in early diagnosis. Furthermore, the field often fluctuates, while the nerve exam is more constant. But what features are typical of the normal nerve, and what features make a nerve glaucomatous?

The normal optic nerve has been well characterized by investigators such as Jost Jonas. Briefly, the optic nerve connects the eye to the brain. It is analogous to a fiber optic cable, in that about a million small nerve fibers from the retinal surface come together and form one large bundled nerve, the optic nerve, as they travel from the retinal surface to the brain. The nerve cells usually don’t completely fill the entire available space in the optic nerve. This results in a central area absent of nerve cells that is cup-shaped (the “cup”) surrounded by a donut-rim of nerve cells (the “neuroretinal rim”). It turns out that the overall size of the optic nerve varies greatly from person to person, while the amount of nerve tissue is relatively constant.

Glaucomatous optic nerve damage is the gradual death of the million or so nerve fibers that fill the optic nerve. When they die, the eye and brain can no longer communicate and the patient becomes blind. As they die, the neuroretinal rim melts away and, by default, the cup enlarges. Thus glaucomatous nerve damage has been defined as a progressive enlarging cup. The most common description is the cup/disc ratio, or the diameter of the cup versus the diameter of the disc. The cup/disc ratio extends from 0.0 (no cup) to 1.0 (no rim) with larger values indicating less nerve tissue. The typical assumption is that a large cup/disc ratio is associated with glaucoma and a small cup/disc ratio is healthy.

Disc size

But if this is the first time a patient is being examined, it is often hard to know if the amount of “cupping” is normal or represents progressive damage. The problem is compounded by the fact that the overall size of the nerve largely determines the size of the cup. Therefore big nerves have big cups (and large cup/disc ratios) and small nerves have small cups (and small cup/disc ratios). If the physician considers a large cup/disc ratio to be a sign of glaucoma there is a risk that persons with large optic nerves, who have a normal large cup/disc ratio, will be diagnosed with glaucoma erroneously. The opposite is true for small nerves, where even a midsized cup/disc ratio might be abnormal since there shouldn’t be much cup at all. To address this problem with the cup/disc ratio classification system, physicians need to appreciate the size of the cup relative to the size of the nerve. That means measuring the nerve size, which is rarely done. In the example above the two optic nerves have asymmetric cup/disc ratios. Normally, the two nerves should be symmetrical, just like your two hands are symmetrical. Therefore one might think that the right nerve is suspicious for glaucoma. However, the overall size of the nerve is larger on the right. This is an example of a normal cup/disc ratio asymmetry due to asymmetrically sized optic nerves.

Neuroretinal rim

The second problem with the cup/disc ratio is that it often fails to identify isolated damage to the neuroretinal rim. While this is a bit more complicated to describe, such damage is often noticed by physicians, but because the cup/disc ratio records the status of the cup and not the rim, this damage is often not apparent when described using this staging system.

Other features of the glaucomatous optic nerve

There are several other optic nerve findings that can indicate glaucoma is present. They are beyond the scope of this article, but they include optic nerve hemorrhages, nerve fiber layer defects and expanding perpapillary atrophy.

The Disc Damage Likelihood Scale

How can the shortcomings of the cup/disc ratio be overcome? Dr. George Spaeth has developed a new optic nerve staging scale that measures neuroretinal rim width in the context of disc size. We call this the Disc Damage Likelihood Scale (DDLS). Using this system requires one to measure the nerve size and determine a rim/disc, not cup/disc, ratio. We have been refining the scale and determining it’s reliability and validity for several years. These studies have resulted in several publications and multiple poster presentations at national meetings. Former Glaucoma Service fellow Dr. Helen Danish-Meyer has investigated how the scale works in comparison to optic nerve imaging within her practice in New Zealand. Dr. Spaeth, with help from Dr.Myers and myself, teaches a course at the national ophthalmology meeting about how to use the DDLS and examine the optic nerve.

Conclusions

The cup/disc ratio is a flawed interpretation scale. It does not account for the effect of disc size and does not describe the neuroretinal rim – the structure of most interest to ophthalmologists. The DDLS is a novel staging system for glaucomatous optic neuropathy that seeks to overcome the limitations of the cup/disc ratio by describing the neuroretinal rim in the context of disc size. Work in our lab and in New Zealand has shown it is a reliable scale and correlates with the visual field better than the HRT. Others have also demonstrated this as well. Many ongoing projects seek to measure its performance further.

