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World Glaucoma Congress 2019: Bound for Australia

This month, the world’s foremost glaucoma experts will come together in Melbourne to share research findings relating to all aspects of the disease. Ahead of the event, INSIGHT spoke to a number of those attending about the past, present and future of glaucoma.


Country: Kronenberg – Canada
Appointments: Professor of Ophthalmology & Vision Sciences, University of Toronto President, Canadian Ophthalmological Society
What do you think the most exciting developments in glaucoma research have been in recent times?
I believe the most exciting developments have been in the area of technology for the diagnosis and monitoring of glaucoma. More specifically, advances in optic nerve head imaging, macular imaging more recently optical coherence tomography (OCT) angiography and the interpretation of these tests.
What do you believe glaucoma research will focus on in the coming years?
The future of glaucoma is very exciting as artificial intelligence transforms the way we detect glaucoma and progression with our existing technologies in OCT imaging and visual fields.
In addition, the development of portable devices for optic nerve imaging and visual fields may help to both decrease the burden of these technologies in the clinic, while increasing frequency of testing which can be done at the convenience of the patient’s preferred location, rather than in an ophthalmologist’s office or hospital.
The number of devices and procedures for the treatment of glaucoma is increasing exponentially. As these improve, the surgical management of glaucoma will change, however the evaluation of these devices and procedures needs more rigor. Agreed upon minimal standards of what outcomes are required for a glaucoma surgical trial need to be developed and followed to facilitate evidence-based use of surgical innovation.
How is glaucoma diagnosis and treatment developing in Canada?
As a result of the improved portability of tests remote disease monitoring is growing, and I suspect teleglaucoma will become a significant part of the patient experience.
This will improve accessibility, which is important for a country like Canada that is challenged by its geography.
Surgical treatment of glaucoma, specifically in the area of ‘minimally invasive glaucoma surgery’ (MIGS), remains a challenge partially due to the health care structure of Canada, which is government funded, limiting access to costly new surgical devices and the paucity of strong evidence to support the role of various MIGS in the glaucoma treatment algorithm.
Is there anything else you would like to add in terms of the future of glaucoma diagnosis, treatment and research?
As technology plays an increasing role in patient care physicians need to be prepared to embrace the changes and evolve. Patients will still want the personal communication of a physician, and we will likely see decreased time spent in interpreting tests and more time spent on explaining disease process and treatment options.



Country: Australia
Appointments: Sydney Medical School Foundation Fellow, The University of Sydney, Save Sight Institute, Chair, Ophthalmic Research Institute of Australia
What do you think the most exciting developments in glaucoma research have been in recent times?
As a corneal specialist, treatments that avoid adverse effects to the ocular surface have helped improve the quality of life for patients with glaucoma. This includes preservative free medications; therapies able to reduce or avoid the use of prolonged topical therapies such combination medications, devices and surgery; and judicious use of anti-metabolites in glaucoma surgery.
Research uncovering the burden of treatment has helped to identify the need for improved therapies. Registries able to track treatment outcomes in the real world are also an exciting development, as they provide an understanding as to the management and outcomes of patients from everyday clinical practice. Clinical trials can be used to establish the efficacy and safety of devices in a selected population of patients and in a highly controlled environment. Registries, however, tell us what happens when the treatments are used by wider groups of patients and in different ways to clinical trials and over a longer time period.
What do you believe glaucoma research will focus on in the coming years?
Research will seek to develop personalised glaucoma therapies. Glaucoma is a group of diseases for which the pathogenesis is still being precisely determined and the genetics understood. Lowering intraocular pressure has been used to reduce vision loss. With improvements in the understanding of glaucoma pathogenesis, new treatments will be able to be developed that will precisely address the underlying aeitology.
A focus, I believe, will also continue on treatments that prevent damage to the ocular surface. This is due to the strong association between ocular surface disease and quality of life in patients with glaucoma. It will be important for our patients that as well as monitoring disease progression in terms of nerve fibre layer and visual field loss, we also consider ‘patient reported outcomes’, that is outcomes patients see as beneficial. Registries will have a role in collecting and tracking such outcomes.
How is glaucoma diagnosis and treatment developing in Australia?
In Australia, there has been an increase in the availability of visual field testing and imaging for glaucoma screening. Nonetheless, clinical examination is still an integral part of glaucoma diagnosis. To improve screening, researchers are looking towards artificial intelligence and this may streamline clinical care further. New therapies, devices and surgical techniques have become available that have allowed patients to access world-standard care. Collaborative care between ophthalmology and optometry has also increased over time.
Is there anything else you would like to add in terms of the future of glaucoma diagnosis, treatment and research?
In my clinical practice, I still see patients who have lost sight from glaucoma. There is still an urgent need for research and improvements in clinical care to prevent vision loss and also reduce the burden of treatment. Early diagnosis will prevent sight being lost and improved therapies will increase the effectiveness and reduce the burden of treatment. Patient reported outcomes would then ensure our focus remains on treatments with overall benefit to the patient.



