Glaucoma 2024

Magnificent Glaucoma Care:

An Offer You Can’t Refuse

Subspecialty Day | AAO 2024

Chicago | Oct 18
Glaucoma 2024
Magnificent Glaucoma Care—
An Offer You Can’t Refuse
Program Directors
Steven L Mansberger MD MPH and Yvonne Ou MD

In conjunction with the American Glaucoma Society

McCormick Place
Chicago, Illinois
Friday, Oct. 18, 2024

Presented by the American Academy of Ophthalmology

Supported by an unrestricted educational grant from Sight Sciences

Glaucoma 2024 Planning Group 2024 Subspecialty Day Advisory Committee Staff
Steven L Mansberger MD MPH R Michael Siatkowski MD Mecca Boutte, Project Specialist
Program Director Associate Secretary Ann L’Estrange, Subspecialty Day Manager
Yvonne Ou MD Julie Falardeau MD Melanie R Rafaty CMP DES, Director,
Program Director Jennifer Irene Lim MD Scientific Meetings
Jody R Piltz MD Debra Rosencrance CMP CAE, Vice
Larissa Camejo MD President, Meetings & Exhibits
Anna T Do MD Sonal S Tuli MD
Sonia H Yoo MD Patricia Heinicke Jr, Copy Editor
Steven Gedde MD Mark Ong, Designer
Regine S Pappas MD Bennie H Jeng MD Jim Frew, Cover Design
Mary Qiu MD Secretary for Annual Meeting
Aakriti Garg Shukla MD
Carla J Siegfried MD
Joshua D Stein MD MS
Richard D Ten Hulzen MD

©2024 American Academy of Ophthalmology. All rights reserved. No portion may be reproduced without express written consent of the American Academy of Ophthalmology.
ii Program Planning Group Subspecialty Day 2024  |  Glaucoma

Glaucoma Subspecialty Day 2024 Planning Group

On behalf of the American Academy of Ophthalmology and the American Glaucoma Society, it is our pleasure
to welcome you to Chicago and Glaucoma 2024: Magnificent Glaucoma Care—An Offer You Can’t Refuse.

Steven L Mansberger MD MPH Yvonne Ou MD

Program Director Program Director
AbbVie: S Oculinea: C
Glaukos Corp.: C
IQVIA: S
Nicox: C
ONL Therapeutics: C
Perfuse: C, S
Tabia: C
Théa: C,S

Program Planning Group

Larissa Camejo MD Anna T Do MD Steven Gedde MD

AbbVie: C,L AbbVie: L None
Alcon Laboratories, Inc.: C
Glaukos Corp.: L
Iridex: L
Johnson & Johnson Vision: L
Lumibird: L
Nova Eye Medical: C,L
Sight Sciences, Inc.: C,L
Subspecialty Day 2024  |  Glaucoma Program Planning Group iii

Regine S Pappas MD Aakriti Garg Shukla MD Joshua D Stein MD MS

AbbVie: C AbbVie: C AbbVie: S
Glaukos Corp.: C,L Alcon Laboratories, Inc.: C Janssen Pharmaceuticals, Inc.: S
Retina AI: SO Théa: L Ocular Therapeutix: S
Théa Laboratories: C

Mary Qiu MD Richard D Ten Hulzen MD

Allergan, Inc.: C Carla J Siegfried MD None
None

2024 Subspecialty Jennifer Irene Lim MD (Retina) Sonal S Tuli MD (Cornea)

AbbVie: C Kowa Pharmaceutical Co. Ltd.: S
Day Advisory Adverum Biotechnologies: S Recordati Rare Diseases: S
Committee Aldeyra Therapeutics: S
Allergan, Inc.: C Sonia H Yoo MD
R Michael Siatkowski MD Astellas: C (Refractive Surgery)
Associate Secretary Aura Biosciences, Inc.: C Carl Zeiss Meditec: C
(Pediatric Ophthalmology) Bausch + Lomb: C Dermavant: C
None Cognition Therapeutics: C Johnson & Johnson Vision: C
Eyenuk, Inc.: C Oyster Point: C
Bennie H Jeng MD Eyepoint: C
(Secretary for Annual Meeting) Genentech: C,S
GlaxoSmithKline: C Greybug: S AAO Staff
Kiora: US Hoffman La Roche, Ltd.: C
Iveric Bio: C Mecca Boutte
Sanofi: C
JAMA Network: C None
Julie Falardeau MD Janssen Pharmaceuticals, Inc.: S
Luxa: C Ann L’Estrange
(Neuro-Ophthalmology)
NGM: S None
Stoke Therapeutics: S
Ocular Therapeutix: C,S
Opthea: C Melanie Rafaty
Regeneron Pharmaceuticals, Inc.: C,S None
RegenexBio: C,S
Spring Vision: S Debra Rosencrance
Stealth Biotherapeutics: S None
Unity: C
Viridian: C Beth Wilson
None
Jody R Piltz MD (Glaucoma)
Alcon Laboratories, Inc.: C,L
Nanoscope Therapeutics: C
Subspecialty Day 2024  |  Glaucoma Contents v

Glaucoma 2024 Contents

Glaucoma Program Planning Group ii

CME vi

The American Glaucoma Society Subspecialty Day Lecture viii

Faculty Listing ix

Using the Meeting Guide to Interact During the Meeting xiv

Program Schedule xv

Section I: These Clinical Trials Will Elevate Your Clinical Practice by a Magnificent Mile 1

Section II: Surgical Pearls in the Second City 11

Protect America’s Eyesight: A United Vision for Ophthalmology’s Future 19

Section III: Glaucoma Unscripted—What Other Specialties Can Teach Us About Glaucoma in the Second City 21

The American Glaucoma Society Subspecialty Day Lecture:

The Unknowable Truths of Glaucoma—Dealing With Uncertainty in Clinical Practice 32

Section IV: Medication & Laser Innovations 33

Section V: The Latest Diagnostics for Glaucoma, and All That Jazz 39

Section VI: Great Debates From the Land of Lincoln 49

Faculty Financial Disclosure 61

Presenter Index 65
vi CME Credit Subspecialty Day 2024  |  Glaucoma

CME Credit

The Academy’s CME Mission Statement place to resolve all conflicts of interest prior to an educational
activity being delivered to the learners.
The purpose of the American Academy of Ophthalmology’s
Continuing Medical Education (CME) program is to present
ophthalmologists with the highest quality lifelong learning Control of Content
opportunities that promote improvement and change in physi-
The American Academy of Ophthalmology considers present-
cian practices, performance, or competence, thus enabling such
ing authors, not coauthors, to be in control of the educational
physicians to maintain or improve the competence and profes-
content. It is Academy policy and traditional scientific publish-
sional performance needed to provide the best possible eye care
ing and professional courtesy to acknowledge all people con-
for their patients.
tributing to the research, regardless of CME control of the live
presentation of that content. This acknowledgment is made in
Glaucoma Subspecialty Day 2024 Learning a similar way in other Academy CME activities. Though coau-
Objectives thors are acknowledged, they do not have control of the CME
content, and their disclosures are not published or resolved.
Upon completion of this activity, participants should be able to:
■ Demonstrate familiarity with controversial management
Subspecialty Day 2024 CME Credit
issues and current gaps in evidence-based glaucoma care
■ Evaluate the status of glaucoma diagnostics and test inter- The American Academy of Ophthalmology is accredited by
pretation, as well as their role in identifying and manag- the Accreditation Council for Continuing Medical Education
ing glaucoma (ACCME) to provide CME for physicians.
■ Demonstrate familiarity with current issues in medical,
laser, and surgical therapy for glaucoma and how these Friday Subspecialty Day Activity: Glaucoma, Neuro-
therapies affect other eye diseases Ophthalmology, Pediatric Ophthalmology, Refractive Surgery,
■ Recognize factors that complicate the care of the adult Retina (Day 1), and Uveitis
and pediatric glaucoma patient The Academy designates this Other (blended live and enduring
material) activity for a maximum of 12 AMA PRA Category 1
Credits™. Physicians should claim only the credit commensu-
Glaucoma Subspecialty Day 2024 Target Audience
rate with the extent of their participation in the activity.
This activity has been designed to meet the educational needs of
general ophthalmologists, glaucoma specialists, residents and Saturday Subspecialty Day Activity: Cornea, Oculofacial
fellows in training, other ophthalmology subspecialists, and Plastic Surgery, and Retina (Day 2)
allied health personnel who are involved in the management of The Academy designates this Other (blended live and enduring
glaucoma patients. material) activity for a maximum of 12 AMA PRA Category 1
Credits™. Physicians should claim only the credit commensu-
rate with the extent of their participation in the activity.
Teaching at a Live Activity
Physicians registered as In Person and Virtual are eligible to
Teaching instruction courses or delivering a scientific paper
claim the above CME credit.
or poster is not an AMA PRA Category 1 Credit™ activity
and should not be included when calculating your total AMA
PRA Category 1 Credits™. Presenters may claim AMA PRA Attendance Verification for CME Reporting
Category 1 Credits™ through the American Medical Associa-
Before processing your requests for CME credit, the Academy
tion. To obtain an application form, please contact the AMA at
must verify your attendance at AAO 2024 and/or Subspecialty
www.ama-assn.org.
Day. Badges are no longer mailed before the meeting. Picking up
your badge onsite will verify your attendance.
Scientific Integrity and Disclosure of Conflicts of
Interest
How to Claim CME
The American Academy of Ophthalmology is committed to
Attendees can claim credits online.
ensuring that all CME information is based on the application
For AAO 2024, you can claim CME credit multiple times,
of research findings and the implementation of evidence-based
up to the 50-credit maximum, through March 31, 2025. You
medicine. The Academy seeks to promote balance, objectivity,
can claim some in 2024 and some in 2025, or all in the same
and absence of commercial bias in its content. All persons in a
year.
position to control the content of this activity must disclose any
For Subspecialty Day 2024, you can claim CME credit
and all financial interests. The Academy has mechanisms in
multiple times, up to the 12-credit maximum per day, through
Subspecialty Day 2024  |  Glaucoma CME Credit vii

March 31, 2025. You can claim some in 2024 and some in Proof of Attendance
2025, or all in the same year.
You will be able to obtain a CME credit reporting/proof-of-
You do not need to track which sessions you attend, just the
attendance letter for reimbursement or hospital privileges, or
total number of hours you spend in sessions for each claim.
for nonmembers who need it to report CME credit:
You can view content in the virtual meeting through March
3, 2025. Academy Members
Academy Members When you claim CME credits and complete the evaluation, you
will be able to print a certificate/proof-of-attendance letter from
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your transcript page. Your certificate will also be emailed to
sions, Subspecialty Day, and/or AAO 2024 credits will be
you.
available to Academy members through the Academy’s CME
Central web page. Nonmembers
The Academy transcript cannot list individual course atten-
When you claim CME credits and complete the evaluation, a
dance. It will list only the overall credits claimed for educational
new browser window will open with a PDF of your certificate.
activities at AAOE Half-Day Coding Sessions, Subspecialty
Please disable your pop-up blocker. Your certificate will also be
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Nonmembers
The Academy provides nonmembers with verification of cred- CME Questions
its earned and reported for a single Academy-sponsored CME
Send your questions about CME credit reporting to cme@aao
activity.
.org. For Continuing Certification questions, contact the Amer-
ican Board of Ophthalmology at [email protected].
viii The American Glaucoma Society Subspecialty Day Lecture Subspecialty Day 2024  |  Glaucoma

