Eyeworld

EW MEETING REPORTER August 2011 59 correlate with glaucoma and its pro- gression in clinical studies. "Neuro- protection is a direct means of protecting retinal ganglion cells and their axons independent of IOP re- duction," he said. Although neuro- protective agents have shown some benefit in slowing the progression of Alzheimer's disease and amy- otrophic lateral sclerosis, this has not yet been the case in glaucoma. Opening Session World Glaucoma Association presi- dent Makoto Araie, M.D., Tokyo, opened the 4th biennial WGC on June 29 in Paris. The WGA has set three goals of the WGC meetings: to provide a forum for the exchange of information and knowledge; to pro- vide an opportunity to establish and renew collaboration and dialogue among the glaucoma community; and to stimulate participation in scholarly activities to achieve the WGA's stated purpose of eliminating glaucoma disability worldwide. Eric Sellen, M.D., president of the French Glaucoma Society, a local organizer of this year's WGC, said, "We in France are honored to be se- lected by the WGA to host the oph- thalmic community for this WGC. This is the most important glaucoma meeting held in Paris to date." In fact, according to Joel Schuman, M.D., University of Pitts- burgh, "The 4th WGC is the largest glaucoma meeting ever held." Atten- dance as of the first day of the Con- gress exceeded 3,000 delegates from 99 countries. The faculty numbered over 300 and hailed from 66 differ- ent countries. Dr. Weinreb summarized the process for this year's Consensus meeting, which focused on glau- coma progression. A selected group of experts discussed topics related to this year's theme online for months before attending a daylong meeting immediately preceding the WGC to establish consensus-based guidelines related to glaucoma progression. The product of this effort will be re- viewed by the Consensus organizers and the WGA member societies be- fore being made available in book form at this year's American Acad- emy of Ophthalmology meeting in October 2011. Dr. Weinreb also described the International Glaucoma Review, the official journal of the WGA, as "the most widely read glaucoma publica- tion in the world." This publication, which has a circulation of over 12,000 and is distributed free to members of the WGA's member soci- eties, serves as a compendium of the relevant published literature in glau- coma. Features include expert com- mentary on recently published articles, opinion pieces, and news re- garding the activities of WGA mem- ber organizations. World Glaucoma Congress 2011 continued Thursday, June 30 Highlights of the day's sessions in- cluded a symposium on glaucoma progression, a session on "Glaucoma Debates: Hot Topics," and a sympo- sium on advances in glaucoma surgery, which focused on new evi- dence in filtration surgery (spon- sored by Alcon, Fort Worth, Texas). Glaucoma progression Ki Ho Park, M.D., Seoul National University, South Korea, discussed the role of nerve fiber layer (NFL) evaluation in detecting glaucoma progression. Clinical examination and red-free photography are both useful qualitative methods. Optical coherence tomography (OCT) pro- vides quantitative assessment of the NFL. Spectral-domain OCT is more sensitive than time-domain OCT in detecting both the presence and pro- gression of glaucomatous NFL de- fects. Marcelo Nicolela, M.D., Dalhousie University, Halifax, Nova Scotia, described methods of detect- ing glaucoma progression based on changes in optic nerve topography, including stereoscopic disc photo- graphs (the clinical standard) and the Heidelberg Retina Tomograph continued on page 60 August 2011 World Glaucoma Congress Reporting live from the EX-PRESS symposium, Paris, France R obert Fechtner, M.D., New Jersey Medical School, Newark, said that the EX-PRESS Glaucoma Filtration Device (Alcon) success depends on patient election and surgical technique. The procedure is similar to trabeculectomy but implanting the trans-scleral device standardizes scleral lumen size and thus aqueous diversion. If the patient is not a candidate for trabeculectomy, the patient is not a candidate for EX-PRESS. He also advocated that surgeons avoid making the scleral flap too small or there will not be adequate resistance to outflow. Also, the flap need not be dissected as far anteriorly as with tra- beculectomy because the device should go through sclera and not through peripheral cornea or filtration will be compromised. "This procedure is an improvement in our evolution of filtration surgery," he said. Leo DeJong, M.D., Academic Medical Center, Amsterdam, the Netherlands, conducted a 5-year, randomized clinical trial comparing EX-PRESS to trabeculectomy in medically uncontrolled glaucoma patients. Both procedures resulted in excellent IOP control. In the first few years, the trabeculectomy group needed more medications than the EX-PRESS group, but this was com- parable by year 5. Five-year IOP-lowering success rates were similar, with comparable proportions of patients achieving IOP <18 and <15 mm Hg without medications in both groups. Time to failure was statistically longer following EX-PRESS compared to trabeculectomy. Complications were generally similar, with slightly more operations required after trabeculectomy versus EX- PRESS. Elie Dahan, M.D., Ein Tal Eye Center, Tel Aviv, Israel, and senior consultant in glaucoma surgery, Rothschild University Hos- pital, Haifa, Israel, conducted a randomized clinical trial in which 15 subjects with bilateral advanced open-angle glaucoma un- derwent trabeculectomy in one eye and EX-PRESS implantation in the fellow eye. After a mean follow up of 2 years, mean IOP reduction was comparable after both procedures. In contrast, the eyes undergoing trabeculectomy required substantially more IOP-lowering medications to maintain glaucoma control than did the EX-PRESS eyes. More eyes achieved complete success (IOP <18 mm Hg without medications) after EX-PRESS versus trabeculectomy through up to 30 months of follow up. Operative complications and the need for reoperation were substantially lower following EX-PRESS versus trabeculectomy. He concluded that EX-PRESS was more beneficial than trabeculectomy in this patient cohort. Malik Kahook, M.D., University of Colorado, Denver, reported a retrospective case series of 70 patients evenly divided into EX-PRESS and trabeculectomy groups. Mean IOP dropped significantly immediately after surgery in both groups and was similar in magnitude between groups (45% reduction for EX-PRESS, 48% for trabeculectomy). Defining success as IOP between 5 and 18 mm Hg with at least a 30% IOP reduction without the need for IOP-lowering medications, 77% of EX-PRESS eyes and 74% of trabeculectomy eyes were deemed successful. In addition, EX-PRESS blebs were larger and less vascular than trabeculectomy blebs during early follow up, but bleb morphology was similar between groups by the last follow up. One important note: Pa- tients with an EX-PRESS device implanted can safely undergo MRI scanning. Marlene Moster, M.D., Wills Eye Hospital, Philadelphia, began using the EX-PRESS device in complicated glaucoma cases, but she was impressed enough with its performance that she now uses it as her primary surgical procedure in some patients. She shared some surgical pearls for implanting the EX-PRESS device. Cautery should be applied lightly to minimize inflamma- tion, and mitomycin C should be applied over a broad area to ensure a large filtering bleb. She prefers a 25 g needle to fashion the implantation track. Also, she pre-places sutures in the scleral flap for prompt closure after device implantation. A watertight conjunctival closure is critical to avoid post-op leaks. Symposium sponsored by Alcon

• Cover