Volume 19, Number 3
September 2010
Announcing the 4th Annual CARES Conference
Another Year of Progress Through Research
You Still Have Time to Register-Please Register Now!!
Since January 2007, the Glaucoma Service Foundation to Prevent
Blindness at the Wills Eye Institute has held a day long conference
called the “CARES Conference.” CARES stands for “Committed
to Awareness through Research, Education, and Support.”
This is a patient directed educational conference about glaucoma.
Last year, over 170 patients and their families from around the
Unites States (primarily Pennsylvania, New Jersey, Delaware, and
New York) attend this conference at Wills Eye Institute.
The event includes lectures given by Wills Eye glaucoma physicians.
Free screenings for glaucoma are offered and encouraged. In addition,
education resources and information are available at the CARES
Conference to patients living with glaucoma.
The Glaucoma Service Foundation to Prevent Blindness is hosting
the 4th Annual Glaucoma Service Foundation CARES* Conference (*Committed
to Awareness through Research, Education, and Support) on Saturday,
October 23rd, 2010, at Wills Eye Institute from 9:00 AM to 3:00
PM to further educate those suffering from glaucoma and those
at risk.
Representatives from pharmaceutical companies with patient assistance
programs, Low Vision Services, Associated Services for the Blind,
and the Glaucoma Research Center will be on hand. Guest speakers
will include Ray Kornman, Outreach Specialist of the Seeing Eye,
Inc. Mr. Kornman will present “Is a Seeing Eye dog right
for you?” and discuss the benefits of owning a guide dog
and the prerequisite skills required to be successful working
with a dog. Cherie Bank, former Channel 10 medical news reporter
and Wills Eye Patient will also be a featured speaker.
The day will begin with a continental breakfast. We look forward
to seeing you there!
Here is the list of some of the exciting lectures that will be
presented:
- Doctor Do I have Glaucoma? – Dr. Spaeth
- Glaucoma: Looking into the future– Dr. Katz
- Laser iridotomy for narrow angles – Dr. Fudemberg
- New glaucoma surgeries – Dr. Pro
- hat eye pressure is safe for me? – Dr. Niknam
- Epidemiology of Glaucoma – Dr. Henderer
- Are some doctors better than others? - Dr. Schmidt
- How does your doctor decide if your condition is deteriorating?
How do we measure progression? – Dr. Moster
- Limitations of eye drops – Dr. Myers
- Maximize the 5 to reach 100% Independence. Tools and techniques
for using all your senses productively - Jule Ann Lieberman,
EZ2C Foundation
- Featured speaker: Cherie Bank, former medical reporter
A special thanks to the Robison D. Harley Fund for Glaucoma Education
and Research for sponsoring this event. There is no charge to
register.
Space is limited, however, so please register now.
Register by email, website or telephone
E-mailing: Rita Stern (rstern@willseye.org) or Robert Kump (rkump@willseye.org)
Via Phone: Please call Rob Kump at 215 928- 3190. We will need
your name, address, phone number, and number of guests.
Website: www.willsglaucoma.org/cares2010.htm
This takes you to a web page dedicated to CARES with information
on registration, parking, accommodations, etc.
There is no charge to register but space is limited, so please
register NOW!
Suggested Treatment for Irritated
Lids, Tired Eyes and Dry Eyes
George L. Spaeth, M.D.
As tissues become traumatized, they lose some of their natural
functions. Normally the tissue that covers the surface of the
eyes – the conjunctiva – secretes a mucous that helps
keep the eyes lubricated. Also, many glands in the margins of
the lids secrete a fatty material that also lubricates the eye,
so that the surfaces do not dry out. This allows the lid to move
up and down over the front of the eye without “scratching”
it. Things that traumatize these tissues include the preservatives
in eye drops, a dry environment and age itself. The glands tend
to get plugged up as a result of which not only do their valuable
lubricants not do their job, but also the bacteria which are in
abundance on all of us multiply and can cause problems.
Solutions:
1) Avoid very dry situations,
2) Avoid preservatives, if possible,
3) Heat the tissues so that the fatty material in the lids is
liquefied and is more easily secreted, and
4) Have a diet which provides the proper nutrients to keep the
fatty material healthy and more fluid.