The American Glaucoma Society

Subspecialty Day Lecture
The Unknowable Truths of Glaucoma:
Dealing With Uncertainty in Clinical Practice
Pradeep Y Ramulu MD PhD

FRIDAY, OCT. 18, 2024

11:38 AM – 12:08 PM

Pradeep Y Ramulu MD PhD

Dr. Pradeep Ramulu was born in Chicago, Illinois, graduated program chair for the Glaucoma Research Society, member of
with Honors from Stanford University, and then joined the the Board of Directors for the Heed Foundation, and member of
MD/PhD program at Johns Hopkins University, completing his the National Eye Institute Council.
doctoral work on retinal biology with Jeremy Nathans. He sub- Dr. Ramulu has mentored numerous junior faculty, PhD
sequently completed his ophthalmology residency at the Johns students, medical students, MPH students, residents, and fel-
Hopkins Wilmer Eye Institute and a glaucoma fellowship at lows, clinically and in research careers. He twice won the resi-
Bascom Palmer Eye Institute. dent teaching award at Wilmer and, in a model that has now
After his fellowship, Dr. Ramulu returned to Wilmer’s become the standard for Wilmer, reorganized resident teaching
Glaucoma Division, where he began a program to study the by placing lectures online and using in-class time for interactive
functional consequences of visual impairment. Using a variety sessions using game-based learning and small-group interactive
of tools, including patient-reported outcomes, observation of case review. On top of caring for his patients’ needs, he serves
task performance, and real-world behavioral monitoring, Dr. as director of the Wilmer Glaucoma Service, consisting of 10
Ramulu has helped define when, how, and why visual impair- faculty and over 20 research, clinical, and administrative staff
ment results in disability. His current work is focused on devel- members.
oping methods to assess/prevent falls in older adults, particu- Dr. Ramulu has received continuous NIH funding since
larly those with visual impairment, and mentoring emerging 2007 and has received the Academy’s Secretariat, Achieve-
clinician-scientists. ment, and Senior Achievement Awards and the Pisart Award for
Dr. Ramulu’s work has resulted in over 240 peer-reviewed Vision Science from the Lighthouse Guild. He was also named
publications, 10 book chapters, and 2 books. Because of his to Newsweek’s list of “America’s Best Eye Doctors” from 2021
expertise, he has helped various agencies, including the Federal through 2023.
Bureau of Investigation, to set vision standards for work. He Dr. Ramulu credits any success to his extraordinary mentors
also holds or has held leadership positions in various national and colleagues at Johns Hopkins and also to his ever-supportive
and international ophthalmic societies, including program parents, Yammanuru and Aruna Ramulu, his 25 years of lov-
chair for the American Glaucoma Society, program chair and ing marriage to his wife and spiritual beacon, Vandana, and
director of the Education Committee for the World Glaucoma his two talented and inspiring children—his son Shreyas and
Association, chair of the Academy’s Public Health Committee, daughter Priyanka.
Subspecialty Day 2024  |  Glaucoma Faculty ix

Faculty

Jella A An MD MBA Yara P Catoira-Boyle MD Julie Falardeau MD

Bethesda, MD Indianapolis, IN Portland, OR

Lauren S Blieden MD Philip P Chen MD David S Friedman MD PhD MPH

Houston, TX Seattle, WA Boston, MA

Carla I Bourne MD Qi N Cui MD Gus Gazzard FRCOphth MA

Lutz, FL Philadelphia, PA MB BChir MD
London, United Kingdom

Larissa Camejo MD Anna T Do MD

Palm Beach Gardens, FL Fountain Valley, CA Steven Gedde MD
Miami, FL
x Faculty Subspecialty Day 2024  |  Glaucoma

Lauren E Hock MD Anthony J King FRCOphth MD Wendy W Liu MD PhD

Philadelphia, PA Nottingham, United Kingdom Palo Alto, CA

Cindy M Hutnik MD PhD Roman Krivochenitser MD Careen Yen Lowder MD PhD

London, Canada Southfield, MI Cleveland, OH

Anthony P Khawaja MBBS Richard Lee MD Jeffrey Ma MD

London, United Kingdom Miami, FL Sacramento, CA

Robert M Kinast MD Ari Leshno MD Steven L Mansberger MD MPH

Portland, OR Tel Aviv, Israel Portland, OR
Subspecialty Day 2024  |  Glaucoma Faculty xi

Sasan Moghimi MD Yvonne Ou MD Lorraine M Provencher MD

San Diego, CA San Francisco, CA Omaha, NE

Giovanni Montesano MD Regine S Pappas MD Mary Qiu MD

London, United Kingdom Melbourne, FL Chicago, IL

Marlene R Moster MD Jody R Piltz MD Nathan M Radcliffe MD

Aventura, FL Huntingdon Valley, PA Larchmont, NY

Paula Anne Newman-Casey MD Andrew E Pouw MD Rithambara Ramachandran MD

MS Iowa City, IA Philadelphia, PA
Ann Arbor, MI
xii Faculty Subspecialty Day 2024  |  Glaucoma

Pradeep Y Ramulu MD PhD John Shepherd MD Kuldev Singh MD MPH

Baltimore, MD Omaha, NE Palo Alto, CA

Douglas J Rhee MD Aakriti Garg Shukla MD Oluwatosin U Smith MD

Cleveland, OH New York, NY Colleyville, TX

Leonard K Seibold MD Carla J Siegfried MD Joshua D Stein MD MS

Aurora, CO Saint Louis, MO Ann Arbor, MI

Brian M Shafer MD Rachel Simpson MD Richard D Ten Hulzen MD

Lafayette Hill, PA Salt Lake City, UT Jacksonville Beach, FL
Subspecialty Day 2024  |  Glaucoma Faculty xiii

Ives A Valenzuela MD Andrew M Williams MD Alice Yang Zhang MD

Baltimore, MD Pittsburgh, PA Chapel Hill, NC

Sarah Van Tassel MD Benjamin Y Xu MD PhD Amy D Zhang MD

New York, NY South Pasadena, CA Bloomfield Hills, MI

Qing Wang MD PhD

New York, NY
xiv Using the Meeting Guide to Interact During the Meeting Subspecialty Day 2024  |  Glaucoma

Ask a Question or Respond to a Poll During the

Meeting Using the Meeting Guide

To ask the moderator a question or

respond to a poll, follow the directions
below.

■ Access at www.aao.org/mtg-guide

■ Select “Polls/Q&A”

■ Select “Current Session”

■ Select “Interact with this session (live)”

to open a new window

■ Choose “Ask a Question”

■ Choose “Answer Poll”

Subspecialty Day 2024  |  Glaucoma Program Schedule xv

Glaucoma 2024: Magnificent Glaucoma Care—

An Offer You Can’t Refuse

FRIDAY, OCT. 18, 2024

8:00 AM Welcome and Introductions Steven L Mansberger MD MPH
8:02 AM American Glaucoma Society Introduction and AGS Patient Programs: Carla J Siegfried MD
AGS Cares and Family Matters
8:07 AM Announcements Yvonne Ou MD

Section I: These Clinical Trials Will Elevate Your Clinical Practice by a Magnificent Mile
Moderators: Anna T Do MD and Aakriti Garg Shukla MD
8:08 AM RCT#1: ZAP 14-Year Results—Case Presentation Ives A Valenzuela MD 1
8:12 AM RCT#1: ZAP 14-Year Results—Trial David S Friedman MD PhD
MPH 2
8:19 AM RCT#2: LiGHT 6-Year Results—Case Presentation Lauren E Hock MD 3
8:23 AM RCT#2: LiGHT 6-Year Trial Results Gus Gazzard FRCOphth MA
MB BChir MD 4
8:30 AM RCT#3: HORIZON Visual Fields—Case Presentation Ari Leshno MD 5
8:34 AM RCT#3: HORIZON Visual Fields—Trial Giovanni Montesano MD 7
8:41 AM RCT#4: TAGS—Case Presentation Wendy W Liu MD PhD 8
8:45 AM RCT#4: TAGS—Trial Anthony J King FRCOphth
MD 9
8:52 AM Discussion

Section II: Surgical Pearls in the Second City

Moderators: Steven Gedde MD and Regine S Pappas MD
9:07 AM Sculpting Success: The Art of Trabeculectomy Philip P Chen MD 11
9:14 AM Tube Triumphs: Mastering Tube Shunt Surgery Yara P Catoira-Boyle MD 12
9:21 AM Navigating the Waterways: Canal-Based Stenting Jella A An MD MBA 13
9:28 AM Breaking Barriers: Canal-Based Stripping/Viscodilation Carla I Bourne MD 15
9:35 AM Bleb Whisperers: Optimizing Microinvasive Bleb Surgery Lorraine M Provencher MD 17
9:42 AM Mastering Comfort: The Ergonomics of Ophthalmic Surgery Amy D Zhang MD 18
9:49 AM Discussion
10:04 AM Protect America’s Eyesight: A United Vision for Ophthalmology’s Future Roman Krivochenitser MD 19
10:09 AM REFRESHMENT BREAK

Section III: Glaucoma Unscripted—What Other Specialties Can Teach Us

About Glaucoma in the Second City
Moderators: Larissa Camejo MD and Mary Qiu MD
10:39 AM Cataract and Refractive Brian M Shafer MD 21
10:46 AM Cornea Jeffrey Ma MD 24
10:53 AM Retina Alice Yang Zhang MD 26
11:00 AM Uveitis Careen Yen Lowder MD PhD 27
xvi Program Schedule Subspecialty Day 2024  |  Glaucoma

11:07 AM Neuro-Ophthalmology Julie Falardeau MD 29

11:14 AM Low Vision John Shepherd MD 31
11:21 AM Discussion

The American Glaucoma Society Subspecialty Day Lecture

11:36 AM Introduction of the Lecturer Carla J Siegfried MD
11:38 AM The Unknowable Truths of Glaucoma: Pradeep Y Ramulu MD PhD 32
Dealing With Uncertainty in Clinical Practice
12:08 PM Presentation of the Award Carla J Siegfried MD
12:09 PM LUNCH

Section IV: Medication and Laser Innovations

Moderators: Larissa Camejo MD and Richard D Ten Hulzen MD
1:30 PM Chicago Rx: New Medications, New Formulations Douglas J Rhee MD 33
1:38 PM The Rise of GLP-1 Receptor Agonists Qi N Cui MD 34
1:46 PM Next-Gen Neuroprotection With Nicotinamide Qing Wang MD PhD 35
1:54 PM Practical Ways to Help Patients With Adherence Paula Anne Newman-Casey
MD MS 36
2:02 PM Transforming Treatment: Novel Drug Delivery Platforms Robert M Kinast MD 37
2:10 PM Glaucoma Lasers: What’s New? Sarah Van Tassel MD 38
2:18 PM Discussion

Section V: The Latest Diagnostics for Glaucoma, and All That Jazz
Moderators: Yvonne Ou MD and Joshua D Stein MD MS
2:28 PM Home Is Where the Jazz Is, but Is Home Testing Ready for Prime Time? Rachel Simpson MD 39
2:35 PM Razzle Dazzle 2.0: Is OCT Angiography Clinically Useful? Sasan Moghimi MD 40
2:42 PM Glamour, Glitz, and Glaucoma Genetics: When to Order Genetic Testing Anthony P Khawaja MBBS 42
2:49 PM Perimetry Pizzazz: Latest Updates on Visual Fields Andrew E Pouw MD 44
2:56 PM Is Anterior Segment OCT Alluring? Practical Tips to Incorporate Lauren S Blieden MD 46
Into Your Practice
3:03 PM OCT Onstage: Updates on Diagnostic Imaging Rithambara Ramachandran
MD 47
3:10 PM Discussion
3:25 PM REFRESHMENT BREAK

