Transcript
Speaker 1:Glaucoma is a group of conditions that lead to deterioration of the peripheral visual field and irreversible vision loss. Although it is the leading cause of irreversible blindness, the only modifiable risk factor currently supported by clinical trials is IOP control. As a result, timely treatment to lower IOP is [00:00:30] imperative to slow the rate of vision loss from glaucoma, with common methods including topical medication, sustained-release drug delivery, laser treatment, and surgery. As the landscape of glaucoma treatment evolves and minimally-invasive options are integrated into clinical practice, early-stage disease management represents a pivotal therapeutic window to which timely intervention may prevent lifelong visual disability.
In recent years, advancements in [00:01:00] both procedural and pharmacologic modalities have transformed clinicians' approach to managing this phase of the disease. The Early-Stage Glaucoma Consensus Group reflects the perspectives of experienced glaucoma specialists and comprehensive ophthalmologists uncovering a harmonized view of how selective laser trabeculoplasty and sustained release drug delivery systems may function as a complimentary tool in the early-stage glaucoma [00:01:30] treatment algorithm. The Consensus Group participated in an online survey and follow-up interviews to address prevailing practice gaps and establish current practice patterns in attempt to advance the care of patients with early-stage glaucoma.
[00:02:00] Survey data from the Early-Stage Glaucoma Consensus Group confirmed that OCT is currently the most essential diagnostic tool for detecting early glaucoma damage. About two-thirds, 67%, consider ganglion cell complex thickness, and 33% consider retinal nerve fiber labor thickness the most reliable parameter [00:02:30] to detect early-stage glaucoma.
Zarmeena Vendal:So my entire clinic, I would say, at any given time, a good 20% of patients could definitely be glaucoma suspect, and that's across the board, irrespective of age, even, actually. So [00:03:00] I would say about 20% of the people that I see.
Inder Paul Sing...:The ones that I see who are coming for glaucoma evaluation, probably 60-70% either are going to have glaucoma or have it or who are going to develop it just because of why they're sent to me, so to speak. Probably GCC. The earliest finding is probably GCC and then RNFL
Zarmeena Vendal:[00:03:30] So two things. I definitely pay attention to corneal thickness and then OCT analysis. So retinal fibrillary and ganglion cell loss, early ganglion cell loss, I think are the primary things that can really tip us off for the diagnosis. And then a close second is neurofibrillary.
You can lose 20% of your optic nerve and have a totally normal visual field, [00:04:00] and so functional testing is important, but it should not be the modality we use to establish the diagnosis. So if there's already loss in the field, of course that seals the diagnosis, but it should not be the leading factor in our analysis. I am not looking for change on both modalities, OCT and field, in order to establish diagnosis. Absolutely not. In fact, if we all had our wish as [00:04:30] interventional glaucoma specialists, we would be diagnosing and treating the disease before any visual field loss has occurred. So definitely not the modality I use to decide if somebody has glaucoma.
Manjool Shah:It's hard to narrow it to just one thing. I think, when looking at OCT, we've got to look at the whole picture. Just relying on single metrics like global RNFL thickness, for example, we're going to miss a lot of glaucoma, because glaucoma is not a uniform [00:05:00] optic neuropathy. It prefers certain regions. It prefers the superior and inferior retinal nerve fiber layer. So if you take the whole average, you're going to miss that. So looking at the superior and inferior sections and the superotemporal and inferotemporal subsections can be particularly useful. Looking at the ganglion cell complex and the macular thickness is also really important because sometimes you'll catch little wedge defects [00:05:30] on the macula that you can't really perceive in the optic nerve, the retinal nerve fiber layer analysis. So I think looking at the superior and inferior, superotemporal and inferotemporal, if you're going to be really specific, as well as the macula is going to be your best bets for early identification.
Lorraine M. Pro...:I look at the RNFL peaks, but basically where it plots the left and right nerve thickness compared to the normal population. [00:06:00] And that's super helpful for me because you can see if they're just shifting their peaks from myopia or hyperopia, but they still have healthy peak height, and then also you get a really good snapshot of how the two nerves are compared to each other. So folks can still be in the "green zone", but one nerve is way thinner in an area than the other, and that's a clue. So I love that, just the peak RNFL thickness.
Emily M. Schehl...:[00:06:30] Technically, if you look at the AAO guidelines, in order to diagnose glaucoma, you have to have an OCT and a visual field. So technically it should be right in the beginning of disease. And I also believe that. I think that. So when patients come into my office, they get an OCT and they get their pressure checked and [00:07:00] they get gonioscopy. And then I look at their OCT, and if it looks pretty normal and healthy, I'll bring them back in a couple of months to do a visual field, because obviously we're not in a huge rush. If it looks like, "Oh man, they probably do have glaucoma," then I'll do a visual field that day.