Understanding the Trabectome: A New Device for Glaucoma Surgery

By Marlene R. Moster, MD

The Trabectome® is a new technology being developed for glaucoma surgery to control intraocular pressure . This device allows the surgeon to improve outflow of fluid from the front compartment of the eye (the anterior chamber), into the main drainage channel called Schlemm’s canal. Most cases of open-angle glaucoma in children and adults are thought to be due resistance of fluid outflow. The basic goal of the Trabectome® is to eliminate the main site of resistance to fluid outflow thus lowering eye pressure back toward normal. Trabectome® surgery may be done under local, regional or general anesthesia depending on patient and surgeon preferences. The Trabectome®, which is about the diameter of a matchstick, is inserted through a small opening (1/16”) on the side of the front window of the eye (the cornea), and directed across the anterior chamber under direct observation by the surgeon.

The surgeon’s view is highly magnified though a special hand held lens and operating microscope. The surgeon holds the lens with one hand while manipulating the Trabectome® handpiece with the other hand.

The Trabectome® tip is specially designed to fit within Schlemm’s canal and protect all other tissues from heat or mechanical injury while the canal is being opened. This is a huge advantage since it prevents unnecessary scarring in areas that may not be directly

involved with the surgery. The complications with this device have been shown to be minimal, and vision usually returns to baseline within 1 to 2 weeks.

To date, in over 195 reported cases, there have been no serious complications other than failure to better control eye pressure in 14 cases, which underwent subsequent traditional trabeculectomy surgery. In this study eye pressures dropped by an average of 40%, with pressures resulting in the low teens. The number of eye medications necessary to maintain acceptable pressures has also dropped compared to preoperative numbers. The longest follow up for this procedure has been 36 months.

This new technology has been studied at the Wills Eye Glaucoma department as well as other centers throughout the country. Our unpublished data has similarly shown few complications with the Trabectome® and the procedure has been easily preformed.

However, the final intraocular pressures in our patients with moderate to advanced glaucoma were not as low as we thought necessary to control the glaucoma damage. Over 50% of our patients were back on their medicines at the 2 to 6 month follow up visit and the intraocular pressure drop was a modest 15 to 25%.

The traditional adult glaucoma operation, trabeculectomy, works quite differently as it involves creating a new drainage space for fluid from the anterior chamber to form a new reservoir above the superior surface of the eye wall. A filtering bleb is created on the surface of the eye, under the upper eyelid. This procedure can reliably lower the intraocular pressure for years in the majority of patients.

In summary, additional studies and research are needed to determine whether or not the new Trabectome® surgery will be added to our armamentarium of standard glaucoma procedures in order to lower the intraocular pressure sufficiently to preserve vision.

Glaucoma Service Physicians - Sharing Their Knowledge

Jonathan S. Myers, MD – Nov 13 - American Academy of Opthamaology, (AAO), Las Vegas - “Assessment of Current Optic Nerve Imagers” as part of Dr. Spaeth’s Optic Nerve as basis for effective treatment of glaucoma course - Nov 12th - JCAHPO annual meeting, Las Vegas, “Medical and Surgical Treatment of Glaucoma” with Dr. Thomas - Oct 7th - Texas at Alcon’s CPE Glaucoma meeting, Fort Worth, “Doc, Will I go blind from glaucoma?”

Jeffrey D. Henderer, MD – gave a series of 12 lectures in Canada (Toronto, Hamilton, Ottawa, Montreal, Quebec City, Moncton and Halifax) during 8 days in September and October about how to examine the optic nerve, trabeculectomy techniques, risk factor analysis for glaucoma and glaucoma medications. Dr. Henderer continues to be a member of the American Academy's Glaucoma Knowledge Base Panel that develops the glaucoma section content from which re-certification board exam questions are created. He is also the new Chair of the American Academy's Maintenance of Certification Committee which is responsible for overseeing the Lifelong Education for the Ophthalmologist courses at the AAO meeting, educating AAO members about the board re-certification process and reviewing the new AAO-sponsored Maintenance of Certification board review course offered each summer.

George L. Spaeth, MD – September 15th-16th – Midwest Glaucoma Symposium, Pittsburgh, PA, Role of Images in Clinical Practice, What to do with Postoperative Complications and When to Refer, How Bad Does Disease or Progression Need to be to Intervene-Is it different for adding a medication versus laser vs. surgery? – September 21st-24th – Prague, Czech Republic, An Overview of Glaucoma (and medical care [and life]) – October 6th-14th – Edinburgh, Scotland – Concentrating on the Essentials Assures the Successful Treatment of Persons with Glaucoma: A New Practical Method, An Overview of Glaucoma (and medical care[and life]), My Time in Ophthalmology. October 19th-20th – Winnipeg, Canada – A Purpose Driven Life, Principles of Glaucoma Diagnosis, Quantitative History Taking and Gonioscopy, Disc Examination and Quantitative Perimetry, The Successful Treatment of Glaucoma – Putting it all Together – October 24th – Temple University, Philadelphia - Indications for Treatment, October 25th – Baltimore, MD - The Importance of Controlling Fluctuations of IOP and . . . October 26th – Malvern, PA - The Importance of Controlling Fluctuations of IOP.