Section VI: Great Debates From the Land of Lincoln

Moderators: Steven L Mansberger MD MPH and Carla J Siegfried MD
3:55 PM Introduction to the Debate Steven L Mansberger MD MPH
3:56 PM Audience Vote
3:57 PM Tube/Trab Failed: What Next? I Vote for Second Tube Marlene R Moster MD 49
4:02 PM Tube/Trab Failed: What Next? I Vote for Ciliary Body Laser Richard Lee MD 50
4:07 PM Audience Vote
Subspecialty Day 2024  |  Glaucoma Program Schedule xvii

4:08 PM Audience Vote

4:09 PM We Can Successfully Treat Poor Adherence! Intracameral Drug Delivery Leonard K Seibold MD 51
4:14 PM Poor Adherence? Just Operate! Andrew M Williams MD 52
4:19 PM Audience Vote
4:20 PM Audience Vote
4:21 PM Mild Glaucoma With Phaco: Nearly Always/Always Offer Minimally Oluwatosin U Smith MD 53
Invasive Glaucoma Surgery With IOP Controlled on 1 Med
4:26 PM Mild Glaucoma With Phaco: Minimally Invasive Glaucoma Surgery Cindy M Hutnik MD PhD 54
Not Necessary if IOP Controlled on 1 Med
4:31 PM Audience Vote
4:32 PM Audience Vote
4:33 PM Managing the Super Senior (>90 yo) With Advanced, Progressive Disease: Kuldev Singh MD MPH 55
Observe
4:38 PM Managing the Super Senior (>90 yo) With Advanced, Progressive Disease: Jody R Piltz MD 56
Surgery
4:43 PM Audience Vote
4:44 PM Audience Vote
4:45 PM Primary Angle Closure Suspect/Early Glaucoma: Phaco Nathan M Radcliffe MD 58
4:50 PM Primary Angle Closure Suspect/Early Glaucoma: Benjamin Y Xu MD PhD 59
Laser Peripheral Iridotomy ± Meds
4:55 PM Audience Vote
4:56 PM Discussion and Rebuttals
5:09 PM Closing Remarks Steven L Mansberger MD MPH
5:10 PM ADJOURN
Subspecialty Day 2024  |  Glaucoma Section I: These Clinical Trials Will Elevate Your Clinical Practice 1

RCT#1: ZAP 14-Year Results—Case Presentation

Ives A Valenzuela MD

I. Case Introduction III. Case Diagnostics

62-year-old African female referred for anatomic A. Visual fields: limited test reliability, no obvious
narrow angles defects
A. No ocular history B. OCT: Full retinal nerve fiber layer (NFL) with full
ganglion cell layer, no NFL thinning
B. No family history of eye disease
IV. Diagnosis
C. No history of diabetes
Primary angle closure suspect.
D. Systemic meds: hypertension, on amlodipine 5 mg,
vitamin D3 V. Treatment Options
E. Travels frequently to Africa to visit family A. Observation
II. Case Exam B. Laser peripheral iridotomy (LPI)
A. Vision: 20/20 OD, 20/25 OS, near J1 OU C. Cataract surgery
B. Rx: OD +3.00 −0.25 × 91, OS: +2.50 −0.25 × 97 VI. Treatment Selection and Rationale
C. IOP: 18 OU Elects for LPI OU, given traveling.
D. Central corneal thickness: 557/516 VII. Post-treatment Course
E. Gonioscopy A. LPI OU with argon pretreatment
1. OD: anterior trabecular meshwork (ATM) B. Post-laser course notable for stable vision
superior/inferior, closed nasal/temporal
C. IOP: 16/17
2. OS: ATM superior, closed nasal/temporal/
D. Gonioscopy
inferior
1. OD: Scleral spur superior, ATM inferior/nasal,
3. No peripheral anterior synechiae
slit temporal
F. Narrow anterior chamber, trace nuclear sclerosis
2. OS: Scleral spur superior, ATM inferior/nasal,
G. 0.4/0.3 cups slit temporal
3. No peripheral anterior synechiae
2 Section I: These Clinical Trials Will Elevate Your Clinical Practice Subspecialty Day 2024  |  Glaucoma

RCT#1: ZAP 14-Year Results—Trial

David S Friedman MD PhD MPH

I. Background III. ZAP subjects were re-examined at 14 years after the

randomization.
A. Primary angle-closure glaucoma (PACG) affects 20
million people worldwide. A. Overall findings were similar to those at 6 years.
B. People classified as primary angle closure suspects B. 4.8/1000 eye-years versus 13.6 in LPI and control
(PACS) have a higher but poorly quantified risk of eyes, respectively, but still, almost all were due to
developing glaucoma. developing PAS.
C. Laser peripheral iridotomy (LPI) is widely practiced C. It would require treating 12.4 suspects to prevent 1
as prophylaxis against PACG, but its efficacy is endpoint, mostly PAS.
unproven.
D. PAS development was 3.6/1000 eye years versus
II. Major trials have been carried out to determine the 12.7 per 1000 years in LPI versus untreated control
effectiveness of LPI in preventing primary angle eyes, and <10% of these eyes had IOP >21 mmHg.
closure and PACG.
E. No additional acute attack cases were seen; to
A. The Asymptomatic Narrow Angles Laser prevent 1 acute attack, we would need to treat 225
Iridotomy Study (ANA-LIS) in Singapore individuals (P = .1).
1. ANA-LIS found a benefit, but mainly for F. PACG was found in 2 LPI-treated eyes and 4
preventing peripheral anterior synechiae. control eyes (1 case was bilateral).
2. ANA-LIS reported 5-year results, and G. Higher IOP and narrower limbal anterior chamber
investigators felt that screening for angle closure depth were associated with the development of
was unlikely to provide a major health benefit. primary angle closure.
B. The Zhongshan Angle Closure Prevention (ZAP) IV. Overall Conclusions
trial
A. ZAP reported a low likelihood of vision-
1. The ZAP trial also published results threatening events in control eyes that were not
documenting a low likelihood of events in eyes treated with LPI. LPI did reduce the occurrence of
not treated with LPI. PAS.
2. Screened nearly 12,000 individuals to identify B. Longer follow-up of the original cohort found
889 participants similar results, but many were lost to follow-up.
3. At 6 years, among 889 randomized eyes of
individuals 50-70 years old, 36 untreated and 19
treated eyes developed an endpoint (hazard ratio
= 0.53; 95% CI, 0.30-0.92).
4. Most endpoints were peripheral anterior
synechiae.
5. Five untreated and 1 treated eye developed an
acute angle closure attack, mostly after dilation.
6. The authors recommended against community
screening for angle closure, given the overall
low rate of events and the likelihood that most
events would not result in vision loss.
Subspecialty Day 2024  |  Glaucoma Section I: These Clinical Trials Will Elevate Your Clinical Practice 3

RCT#2: LiGHT 6-Year Results—Case Presentation

Lauren E Hock MD

I. Case Introduction B. Selective laser trabeculoplasty (SLT): Treatment

with primary 360-degree SLT was also offered.
A 62-year-old male with a history of mild myopia OU
The risks of IOP spike, uveitis, transient blurred
was referred for glaucoma evaluation. He denied any
vision, discomfort, photophobia, and hyperemia
family history of glaucoma and had never received
were discussed, as was the likelihood that laser
treatment for glaucoma. His past medical history was
treatment might delay or reduce his need for eye
significant for hypertension.
drops and the option of repeating the treatment
II. Patient Exam in the future. Primary SLT could reduce his risk
of glaucoma progression and need for cataract or
A. The patient’s visual acuity was 20/20 OU, his
incisional glaucoma surgery at 6 years.1
gonioscopy was open to scleral spur in both eyes,
and his untreated IOP was 26 mmHg OD and C. Observation: This was not recommended due to
24 mmHg OS. His anterior segment exam was the glaucomatous changes noted in both eyes on
unremarkable aside from mild cataract in both fundus exam and on OCT.
eyes. He had bilateral optic disc cupping with a
IV. Treatment Pursued
vertical cup:disc ratio of 0.8 OD and 0.75 OS. His
dilated fundus exam was otherwise unremarkable The patient underwent primary 360-degree SLT OU
OU. without complication.
B. Central corneal thickness was 560 microns OU. V. Patient Outcome
C. Visual field was full in the right eye and showed The patient’s IOP at 4 weeks following SLT was
nonspecific changes in the left eye. 20 mmHg OD and 17 mmHg OS. The plan was to
closely monitor him off medications and to repeat
D. OCT demonstrated retinal nerve fiber layer
testing. Given his good response to laser, repeat
thinning OU. The ganglion cell layer analysis was
SLT remained an option in the future if the effect
abnormal OU.
diminished over time. The patient was counseled he
III. Management may need drops or other escalation of therapy if he
demonstrated disease progression.
The patient was diagnosed with mild primary open-
angle glaucoma OU, and treatment was recommended VI. Conclusion
OU with a goal of IOP reduction of at least 20% or
Primary SLT is a safe and effective treatment for mild
<21 mmHg in both eyes, whichever was lower.
open-angle glaucoma.
A. Medication: Treatment with a prostaglandin
analogue was offered in both eyes. The patient
Selected Readings
had anticipated that he would need eye drops but
led an active lifestyle and thought he would have 1. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al;
difficulty remembering to take them every day. He LiGHT Trial Study Group. Laser in Glaucoma and Ocular
was concerned about potential aesthetic side effects Hypertension (LiGHT) Trial: six-year results of primary
or ocular allergic reactions with drops. selective laser trabeculoplasty versus eye drops for the treatment
of glaucoma and ocular hypertension. Ophthalmology 2023;
130(2):139-151.
2. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al;
LiGHT Trial Study Group. Selective laser trabeculoplasty versus
eye drops for first-line treatment of ocular hypertension and
glaucoma (LiGHT): a multicentre randomised controlled trial.
Lancet 2019; 393(10180):1505-1516.
4 Section I: These Clinical Trials Will Elevate Your Clinical Practice Subspecialty Day 2024  |  Glaucoma

RCT#2: LiGHT 6-Year Trial Results

Gus Gazzard FRCOphth MA MB BCHIR MD

I. Selective Laser Trabeculoplasty (SLT) III. Conclusions

There is now extensive clinical trial (RCT) evidence A. Cost-effectiveness has been proven in certain
for excellent IOP control after SLT, which can last health-care settings.
several years in the majority of cases when used as
B. Repeat SLT has been shown to be at least as
primary therapy.
effective as first treatment, when used before
II. The LiGHT Trial topical medication (eye drops).
A. Over 700 patients randomized to 1 of 2 treatment C. SLT has also been shown to confer greater
pathways—laser first or medication first protection to the visual field than topical
medication, in an RCT setting, despite similar IOP
B. Three-year outcomes showed drop-free disease
profiles.
control in three-quarters of eyes treated (with
preset eye-specific treatment targets). D. SLT as is now widely recommended as a primary
therapy by several national (UK) and supranational
C. Six-year results, now available, show that:
(European Glaucoma Society, American Academy
1. Drop-free control can be obtained with laser- of Ophthalmology) treatment guidelines.
only treatment for 70% of eyes.
2. Glaucoma and cataract surgery rates were both
lower for the laser-first group.
3. Medication-first patients who received laser
after 3 years (“cross-over” subjects) still
obtained good IOP lowering and rates of drop-
free control (paper in submission).
Subspecialty Day 2024  |  Glaucoma Section I: These Clinical Trials Will Elevate Your Clinical Practice 5