5) Stopping aging is not a reasonable option.
1) Avoid very dry situations. Keep the environment
in which you live and work reasonably moist. This can be accomplished
by having lots of houseplants, keeping the thermostat down, and/or
using a humidifier.
2) Avoid preservatives, if possible. Almost all
eye drops are required to have preservatives in them so that if
they become contaminated with bacteria, the bacteria do not multiply
and cause a problem. Using eye drops is often necessary to preserve
the health of the eye, but such a use is always a two-edged sword;
eye drops should only be used when needed (as in many people with
glaucoma). Some artificial tears have preservatives in them, and
using them may actually make “dry eyes” worse. Some
artificial tears, now, however, are manufactured without preservatives,
and they can be helpful.
3) Heat the tissues. Heating the tissues is one
of the most valuable general measures to help preserve health.
That is why hot baths, saunas, steam baths, etc. have been used
by almost every culture in the world. Giving the eyes a hot bath
can be very helpful, increasing blood flow to the area, cleansing
and liquefying substance such as fatty materials that become more
solid when they are cooler.
4) Diet. Certain substances, such as fish oil,
flaxseed oil and primrose oil can change the basic composition
of the fats in the body. That is why they are sometimes advised
for people who have elevated cholesterol, and have been found
to be effective in reducing the agents of heart attacks. Recent
evidence has shown that Omega-3-containing substances affect the
way chromosomes age, and may be able to slow down the normal process
of aging. There is some evidence that people with “dry eyes”
can decrease their symptoms by using such agents.
How to Use Hot
Compresses
Fill the sink with hot water from the tap. It does not need to
be boiled water from the stove. It should be hot. It should not
be hot enough that it burns your hands, but it should be hot enough
that it is a little bit uncomfortable on your hands. Place a face
cloth or a small towel in the hot water in the sink. Bend over
the sink. Close the eyes. Fold the towel so it is crumpled up
so it is about two inches wide in the vertical direction and about
six inches wide in the horizontal direction. Put the hot towel
over the closed lids and press moderately against the towel so
the towel pushes against the closed lids. Hold the towel in that
position for about one minute. By that time the towel will have
gotten cool. Put it back in the hot water in the sink and again
put it on the closed lids for about a minute. Do that about five
times for a total of five minutes.
Note: the lids should be closed, the water should
be hot, and there should be some pressure placed against the lids
by the hot towel. Do not try to do this using cotton balls or
small compresses. That will not do anything beneficial. Those
small cotton balls do not hold enough heat to make a difference.
Running hot water from the shower on the closed lids is not a
substitute for the hot compresses. Shower water is not as hot,
and by the time it lands on the lids it is cooler, and the tissues
do not get as heated as with the hot compresses.
I suggest purchasing the flaxseed oil in capsule form. It usually
comes in 1,000 mg. capsules. There may be an advantage in buying
organic flaxseed oil, but that has not been demonstrated. Flaxseed
oil can also be purchased in a bottle, so that the required dose
can be taken by a spoon or used on a salad or in some other way.
Europeans use flaxseed oil this way, and also use the whole grain
flaxseed on their cereals.
Omega III and Omega VI
Fatty Acids
Primrose oil is similar in composition to flaxseed oil, but tends
to cost more.
Fish oil comes in various forms. Purchase a type which is high
in Omega-3. Cod liver oil is not the best in this regard. A problem
with fish oil is that the oil usually comes from the liver of
the fish, and livers serve as ways the body filters out harmful
products. Consequently, mercury tends to be concentrated in the
liver. Some fish liver oils have toxic levels of mercury, especially
those made from salmon, as salmon is one of the fish which is
most likely to have toxic levels of mercury. When you are purchasing
fish oil, purchase a brand which says in a believable way that
it does not contain mercury.
The studies which have demonstrated a beneficial effect on the
cardiovascular system have mostly been done with fish oil. Some
of those who have studied the effects of these agents, however,
believe that the Omega-6 compound is also important, and there
tends to be more Omega-6 in flaxseed oil than there is in fish
oil. Taking one 1,000 mg. capsule of Omega-3 fish oil and one
1,000 mg. capsule of flaxseed oil or primrose oil makes sense,
as it may provide the widest range of beneficial compounds.
