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123 March 2016 EW MEETING REPORTER He cited data from a 2015 JAMA Ophthalmology study that found one-fifth of patients who have trab- eculectomy will have early compli- cations, and one-fourth will have late complications. The study, which focused on 20 years of follow-up from the Olmstead, Minn., popula- tion, found a 53% or larger decrease in trabeculectomy over time as surgeons were able to use other treatments. Some alternatives or adjuncts to trabeculectomy that surgeons can now use include microinvasive glaucoma surgery (MIGS), the EX-PRESS Glaucoma Filtration Device (Alcon, Fort Worth, Texas), the collagen matrix Ologen (Aeon Astron, East Brunswick, N.J.) used in conjunction with trabeculectomy, and the combination of phacoemul- sification with trabeculectomy. Wave of advances reaches cornea disease, cataract surgery, and refractive surgery Corneal crosslinking (CXL), limbal stem cells, epigenetics, and exo- somes are hot areas in corneal and external disease—and research in these areas will continue to grow in the coming years, said Sally Atherton, PhD, Augusta, Ga., speaking during the "WOC Day IOP. With this test, the patient is required to drink 800 ml (27 ounces) of tap water in 5 minutes. The IOP is then measured 3 times at 15-minute intervals, and the maximum value of the 3 measurements is consid- ered the maximum IOP for the test. Using a WDT is a reproducible and reliable parameter, he said. Dr. Susanna stressed two import- ant take-home messages. The first was that peak IOP is a constant and crucial parameter, which is indepen- dent of initial IOP and underscores a patient's likelihood of future pro- gression. The second point was that drugs that show a similar mean IOP reduction but better ability to avoid IOP peaks may have an additional benefit for glaucoma treatment. Considering KPro advantages and complications Glaucoma drainage device complica- tion can be the "Mount Everest" in patients with the Boston keratopros- thesis (KPro, Massachusetts Eye and Ear Infirmary, Boston), said Jennifer Li, MD, Sacramento, Calif., in the session "Ocular Surface and Kerato- prosthesis." That's because while the device has several complications, the most pervasive problem is complications associated with glaucoma drainage devices, she explained. Patients using the KPro who have glaucoma drainage devices likely have had multiple procedures and other complications, Dr. Li explained. Although some surgeons argue that tube shunts should be inserted at the same time the KPro is used, that approach doesn't always work. "Postoperative glaucoma can contin- ue to be a problem," she said. Possible solutions to this preva- lent problem include covering older devices again, considering pars plana insertion, using a longer length of tube in the anterior chamber, and changing the contact lens diameter. Despite complications, patients with a KPro as the primary proce- dure tend to have more consistent visual success at 2–4 years postop- eratively, according to data from Anthony Aldave, MD, Los Angeles. The work he has done in this area compared patients with KPro against those with multiple penetrating ker- atoplasty procedures, and he found that 70% of eyes were better than 20/200 through 4 years. If you're considering penetrat- ing keratoplasty in a patient who has a low chance for success, Dr. Aldave thinks that the KPro may be a better choice. Surgeons talk glaucoma research and innovations When Robert Ritch, MD, New York, first brought up the possible connec- tion between glaucoma and lifestyle and nutrition 20 years ago, people thought he was joking. Fast forward to 2016. "Now, there's a vast increase in interest and importance in the topic," Dr. Ritch told attendees during the session "New Clinical Pearls to Assess and Manage Glaucoma." Despite the strong interest, ophthalmology still needs more clinical trials to truly show which of these less common therapies can help prevent or reduce the effects of glaucoma. Although there is no evidence of natural compounds that can low- er IOP, there is research that sheds light on how they can benefit other biological functions that play a role in glaucoma, Dr. Ritch said. This includes lowering blood pressure, providing neuroprotection, and helping brain function. "We have to think of glaucoma as a brain disease and not an eye disease," he said. One such natural compound is ginkgo biloba, which has been used in Chinese medicine for thousands of years, Dr. Ritch said. It's a power- ful antioxidant and has been shown in many research models to be neuroprotective while also improv- ing blood flow. Some studies show that ginkgo biloba protects against degeneration in the trabecular mesh- work as well. There is also curcumin, which has beneficial effects for diabetic retinopathy, uveitis, ocular surface disease, and possibly glaucoma, Dr. Ritch said. Interest in curcumin has exploded, with more than 8,500 re- lated studies in progress on PubMed, he added. Other supplements under research are omega-3 fatty acids—al- ready used by some patients to help with ocular surface disease—and citicoline, Dr. Ritch said. Exercise is another more natural "therapy" that many within med- icine have researched and found benefits related to oxidative stress. Exercise's role in glaucoma may be additive along with diet and sup- plements, he explained. However, glaucoma patients should be careful to avoid inversion poses in yoga that may actually increase instead of lower IOP, Dr. Ritch cautioned. Neeru Gupta, MD, Toronto, addressed biomarkers for glaucoma damage, noting that IOP, vascular signs, genetics, proteomics, newer vision tests, and neuroimaging all may be used now or in the future for this purpose. One area of particular interest right now is brain-related biomark- ers—including structure, perfusion, activity, connection, and metabo- lism—as researchers try to track a stronger connection between the brain and glaucoma. The ultimate goal is to develop disease-modifying therapies, Dr. Gupta said. Prin Rojanapongpun, MD, Bangkok, discussed the tricky balance between benefits and complications from trabeculectomy. View videos from WOC 2016: EWrePlay.org Bruce Koffler, MD, discusses the use of orthokeratology in children. continued on page 124

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