RCT#3: HORIZON Visual Fields—Case Presentation

Ari Leshno MD

I. Introduction IV. What Was Chosen for This Patient

Results from the prospective randomized multicenter V. Drawbacks of Hydrus Microstent
HORIZON trial1-3 and other similar studies4,5
A. Currently approved only in conjunction with
suggested that implantation of the Hydrus Microstent
cataract surgery
(HMS; Alcon), in conjunction with cataract surgery,
is an effective procedure for long-standing control of B. Indication limited to primary open-angle glaucoma
IOP. A recent post-hoc analysis by Montesano et al patients
found that cataract surgery combined with Hydrus
C. Risk for potential complications
has a significant effect on visual field preservation in
glaucoma patients compared with cataract surgery 1. Intraoperative
alone, reducing the proportion of fast progressors.2
a. Excessive bleeding in the anterior chamber
We will present an example case of a good surgical
b. False passage into the suprachoroidal space
candidate for canalicular MIGS and discuss the effect
of canalicular stents on rate of visual field progression. c. Iris or ciliary body recession
We will also briefly discuss the advantages and
d. Cheese wiring of the trabecular meshwork
drawbacks of this procedure.
2. Postoperative
II. Preoperative Evaluation
a. Transient hyphema6
A. Glaucoma type: primary open angle
b. Persistent inflammation7
B. Glaucoma severity: mild–moderate (based on
Hodapp-Anderson-Parrish criteria) c. Stent migration/malposition6
C. Goldman applanation IOP d. Endothelial cell loss8
1. Untreated: 22-34 mmHg e. PAS formation1
2. Treated: <30 mmHg VI. Discussion
D. Gonioscopy The literature suggests that the Hydrus Microstent
combined with cataract surgery is an effective and
1. Open iridocorneal angle (Shaffer grade 3 or
relatively safe surgical intervention for glaucoma
higher)
management. This type of incisional intervention also
2. No peripheral anterior synechiae (PAS) seems to reduce the rates of visual field progression.
It is important to ensure that the patient is a good
E. Clinically significant cataract with reduced visual
candidate for the procedure in order to avoid
acuity (20/40 or worse)
complications and weigh the possible benefits against
III. Surgical Options the risks.
A. Phacoemulsification alone
References
B. Phacoemulsification ±
1. Ahmed IIK, Rhee DJ, Jones J, et al. Three-year findings of the
1. Canalicular MIGS HORIZON trial. Ophthalmology 2021; 128(6):857-865.
a. Microstent (Hydrus or iStent) 2. Montesano G, Ometto G, Ahmed IIK, et al. Five-year visual
b. Incisional goniotomy field outcomes of the HORIZON trial. Am J Ophthalmol. 2023;
251:143-155.
c. Excisional goniotomy
3. Salimi A, Kassem R, Santhakumaran S, Harasymowycz P.
d. Canaloplasty Three-year outcomes of a Schlemm canal microstent (Hydrus
Microstent) with concomitant phacoemulsification in open-angle
2. Suprachoroidal MIGS glaucoma. Ophthalmol Glaucoma. 2023; 6(2):137-146.
3. Trabeculectomy 4. Creagmile J, Kim WI, Scouarnec C. Hydrus Microstent
implantation with OMNI Surgical System ab interno canaloplasty
4. Glaucoma drainage implant
for the management of open-angle glaucoma in phakic patients
refractory to medical therapy. Am J Ophthalmol Case Rep. 2023;
29:101749.
6 Section I: These Clinical Trials Will Elevate Your Clinical Practice Subspecialty Day 2024  |  Glaucoma

5. Kiramira D, Voßmerbäumer U, Pfeiffer N, Linnerth-Braun LKM,

Lorenz K, Prokosch V. Mid-term real world outcomes of the
Hydrus® Microstent in open angle glaucoma. Eye (Lond). 2024;
38(8):1454-1461.
6. Jabłońska J, Lewczuk K, Rȩkas MT. Comparison of safety and
efficacy of Hydrus and iStent combined with phacoemulsification
in open angle glaucoma patients: 24-month follow-up. Int J
Environ Res Public Health. 2023; 20(5):4152.
7. An J, Dossantos J. A rare case of postoperative uveitis and
obstructive peripheral anterior synechiae following combined
OMNI canaloplasty and Hydrus Microstent implantation. J Curr
Glaucoma Pract. 2024; 18(1):37-41.
8. Ahmed IIK, Sheybani A, De Francesco T, Samuelson TW. Corneal
endothelial safety profile in minimally invasive glaucoma surgery.
J Cataract Refract Surg. 2024; 50(4):369-377.
Subspecialty Day 2024  |  Glaucoma Section I: These Clinical Trials Will Elevate Your Clinical Practice 7

RCT#3: HORIZON Visual Fields—Trial

Giovanni Montesano MD

The HORIZON study is a prospective randomized clinical

trial testing the effectiveness of a minimally invasive glaucoma
surgery (MIGS) device, the Hydrus Microstent (HMS, Alcon;
Fort Worth, TX).1 556 eyes with glaucoma (1 per patient) were
randomized 1:2 to stand-alone cataract surgery (CS) (n = 187)
or in combination with the HMS (CS-HMS) (n = 369). The pre-
determined outcome of the trial was a comparison of washed-
out IOP reduction between the 2 arms. At 3 and 5 years, the
CS-HMS group showed better IOP control and a lower number
of glaucoma medications on average.1,2
IOP remains, at present, the only confirmed modifiable risk
factor to control progression of damage in patients with glau-
coma, the ultimate objective of glaucoma treatment. However,
IOP-lowering treatment strategies can have variable effects on
the trajectory of the disease, even among patients achieving a
similar treated pressure.3 On the other hand, patients with glau-
coma can show no progression even when not treated.4
It is often difficult to predict which patients will benefit
from a specific treatment. Moreover, the effect on IOP is usu-
ally assessed based on measurements taken in the clinic, which Figure 1. Distribution of the rate of progression (RoP) of eyes in receiv-
ing stand-alone cataract surgery (bottom) or in combination with a
might not be representative of the actual IOP profile. Therefore, Hydrus Microstent (top). The arrow highlights the longer tail of fast-
the effect of treatment on the rate of disease progression is the progressing patients in the stand-alone cataract surgery arm.
outcome most relevant for gauging the effectiveness of an inter-
vention.
During the HORIZON trial, visual field (VF) data were col- This talk will present the results of this investigation in
lected for up to 5 years for all participants. While these were detail, expanding on the methodology, the relationship between
performed as part of their safety endpoints, they constitute an measured IOP control and rate of VF progression in the trial,
unprecedented opportunity to assess the effect of a MIGS pro- the clinical significance of the findings, and future directions
cedure on the rate of glaucoma progression. We have recently for additional analyses and future investigations.
published a post-hoc investigation of the differences in the rate
of VF progression between the 2 arms of the trial.5 We analyzed References
the rate of change of point-wise sensitivity using a hierarchical
linear model. We showed that the average rate of VF progres- 1. Ahmed IIK, Rhee DJ, Jones J, et al. Three-year findings of the
HORIZON trial: a Schlemm canal microstent for pressure
sion was significantly slower (P = .0138) in the CS-HMS arm
reduction in primary open-angle glaucoma and cataract.
(−0.26 dB/year) compared to stand-alone CS (−0.49 dB/year).
Ophthalmology 2021; 128:857-865.
We then showed that this difference was mainly driven by a
subgroup of fast-progressing patients in the stand-alone CS arm 2. Ahmed IIK, De Francesco T, Rhee D, et al. Long-term outcomes
(Figure 1). from the HORIZON randomized trial for a Schlemm’s canal
microstent in combination cataract and glaucoma surgery.
Ophthalmology 2022; 129:742-751.
3. Wright DM, Konstantakopoulou E, Montesano G, et al. Visual
field outcomes from the multicenter, randomized controlled
Laser in Glaucoma and Ocular Hypertension Trial (LiGHT).
Ophthalmology 2020; 127:1313-1321.
4. Garway-Heath DF, Crabb DP, Bunce C, et al. Latanoprost for
open-angle glaucoma (UKGTS): a randomised, multicentre,
placebo-controlled trial. Lancet 2015; 385:1295-1304.
5. Montesano G, Ometto G, Ahmed IIK, et al. Five-year visual
field outcomes of the HORIZON trial. Am J Ophthalmol. 2023;
251:143-155.
8 Section I: These Clinical Trials Will Elevate Your Clinical Practice Subspecialty Day 2024  |  Glaucoma

RCT#4: TAGS—Case Presentation

Wendy W Liu MD PhD

We will illustrate a case of a patient tried on the typical regi- He experienced irritation with dorzolamide, so he was tried
men of escalating medications prior to surgery, and discuss if on dorzolamide/timolol (Cosopt) but could not tolerate it either.
primary trabeculectomy surgery may offer better outcomes in He was also not using his medications as instructed due to bar-
certain scenarios. riers in understanding. At one visit, his IOP was elevated to 23
This is a case of a 74-year-old man with moderate stage pri- OS after dilation, with subjectively worse vision. Brimonidine
mary open-angle glaucoma, both eyes. Vision was 20/40 OD, was added. After 2 months on brimonidine, he developed
20/50 OS, and IOP was 19 OD, 21 OS on latanoprost and dor- severe follicular conjunctivitis, and IOP increased to 42 OD and
zolamide. He had selective laser trabeculoplasty (SLT) 2 years 28 OS. He was started on oral acetazolamide (Diamox) and
prior. Optic nerve exam showed superior and inferior notches. prednisolone drops. Two weeks later, his IOP improved to 15
OCT showed thinning of the retinal nerve fiber layer, both OD, 20 OS, with decline in visual acuity to 20/300 OS. Trab-
eyes. Humphrey visual field was not reliable due to high false eculectomy was offered, but patient wished to wait. However,
positives but showed nonspecific defects OD and generalized he could not tolerate Diamox, and his IOP increased to 31 OS.
depression OS. Trabeculectomy was again recommended, but patient had to
Due to elevated IOP, escalated therapy was recommended, travel out of the country and could not return for surgery until 2
with additional drops, SLT, and surgery presented as options. months later. He underwent a successful trabeculectomy, and 1
Patient was not keen on drops or surgery and elected SLT due to year later, his IOP was 11 OS on no drops. However, his visual
reported good response previously. After SLT, IOP was 16 OD, acuity had declined to 20/500, likely from glaucoma progres-
18 OS. sion during the period of high IOP.
In light of the Treatment of Advanced Glaucoma Study
(TAGS) trial, we will discuss if primary trabeculectomy sur-
gery would offer better outcomes given that patients often have
medication intolerances, allergies, difficulties in compliance,
and delays in surgeries.
Subspecialty Day 2024  |  Glaucoma Section I: These Clinical Trials Will Elevate Your Clinical Practice 9

RCT#4: TAGS—Trial
Anthony J King FRCOphth MD

Introduction VFQ-25, or any of the other quality-of-life outcomes measured.

