EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/357599
69 August 2014 EW MEETING REPORTER Keynote 1: Happiness in equity A former WHO consultant and regional advisor who "witnessed Asian ophthalmology from the beginning," Ramachandra Pararajasegaram, MD, Switzerland, discussed "Sustaining global elimi- nation of avoidable blindness in an era of ASEAN integration. Challenges and opportunities." Reiterating the goal of ASEAN—"one vision, one identity, one community"—Dr. Pararajaseg- aram emphasized how it is "talking about vision already," thus establish- ing a key role for ophthalmologists in the organization's aim of coopera- tion and collaboration. In thinking about the challenges of sustaining global elimination of avoidable blindness, he encouraged ophthalmologists to "think outside the box" of eye health, and think about the determinants of health in general. These include life expectan- cy, under 5 mortality, health budgets and services, and maternal and child health. Each of these, he said, has a not insignificant impact on eye health. For instance, life expectancy is significant when considering age- related conditions; in higher income countries like Singapore where the average life expectancy is higher than in other countries, age-related conditions thus take center stage in public health issues. Meanwhile, under 5 mortality is significant to childhood blindness, with countries with higher under 5 mortality tend- ing to have greater problems with childhood blindness. "It is not enough to say how much cataract or childhood blind- ness we have," he said. "We have to look at the causes." With ASEAN integration, two things in particular become clear: disparities between countries, and inequity within. Ultimately, he said, the goal of ASEAN can also apply to eye health and the goals of Vision 2020. ASEAN in general and AOS in particular provide "wonderful opportunities for the 10 countries to work togeth- er," sharing policies, institutions, health, and ultimately happiness. In conclusion, he said: "The time to be happy is now. The place to be happy is here. The way to be happy is to make others happy." Keynote 2: Brain pressure and the eye In the second keynote lecture of the 1st AOS Congress, Jost B. Jonas, MD, Germany, shared how "anatomical facts" with regard to glaucoma have led him and col- league Ningli Wang, MD, China, to examine certain assumptions about the pathophysiology of the disease. These facts—or hallmarks, characteristics—include: 1. Loss of neuroretinal rim, which Dr. Jonas said is only seen in glaucoma and one other condi- tion: giant cell optic neuritis. 2. Peripapillary atrophy, which is most specific for glaucoma, particularly the enlargement of the zone beta component. 3. Disc hemorrhage, more often seen and typically larger in normal tension glaucoma. 4. Retinal arteriolar thinning, which is least specific, found in any optic neuropathy. What Dr. Jonas and Dr. Wang found particularly striking about these "facts" was the similarity in optic nerve changes between high pressure and normal tension glau- coma. This led them to look outside the eye, at the optic nerve itself. Could there be a correlation be- tween IOP, orbital cerebrospinal fluid pressure (CSFP), and, going further, blood pressure (BP)? In their study, they found that CSFP was slightly—but significant- ly—lower in patients with normal tension glaucoma. Meanwhile, looking at their controls, they found a correlation between CSFP and BP, while IOP was also correlated with BP. The pressure in the three fluid compartments, he said, may thus be correlated. They concluded that, given the clear morphological characteristics that differentiate the different forms of glaucoma from other forms of optic neuropathy, glaucoma may well be a "misbalance" between BP, CSFP, and IOP. Keynote 3: When to refer to an ocular genetics specialist These, said Alex V. Levin, MD, U.S., are exciting times: A new subspecial- ty, ocular genetics, is "completely changing the playing field for ophthalmology," he said. In his keynote lecture on "Retinal dystrophies in childhood: Do I need to refer?" Dr. Levin pre- sented two cases that were "instruc- tive of the role of ocular genetics." In the first case, a 3-year-old male presented with poor vision and strabismus with a known history of laser treatment for some retinal condition. A look at his history revealed he had undergone surgery for a double aortic arch; he also had a secondary pulmonary concern, speech and developmental delay, and obesity—not things you are like- ly to find an ophthalmologist taking note of in the history. Visual acuity testing revealed preferential fixation with the left eye, with resistance to covering that eye. Fundus examination showed retinal traction with total retinal detachment in the right eye; there was also some traction in the left. Dr. Levin wondered, could there be a single unifying diagnosis for all of these findings? Today, microarray testing can be used to scan the patient's entire ge- nome for deletions and duplications. Meanwhile, the completion of the Human Genome Project means that we can now check these deletions and duplications against a map to find any phenotypic expressions that have been reported for these errors. Forgoing the specifics, the findings in this particular patient had the following implications: The patient's parents were given a di- agnosis, bringing them some peace of mind; in addition, Dr. Levin was able to counsel the patient and his parents, provide a prognosis, devel- op a treatment plan, establish sur- veillance, and identify other family members at risk, thus giving him the opportunity to examine them and potentially prevent some if not all the consequences of the condition. In the second case, a patient was found to have retinitis pigmen- tosa—a condition that was once considered an untreatable blinding disorder. Ocular genetics, said Dr. Levin, has also revolutionized the approach to this condition: Full field electro- retinogram can show if the retina is still responsive ("not yet dead"); Goldmann visual field testing can assess function; the status of the disease can be determined by fundus autofluorescence and OCT; geno- typing provides an opportunity for counseling, allowing the clinician to give patients and their relatives appropriate support and education, while assessing the risk of recur- rence, prognosis, and providing opportunities for research. It used to be that in such cases, all an ophthalmologist could say were things like "He/she will go blind ... see you later," or "Nothing we can do ... see you later," or "I'm not sure what you have ... see you later." continued on page 70 (AOS) Congress, Bangkok, July 9–11, 2014