Getting to grips with glaucoma

It was a case of third time lucky for the 2021 Glaucoma New Zealand (GNZ) Symposium. After two postponements over the past year, the symposium successfully went ahead at Alexandra Park in Auckland on 16 May. Given that in-person educational events have been few and far between recently, it was a fantastic opportunity to mix with colleagues and sponsors and to enjoy some excellent glaucoma education from a diverse range of speakers. This year, GNZ also provided the opportunity for delegates to attend remotely, with 26 people livestreaming the event, in addition to the 100-plus attendees in the room, which resulted in some great feedback.

 

Zooming in on red eye

 

Presenting via an (almost completely glitch-free) Zoom call from Brisbane, Professor Graham Lee from The University of Queensland was this year’s keynote speaker. Prof Lee gave a whistle-stop tour of red eye in glaucoma. Being fellowship trained in both cornea and glaucoma, he is uniquely qualified to cover this topic. The presentation detailed a wide variety of red-eye cases in glaucoma, ranging from sight-threatening emergencies (acute angle closure) to mild iatrogenic red eye (this part of the talk also highlighted the wider range of preservative-free medications available for glaucoma treatment in Australia compared with New Zealand). Prof Lee raised the importance of asking about a patient’s nutrition, describing an interesting case of reduced conjunctival healing in a patient suffering from alcoholism.

 

 

Prof Graham Lee

 

Dr Sam Kain, one of GNZ’s trustees, was tasked with chairing the day’s rapid-fire sessions. As usual, he provided some light relief in the form of a humorous introduction for each speaker. The first of these sessions was entitled Clinical pearls for glaucoma management: mastering the basics. Dr Hussain Patel spoke on the epidemiology of glaucoma, with a focus on his research in Aotearoa. His retrospective review of the Auckland District Health Board’s (ADHB’s) clinical records showed that Māori and Pasifika patients were under-represented in primary open-angle patient clinic numbers and that non-glaucomatous optic neuropathies should always be considered for patients in these ethnic groups.

 

The ABC of OCT

 

Determining visual field progression in glaucoma is always a challenging task. Dr Keli Matheos highlighted reasons for this, including the large number of non-repeatable visual field defects and the fact that many of us are likely to be under-testing our patients. Dr Graham Reeves’ presentation included an entertaining alphabet of optical coherence tomography (OCT) in glaucoma. However, he was unable to come up with OCT-themed words starting with K, U and W (I’ve unsuccessfully racked my brains for these too). Although their talks were technology-based, both Dr Matheos and Dr Reeves homed in on the continued importance of clinical disc interpretation as an integral part of every glaucoma assessment. Dr Alex Buller, a regular at the GNZ Symposium, was gifted the unsexy but extremely important topic of compliance (also commonly referred to as adherence) in glaucoma. Dr Buller summarised a number of high-level studies to highlight the importance of adherence to topical medication regimens and a long list of reasons why patients may stray from their instructions.

 

 

Stephen Hill and Theresa Nowak

 

Session two: surface value

 

The second session of the day, Holistic approach to glaucoma care, included topics from across the full glaucoma spectrum. One of the highlights was Professor Jennifer Craig’s presentation on the intersection of dry eye and glaucoma. Prof Craig outlined why preserving the ocular surface is key in glaucoma patients, particularly for those with existing dry eye disease, and in younger patients who may have decades of therapy ahead of them. New Zealand’s lack of subsidised preservative-free glaucoma medications was again mentioned, and it is my hope that more of these unit-dose eye drops will be available for our patients in the not-too-distant future. Other methods that can help reduce the burden on the ocular surface in glaucoma patients include using preparations with lower toxicity preservatives, reducing the number of instilled doses and considering laser or surgical treatments for some patients.

 

Lifting weights, lifting IOP

 

Dr Geraint Phillips provided an overview of research from the University of Auckland – a collaboration between optometry, ophthalmology and sports science that looked at how resistance training affects intraocular pressure (IOP). They found that resistance training caused spikes in IOP (to above 60mmHg in some participants!), which thankfully returned to normal very quickly post-lift. This provided some food for thought around advising glaucoma patients on lifestyle factors. It has already been established that aerobic exercise lowers IOP, encouraging all of us to take time away from the couch over the coming winter months.

 

New angles on primary angle closure

 

Following lunch, we settled back into our seats for a variety of angle-closure presentations. Prof Lee returned to our screens to provide an update on the management of primary angle closure, including interpretation of the ‘Effectiveness of early lens extraction for the treatment of primary angle-closure' (Eagle) and ‘Zhongshan angle-closure prevention’ (ZAP) studies. He also reminded the audience of interpreting the ZAP study with caution as it was undertaken with a Chinese population, meaning the results will not be applicable to New Zealand’s demographics. GNZ chair Professor Helen Danesh-Meyer reminded the audience of an oft-neglected technique in the management of acute angle closure: corneal indentation. This can be performed to force aqueous humour into the peripheral angle, which can be effective in breaking the acute attack and allowing some symptomatic relief for the patient while they wait for definitive treatment.

 

 

Aimee Lloyd-Parangi and Renate Botha

 

Mimics, scandal and the scholarship

 

The symposium continued its tradition of holding a case-presentation session, with speakers from both optometry and ophthalmology covering glaucoma diagnoses and glaucoma mimics. Dr Jesse Gale covered a particularly interesting case of a congenital conduit to the retrolaminar space and the use of clinical methods to investigate corneal biomechanics (surprisingly, they were not affected). Later, Greelane optometrist Richard Johnson discussed the most scandalous diagnosis, with an unusual case of topless disc syndrome (superior segmental optic nerve hypoplasia).

 

The day concluded with the Gordon Sanderson Scholarship presentation. The scholarship – named for one of the founding trustees of GNZ and a titan of eyecare in New Zealand – has been awarded every year since Gordon died in 2017. The 2019/2020 recipient, Blair Lowry, received the scholarship to investigate the demographic factors surrounding acute angle closure in New Zealand. He summarised 65 cases that presented to ADHB over the course of two years. It’s great to see the scholarship being put towards research that will help future generations of eyecare professionals.

 

Overall, it was a fantastic weekend of glaucoma education (even if it did mean giving up a Sunday). Special thanks should go to Pippa and Tersia at GNZ for organising the event, all of the excellent speakers, and to the sponsors: AFT Pharmaceuticals, Allergan, Designs for Vision, Device Technologies, Glaukos, Humanware, Medix21, OIC and Tristel, for their generous support of the event.

 

Dr Hannah Kersten is a therapeutic optometrist with a particular interest in glaucoma and neuro-ophthalmic disorders. A trustee of GNZ, she currently holds clinical and research roles at Eye Institute in Auckland.

 

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