Country: UK
Appointments: Professor of Ophthalmic Epidemiology & Glaucoma Studies, University College London
What do you think the most exciting developments in glaucoma research have been in recent times?
The most exciting aspect of glaucoma research in recent years has been development of data and techniques that promote a more focussed approach to getting better results for patients – often called ‘precision medicine’. In particular, we now understand the genetic basis of glaucoma much better, and believe we can predict who is likely to develop this condition with around 75% certainty from birth.
What do you believe glaucoma research will focus on in the coming years?
I would expect to see genetic testing rolled out much more widely in the near future, and would expect more dense genotyping to become more widely available both in clinical practice and research. Studies like UK Biobank have led the way in creating sophisticated, data rich resources that are driving advances in the causes of human disease and their prevention and treatment. The personal genome project offers similar, exciting opportunities.
How is glaucoma diagnosis and treatment developing in UK?
The UK is fortunate to have a large complement of highly trained optometrists. The routine sight test in the UK is the primary route to diagnosis. Recent studies have shown that well over 90% of high pressure glaucoma cases in the community are known and have been offered treatment.
Normal pressure glaucoma cases represent more of a challenge. A greater emphasis on examination of the optic disc is needed to consistently identify these cases. The increasing availability of OCT in optometry will help to ensure that these cases are picked up before advanced loss of vision has occurred.
In the UK, there have been several clinical trials that have helped identify optimal treatments for patients with a range of different types of glaucoma – the United Kingdom Glaucoma Treatment Study, the LiGHT and TAGS trials that primarily inform management of primary open angle glaucoma, to the ZAP and EAGLE trials that have looked at primary angle-closure glaucoma. Crucially, these trials look at patient reported outcome measures, and the economic effectiveness of treatments.
Is there anything else you would like to add in terms of the future of glaucoma diagnosis, treatment and research?
Medicine is moving into the age of big data. To create very large datasets, collaboration within and between countries is important, and probably essential, to create data that can be shared and compared.



Country: Australia
Appointments: Glaucoma surgeon and neuro-ophthalmologist, Clinical Associate Lecturer, The University of Sydney, Save Sight Institute Chair, Fight Glaucoma Blindness Registry
What do you think the most exciting developments in glaucoma research have been in recent times?
One thing has been the use of machine learning in aiding glaucoma diagnosis. Moorfields Eye Hospital has a collaboration with Google, where they were using machine learning to grade diabetic retinopathy. Certainly, glaucoma is heading in the same direction where we can use machine learning, and I think we’re getting pretty good at being able to aid with diagnosis using some of those tools.
The other importnat area of research at the moment is that over the last 10 or 15 years there has been some really good modelling of the optic nerve head. One thing we don’t know is what actually is the underlying cause of glaucomatous nerve damage, so some of the existing research has been really good in incrementally looking at the different biomechanical structural changes that comprise glaucoma. And so I think that in future they will develop more.
The other thing in future is that we’re probably going to be looking at, and is a hot topic at the moment, is MIGS. That’s an area where there all sorts of new devices have been coming to market from a surgical glaucoma perspective. And so I think research in the future is really going to have to start to focus on looking at longer-term safety and efficacy of these devices.
One of the jobs that I do at the University of Sydney is that I chair the glaucoma registry, which is tracking the long-term outcomes of all the patients with these devices. So our registry eventually will be able to tell us over time if they work in the short term, if they work in the long term and the safety considerations.
How is glaucoma diagnosis and treatment developing in Australia?
Even in a wealthy country like ours, glaucoma is under diagnosed. Because glaucoma really has no symptoms until very late, we think about 50% of the people in Australia who have glaucoma don’t know they have it. And so what we’re really trying to do is develop better methods of diagnosing glaucoma with increased sensitivity and specificity. Our tests are not good enough at the moment that you can just do it on anyone, but if we can improve them to the point that they’re a bit more accurate we can look at screening for glaucoma.
Is there anything else you would like to add?
Sometimes we tend to think of glaucoma as a single disease, whereas it is really is a number of different diseases which all have the final common pathway of cupping the optic nerve. But there are many different types of glaucoma, so if you have primary angle closure glaucoma, that’s a very different entity to open angle PXF glaucoma, for example.
I think one of the things that we’re going to have to do over time is better sub-type patients with glaucoma so we can with an individual patient, depending on their sub-type of glaucoma, work out what is their risk of progression. If we can combine those to really use personalised medicine, I think that’s going to be a big area of growth for glaucoma over the next 10 years.