The mean IOP at 5 years was 12.07 (standard deviation [SD]:
Advanced glaucoma damage has serious effects on an individ-
5.18) for the trabeculectomy arm and 14.76 (SD: 4.14) for the
ual’s capacity for independent living. Primary open-angle glau-
medical arm (P < .001) (Figure 1). This translated into a clini-
coma (POAG) affects around 2% of the UK population over 40
cally meaningful difference in disease (VF) progression of
years of age, and glaucoma is the second commonest cause for
nearly 2 dB MD favoring trabeculectomy (P < .001) (Figure 1).
certification as visually impaired. As glaucoma is asymptomatic
At 5 years, 35.4% of participants (62/175) required IOP-lower-
in its early phases, people are often unaware of its onset, result-
ing drops in the trabeculectomy arm, and 72.5% (124/171) in
ing in presentation with advanced disease; in the UK around
the medical management arm (P < .001). There was no differ-
25% of patients present with advanced disease in at least 1 eye.1
ence in any of the other clinical outcomes.
Presentation with advanced glaucoma is the main risk factor
for progression to blindness.2 Reducing IOP is the only effective
treatment for glaucoma. Better IOP control at an early stage
reduces the risk of further progression.
In the UK, the National Institute for Health and Care Excel-
lence (NICE) guidelines suggest that patients presenting with
advanced disease should be offered trabeculectomy as a primary
intervention. However, most UK ophthalmologists do not fol-
low this guidance and treat patients medically with escalating
topical medication therapy,3 offering trabeculectomy if medical
management is unsuccessful. This approach is due to the poor
evidence supporting trabeculectomy as a primary intervention
and concern regarding surgical complications.3

Methods
We undertook a multicenter, parallel group, open label, prag-
matic randomized clinical trial in 27 hospitals in the UK. Adults
with severe glaucoma (Hodapp-Parrish-Anderson classification) Figure 1. IOP outcomes.
in one or both eyes at presentation were recruited. Inclusion
criteria was diagnosis of OAG (including pigment dispersion
glaucoma, pseudoexfoliative glaucoma, and normal-tension
glaucoma). Participants were randomly assigned to mitomycin
C-augmented trabeculectomy or escalating medical manage-
ment. The primary outcome was vision-related quality of life
measured with the Visual Function Questionnaire-25 (VFQ-
25). Other patient-reported outcomes—the EQ-5D-5L, Health
Utility Index-mark 3 (HUI-3), Glaucoma Utility Index (GUI),
VFQ-25, and patient experience—were secondary outcomes.
Clinical effectiveness outcomes were IOP, logMAR visual
acuity (VA), glaucoma severity according to VF mean devia-
tion (MD), need for cataract surgery, accordance with visual
standards for driving (Esterman visual field), eligibility for sight
impairment certification, and safety of interventions. Adverse
events (AEs) were recorded by the local research team.

Results
Figure 2. Visual field outcomes.
453 participants from 27 hospitals were allocated to either trab-
eculectomy (227) or medical management (226). In the trabecu-
lectomy arm, 201 participants (88.5%) received trabeculectomy In total, 115 participants (52.2%) in the trabeculectomy arm
in their study eye. All participants received their allocated treat- and 124 (57.9%) in the medical management arm had a safety
ment in the medical management arm. event (P = .54). Two participants developed endophthalmitis, 1
There was no difference between arms at baseline. At 5 in each arm of the study; 4 participants lost more than 10 let-
years, there was no difference for the primary outcome, the ters of logMAR VA, 3 in the trabeculectomy arm and 1 in the
10 Section I: These Clinical Trials Will Elevate Your Clinical Practice Subspecialty Day 2024  |  Glaucoma

medical arm; there were no episodes of wipeout following tra- References

beculectomy. In the medical management arm, 48 participants
1. Boodhna T, Crabb DP. Disease severity in newly diagnosed
(21%) required a trabeculectomy for IOP control. glaucoma patients with visual field loss: trends from more than a
decade of data. Ophthalmic Physiol Opt. 2015; 35(2):225-230.
Discussion 2. Mokhles P, Schouten JS, Beckers HJ, Azuara-Blanco A, Tuulonen
A, Webers CA. Glaucoma blindness at the end of life. Acta
At 5 years, initial surgery was associated with better IOP con-
Ophthalmol. 2017; 95(1):10-11.
trol and less disease progression. Adverse events, including
serious adverse events, between arms were similar.4 The IOP 3. Stead R, Azuara-Blanco A, King AJ. Attitudes of consultant
lowering achieved in the trabeculectomy arm is consistent with ophthalmologists in the UK to initial management of glaucoma
current results reported from the NHS by Kirwan5 and Stead.6 patients presenting with severe visual field loss: a national survey.
Clin Exp Ophthalmol. 2011; 39(9):858-864.
There was less disease progression in the initial trabeculectomy
arm. This is particularly important in people with severe disease 4. King AJ, Hudson J, Azuara-Blanco A, et al. Evaluating primary
who have less visual field reserve. For patients, there was no treatment for people with advanced glaucoma: five-year results
difference in quality of life between the interventions. A major of the Treatment of Advanced Glaucoma Study. Ophthalmology
concern for clinicians was the perceived risk of complications 2024; 131(7):759-770.
associated with trabeculectomy.3 At 5 years there was no evi- 5. Kirwan JF, Lockwood AJ, Shah P, et al. Trabeculectomy in the
dence to support these concerns. 21st century: a multicenter analysis. Ophthalmology 2013;
120(12):2532-2539.

Conclusion 6. Stead RE, King AJ. Outcome of trabeculectomy with mitomycin

C in patients with advanced glaucoma. Br J Ophthalmol. 2011;
At 5 years, the Treatment of Advanced Glaucoma Study (TAGS) 95(7):960-965.
has demonstrated that primary trabeculectomy surgery is more
effective in lowering IOP and preventing disease progression
than primary medical treatment in patients presenting with
advanced disease and has a similar safety profile. Trabeculec-
tomy should be offered as a primary intervention in patients
presenting with advanced glaucoma.
Subspecialty Day 2024  |  Glaucoma Section II: Surgical Pearls in the Second City 11

Sculpting Success: The Art of Trabeculectomy

Philip P Chen MD

I. Indication: IOP Reduction to Control Glaucoma IV. Postoperative Management

A. Progression despite maximum tolerated medical A. Laser suture lysis (or slit-lamp suture removal):
therapy (MTMT) Timing
B. IOP uncontrolled on MTMT or near-MTMT, with 1. Wait until Week 1 if possible
progression likely. Fewer tolerated meds = greater
2. But beware of early episcleral fibrosis with
indication for trabeculectomy.
injected MMC.
C. Less invasive/intensive procedures (selective laser
B. Leak
trabeculoplasty, MIGS) already performed or
unlikely to achieve IOP reduction necessary to 1. Bandage contact lens (BCL), aqueous
control glaucoma suppression, ± light handheld low-temp cautery
II. Patient Selection 2. Cautery: Press to glow, then release, then apply
at slit lamp.
A. Mobile superior conjunctiva
C. Overfiltration/hypotony: Reduce steroid, to zero if
B. Ability to adhere to postoperative appointments
warranted.
and cooperate with possible postoperative
manipulations/slit-lamp procedures (eg, suture 1. Hypotony precautions to reduce risk of
lysis/removal, leak treatments) choroidal hemorrhage
C. Cleared for surgery from a medical standpoint. OK 2. Shallow anterior chamber (AC), choroidal
to stop anticoagulation/antiplatelet therapy prior to effusions: Cycloplegia
surgery.
3. Stop beta blockers (topical - fellow eye, oral)
III. Surgical Tips
4. BCL?
A. Topical anesthesia works well. Augment with
5. Early hypotony: Hypertensive phase is your
tetracaine-soaked surgical spears prior to
friend.
mitomycin C (MMC) injection, cautery.
6. Reform AC with viscoelastic at slit lamp if grade
B. MMC injection
2-3 flat.
1. 0.4 mg/mL
7. Revise in OR: (Transconjunctival) flap sutures
2. Mix 1:1 with 1% preservative-free lidocaine. 9-0 or 10-0 nylon, ± open conjunctiva, induce
scarring with cautery, polyglactin bleb sutures,
C. Scleral flap
± drain choroidals if indicated.
1. Not too large or thin
D. Hypertensive phase: Use meds, needling.
2. Preplace 2 flap sutures
E. Later IOP elevation: Scarring
D. Punch ostium: Sufficiently large/posterior
1. Needling at slit lamp (may use same MMC
E. Iridectomy mixture, 0.05 to 0.1 mL).
1. Always. 2. OR revision with limbus-based incision, MMC
on sponge
2. Do not instill intracameral anesthetic prior.
F. Malignant glaucoma/aqueous misdirection:
F. Flap sutures: Adjust tension intraoperatively.
Shallow AC, patent peripheral iridotomy, IOP
G. Conjunctival closure normal to high
1. Incorporate Tenon layer G. Bleb dysesthesia: Compression sutures, bleb
revision as above
2. 8-0 polyglactin on vascular tip needle
12 Section II: Surgical Pearls in the Second City Subspecialty Day 2024  |  Glaucoma