Welcome New Fellows
 Dr.
Shelly Gupta received her medical degree from Northeastern Ohio
Universities College of Medicine where she graduated with Honors
in Ophthalmology, Surgery, Radiology, Family Medicine, Pediatrics,
Internal Medicine, and Obstetrics and Gynecology. After graduation,
she did an Internal Medicine internship at Good Samaritan Hospital
in Cincinnati, Ohio. Dr. Gupta then completed her ophthalmology
residency at The University of Alabama at Birmingham. During her
time at The University of Alabama at Birmingham, Dr. Gupta was
awarded the Lynn B. McMahan, M.D. Award for Outstanding research,
she served on the Board of Directors of the Alabama Academy of
Ophthalmology, and she participated in numerous community outreach
projects both locally and abroad. When asked about her thoughts
for this coming year, Dr Gupta replied, “I am extremely
excited to be a Glaucoma Fellow at the Wills Eye Institute. I
find glaucoma fascinating because of its diversity of presentation,
its challenge of diagnosis, and its broad scope of treatment.
I look forward to learning about the cuttingedge imaging modalities
and seemingly endless surgical advancements from the experienced
and well respected physicians at Wills Eye. I am also eager to
build close relationships with the patients of the Glaucoma Service
as we work together to prevent vision loss and save sight. Serving
patients as a glaucoma specialist will truly be an honor for me.”
 Dr.
Kathryn Burleigh Freidl graduated from Jefferson Medical College
with Honors in several disciplines, including Ophthalmology. In
addition to her studies there, she spent several years as a member
of the student government and received the Helen and Gabriel Levine
Scholarship for medical research endeavors. After graduation,
Dr. Freidl traveled a few blocks north to complete her medical
internship at the Albert Einstein Medical Center of Philadelphia.
Dr. Freidl then went on to complete her Ophthalmology residency
at Mount Sinai Medical Center in New York City. Dr. Freidl has
now returned to Philadelphia to complete a Glaucoma Fellowship.
She was asked why she chose to pursue her glaucoma fellowship
at Wills Eye Institute. “I am so excited to work with the
people here. It is a wonderful patient population and there is
such diversity in patient backgrounds, ages and treatment challenges.
I am looking forward to a great year with the doctors of the Glaucoma
Department at Wills Eye. These doctors are excellent clinicians,
surgeons, teachers and scientists, but even more importantly,
they are good people. Glaucoma is an exciting field with options
like medicines, lasers or surgeries, but the most important aspect
is your relationship with your patients. I am passionate about
preserving vision, and I love helping people to see better. Changes
in vision alter the way we interact in the world. But the day-
to-day joy of coming to work is really about the good long term
relationships we have with our patients.”
 Rob
Goulet comes to Philadelphia from his hometown of Indianapolis,
Indiana. His medical school, internship, and residency were all
completed in Indianapolis on the campus of Indiana University
School of Medicine. He served as chief resident of the Methodist
Hospital transitional year in 2008/2009 and as academic chief
resident in ophthalmology in 2009/2010. As an elected member of
the Gold Humanism Honor Society, he has been recognized for his
“demonstrated excellence in clinical care, leadership, compassion
and dedication to service.” His chairman at Indiana University
is a former Wills glaucoma fellow and offered this assessment
of the fellowship: “In my opinion, it’s the best in
the country.” “As you progress through your medical
training, you become very aware of the responsibility owed to
your patients in regards to providing the highest quality of clinical
care. Eventually, we all must leave the sides of our mentors to
fulfill this responsibility on our own. The quality of those individuals
with whom you have trained has an enormous impact on your evolution
into an independent physician,” states Dr. Goulet. “It
is an honor to be able to continue this process with the patients,
staff, and physicians that make Wills Eye such an esteemed and
respected institution.”
FROM THE “CHAT HIGHLIGHTS” OF THE
GLAUCOMA SERVICE WEBSITE
"Am I a candidate for new glaucoma surgery?
Chat Highlights
June 2, 2010
Steven Beck, Editor
On Wednesday, June 2, 2010, Dr.