L. Jay Katz, MD – September - Temple University Hospital, Philadelphia, PA (Lecture to Residents) - Introduction to Gonioscopy, American Osteopathic Colleges of Ophthalmology and Otolaryngology (AOCOO) Mid-Year Seminar, Philadelphia, PA - Imaging in Glaucoma: Ready for Clinical Practice?, The 29th Annual Midwest Glaucoma Symposium, UPMC, Pittsburgh, PA - IOP Revisited, Using the HRT to Improve Clinical Outcomes in Glaucoma, Grant Medical Center, Columbus, Ohio - SLT: Role in the Treatment of Glaucoma? - New Direction for Glaucoma Surgery? - Setting a Target Pressure October - CPE Fellows Glaucoma Program, Alcon, Fort Worth, Texas - Target IOP, Ophthalmology Seminar, Mayo Clinic College of Medicine, Jacksonville, Florida - Setting a Target Pressure, Image Analysis of the Optic Nerve – Clinical Utility, Neuroprotection: Role in Glaucoma - PI: Who Needs It?, SLT: Role in the Treatment of Glaucoma - New Surgical Directions - Management of Disorders of the Anterior Segment, UPMC, Pittsburgh, PA - Update on Diagnosis and Monitoring of Glaucoma – November - American Academy of Ophthalmology, Las Vegas, Nevada - Instructor: Scanning Laser Imaging of the Optic Nerve and Retinal Nerve Fiber Layer, Moderator at Roundtable: Clinically Relevant Imaging in Caring for Glaucoma Patients, Poster Presentation: Comparison of Selective Laser Trabeculoplasty vs. Medical Therapy for Initial Therapy for Glaucoma or Ocular Hypertension.

Marlene R. Moster, MD – November 11-13 – American Academy of Ophthalmology - To Needle or Not to Needle: How to Bring Life to a Dead Bleb!, Combined Phaco and Glaucoma Surgery, The Juggling Act: Finding Balance in a Busy Life, The Art of Having It All, Philadelphia Experience with the ExPRESS Shunt, Breakfast With The Experts, Normal-Tension Glaucoma: Evaluation and Treatment - October 20-21- New Frontiers in Clinical Glaucoma Symposium III, New York, NY - Challenging Glaucoma cases: Video Play, Glaucoma Associated with Corneal Disease. – September 9-10 - AOCOO-HNS Foundation’s 2006 Mid-Year Seminar – Glaucoma Update.

The Foundation Welcomes Two New Board Members

The Foundation’s Board is pleased to announce two new members, Mr. Irvin Schorsch and Dr. Leonard Rosenfeld. Welcome Mr. Schorsch and Dr. Rosenfeld, we look forward to working with you!

Through a program called Great Expectations – Glaucoma Risk Evaluation and Treatment, Steven Mansberger, MD, MPH from Devers Eye Institute in Portland Oregon visited Wills Eye on October 28, 2006 to present glaucoma rounds. The Great Expectations program is designed to provide general ophthalmologists, glaucoma specialists, fellows, residents, and staff with current information related to treatment of glaucoma and is provided for by the Academy for Healthcare Education Inc., and supported by an unrestricted educational grant from Pfizer, Inc.

Assessment of Disability Related to Vision

By Sheryl Wizov, COA

Sheryl Wizov is a certified ophthalmic assistant and a clinical research coordinator who has been working in the Glaucoma Research Center for the past 6 years. Prior to her work in glaucoma, she worked with a Pediatric Ophthalmologist for 19 years. She has been involved in some very specialized vision research that requires spending a significant amount of time with individual patients and feels fortunate because she learns so much from these patients while educating them about their glaucoma. Ms. Wizov recently spoke at a Macula Vision Research Foundation SupportSight meeting about “The Assessment of Disability Related to Vision”, a research study being performed by the Glaucoma Research Center at Wills Eye.

What does visual acuity tell the doctor? How do we fare in understanding what patients experience when their vision is deteriorating due to certain eye disorders? How does the eye doctor know that getting on the right bus has become a problem? Or that recognizing family and friends is difficult unless a familiar voice is heard. How do we know that a particular choice of clothing is being scrutinized by more than just a fussy daughter? Or maybe the phone company is charging for wrong numbers dialed. Or the bank is concerned about a check recently written out incorrectly.

