Volume 2, Number 1
Fall, 1993
WHO Fellow from China
Studies Optic Disc Damage in Open-Angle and Low-Tension Glaucoma
Liu Sen, our most recent
visiting doctor and full-time Research Fellow, received his medical
training in his native land of China, where for the last 10 years
he has been on the staff of the Department of Ophthalmology of
a large university hospital affiliated with Ningxia Medical College
in Northwest China, approximately 250 miles from the Mongolian
border. The fluent English and calm, friendly demeanor of this
ardent devotee of tai chi have won him the admiration of all who
have come to know him.
Since his graduation from
medical school in 1983, Dr. Liu's professional life has centered
on clinical work and research in glaucoma. Not unlike many other
such individuals throughout the world, Dr. Liu's interest in glaucoma
stems from the fact that it is both one of the most devastating
and one of the most puzzling of diseases. On the one hand, there
is a deeply-felt sympathy for the millions worldwide who suffer
from a condition that seriously diminishes the quality and productivity
of their lives. On the other hand, there is the intellectual challenge
of learning more about a disease which, despite considerable efforts,
remains largely a mystery.
Having received a Fellowship
from the World Health Organization of the United Nations, Dr.
Liu chose to spend it honing his research skills and observing
surgery at the Glaucoma Service of Wills Eye Hospital. Here, he
believes, three vital components have merged to create an excellent
climate for clinical research: a vast storehouse of records of
glaucoma patient visits; superb clinical equipment; and doctors
with great clinical and research skills.
Dr. Liu is involved with
many projects. Among the most exciting are ones, in collaboration
with Drs. Spaeth and Katz, focusing on the causes of optic disc
damage in open-angle and low-tension glaucoma. The fact that glaucomatous
damage to the optic disc can occur in eyes with normal or low
intraocular pressure is extremely intriguing. It suggests that
there is, perhaps, a more basic cause involved in the disease
than high intraocular pressure, as often traditionally assumed.
There is much to learn from the records of the Glaucoma Service
about whether, for example, low-tension glaucoma is associated
with a particular kind of optic disc damage, and whether, for
example, this damage could be related to levels of blood flow
in the eye.
Like all of the research being
carried out on the Glaucoma Service, this research is clinical.
It is directly related to providing doctors with the information
they need to better diagnose and treat their patients. As clinicians
themselves, Dr. Liu and the other physicians on the Glaucoma Service
are well aware of the kind of knowledge that is needed to better
serve their patients.
Dr. Liu's efforts to gain
that knowledge will undoubtedly reap a bountiful harvest--here,
in China, and throughout the world.
Research Fellow Liu Sen (middle) shares
photographic data with Research Fellows Silvana Araujo (left)
and Sharad Mansukani (right). (photograph by Jamie Nicholl)
Glaucoma Drugs and Depression
One of the most difficult
problems in the medical treatment of glaucoma is anticipating
the side effects certain drugs will have on particular patients.
Suspecting that some of these drugs may be responsible for problems
with depression, so-called "failure to thrive," and impotence,
the Foundation is pursuing studies in all three of these areas.
- Another ongoing study is seeking to determine
whether laser treatment on surgical treatment works as well
in black as in white patients and, if there is a difference,
why?
- National multi-centered trials in which
Glaucoma Service researchers are now participating include the
Collaborative Initial Treatment of Glaucoma study, which is
attempting to determine the effect of surgery in comparison
with drops and pills used for treatment of glaucoma on the quality
of life of the individual being treated; and the Ocular Hypertension
Treatment study, which seeks to determine whether the use of
drops to treat elevated intraocular pressure can prevent the
development of glaucomatous damage.
New Clinical/Research Fellows Immersed
in Projects
Glaucoma staff
members Courtland Schmidt (right) and Richard Wilson (left)
work with Clinical/Research Fellow Stephen Wahl (middle)
on a laser research project.
(photograph
by Jamie Nicholl) |
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Each year, the Glaucoma Service
selects three individuals from over 80 top-notch applicants to
serve as Clinical/Research Fellows. These Fellows devote a substantial
part of their time to learning and applying research techniques.
David Boes
One of three current Clinical/Research
Fellows, Dr. Boes has a B.S. from Creighton University in Omaha,
and his M.D. from the University of Nebraska Medical Center. He
completed his residency at the University of Washington Medical
Center in Seattle. In one of his research projects he is attempting
to determine the best stereophotographic procedure for measuring
the depth of the "cup" in glaucomatous eyes, one measure of the
extent of optic disc damage. Successful treatment, of course,
is directly related to the accuracy of such measurements.
Brian Caputo
Another Clinial/Research Fellow,
Dr. Caputo has a B.S. and M.D. from the University of Pittsburgh,
and completed his residency at the Eye and Ear Institute of that
institution. His research projects include a comparison of the
results of certain laser procedures performed by residents with
the results achieved by the permanent staff using the same procedure.
By helping doctors better understand the learning curve involved,
both patient and resident training can be optimized.