Country: Australia
Appointments: Head of the Glaucoma Unit, Sydney Eye Hospital, Clinical Professor, University of Sydney, Director of Eye Associates and Life Governor of Glaucoma Australia
What do you think the most exciting developments in glaucoma research have been in recent times?
Slowly we are unraveling the maze of cell-based mechanisms that underlie the glaucomatous degenerative process. As this proceeds, new avenues of cell-based treatment strategies are promised. Two main avenues of research are being pursued in this regard: neuro-protection and neuro-regeneration on the one hand, and genetic aberrations on the other.
What do you believe glaucoma research will focus on in the coming years?
Besides these fundamental approaches, glaucoma research is also actively attempting to improve understanding of intra-ocular pressure contributions to visual damage with continuous real-time measurements, to improve drug delivery systems that deliver pressure-lowering agents without the need for active patient participation and to find less invasive and safer surgical techniques to control eye pressure.
How is glaucoma diagnosis and treatment developing in Australia?
As in other developed communities, we face the challenge of the 50% of glaucoma patients undiagnosed and untreated - and this is for a disease that is progressively causing irreversible visual damage. To optimise visual outcomes for glaucoma sufferers, we need earlier diagnosis and treatment commencement, as well as improved treatment program adherence.
Glaucoma Australia works hard to meet these challenges by increasing general community and specifically glaucoma-first-degree-relative awareness of the need for regular eye checks, and by supporting persons with glaucoma with information and encouragement. As members of the vision community, whether we are ophthalmologists, optometrists, opticians, general practitioners or pharmacists, we need to be part of this multi-disciplinary, multi-dimensional series of activities and strategies.
Is there anything else you would like to add in terms of the future of glaucoma diagnosis, treatment and research?
Over the past 10 years we have made amazing advances in our ability to diagnose glaucoma earlier and more accurately, especially with the use of OCT and improved automated perimetric testing as well as the options we can offer patients to reduce intra-ocular pressure: more drugs, more drug combinations, alternative preservative and preservative-free drug products, more common use of SLT and new surgical options.
Soon to come are ways to measure pressure continuously, to deliver drugs more effectively and to operate more safely. A little further down the track there promises to be new approaches based on cellular mechanisms for individual patients, information from genetics research and the neuro-sciences. And then there is the tantalising prospect of stem cell visual recovery. There’s a great deal of good to anticipate.