But everybody gets at least one baseline visual field because I need to be able to say, "This was your baseline visual field. This is what it looked like. This is how it changed over time." So I absolutely think that we should [00:07:30] still be doing visual fields for every glaucoma suspect who is just being watched. Like, just a baseline. Even if you see the OCT never changing, you should do a baseline visual field. And then for every glaucoma patient, they should have a visual field on diagnosis.
Manjool Shah:The fact is early glaucoma is going to have normal visual fields by its very definition. We call mild glaucoma pre-parametric. Glaucoma without visual field loss in the US, certainly. [00:08:00] But I think there's real value in training visual fields. So it's a skill to perform an accurate visual field on a patient standpoint. So even if a patient has no chance of having visual field loss, I'm still going to do visual fields fairly frequently on those patients so that we get that skillset developed so the patient knows how to do a field and can deliver [00:08:30] an accurate diagnostic test in the future when perhaps they might be at risk of having something progressive having happened to them. So I like to do fields even when I know that they're going to be normal. And sometimes we're surprised. Sometimes we're caught off guard by something that looked rather benign on imaging and disc examination that actually turns out to be something that's already crossed the threshold. So I think there is value in doing fields early and often.
Swarup S. Swami...:[00:09:00] I typically feel that if I have a patient who I see some mild OCT changes on and I believe them to be real, they're not artifact, I would probably say that I still like to get a visual feel at that point, just, honestly, to serve as a kind of a benchmark or a baseline to either show they have some early changes or they don't have any early changes because that really serves, again, as a nice kind of benchmark for me to compare later on. So I honestly think [00:09:30] that it's still important to get, it's just something that may not change over time as quickly. Sometimes those changes take a little bit for them to manifest on the visual field. But I still think there's a role for perimetry at the beginning, but primarily for the purpose, I think, of getting a baseline so that you can then compare it later on if the person were to develop changes on the testing.
Speaker 1:According to the Early-Stage Glaucoma Consensus Group, the most promising [00:10:00] emerging diagnostic technologies include AI-based glaucoma prediction modeling, OCT angiography, and at-home tonometry IOP measurements.
Lorraine M. Pro...:Of those, I already use at-home tonometry, I use ganglion cell analysis religiously, and I use virtual reality perimetry already. To [00:10:30] me, VR is sort of a sub for mole-based traditional perimetry. So that, to me, isn't really a diagnostic addition or subtraction, it's just sort of a more useful tool. Like an upgraded field. Mac ganglion cell is great for early detection because that can be the first thing that you find to be abnormal even with the RNFL thickness looking normal. So that's huge.
But I think what we're all doing with all [00:11:00] of these different tests is just synthesizing and using that and applying it to what we know about glaucoma and what we've seen. So if AI could do that, I think that would be the next step, is something that can synthesize and provide decision support to the physician. Because all those other things you've listed that are more peripheral like OCTA or adaptive optics and stuff like that, those could help, but it's just another tool that you would throw into that bucket that we all used to make decisions. So I think AI would be the most revolutionary.
Inder Paul Sing...:[00:11:30] There's a company called OcuSciences that has a new diagnostic test that measures stressed out cells, basically. And these cells release a marker on their cell wall called flavoproteins, and this machine is a fundus photograph that actually can pick up those flavoprotein autofluorescence and it can actually highlight them. So you can actually now detect cells even before they become apoptotic when they're stressed out. So it's called OcuSciences, it's called [00:12:00] OcuMet. Probably the Ocumet, I think, has the most potential along with segmental OCT. I think OCT angiography is going to be really helpful.
Emily M. Schehl...:I think that OCTA is cool, and I use it sometimes in my practice, but it's not something I rely on all the time. I think the biggest thing is going to be AI glaucomatous detection. So I have a large grant with the [00:12:30] International Eye Foundation where we're validating an OCT combined fundus photo technology to diagnose glaucoma or screen for glaucoma in rural populations in India. And I think that that is going to be the biggest thing because it's non-contact, non-mydriatic, patient doesn't have to do anything, patient doesn't have to speak English, doesn't have to be able to talk to you. So I think that that is the way of the future and is going to be huge. [00:13:00] We do utilize virtual reality visual field testing as well. I think that is also going to be the way of the future because it's just expanding access to diagnosis to more patients.
Speaker 1:To read the consensus statement in its entirety and complete the related CME activity, scan the QR code on this screen.