Tube Triumphs: Mastering Tube Shunt Surgery

Yara P Catoira-Boyle MD

Introduction Triumph Tip 2: Enter the eye as posteriorly as

possible to prevent conjunctival tube erosion, and
Over the last decade, minimally invasive glaucoma procedures
use graft or scleral tunnel for coverage of entire tube.
have flourished in the hands of both general ophthalmologists
and glaucoma specialists. Unfortunately, these procedures are Tube exposure is the most important risk factor for endophthal-
still unable to lower and keep the IOP at the levels required mitis, panophthalmitis, and even orbital cellulitis due to the
to stabilize or control severe glaucoma. In the same period, presence of a foreign body. The rate of tube erosion through the
Medicare claims show that tube shunt surgery numbers have conjunctiva in the TVT study was 5% by 5 years. Risk factors
increased significantly. Both the Primary Tube vs. Trabeculec- for late tube erosion include the constant mechanical rubbing
tomy (PTVT) and the Tube Versus Trabeculectomy (TVT) stud- of the upper eyelid during blinking; the friction of the palpebral
ies showed that while trabeculectomy delivered lower IOP, tube with the bulbar conjunctiva elevated by the plate and tube,
shunt surgery had fewer complications and less loss of visual causing it to become progressively thinner; and habits like eye
acuity. As patients become more informed about glaucoma rubbing. During surgery, it is important to cover the tube with a
treatment options, safety is a high priority. scleral flap dissected from the same area with hinge at the lim-
bus, or ideally a corneal patch graft, scleral patch graft, pericar-
dium, or fascia lata graft, cited in decreasing order of strength
Most Common Reasons for Tube Shunt Surgery
of patch material. Closure of the conjunctiva under tension
Failure
must be avoided, as it can lead to early erosion, as opposed to
The most common reason for tube shunt failure is poor IOP late tube erosion.
control. The randomized clinical trials show that IOP control in
severe glaucoma with tube shunt is average at best, with 5-year
Triumph Tip 3: Place the plate as posteriorly as
data showing failure rates between 49% (Ahmed) and 37%
anatomy allows it.
(Baerveldt). Other reasons for failure were de novo glaucoma
surgery, loss of LP vision, and removal of implant. Loss of Posterior placement of the plate is aimed at preventing the most
vision of 2 or more Snellen lines happened on average to 46% of potentially dangerous complication of tube shunt, plate expo-
all tube shunts at 5 years. It has been postulated that the refine- sure and subsequent endophthalmitis. We recommend securing
ment of surgical techniques over time led to lower than usual the plate with substantial suture to prevent it from moving for-
tube shunt complications seen in the TVT study. ward. We believe 9-0 or 10-0 sutures are too thin and recom-
To master tube shunt surgery, the surgeon must look at each mend a nonabsorbable suture between 4-0 and 6-0. If the plate
patient with a proactive plan to prevent complications. The rate is too anterior, its exposure and possible extrusion has the same
of early complications in the tube arm of both studies (PTVT mechanism as tube erosion. Patients often present with mild for-
and TVT) was 20%. The late complications rate was 34% in eign body sensation despite the highly concerning physical exam
the TVT study. Serious complications requiring reoperation or findings where a plate is often about to spontaneously extrude.
causing vision loss were at an acceptable 1%. Patients should understand and be warned to seek help immedi-
ately for persistent eye redness, irritation, or ocular discharge.
Most often the plate must be removed for repair, and a new tube
Triumph Tip 1: Protect the cornea!
would have to be installed on a different quadrant.
Tube shunts are a known cause of corneal decompensation with In summary, it is hard to master tube shunt surgery. It is a
corneal edema leading to vision loss. In fact, the TVT study road, not a destination. Proactively considering the patient’s
5-year report showed that corneal edema was the only compli- anatomy, the surgeon’s skill, plans for the possible need for
cation that predicted vision loss in the multivariate analysis, as reoperation, and the patient’s willingness to undergo repeat sur-
visual acuity decreased in 81% of patients with corneal edema gery are to be considered.
compared to 38% of patients without edema. Since the removal
of the CyPass stent from the market due to the finding of sta-
Selected Readings
tistically significant endothelial cell loss, multiple studies have
looked at endothelial cell loss with tube shunts and found it to 1. Chen J, Gedde S. New developments in tube shunt surgery. Curr
be significant. Opin Ophthalmol. 2019; 30(2):125-131.
Some studies have demonstrated a decrease in endothelial 2. Gedde SJ, Singh K, Schiffman JC, Feuer WJ; Tube Versus
cell loss with transiridial tube shunt position and with increased Trabeculectomy Study Group. The Tube Versus Trabeculectomy
measured distance between the tube shunt and the cornea study: interpretation of results and application to clinical practice.
(>2 mm). To obtain this corneal protection, we recommend Curr Opin Ophthalmol. 2012; 23 (2):118-126.
entering the anterior chamber as posteriorly as possible in rela- 3. Catoira-Boyle YP, WuDunn D, Cantor L. Drainage devices:
tion to the cornea and parallel to the iris. The tube length should post-operative complications. In: Shaarawy TM, Sherwood MB,
be 2-3 mm in the anterior chamber without corneal touch. In Hitchings RA, Crowston JG, eds. Glaucoma. 1st ed. Saunders;
a pseudophakic patient, consider a sulcus entrance. In a vitrec- 2009: ch. 116.
tomized eye, consider pars plana placement. These approaches
have been shown to significantly improve corneal graft survival.
Subspecialty Day 2024  |  Glaucoma Section II: Surgical Pearls in the Second City 13

Navigating the Waterways: Canal-Based Stenting

Jella A An MD MBA

Introduction achieved unmedicated IOP of 18 mmHg or lower and required

fewer invasive surgeries (2.5% vs. 6.4%; log-rank P = .022).
Glaucoma treatment has evolved significantly in recent years.
Moreover, visual field progression was slower in the Hydrus
Traditionally, the primary surgical interventions for glaucoma
group, with the number needed to treat to prevent extremely
patients included trabeculectomies, tube shunts, or cycloabla-
fast progression being only 18. The difference in the rate of pro-
tion. These procedures, while effective at reducing IOP, often
gression between the 2 arms was not explained by differences in
come with high risks of severe complications and long recovery
IOP, suggesting that medication adherence and dosing gaps may
times. In response, the concept of microinvasive glaucoma sur-
have played a role in progression.
geries (MIGS) has emerged, aiming to bridge the gap between
nonincisional management and traditional filtering surgeries.
The goal of MIGS is to provide a safer, earlier intervention that Patient Selection and Personalized Treatment
reduces morbidity and potentially obviates the need for more
When choosing between Schlemm canal MIGS and subcon-
aggressive surgeries. This presentation focuses on canal-based
junctival filtering surgeries, patient-specific factors such as IOP
stenting MIGS available in the United States, including iStent
target, medication tolerance, risk tolerance, and the presence
and Hydrus.
of cataracts must be considered. Although classic indications
for canal-based stents are limited to mild to moderate POAG
Mechanism of Action: Schlemm Canal Stents well controlled on medications undergoing phacoemulsifica-
tion, many more patients can potentially benefit as well. The
Research in both human and bovine eyes indicates that when
iStent infinite stand-alone study showed clinically significant
IOP increases, the inner wall tissue of the trabecular meshwork
IOP reduction and favorable safety in patients with OAG
(TM) herniates into the collector channels, blocking aqueous
uncontrolled by prior surgical or maximum-tolerated medical
outflow. Therefore, the goal of Schlemm canal MIGS is to
therapy. For patients requiring rapid recovery or those with high
decompress and maintain the patency of the canal to optimize
risks associated with traditional filtering surgeries, canal-based
outflow. Aqueous outflow through the TM is not uniform but
MIGS can be considered as the first-line surgical option. It’s
segmented into high- and low-flow regions. High-flow regions
important to remember that not all patients require very low
typically have aqueous veins nearby (4-6 per eye, mostly located
target IOP, which can come with increased risks. On the other
inferonasally), which directly drain into the episcleral venous
hand, young low-tension glaucoma patients progressing in
system. Effective stenting aims to bypass the TM near these
below episcleral venous pressure (low teens) and poorly tolerant
veins for maximum efficiency, although newer experimental
to medications may benefit more from primary subconjunctival
studies show improved outflow when stenting is done in lower-
procedures.
flow (temporal) regions. Studies comparing various stents, such
as the Hydrus Microstent versus two original iStents and iStent
injects, demonstrate significant differences in outflow facility Conclusion
changes, with larger stents generally providing greater improve-
The evolution of MIGS, particularly canal-based stenting,
ment.
represents a significant advancement and paradigm shift in
glaucoma care, providing safer, less invasive options for earlier
Clinical Comparisons and Outcomes intervention to address prevalent adherence issues. While long-
term data is still being collected, current evidence supports the
The COMPARE study, a prospective randomized controlled
effectiveness of these procedures in managing IOP and reducing
trial, evaluated the effectiveness of 1 Hydrus versus 2 origi-
medication dependency, the need for more invasive surgery, and
nal iStents in 152 patients with mild to moderate open-angle
visual field progression in a broader group of glaucoma patients.
glaucoma. Results showed higher success rates (defined as IOP
Personalized treatment planning and expanding current indica-
≤18 mmHg and no glaucoma medications or surgery at 12
tions through further research, considering individual patient
months) with the Hydrus group (35.6% vs. 10.5%; P = .001),
needs and risk profiles, remain crucial in optimizing outcomes
although both groups had similar IOP reductions over time.
in glaucoma care.
Limitations of these studies include small sample sizes and
failure to washout at 12 months in a higher proportion of the
iStent group, but they provide valuable insights into the relative Selected Readings
efficacy of different stents. 1. Samuelson TW, Katz LJ, Wells JM, Duh YJ, Giamporcaro JE;
US iStent Study Group. Randomized evaluation of the trabecular
Long-term Outcomes micro-bypass stent with phacoemulsification in patients with
glaucoma and cataract. Ophthalmology 2011; 118(3):459-467.
The HORIZON study, one of the largest and longest MIGS tri-
2. Ahmed IIK, De Francesco T, Rhee D, et al. Long-term outcomes
als, followed patients for 5 years to compare phaco-Hydrus (n =
from the HORIZON randomized trial for a Schlemm’s canal
369) with phaco alone (n = 187). At 5 years, a higher percentage microstent in combination cataract and glaucoma surgery.
of patients (66% vs. 46%; P < .001) in the phaco-Hydrus group Ophthalmology 2022; 129(7):742-751.
14 Section II: Surgical Pearls in the Second City Subspecialty Day 2024  |  Glaucoma

3. Ahmed IIK, Fea A, Au L, et al. A prospective randomized trial 7. Hays CL, Gulati V, Fan S, Samuelson TW, Ahmed IIK, Toris
comparing Hydrus and iStent microinvasive glaucoma surgery CB. Improvement in outflow facility by two novel microinvasive
implants for standalone treatment of open-angle glaucoma: the glaucoma surgery implants. Invest Ophthalmol Vis Sci. 2014;
COMPARE study. Ophthalmology 2020; 127(1):52-61. 55(3):1893-1900.
4. Montesano G, Ometto G, Ahmed IIK, et al. Five-year visual 8. Toris CB, Pattabiraman PP, Tye G, Samuelson TW, Rhee DJ.
field outcomes of the HORIZON trial. Am J Ophthalmol. 2023; Outflow facility effects of 3 Schlemm’s canal microinvasive
251:143-155. glaucoma surgery devices. Ophthalmol Glaucoma. 2020;
3(2):114-121.
5. Battista SA, Lu Z, Hofmann S, Freddo TF, Overby DR, Gong
H. Reduction of the available area for aqueous humor outflow 9. Majstruk L, Leray B, Bouillot A, et al. Long term effect of
and increased trabecular meshwork stiffness in eyes with phacoemulsification on intraocular pressure in patients with
primary open-angle glaucoma. Invest Ophthalmol Vis Sci. 2008; medically controlled primary open-angle glaucoma. BMC
49(12):5346-5352. Ophthalmol. 2019; 19(1):149.
6. Swaminathan SS, Oh DJ, Kang MH, Rhee DJ. Aqueous outflow: 10. Sarkisian SR Jr, Grover DS, Gallardo MJ, et al; iStent infinite
segmental and distal flow. J Cataract Refract Surg. 2014; Study Group. Effectiveness and safety of iStent infinite trabecular
40(8):1263-1272. micro-bypass for uncontrolled glaucoma. J Glaucoma. 2023;
32(1):9-18.
Subspecialty Day 2024  |  Glaucoma Section II: Surgical Pearls in the Second City 15

Breaking Barriers: Canal-Based Stripping/

Viscodilation
Surgical Pearls
Carla I Bourne MD

I. Breaking Barriers: Viscodilation J. Trabectome (MST, Microsurgical Technology;

Redmond, WA)
A. Viscoelastic directed into Schlemm canal (SC)
K. TrabExPro (MST, Microsurgical Technology;
B. Controlled flushing expands natural outflow
Redmond, WA)
pathway.
VI. Device Selection: Factors
C. ↓ Resistance downstream in collector channels
A. Titratability
D. ↓ Resistance upstream in inner wall of SC and the
trabecular meshwork (TM) B. Combinations
II. Breaking Barriers: Canaloplasty C. Cost
The flexible microcatheter/suture dilates SC and opens D. Technician ability
blockages and herniations.
E. Operating scope optics
III. Breaking Barriers: Canal Stripping
F. IOP goals
Targets the area of highest resistance of aqueous
VII. Breaking Barriers: The Plan and the Surgery
outflow via incision or excision of TM.
A. Planning tips
IV. Planning: Patient Selection and Goal Setting
1. Adequate dry and wet lab time
A. Anticoagulation status, sickle cell, Valsalva risk,
neck mobility, ability to follow instructions 2. Decisions: titration and device combinations,
angle surgery before or after phaco
B. Glaucoma severity, corneal clarity, detailed
gonioscopy B. Visualization tips
1. Peripheral anterior synechiae 1. Obtaining en-face view and ability to identify
TM
2. Iris processes
2. Choice of gonioprism, viscoelastic
3. TM pigmentation
3. Appropriate pressure with gonioprism
4. Prior surgery
C. Efficiency tip: Preset mark on microscope.
V. Breaking Barriers: Device Options
D. Comfort tips
A. Bent ab-interno needle goniotomy (BANG)
1. Topical and intracameral anesthesia; pros and
B. Gonioscopy-assisted transluminal trabeculotomy
cons for retro/peri bulbar blocks
(GATT)
2. Pay attention to patient cues! Sensation of
C. iAccess Precision Blade (Glaukos; Laguna Hills,
pressure = normal pain ≠ normal
CA)
E. Incision placement tips
D. iPrime (Glaukos; Laguna Hills, CA)
1. Too anterior impedes device and gonioprism.
E. iTrack Advance (Nova Eye Medical; Fremont, CA)
2. Too posterior creates limbal blood vessel heme.
F. Kahook Dual Blade (KDB) Glide (New World
Medical; Rancho Cucamonga, CA) 3. Ease of access
G. OMNI Ergo Surgical System (Sight Sciences; F. Angle access tips
Menlo Park, CA)
1. Angle device tip slightly up toward top of TM if
H. SION (Sight Sciences; Menlo Park, CA) canulating or upper third of TM if piercing.
I. Streamline (New World Medical; Rancho 2. Gentle pressure against back wall of SC to
Cucamonga, CA) minimize eye rotation but do not pierce.
16 Section II: Surgical Pearls in the Second City Subspecialty Day 2024  |  Glaucoma