AFT Pharmaceuticals


Country: Australia
Appointments: University of Melbourne Senior Lecturer, Federal Councillor and Chair of the Ophthalmology Committee for Glaucoma Australia
What do you think the most exciting developments in glaucoma research have been in recent times?
The last 10 years of research has revolutionised surgical management of glaucoma; namely via MIGS. MIGS represents a broad group of small surgical devices characterised by minimal conjunctival dissection, shorter operating times, rapid post-operative recovery and a good safety profile. Trans-trabecular drainage devices, such as the iStent, are now common-place for stable glaucoma patients undergoing routine cataract surgery; subconjunctival drainage devices, such as the Xen drainage implant, are increasingly used in the place of trabeculectomy for suitable patients requiring filtration surgery.
In the future new sustained release ophthalmic drug delivery systems, such as periocular rings, canalicular inserts and intracameral rods may deliver IOP-lowering agents to the eye instead of regular eye drops. There are several challenges with long-term drop use that new systems aim to overcome, including suboptimal adherence to therapy, ocular surface disease and agent tachyphylaxis.
Research into neuroprotective agents, which for so long have seemed promising but have not translated into clinical practice, may yet yield fruitful results. For instance, thanks to improved gene-delivery systems, neurotrophic factors that promote retinal ganglion-cell (RGC) survival in glaucoma have been effectively delivered to the RGCs using viral vectors.
What do you believe glaucoma research will focus on in the coming years?
Compared to traditional therapies, key potential advantages of MIGS and new drug delivery systems are improved quality of life with reduced treatment-related side effects. For medications, this may be achieved through tolerability, reliable delivery and comfort. For surgical devices; reduced surgical risk, recovery time, complications and discomfort. A flow on effect may be better treatment delivery, acceptability and control, reducing glaucoma related visual loss over time.
For this reason clinical research in glaucoma must be better at evaluating quality of life and health-economic outcomes to guide clinical practice. New patient-centered health measures must be developed that measure these important outcomes. Large, multicentre international clinical trials using validated consensus measures are required to evaluate MIGS and new drug delivery systems.
How is glaucoma diagnosis and treatment developing in Australia?
Glaucoma is ‘the sneak thief of sight’; it is asymptomatic until late stages of disease. Late diagnosis of glaucoma at advanced stages tragically continues today. Still a large proportion of glaucoma patients, as much as 50%, remain undiagnosed in Australia. Yet exciting changes are occurring in Australia that may improve detection rates. The introduction of OCT into routine optometric practice will undoubtedly lead to increased glaucoma detection and an earlier age and stage of glaucoma diagnosis. It will also inevitably bring us the challenge of increased false-positive tests.
Optometric screening for glaucoma is crucial to the eye health of our community. An increased emphasis on screening first-degree relatives of glaucoma patients should be made. Closer collaborative teamwork between optometry and ophthalmology can hopefully reduce glaucoma-related vision loss in the future. Increasingly, Selective Laser Trabeculoplasty (SLT) is used as a primary treatment for ocular hypertension or open angle glaucoma, instead of topical drop therapy. SLT achieves 25% IOP lowering success in 75% of cases, with a duration of effect lasting 3 – 4 years. SLT demonstrates similar efficacy to topical agents, but without many of the problems associated with eye drop use.
Ocular surface disease (OSD) is present in up to 60% of glaucoma patients, often exacerbated by preserved topical drug therapy. Gone are the days when preserved drops are the only option. Today many options are available to control the IOP in a way that is relatively gentle on the ocular surface. SLT is much gentler on the ocular surface than regular preserved topical drops. Combination IOP-lowering drop preparations, preservative free preparations, and judiciously ceasing glaucoma medications when no longer needed are good therapeutic options for people with glaucoma and OSD.
Glaucoma Australia (GA) is evolving its digital resources and providing support for people with glaucoma and their relatives. GA’s support leads to an improved treatment experience and associated outcomes. GA has partnered with Oculo, allowing potential glaucoma patients detected on optometric screening be referred electronically to Glaucoma Australia to access support and resources.
Is there anything else you would like to add in terms of the future of glaucoma diagnosis, treatment and research?
Both internationally and in Australia there are many bright clinicians and scientists committed to advancing our understanding of glaucoma and discovering new treatments and applications. It is an exciting time and a privilege to be part of this community.



Country: Brazil
Appointments: Chair, Department of Ophthalmology, University of São Paulo, Past president of the World Glaucoma Association
What do you think the most exciting developments in glaucoma research have been in recent times?
The improvement of digital image devices, particularly the OCT with its capability to diagnose and follow estrutural progression, is without doubt an important upgrade in glaucoma management. However, one exciting development is in the field of intraocular pressure.
IOP is the most important causal factor for the development and progression of glaucoma. It is well established that IOP peak is one of the most important IOP parameter for glaucoma progression. Although IOP fluctuation may be important in some occasions, IOP peak has been shown to be important in all situations regarding glaucoma progression. The exciting development is the fact that IOP peak can be estimated using the water-drinking test.
The peak IOP elicited by this test is reproducible and corresponds to IOP peak of the patients during the day. So, it can be use to estimate the probability of progression, to assess the efficacy of ocular hypotensive medications, and be used to optimise glaucoma treatment.



