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glaucoma. "Evidence of glaucoma risk was present in the optic nerves of these subjects. The experts missed it, but imaging detected it," Dr. Schuman said. Defending stereo disc photos, Dr. Spaeth countered that "these technologies are not as objective as they seem. In contrast, photographs are objective, they are useful, and they are what really work now and for years to come. If I develop glaucoma, I hope my physician obtains disc photography on me." Ocular surface important to glaucoma cases Physicians discussed glaucoma therapies and ocular surface diseases at a symposium Thursday, examining the prevalence, treatment, and causes of ocular surface disease. "Here is what I think is the most important point to understand what ocular surface disease is: the instability of the [tear] film. The disease or damage to any component of the lacrimal functional unit can destabilize the tear film, leading to ocular surface disease that expresses itself as dry eye," said Felix Goñi, MD, Spain. "So dry eye is the expression of ocular surface disease." Ocular irritation produces an increase in tear secretion, leading to inflammation and decreased corneal sensation, he said. He said when glaucoma specialists are in front of their patients, they must think of dry eye because the disease is a real possibility. Preservative use in topical therapies, including the use of benzalkonium chloride (BAK), was covered, including in a presentation by Anton Hommer, MD, Austria. Dr. Hommer gave a comprehensive overview on the preservative, and among his conclusions was, "BAK seems not to be needed for better IOP lowering." Dry eye occurs in about 10% of women aged 75 and older, and is less common in men but still statistically significant, said Albert Khouri, MD, U.S. He said glaucoma specialists must be aware of how prevalent ocular surface disease is and how it can affect the very population that they treat with glau- coma—the elderly. "We all know that ocular surface disease and dry eye is heavily influenced by environmental factors, whether you practice in a cold or a warm environment, in an urban or rural setting, all of these affect the ocular surface and the tear film," he said. "And in glaucoma patients, you add to that the factor of topical medications." He showed photos of a case with significant asymmetric ocular surface disease. One eye had a trabeculectomy and was no longer on medications, while the other had not undergone surgery and was still receiving topical treatment. "You can tell the degree of asymmetry in corneal disease [from the images]," Dr. Khouri said. Corneal specialist David S. Chu, MD, U.S., discussed how glaucoma specialists could best manage the use of preservatives in topical treatment and resulting ocular surface disease. "Studies after studies have shown the correlation between glaucoma, glaucoma therapy, and ocular surface disease," Dr. Chu said. Functional impact important in glaucoma cases Glaucoma specialists need to be aware of how the functional impact of glaucomatous visual loss affects patients, referring them for low vision counseling more often and knowing what aspects of their patients' lives might be impacted. "We tend to think blindness equals death, and it really does not," said Joseph Lovett, U.S., speaking about the patient's perspective of having glaucoma. "That's a myth," he said. "It's a myth that must be disposed of in the medical world and in the public because too few of us that are sighted know people with severe vision loss, and when you know them, and see how they function, you understand [how they manage]." Mr. Lovett has glaucoma and made a documentary film about the functional impact of living with the disease called Going Blind. In the "Impact of functional impairment from glaucoma, enhancing visual performance in patients with glaucontinued on page 80