Eyeworld

EW MEETING REPORTER 86 Reporting from the Singapore National Eye Centre (SNEC) 25th Anniversary International Meeting, May 22–24, 2015, Singapore receiving her topic, "Management of ROP in Asia." The symposium brought togeth- er experts from SNEC and Duke Eye Center, Durham, N.C., to compare and contrast ophthalmology prac- tice and research in the "East" with those in the "West." In his talk on the "Management of Glaucoma in the West," Rand Allingham, MD, Duke, took a glob- al view, stating that glaucoma is the leading cause of irreversible blind- ness around the world. He focused his talk on primary open angle glaucoma (POAG) and exfoliation syndrome—which are certainly common in the U.S. and Europe, although prevalence varies elsewhere (e.g., while it is low in Singapore in China, the syndrome rates high in Japan). Specifically, Dr. Allingham called into question the prevailing wisdom for glaucoma manage- ment that prefers first line medical treatment, followed by laser trabecu- loplasty, and finally surgery. Current studies such as the Glaucoma Laser Trial, he said, strongly suggest that laser trabec- uloplasty should be considered as primary therapy, with no significant difference between selective laser trabeculoplasty (SLT) and argon laser trabeculoplasty (ALT). Further comparison between SLT and latanoprost as primary ther- apy showed no difference. Moreover, survival at 5 years after a single laser intervention was 30%, and consider- ing the cost of medical therapy over 2 years, laser trabeculoplasty shows a clear advantage. However, he noted that the approach to treatment of POAG is "one size fits all"—reducing IOP by whatever means. This also needs rethinking. Research has revealed a number of genes associated with POAG. If the genetic architecture varies, Dr. Miller asked, why treat all cases the same? This same question was raised by Tina Wong, MD, Singapore, in her talk on "Management of Glaucoma in Asia." Dr. Wong focused her talk on primary angle closure glaucoma (PACG)—the more aggressive form of glaucoma, she said. As with POAG, various genes for PACG have also been identified, thus calling into question the "one size fits all" approach Dr. Miller cited, Dr. Wong agreed. While Asia is a large, multifac- eted, heterogeneous territory, Dr. Wong said that the focus of research in Asia tends toward screening methods for early detection. In terms of treatment, cost effective- ness is a concern particularly in more remote areas. Among the more recent findings from research in the region, imag- ing, she said, has revealed new risk factors: a smaller anterior chamber, larger lens vault, and a greater iris have been found to contribute to angle width issues. Considering these factors, imag- ing may play a role in screening. As for treatment, studies are still ongoing that hopefully will help de- cide whether and when to use laser peripheral iridotomy or surgery. Editors' note: The physicians have no relevant financial interests. Advances and the "non-visual" eye Before proceeding with his Barry Cullen Lecture for Excellence and Leadership in Neuro-Ophthalmol- ogy, Neil R. Miller, MD, expressed his admiration for J.F. (Barry) Cullen, FRCS, for whom the lecture is named. Few people can claim to have developed neuro-ophthalmol- ogy in one country, Dr. Miller said; Dr. Cullen did it in 2: Singapore and Scotland. He was thus greatly honored to be giving the lecture, he said. For his lecture, he discussed "Advances in Neuro-Ophthalmolo- gy," beginning with a brief look into the potential use of nanoparticles to treat non-arteritic anterior ischemic optic neuropathy (NAION). It may be possible, he said, to conjugate nanoparticles with medication to allow them to target specific tissue. While this may lie in the near future, one advance in neuro-oph- thalmology already at hand is opti- cal coherence tomography (OCT). OCT, Dr. Miller said, has changed the practice of ophthalmology in general, neuro-ophthalmology in particular. One caveat regarding the use of OCT is that it only reveals struc- ture—not function. Nonetheless, OCT has come to play a role in the diagnosis, progno- sis, and treatment guidance, moni- toring of neuro-ophthalmic disease, and research. In terms of diagnosis, Dr. Miller said, OCT now allows ophthalmol- ogists to see "virtually all working parts of the eye." In terms of prognosis, it is now known that the thickness of the ret- inal nerve fiber layer (RNFL) predicts visual outcome in compressive optic neuropathies: Patients with RNFL thickness ≥100 μm will do well, while those with RNFL ≤70 μm are less likely to do well. Meanwhile, OCT measure- ments of the thickness of the retinal ganglion cell-inner plexiform layer (RGC-IPL) has been found to have "excellent reproducibility" in healthy patients. This measurement is known to be sensitive in the detection of permanent damage and is reduced before the peripapillary RNFL. In the same symposium, Dan Milea, MD, Singapore, drew the at- tention of attendees to "The Non-Vi- sual Eye"—as the ear is known to have both sensory and vestibular functions, the eye is now known to serve other functions associated with physiological and behavioral circadian rhythm. The eye's nonvisual response to light is now known to influence sleep structure, cognitive perfor- mance, learning and mood, alertness and sleepiness, depression, photo- phobia, and migraine. Research has led to a more detailed understanding of the ana- tomical and neurological relations associated with these nonvisual functions, and has produced inno- vative approaches to disorders such as blue light therapy for seasonal affective disorder (SAD). Among other things, he said, half in jest, surgeons should thus think twice about enucleating blind patients. EW Editors' note: The physicians have no relevant financial interests. June 2015

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