EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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46 EW FEATURE February 2011International techniques and technology June 2012 Glaucoma treatments worldwide by Faith A. Hayden EyeWorld Staff Writer AT A GLANCE • Surgical intervention is the first-line glaucoma therapy in countries where access to medication is limited • Glaucoma specialists in Saudi Arabia and Nepal favor beta blockers over prostaglandins W ith more than 60 mil- lion people worldwide with glaucoma, the vi- sion-stealing eye dis- ease is without a doubt a global issue. How to treat glau- coma is an international concern, too, as a cure remains elusive. Myriad options, from medications to surgery to a combination of both, Crosslinking continued from page 45 week are the same as the outcomes of regular LASIK performed without crosslinking," Dr. Tomita said. Dr. Tomita argued that using CXL as a preventative measure for eyes at risk of ectasia is better than post-op treatment because "treating iatrogenic ectasia is difficult once [it has] developed." Dr. Reinstein echoed Dr. Schallhorn's sentiment about safety benefits needing to be proven over a long time period. Meanwhile, LASIK remains a safe procedure, and if per- formed properly, ectasia develop- ment may not be as big a risk as some think. "In any case, there is no need for crosslinking in LASIK if current safety criteria with respect to corneal thickness and residual stromal thick- ness are observed," he said. "There have been over 20 million proce- dures performed to date, and the long-term safety with respect to ec- tasia is excellent, particularly with the use of thin flaps created by fem- tosecond lasers. It is hard to justify crosslinking in routine cases at this point." EW Editors' note: Dr. Schallhorn has financial interests with Abbott Medical Optics (Santa Ana, Calif.). Dr. Tomita has financial interests with Avedro. Drs. Reinstein and Stulting have no financial interests related to this article. Contact information Reinstein: +44 020 7224 1005, dzr@londonvisionclinic.com Schallhorn: 619-920-9031, scschallhorn@yahoo.com Stulting: 770-255-3330, dstulting@woolfsoneye.com Tomita: +81-3-5221-2207, tomita@shinagawa.com are available, and the suitability of each treatment varies from country to country. For example, in the U.S., where the estimated 2.2 million glaucoma patients have easy access to medications and follow-up care, the favored approach is pharmaceu- ticals. But in some parts of Africa, where drugs are often unavailable and unaffordable, medications may not make sense. So what are the preferred glau- coma treatments around the world? EyeWorld spoke with glaucoma spe- cialists in Ethiopia, Saudi Arabia, and Nepal to hear their approaches to controlling the disease. Ethiopia In Ethiopia, the national prevalence of blindness is 1.6% and low vision is 3.7%, according to the World Health Organization, making it one of the world's prominent countries with preventable vision loss. Glau- coma is responsible for 5.2% of blindness, according to the National Survey on Blindness, Low Vision, and Trachoma in Ethiopia. For Abeba T. Giorgis, M.D., glaucoma specialist, Department of Ophthalmology, Addis Ababa Uni- versity, Ethiopia, the treatment of choice depends on a number of fac- tors glaucoma doctors anywhere would expect, such as the IOP level, type of glaucoma, and stage of the disease. But there are influences unique to the country, such as drug availability and accessibility and proximity of patients to an eyecare center, that come into play as well. During the Africa Glaucoma Summit and Workshop on Public Health Control of Glaucoma Blind- ness in Africa, which were both held in 2010, "the primary management option for glaucoma in Africa was decided to be surgical," Dr. Giorgis said. "Most African glaucoma pa- tients come to attention when the glaucoma is at an advanced stage, [they have] a high IOP, live in a [remote] area, and drug options are limited and unaffordable." The surgery of choice for Dr. Giorgis is a modified trabeculec- tomy. "Most patients with advanced glaucoma do very well with my modified filtration surgery that is trabeculectomy with anti-metabo- lites and releasable sutures," Dr. Giorgis said. "[Their] vision [is] Monthly Pulse Keeping a Pulse on Ophthalmology T he responses to June's Monthly Pulse reflect in several instances a marked contrast between health- care in the U.S. and elsewhere. It was interesting to see that more than half of survey respondents refer their post-cataract patients to a retinal specialists if vitrectomy needs to be done. Is this a posi- tive nod to U.S. ophthalmologists and their ability to work collaboratively as a team? It might also beg the question: Have we become too specialized in our training? Also interesting was the fact that more than a third of respondents did not feel that they knew enough about CXL to have an opinion regarding its use. Once again the rest of the world is leading the way with a treatment that has quickly gained acceptance while U.S. doctors wait for approval. The final question about first-line treatment for glaucoma was perhaps the most telling of the differ- ences between the U.S. and other countries. A resounding majority of respondents indicated that they will add a second medication before surgical treatment and less than 5% use surgical management as a first line of treat- ment. Will this change as micro-invasive glaucoma surgery comes onto the scene? Only time will tell. John A. Vukich, M.D., international editor