Stephen Wahl
Also a Clinical/Research Fellow,
Dr. Wahl has a B.A. from Johns Hopkins, and received his M.D.
from Hahnemann. He completed his residency at the Krieger Eye
Institute in Baltimore, Md. He is working on a project attempting
to determine whether there is any relation between pigmentary
glaucoma and retinal detachment. In pigmentary glaucoma, pigment
eroded from the iris may plug the pores of the trabecular meshwork,
the mesh-like structure through which aqueous humor flows as it
exits the anterior chamber. Ther result of this clogging is increased
intraocular pressure. Dr. Wahl's research will help doctors better
understand the causes and mechanisms of this type of glaucoma.
What Treatment is Best?
[In this article, Dr.
George Spaeth, President of the Glaucoma Service Foundation
to Prevent Blindness and Director of the Glaucoma Service at
Wills Eye Hospital, presents the second part of a three-part
discussion of an issue of the utmost importance for all glaucoma
patients and physicians: How to decide what treatment is best.
The first part concluded with two basic difficulties that each
patient's uniqueness poses in bringing the results of clinical
studies to bear on treatment decisions: studies provide information
about groups, not individuals; and "success" as defined by a
study may not be the same as "success" as defined by a particular
patient.]
A third factor in deciding
what "treatment" is best is the clear realization that there is
no way to avoid risk. Glaucoma, left to itself, inevitably gets
worse. The avoidance of treatment does not avoid risk.
All treatments for glaucoma,
medical or surgical, carry risk with them. Most drops and pills
used for glaucoma pose risks that stop when the drop or pill is
stopped, but there are exceptions: Pilocarpine and it's reactions
can cause retinal detachments in susceptible individuals. Acetazolamide
and methazolamide can, in extremely rare situations, cause abnormalities
of the formation of blood that persist and can be fatal in susceptible
individuals, even after cessation of the pill. The beta-blockers--Timoptic,
Betagan, and Betoptic--quite frequently cause slight changes in
breathing, blood pressure, heart rate, and other functions; in
extraordinary cases, the changes can be so severe as to cause
death.
Virtually everybody experiences
to some extent the temporary side effects caused by medications
prescribed for glaucoma. Although studies have provided important
clues as to who may be likely to be affected, how much each individual
will be bothered can be determined only by that individual trying
the medications. In patients under 40, those who are nearsighted,
and those with early central cataracts, vision is likely to be
blurred by pilocarpine. The very elderly or those with asthma
or chronic lung problems are likely to have side effects from
beta-blockers. Many who have problems with their prostate are
more likely to be bothered by acetazolamide and methazolamide,
etc, etc.
Nevertheless, as emphasized
in the first part of this article, each patient is unique. Therefore,
some young people will tolerate pilocarpine well, some elderly
individuals will have no problem with pilocarpine, and some asthmatic
patients will have no difficulties taking beta-blockers.
As mentioned above, one advantage
of drops and pills is that the undesirable side effects caused
by them are almost always temporary and stop when the medication
is stopped. In contrast, the changes caused by surgery by laser
or knife, are usually permanent in virtually every individual.
Even argon laser trabeculoplasty, the effects of which are seldom
noted by the patient, permanently changes the eye.
The side effects of surgery
with a knife are usually mild--a sensation that there is something
in the eye, a slightly droopy lid, a change in the sense of brightness,
etc.
Most patients very quickly
get acclimatized to these changes. However, occasionally, they
can be extremely serious, such as an infection or massive bleeding
into the eye. These problems are rare but some individuals are
pre-disposed to them. For example, someone who has had very high
eye pressure (over 30 mm Hg) for years, and who has far advanced
glaucoma, is far more likely to have massive bleeding into the
eye than an individual who is young, healthy, and has only recently
developed glaucoma.
Thus, in attempting to decide
what treatment is "best," patients must carefully consider the
specific types of side effects associated with medical and surgical
(laser or knife) treatment (as established by studies, with all
their limitations), and decide which of these likely or unlikely
side effects they are willing to risk.
Vision for the Future
Achieving the Foundation's
mission--doing all within our power to minimize the blindness
caused by glaucoma--requires the help of many, many people.
To sustain our present level
activities and grow, more resources are desperately needed. We
need to invest in new technology (image analyses equipment, psychological
testing instruments, high-resolution video) and hire more staff
(statisticians and, most importantly, a full time, Ph.D., trained
investigator). Looking beyond these immediate needs, to ensure
that our research program can continue uninterrupted for many
years to come, we need to establish an endowed professorship and
an endowment fund to support research Fellows. And inevitably
we will need more space; our present quarters are already cramped.
Please consider helping us grow.
Brith Sholom Women Donate Instrument
The Glaucoma Service of Wills
Eye Hospital recently purchased an episcleral venous pressure
device, thanks to a donation from the Emile Zola Chapter of Brith
Sholom Women. The state-of-the-art equipment is used to determine
patterns of blood pressure and blood flow in glaucoma patients.
A plaque acknowledging the important contribution was placed outside
a glaucoma research room housing the new equipment along with
other instruments related to blood-flow studies. Pictured here
are Chapter members at the dedication ceremony (left to right):
Margery Roomberg, Irene Schmuckler, Lillian Altshuler, Annette
Weiss, Rose Weinfeld, President of the Chapter Gertrude Taylor,
and Dorothy Weissman.
(Photograph by Roger Barone)
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