Michael Pro, a glaucoma specialist at Wills, and the glaucoma
chat group discussed "New" Glaucoma Surgery.
Moderator: The
topic tonight is "Am I a candidate for new glaucoma surgery?"
Dr. Pro, what are the new surgeries under consideration.
Dr. Pro: It's a
great topic, I think. Let's talk about the ECP, Canaloplasty,
ExPress Shunt, and Trabectome if time allows.
Moderator: OK.
Do you want to start at the top with ECP? What is ECP?
Dr. Pro: ECP (Endocyclophotocoagulation)
is in an interesting subset of glaucoma treatment modalities.
See, with most glaucoma surgeries you are working on the outflow
side of the equation. So, the IOP is too high and you are basically
making a new drain. That's what we do with trabs and tube shunts,
but ECP belongs to the subset of "cycloablative" surgeries
where you are trying to reduce the amount of fluid that the eye
naturally makes, basically "turning down the faucet".
ECP is a special probe that is inserted into the front of the
eye, most often during routine cataract surgery, and on a monitor
the surgeon applies laser energy with the probe to shrink the
glands that make aqueous fluid. These glands are called the ciliary
body and are located right under the iris.
P: Can ECP follow
a failed trabeculectomy or shunt implant surgery? Is it a “last
ditch”plan?
Dr. Pro: It can
be. In a sense right now we see the ECP used in two ways. First,
it is frequently used in patients who are undergoing routine cataract
surgery. A patient may have early glaucoma or ocular hypertension
and be on one or two drops. ECP can be done during surgery in
the thought that the IOP could be controlled post-op and the patient
may not need more drops. Second, ECP can be used in patients with
"refractory glaucoma." These are patients who have had
several glaucoma procedures. Perhaps there isn't really room for
another tube shunt and the ECP can be considered as an attempt
to control the IOP.
P: Can ECP be done
as a stand-alone surgery or is it always in conjunction with cataract
surgery?
Dr. Pro: It is
most often done with the cataract surgery, but it can be done
as a stand-alone. It is technically easier to do at the time of
cataract surgery as the view of the ciliary body through the probe
is often clearer than in an eye that had cataract surgery years
ago.
P: Can too much
ciliary processes be effected and the eye not produce enough fluid
post ECP surgery?
Dr. Pro: Yes, hypotony
(a low IOP) is a possible adverse outcome. It is more common with
the predecessor of ECP which is trans-scleral cyclophotocoagulation
(TSCPC). That procedure is a non-cutting surgery where a probe
delivers laser energy through the eye wall to shrink the ciliary
body. It is often reserved for more poorly sighted eyes.
Moderator: Shall
we discuss canaloplasty?
Dr. Pro: OK. Canaloplasy
is a newer procedure, more like a trab in the sense that you are
trying to improve on aqueous outflow. It is limited to open angle
glaucoma. It is often performed as a stand-alone procedure, but
can also be done at the time of cataract surgery. The approach
is a bit like a trab, but in this surgery a fiberoptic cannula
is advanced through the Schlemm's canal, a collector channel that
runs around the eye. A fine suture is tied off in the canal and
this dilation of the canal improves the outflow of aqueous fluid
from the eye. In addition some aqueous fluid percolates out from
where the flap incision is located at the top of the eye.
P: What makes a
good candidate for canaloplasty?
Dr. Pro: Well,
you need to have an open angle. Angle closure patients won't work
because their natural drain is scarred shut. Also we don't yet
have great data comparing this surgery to standard trabeculectomy,
so it might not be as good at getting the IOP quite as low as
in a trab. Persons with normal tension glaucoma who need a really
low IOP might do better with a trab. It might be better for someone
with early glaucoma, or someone who would do better without a
high bleb (like a person who insists on continuing contact lens
wear after glaucoma surgery).
Moderator: Excellent.
Let's move on to ExPress shunts.
Dr. Pro: OK, the
ExPress shunt has been around for a while now, but is getting
more traction these days. It is a small stainless steel device
that is used to augment standard trabeculectomy surgery. The device
is seated under a scleral flap and may help improve post-operative
success by creating a more controlled aqueous flow under the flap.
