Eyeworld

AUG 2011

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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World Glaucoma Congress August 2011 several groups of patients who might benefit from primary LTP (ei- ther argon or selective). These in- clude non-compliant patients, older patients whose risk of blindness is low due to relatively short life ex- pectancy, disabled patients who can- not instill eye drops correctly, people who live in developing countries and have limited access to IOP-low- ering therapies, and those for whom cost limits adherence to therapy. Tony Realini, M.D., M.P.H., West Virginia University, Morgan- town, reviewed the evidence and concluded that argon and selective laser trabeculoplasty (ALT and SLT) have comparable IOP-lowering effi- cacy based on five well-designed randomized clinical trials. ALT can be repeated, but repeat ALT has a rel- atively poor success rate, and a small but significant number of patients will have extreme IOP spikes necessi- tating urgent filtering surgery. SLT also appears to be safely repeatable, although repeat SLT may not lower IOP as much as initial SLT. Non-adherence statistics lead to reconsideration of the value of sur- gery earlier on. Tanuj Dada, M.D., All India Institute of Medical Sci- ences, New Delhi, reported that nine out of 10 glaucoma patients are un- able to correctly instill their eye drops despite having the technique demonstrated for them. This form of non-adherence results in preventa- ble glaucoma blindness. He sug- gested that selective laser trabeculoplasty (SLT) should be con- sidered early in the course of glau- coma. This will require that we overcome the SLT paradox: SLT is most attractive to patients when it is least likely to make a difference for them (when medical therapy has failed and surgery is looming), and is least attractive to them when it might make the greatest difference (early in the course of the disease). Surgery as earlier intervention may be the key to reducing blind- ness. Eytan Blumenthal, M.D., Hadassah University, Jerusalem, listed the reasons why patients with glaucoma go blind despite being under the care of an ophthalmolo- gist. These include discontinuity of care resulting from transferring care from one doctor to another, failure of the treating doctor to look back far enough in the medical record to detect long-term progression, and the tendency to repeatedly set new baselines each time therapy is changed, thus creating a moving tar- get. He proposed surgery as an ear- lier intervention than it is currently considered, and suggested that sur- gery should be performed as soon as the first of the four central spots on the visual field's pattern deviation plot becomes abnormal. Editors' note: Dr. Blumenthal has no financial interests related to his com- ments. Dr. Dada has no financial interests related to his comments. Dr. Realini has financial interests with Alcon, Lumenis (Yokneam, Israel), Reichert, and Zeimer (Port, Switzer- land). Dr. Topouzis has financial interests with Alcon, Merck, Pfizer (New York), Novartis (Basel, Switzerland), Allergan (Irvine, Calif.) and Heidelberg Engineering. New ideas in medical treatment Arthur Sit, M.D., Mayo Clinic, Rochester, Minn., discussed the clin- ical relevance of 24-hour IOP evalua- tion. Circadian IOP is difficult to measure, but can be accomplished using a sleep laboratory, home self- tonometry, or continuous IOP moni- toring. Several devices are becoming available to perform continuous IOP monitoring for up to 24 hours at a time, such as the contact lens-based Triggerfish device (Sensimed, Lausanne, Switzerland). Knowledge of patients' nocturnal IOP behavior is important because IOP is highest at night when blood pressure is low- est, thus compromising blood flow to the optic nerve at night. Several therapies, such as prostaglandin analogues, carbonic anhydrase in- hibitors, and laser trabeculoplasty lower IOP effectively in the noctur- nal period. Rohit Varma, M.D., M.P.H., University of Southern California, described a novel drug delivery sys- tem currently under development. The Replenish device (Replenish Inc., Pasadena, Calif.) consists of a reservoir of IOP-lowering medica- tion, a hydrolysis-based pump sys- www.ASOA.org I trust my business to ASOA. In today's economic climate... The Physician's PERSPECTIVE day o In t onomic clima c s e 's e day ... e t onomic clima World continued from page 61 continued on page 64

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