3. Reposition hand and/or relocate goniotomy site VIII. Postop Optimization and Complication Management
if no success engaging SC.
A. Phakic patients: Consider pilocarpine.
4. Use width of incision, not the wall of incision, to
B. Timing for drop “holiday”: Severity of glaucoma
allow device movement.
C. Hyphema management, early and late
5. Align devices with curvature of the eye.
D. Iridodialysis and clefts: Patient education of
6. Appropriate amount of anterior chamber (AC)
symptoms and signs, hypotony management
pressurization with viscoelastic
E. Late IOP elevations: Consider steroid response.
7. Goniotomy (stand-alone devices)
8. Advance parallel to TM.
Selected Readings
9. Combine approaches to maximize excision area.
1. Bourne CI. So, you want to be a MIGS surgeon—a bootcamp
G. Intraoperative heme management tips guide to angle surgery. OSWI Times, vol. 2 (2021), Go Green
Caribbean for Glaucoma: 13-14. https://online.anyflip.com/bozej
1. Heavier molecular weight viscoelastic /bgqr/mobile.
2. Irrigation and aspiration (I/A) of heme 2. Sheybani A. Pearls for angle based surgery. Review of
Ophthalmology, April 4, 2024. https://www.reviewof
3. Ensure eye remains pressurized to minimize ophthalmology.com/article/pearls-for-anglebased-surgery.
more reflux.
3. Johnstone M. Aqueous humor outflow system overview. In:
4. Air bubble Stamper RL, Lieberman MF, Drake MV, eds. Diagnosis and
Therapy of the Glaucomas. 8th ed. Mosby; 2009:25-46.
5. Adequate AC pressurization with BSS at end of
case 4. Nichani P, Popovic MM, Schlenker MB, Park J, Ahmed IIK.
Microinvasive glaucoma surgery: a review of 3476 eyes. Surv
Ophthalmol. 2021; 66(5):714-742.
Subspecialty Day 2024  |  Glaucoma Section II: Surgical Pearls in the Second City 17

Bleb Whisperers: Optimizing Microinvasive Bleb

Surgery
Lorraine M Provencher MD

Overview VI. How to Assess Bleb Morphology

Microinvasive approaches for subconjunctival filtration, A. Height and distribution
primarily via stents, have simplified intraoperative surgical
B. Vascularity
techniques and increased postoperative safety. However, an in-
depth understanding of preoperative surface optimization, bleb C. Microcysts and cystic change
morphology, bleb management, and postoperative medical and
VII. Steroid Modifications
procedural bleb manipulation is crucial to long-term success.
An approach to maximizing outcomes in microinvasive bleb A. Taper: hypotony due to overfiltration or steroid
surgery will be reviewed in this session, which will address the response
following:
B. Increase: inflammation, vascularity, baseline use,
I. Microinvasive Bleb Surgical Options combined cases
A. Xen gel stent (Most of the discussion will be based VIII. Postoperative Interventions: When do they apply?
on Xen experience.)
A. Bleb needling
B. PreserFlo MicroShunt
B. 5-fluorouracil
C. Minimally invasive micro sclerotomy (MIMS)
C. YAG of internal ostium4
procedure
IX. When to Consider Aqueous Suppression5
II. Preparing the Ocular Surface for Surgery
A. Treat pre-existing ocular surface disease and
References
blepharitis.
1. Cutolo CA, Iester M, Bagnis A, et al. Early postoperative
B. Reduce topical glaucoma medications if possible. intraocular pressure is associated with better pressure control
C. Start preoperative steroid drops. after Xen implantation. J Glaucoma. 2020; 29(6):456-460.
2. Wells AP, Ashraff NN, Hall RC, Purdie G. Comparison of two
III. End Surgery With Confidence in Patency/Flow
clinical bleb grading systems. Ophthalmology 2006; 113(1):77-
A. Confirm anterior chamber positioning. 83.

B. Check for flow or evidence of flow in the 3. Mastropasqua L, Agnifili L, Brescia L, et al. A deep learning
subconjunctival space. approach to investigate the filtration bleb functionality after
glaucoma surgery: a preliminary study. Graefes Arch Clin Exp
C. Primary needling techniques Ophthalmol. 2024; 262(1):149-160.
D. Open conjunctival techniques 4. Fellman RL, Grover DS, Smith OU, Kornmann HL. Rescue of
failed Xen-45 gel implant by Nd:YAG shock wave to anterior
IV. Postoperative Day 1 IOP Assessment chamber tip to dislodge hidden intraluminal occlusion. J
A. Low starting IOP is a predictor of success.1 Glaucoma. 2021; 30(7):e338-e343.
5. Shalaby WS, Wong JC, Zhang TZ, et al. Early postoperative
B. Troubleshooting a high IOP: blood, viscoelastic,
aqueous suppression therapy and surgical outcomes of Ahmed
iris, Descemet membrane, or Tenon capsule
tube shunts in refractory glaucoma. Ophthalmol Glaucoma.
occlusion 2024; 7(1):47-53.
V. Monitoring the Bleb Over Time
A. Various bleb grading systems have been published.2
B. Deep learning may be a future tool for monitoring
bleb functionality.3
C. Review of my simplified system
18 Section II: Surgical Pearls in the Second City Subspecialty Day 2024  |  Glaucoma

Mastering Comfort: The Ergonomics of Ophthalmic

Surgery
Amy D Zhang MD

I. The Scope of Musculoskeletal Disease in

Ophthalmology
A. Impact of pain in the workplace
B. Pain and burnout
II. OR Environment
A. Review of the ophthalmic literature on OR
ergonomics
B. High-risk tools
1. OR bed
2. OR chair
3. OR microscope
4. Foot pedals
C. Patient ergonomics
D. Surgeon OR ergonomics
III. Ergonomics Affected by Other Settings Outside of OR
IV. General Strengthening Exercise, Intraop/Interop and
at Home
Subspecialty Day 2024  |  Glaucoma Protect America’s Eyesight 19

Protect America’s Eyesight: A United Vision for

Ophthalmology’s Future
2024 Glaucoma Subspecialty Day
Roman Krivochenitser MD

Action Requested: Donate to strengthen OPHTHPAC for Federal Advocacy

ophthalmology’s legislative voice and protect
OPHTHPAC is the Academy’s award-winning, nonpartisan
patients and your profession
political action committee representing ophthalmology on
Join your colleagues in advocating for ophthalmology: Give to Capitol Hill. OPHTHPAC works to build invaluable relation-
OPHTHPAC, the Surgical Scope Fund, and your State Society’s ships with our federal lawmakers to garner their support on
PAC. Ensure you and your patients are heard by our nation’s issues such as:
lawmakers and donate to each of these funds.
■ Improving the Medicare payment system, so ophthal-
mologists are fairly compensated for their services, and
Where and How to Contribute working to avert impending payment cuts included in the
proposed 2025 CMS Physician Fee Schedule rule
During AAO 2024 in Chicago, please contribute to OPH- ■ Securing payment equity for postoperative visits, which
THPAC® and the Surgical Scope Fund at one of our two con-
will increase global surgical payments
vention center booths. You can also donate by:
■ Stopping optometry from obtaining surgical laser privi-
■ Texting MDEYE to 41444 for OPHTHPAC leges in the veterans’ health-care system
■ Texting GIVESSF to same number (41444) for the Surgi- ■ Increasing patient access to treatment and care by reduc-
cal Scope Fund ing prior authorization and step therapy burdens
■ Donating to both funds online at aao.org/protecteyesight
Academy member support for OPHTHPAC makes all
We also encourage you to support our congressional champi- this possible. Your support provides OPHTHPAC with the
ons by making a personal investment via OPHTHPAC Direct, resources needed to engage and educate Congress on our issues,
a unique and award-winning program that lets you decide who helping advance ophthalmology’s federal priorities. Your sup-
receives your political support. You can donate online at http:// port also ensures that we have a voice in helping shape the poli-
ophthpac-direct.aao.org. cies and regulations governing the care we provide. Academy
To learn more about giving to your State Society’s PAC, visit member support for OPHTHPAC is the driving factor behind
aao.org/statesocieties and contact your society’s leadership our advocacy push, and we ask that you get engaged to help
team. strengthen our efforts and make sure that the ophthalmology
specialty has a seat at the table for the critical decisions being
made that affect our ability to care for our patients.
Why Should You Contribute?
At the Academy’s annual Mid-Year Forum, the Academy
Member support for the Academy’s advocacy funds, OPH- and the American Glaucoma Society ensure a strong presence
THPAC and the Surgical Scope Fund, powers our advocacy of glaucoma specialists to support ophthalmology’s priorities.
efforts at the federal and state levels. When you give to OPH- As part of this year’s meeting, the American Glaucoma Society
THPAC, you give ophthalmology a voice on Capitol Hill on supported participation of fellowship trainees via the Acad-
critical issues like Medicare payment, optometry’s scope expan- emy’s Advocacy Ambassador Program. During Congressional
sion efforts in the VA, and prior authorization and step therapy Advocacy Day, they visited Members of Congress and their
burdens. When you give to the Surgical Scope Fund, you’re key health-care staff to discuss ophthalmology priorities. The
funding our efforts to fight dangerous optometric surgery initia- American Glaucoma Society remains a crucial partner with the
tives at the state level, whenever and wherever they arise. And Academy in its ongoing federal and state advocacy initiatives.
finally, when you give to your State Eye PAC, you help elect
officials in your state who will support the interests of you and
Surgical Scope Fund (SSF) for State Advocacy
your patients. Giving to each of these three funds is essential to
helping Protect America’s Eyesight and empower lives. The Surgical Scope Fund works in partnership with state oph-
Defending quality patient eye care and high surgical stan- thalmic societies to protect patient safety from dangerous opto-
dards is a “must” for everybody. Our mission of “protecting metric surgery proposals through advocacy. The Fund’s mission
sight and empowering lives” requires robust funding of both is to ensure surgery by surgeons, and since its inception it has
OPHTHPAC and the Surgical Scope Fund. Each of us has a helped 44 state/territorial ophthalmology societies reject opto-
responsibility to ensure that these funds are strong so that oph- metric scope-of-practice expansions into surgery.
thalmology continues to thrive and patients receive optimal Support for the Surgical Scope Fund from members of oph-
care. thalmic interest societies like the American Glaucoma Society
makes our advocacy efforts possible. These efforts include
research, lobbyists, political organization, polling, advertising,
20 Protect America’s Eyesight Subspecialty Day 2024  |  Glaucoma