Country: Canada
What do you think the most exciting developments in glaucoma research have been in recent times?
• The development of two new classes of glaucoma drops (Rho kinase inhibitor and latanoprostene bunod)
• The development of MIGS surgery devices and procedures
• Imaging in glaucoma to make earlier diagnoses
What do you believe glaucoma research will focus on in the coming years?
• The outcomes of MIGS surgery compared to trabeculectomy and longer term success rates
• Neuroprotection
• Artificial Intelligence and deep learning will contribute increasingly to glaucoma diagnosis and detection of progression
How is glaucoma diagnosis and treatment developing in Canada?
• Our main concern currently is the difficulty in accessing MIGS devices for our patients; variations in access and payment across the country need to be addressed
• OCT including Ganglion Cell Analysis (and potentially OCT Angiography in the future) have become an essential tool in the diagnosis of glaucoma
• Teleglaucoma for glaucoma screening in remote areas is in the early stages but showing promise
Is there anything else you would like to add in terms of the future of glaucoma diagnosis, treatment and research?
• Glaucoma specialists still need a better means of diagnosing early glaucoma as opposed to physiological but unusual discs. • Better diagnosis and treatment of normal pressure glaucoma is a high priority
• Neuroprotection as well as intraocular pressure (IOP) lowering treatments would be very helpful. Successful and safe surgery is still not a given for all patients.
• 24-hour recordings of IOP would give significant insight into risk of progression
• Sustained drug release options for enhanced compliance would be very helpful for treatment



Country: Australia
Appointments: Principal Research Fellow in Glaucoma Research, Centre for Eye Research Australia
What do you think the most exciting developments in glaucoma research have been in recent times?
The increasing recognition that glaucoma is a catch-all clinical grouping, and that different sub-groups within the commonest glaucoma grouping of primary open angle glaucoma are likely to have different underlying genetics, which will lead to different therapies when these are better characterised.
An exciting development in basic glaucoma research in recent years is the ability to culture, in the lab, cells from patients, and induce these cells to various cell types, including the retinal ganglion neurons that are affected in glaucoma. Another exciting development is the potential for the nutraceutical called nicotinamide to slow glaucoma progression. The first clinical trials are beginning.
What do you believe glaucoma research will focus on in the coming years?
With the explosion of genetic technologies and increasing ease of personalized genetics, the definition of glaucoma sub-types will soon be re-written, which in turn will direct development of alternate therapies to the predominant pressure-lowering therapies now being used with limited success. One active area of glaucoma research is on metabolic compromise, particularly mitochondrial dysfunction.



Country: Singapore
Appointments: Centre for Vision Research, Duke-NUS
What do you think the most exciting developments in glaucoma research have been in recent times?
There are heaps. I think the most exciting ones relate to our most fundamental understanding of why retinal ganglion cells die, and why ageing predisposes to that. I also think some of the new surgical innovations are very exciting.
There are two things I’m really interested in and there is some headway being made. One of them is why retinal ganglion cells are vulnerable in glaucoma and ageing, and from these deriving new treatments. What I would really like to see are treatments that actually target retinal ganglion cells, and ways to make retinal ganglion cells resistant to intraocular pressure elevation. That will be a major advance, and I think there is some progress in that direction.
The second key area is trying to find ways in which we can shorten the amount of time it takes to tell whether someone has glaucoma, and understand how quickly they are getting worse. This means real-time assessment to the state of retinal ganglion cell health. I think that is the major challenge for the future, because that will change the way we diagnose the disease and open up the door for new drugs that will actually improve the state of ganglion cell health.
What do you believe glaucoma research will focus on in the coming years?
Another area from a health systems point of view that is critically important is working out robust structures by which the increasing number of patients with glaucoma can all be properly cared for. This means driving safe and effective community-based care for glaucoma, and part of that goes back to the research I mentioned before.
Being able to differentiate which patients are at a high risk of going blind and which ones are not is crucial. I think working out better ways of classifying the disease, classifying people’s risk of going blind and then managing them accordingly by stratifying care, goes together with reducing the risk of blindness.


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