Some surgeons also feel it helps create a more desirable bleb
development.
P: What is the benefit
of this shunt in combination with a trabeculectomy? What determines
when the ExPress shunt is used in combination with a trabeculectomy
and when a trabeculectomy should be performed without the shunt?
Dr. Pro: Well,
there are no hard and fast rules. Some surgeons like to use the
ExPress shunt when a standard trab has failed. Instead of moving
on the larger tube shunt, an ExPress shunt can be tried. The thought
is that maybe the patient would have a better outcome, with less
chance of failure.
P: Will an ExPress
shunt added to the trabeculectomy provide a lower IOP than just
a trabeculectomy?
Dr. Pro: No. In
fact one of the advantages of the Express may be that it prevents
some cases of too low IOP which can be seen in standard trabeculectomy.
P: Is anyone at
Wills Eye Institute trained in the ExPress shunt?
Dr. Pro: All of
us are familiar with it and I would think just about all of us
have used it. I perform ExPress shunt surgeries occasionally.
Some of my colleagues are big proponents.
P: Dr. Pro, have
you heard about the Gold Micro Shunt (by Solx)?
Dr. Pro: Yes, this
is a device that has been in development for years now. It tries
to improve outflow by shunting aqueous flow to the supraciliary
space (a potential space between the vascular plexus within the
eye and the eye wall). Newer generations of this device have been
developed and are showing promise to lower the IOP. We need more
data on this device, but it may be a promising new surgical option.
P: Dr. Pro, do you
want to say a word about trabectome? There's a lot to discuss
in each of these new surgeries! What is a trabectome and who's
a candidate?
Dr. Pro: Briefly,
the trabectome is a new device which revives an old procedure.
Angle surgery is usually done on congenital and pediatric glaucoma.
The theory is that there is a membrane which is blocking aqueous
outflow to the Schlemm's canal. In one technique a needle is passed
into the eye and the membrane is opened. This can be very successful
in pediatric glaucoma, but showed much less success in adult glaucoma.
The trabectome is a device which is passed through the eye and
which cuts through the eye tissue covering the Schlemm's canal.
This “unroofs” the canal and has been effective in
many patients. It can be done as a stand-alone procedure or at
the time of cataract surgery.
P: Which new surgeries,
when done, make it impossible to do a trabeculectomy or add a
shunt in the future?
Dr. Pro: The canaloplasty
needs a large superior conjunctival incision and may make another
trab difficult to perform. So would the gold shunt or ExPress
shunt.
P: How many trabs
and/or shunts have you ever seen in one eye?
Dr. Pro: I have
seen three tubes in a single eye, with several failed trabs.
P: Is there data
on the life of a trab with a shunt compared to just a trabeculectomy?
Dr. Pro: No, not
yet.
Moderator: That
about wraps it up! We're out of time.
P: This has been
a lot of information. I think sometime in the future it might
be nice to just have a discussion more in depth about one or two
of these subjects.
Dr. Pro: I think
that was a good chat! Thanks for all the great questions. Good
night.
Mary Jude Cox, MD
Scott Fudemberg, MD
L. Jay Katz, MD
Anand Mantravadi, M.D.
Marlene R. Moster, MD
Jonathan S. Myers, MD
Rachel Niknam, MD
Michael J. Pro, MD
Courtland Schmidt, MD
Geoffrey Schwartz,
MD
George L. Spaeth, MD
Patrick Tiedeken, MD
Tara Uhler, MD
CHAT SUPPORT
GROUP
1st and 3rd Wednesday of the month 8:30 –
9:30 pm
Hosted by a Wills Glaucoma Specialist
Mondays, 8:00-9:30 pm
Saturday, 10:00 am
Patients and family members only
Current and archived chat highlights are available for review
on our website www.willsglaucoma.org
If you do not have access to a computer, call the Foundation to
have a printed copy mailed to you.
MEETING THE CHALLENGE OF GLAUCOMA THROUGH EDUCATION AND
RESEARCH
Please consider us when you are planning your estate. Help us
to fight this progressive disease. Please contact Dr. Zeff Lazinger,
Chairman of the Board at 484-362-8800 to make an appointment.
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