Questions and situations such as these produce a lot of stress and anxiety.

This important information about loss of functionality doesn’t always find its way to the doctor. And even when it does, how can the doctor use it to significantly impact the patients’ every day life? Most people would think, ”If I go to the doctor and they know how bad my vision is, then isn’t it obvious that I can’t do things that I used to do?” Well, that’s not always the case. It turns out, that ability to function and quality of life are two separate issues that are extremely difficult to measure in a persons’ life. Some people simply don’t recognize there are problems while others choose not to admit they’re struggling visually with daily activities that used to be second nature to them. Some people are excellent at coping and “making do” whereas others cannot manage as well. Not one of us wants to lose our independence or become a burden to family, friends or the community. However, vision is paramount to every single thing a sighted person does and as visual loss progresses in an adult, safety becomes the number one issue.

Our goal is to find some answers for many of these questions. We’d like to measure quality of life and ability to function and to analyze it in a way that may provide better treatment to the whole individual and not just their eyes. We hope to educate patients and society, by raising awareness of the problems people encounter every day with decreased vision.

In the Glaucoma Research Center at Wills Eye, we are comparing the amount of functionality to the amount of vision and visual field loss in certain eye disorders. In other words, we are trying to measure and quantify how much vision has to deteriorate before certain daily living activities become affected in an individuals’ life. We are also comparing an individuals’ functionality to their perception of how well they think they are getting along. This is done through a quality of life (QOL) questionnaire developed by the National Eye Institute, which has been available for public use since 1996.

Let me give you some examples of how we combine functionality and quality of life. One activity we do measures color and texture recognition. Coordinating clothes, deciphering traffic signals or noticing when spills occur all require color vision. When vision decreases, contrast and color vision become problematic. Our task involves matching seven similar dark colored men’s socks from a pile of ten choices. Subtle changes in shades of blue, black and gray, in addition to textured patterns, make this task visually challenging. The socks to be matched are hung on a wall on top of a gray background increasing the difficulty of the task. The related question in the QOL survey asks, “Because of your eyesight, how much difficulty do you have picking out and matching your own clothes?”

Another activity we measure is street sign recognition. Reading street signs or store names can be particularly frustrating with decreased vision, especially while moving in traffic or at night. Many signs have become household names and are easily recognized such as Cadillac, Nike or Target. The brain is a magnificent organ, which is capable of filling in information in spite of the eyes inability to see clearly. Street signs, however, pose tremendous difficulty, especially in unfamiliar places or when it’s dark. To test this, we purposely rearranged phrases that should be familiar. We changed one character in each sign to make sure that one needs to use their vision to carefully read what they see and not guess at what they think they see. For instance, we may use the word ‘B o a r d w a y’ instead of the more popular word ‘B r o a d w a y’. Each sign, of course, gets smaller than the next in order to simulate being further away, which is also testing for better vision. Several items from the QOL questionnaire address this situation by asking, “How much difficulty do you have reading street signs or the names of stores?” and “If you are currently driving, how much difficulty do you have driving during the daytime in familiar places?”

One more example of the activities we measure is facial recognition. We hear many complaints from people who are being accused of becoming snobbish for not distinguishing a close friend from across the street. Four facial expressions are used for this task in photos, which are presented on a computer screen from large to small size simulating a person being further and further away. Expressions to be identified are happy, sad, angry or surprised. The QOL questionnaire addresses this activity by asking two similar questions, “Because of your eyesight, how much difficulty do you have seeing how people react to things you say?” and “Because of your eyesight, how much difficulty do you have recognizing people you know from across the room?”

We do know that quality of life is reduced when vision loss occurs. But until we can effectively measure this and report the results, many patients miss out on the added attention they need. Vision loss comes in many varieties. It can start in the central area and gradually work its way outward to the periphery as in macular degeneration. It can start way out in the periphery and work its way in towards the center as in glaucoma. Or it can deteriorate equally across the visual field as in diabetic retinopathy. This loss can progress rapidly or slowly. The common denominator in any vision loss is fear of losing ones ability to perform daily activities. By setting up guidelines called study protocols and testing large groups of people in the same manner, we are able to make more sense of the data collected and transform this information into meaningful results that help doctors and care givers better treat these individuals.

If you or someone you know has diabetic retinopathy or macular degeneration and would like to participate in this study, please contact the Glaucoma Research Center at 215-928-3123 to see if you qualify.