social media, digital communications, and grassroots mobili- OPHTHPAC Committee

zation. However, the number of states facing aggressive opto-
Sohail J Hasan MD PhD (IL)—Chair
metric surgery legislation each year has grown exponentially.
Amin Ashrafzadeh MD (CA)
And with organized optometry’s vast wealth of resources, these
Renee Bovelle MD (MD)
advocacy initiatives are becoming more intense—and more
Ninita Brown MD PhD (GA)
expensive. That’s why ophthalmologists must unite in donating
Jeremy Clark MD (KY)
to the Surgical Scope Fund to fight for patient safety and the
Zelia M Correa MD PhD (FL)
rigorous standards of surgical eye care.
Lindsey D Harris MD (TX)
The Academy’s Secretariat for State Affairs thanks the
Jeffrey D Henderer MD (PA)
American Glaucoma Society for its past support for the Surgi-
John B Holds MD (MO)
cal Scope Fund and looks forward to its 2024 contribution. The
Gareth M Lema MD PhD (NY)
American Glaucoma Society’s support for the Surgical Scope
Stephen H Orr MD (OH)
Fund is essential to fighting for patient safety and quality eye
Sarwat Salim MD (MA)
care!
Steven H Swedberg MD (WA)
Patty Terp MD (NE)
Your State Society’s PAC Matthew J Welch MD (AZ)
The presence of a strong State Society PAC is critical in provid- Ex-Officio Members
ing financial support for campaign contributions and legislative
Jane Edmond MD
education. State Society PACs help elect ophthalmology-friendly
John McAllister MD
candidates to the state legislature, which is crucial as scope-of-
Stephen D McLeod MD
practice battles are fought on the state level.
Michael X Repka MD MBA
George A Williams MD
Support Your Colleagues Who Are Working on Your
Behalf
Surgical Scope Fund Committee
Two Academy committees made up of your ophthalmology
Lee A Snyder MD (MD)—Chair
colleagues are working hard on your behalf. The OPHTHPAC
K David Epley MD (WA)
Committee continues to identify Congressional Advocates in
Nina A Goyal MD (IL)
each state to maintain close relationships with federal legisla-
Roman Krivochenitser MD (MI)
tors to advance ophthalmology and patient causes. The Surgical
Saya V Nagori MD (MD)
Scope Fund Committee is raising funds used to protect Surgery
Christopher C Teng MD (CT)
by Surgeons during scope battles at the state level.
Sarah Wellik MD (FL)

Ex-Officio Members
John D Peters MD
George A Williams MD

Surgical Scope Fund OPHTHPAC® Your State Society’s PAC

Purpose To protect patient safety by defeating Working in a nonpartisan fashion to advance Support for candidates for state
optometric surgical scope-of-practice ophthalmology and protect its members and House, Senate, and governor
initiatives that threaten quality surgi- patients at the federal level
cal care
Support for candidates for U.S. Congress
What Funds Political grassroots activities, govern- Campaign contributions, legislative and policy Campaign contributions, legisla-
Support ment relations, advertising, PR and education, having a seat at the table to be a tive and policy education
media campaigns voice on the critical issues affecting our spe-
cialty at the federal level
No funds may be used for campaign
contributions or PACs. Personal contributions go directly to elect and
re-elect our champions in Congress, and cor-
porate contributions go toward OPHTHPAC’s
administrative expenses.
Limits Contributions are unlimited. Contributions: Personal contributions are Contribution limits vary based on
limited to $5,000/year. state regulations.
Individuals, practices, corporate enti-
ties, and organizations can give. Corporate contributions are unlimited and
confidential.
Contribution Contributions are 100% confidential. Personal contributions of $199 or less and all Contributions are on the public
Disclosures corporate contributions are confidential. record depending upon state statutes.
Subspecialty Day 2024  |  Glaucoma Section III: Glaucoma Unscripted 21

Cataract and Refractive

Brian M Shafer MD

Refractive cataract surgery in glaucoma patients poses unique The Dogma

challenges and considerations. The primary question driving
Historically, the belief was that patients with glaucoma should
this discussion is: Do we correct astigmatism and presbyopia in
not undergo refractive cataract surgery due to concerns about
patients with glaucoma? The answer is, of course! We typically
contrast sensitivity, pupil size, and refractive stability. These
do it with glasses or contact lenses, but what about with IOLs?
concerns have significantly influenced clinical decision-making,
often leading to conservative treatment approaches.
Why the Conversation?
Over the years, there has been commentary cautioning against Contrast Sensitivity
aggressive refractive corrections in glaucoma patients due to
Contrast sensitivity, a measure of the eye’s ability to distinguish
potential complications and the delicate nature of their eye con-
objects from their background, is crucial for functional vision.
dition.
In glaucoma patients, there is a baseline reduction in contrast
sensitivity that worsens with disease severity. This is effectively
what mean deviation is showing.

Figure 1

Figure 2
22 Section III: Glaucoma Unscripted Subspecialty Day 2024  |  Glaucoma

Pupil Size Advanced Technology IOLs (AT-IOLs) and Contrast

Sensitivity
Pupil size plays a significant role in the success of refractive
cataract surgery. Large pupils can lead to worse near vision and The Pelli-Robson chart is often used to measure contrast sensi-
more dysphotopsia, while small pupils may create difficulties in tivity, helping guide the choice of IOLs. A clinically meaningful
adjusting light-adjustable lenses (LALs). The size of the pupil, reduction in contrast sensitivity is considered a 0.3 logMAR
especially at its extremes, can significantly affect the visual reduction in contrast sensitivity score (CSS).
outcomes and must be carefully considered during preopera-
tive planning. In pseudoexfoliation, patients may have smaller
New Era of Presbyopia-Correcting IOLs
pupils.
Advancements in IOL technology have ushered in a new era of
presbyopia-correcting lenses. Some of the notable lenses include
Refractive Stability
the Alcon PanOptix Trifocal IOL, Tecnis Symfony OptiBlue
Refractive stability is paramount for ensuring a good outcome IOL, Alcon Vivity IOL, Tecnis Odyssey IOL, and the RxSight
in refractive cataract surgery, and trabeculectomies and tube Light Adjustable Lens. Each of these lenses has received FDA
shunts are not refractively neutral procedures. premarket approval, reflecting their safety and efficacy.

Stop blaming contrast sensitivity.

None of the new AT-IOLs have meaningful reduction in con-
tract sensitivity in binocular conditions.

Figure 3

Figure 4
Subspecialty Day 2024  |  Glaucoma Section III: Glaucoma Unscripted 23

Figure 5

Pupil size matters at the extremes. Selected Readings

Pupil size extremes significantly impact surgical outcomes. 1. Moshirfar M, Hoggan RN, Muthappan V. Cataract surgery
Large pupils can cause issues with near vision and increased in the glaucoma patient. Middle East Afr J Ophthalmol. 2013;
dysphotopsia, while small pupils may present challenges with 20(3):197-203.
the adjustment of LALs. Understanding and addressing these 2. Ahmed IIK, Ahmed I. Refractive surgery in glaucoma. Curr Opin
variations can help optimize surgical results. Ophthalmol. 2014; 25(2):98-104.
3. Vizzeri G, Weinreb RN. Cataract surgery and glaucoma. Curr
Refractively Unstable vs. Stable Glaucoma Surgery Opin Ophthalmol. 2010; 21(1):20-24.

Angle-based, minimally invasive glaucoma surgeries (MIGS) 4. Agrawal P, Shih CY. Advanced intraocular lens technology and
are refractively neutral procedures. They can be safely coupled glaucoma. Curr Opin Ophthalmol. 2019; 30(2):118-124.
with refractive cataract surgery without fear of induced astig- 5. Richman J, Lorenzana LL, Lankaranian D, et al. Importance of
matism or changes in effective lens position. visual acuity and contrast sensitivity in patients with glaucoma.
Arch Ophthalmol. 2010; 128(12):1576-1582.

Paradigm Shift 6. Ross JE, Bron AJ, Clarke DD. Contrast sensitivity and visual
disability in chronic simple glaucoma. Br J Ophthalmol. 1984;
A paradigm shift is occurring in the field of refractive cataract 68(11):821-827.
surgery for glaucoma patients. This shift involves recogniz-
7. Atkin A, Bodis-Wollner I, Wolkstein M, Moss A, Podos SM.
ing the importance of individualized treatment plans based on
Abnormalities of central contrast sensitivity in glaucoma. Am J
factors such as the trajectory of the disease, severity, age, and Ophthalmol. 1979; 88(2):205-211.
etiology. By focusing on what’s best for each patient, clinicians
can provide tailored care that addresses the unique needs of 8. Sample PA, Juang PS, Weinreb RN. Isolating the effects of
glaucoma patients undergoing cataract surgery. primary open-angle glaucoma on the contrast sensitivity function.
Am J Ophthalmol. 1991; 112(3):308-316.
9. Gundersen KG, Potvin R. Comparing visual acuity, low
Conclusion contrast acuity and contrast sensitivity after trifocal toric and
Refractive cataract surgery in glaucoma patients requires a extended depth of focus toric intraocular lens implantation. Clin
nuanced approach that considers contrast sensitivity, pupil size, Ophthalmol. 2020; 14:1071-1078.
and refractive stability. With advancements in IOL technology
and a better understanding of the unique needs of glaucoma
patients, it is possible to achieve excellent visual outcomes and
improve quality of life. By adopting a patient-centered approach
and focusing on what truly matters, clinicians can successfully
navigate the complexities of these challenging cases.
24 Section III: Glaucoma Unscripted Subspecialty Day 2024  |  Glaucoma

Cornea
Glaucoma and Cornea: A Two-Way Street of Problems
Jeffrey Ma MD

I. Glaucoma After Corneal Surgery 3. Change in aqueous humor flow dynamics

A. Significant proportion of patients develop a. Fluid turbulence at tube tip
glaucoma after corneal transplant, with highest
b. Disruption of nutrient flow to corneal
incidence after keratoprosthesis, penetrating
endothelium
keratoplasty, and Descemet-stripping automated
endothelial keratoplasty (in decreasing order of C. Risk factors for corneal decompensation after
incidence).1 tube surgery include older age, history of Fuchs
dystrophy or iridocorneal endothelial syndrome,
B. Causes of glaucoma after corneal transplant2
postoperative complications, and greater number of
1. Steroid response from topical corticosteroids prior glaucoma surgeries.6
2. Peripheral anterior synechiae formation D. 2018: Discontinuation of CyPass microstent due to
endothelial cell loss
3. Gas bubble causing pupillary block or angle
closure due to posterior migration of gas bubble III. Ocular Surface Disease and Corneal Decompensation
due to Glaucoma Medications
4. Vitreous and/or viscoelastic blockage of angle
and/or glaucoma drainage device A. Preservative problems from topical glaucoma
drops: Benzalkonium chloride disrupts corneal
5. Iatrogenic injury to angle or existing glaucoma
epithelial tight junctions, causing subconjunctival
drainage device
fibrosis and loss of goblet cells.
II. Corneal Disease After Glaucoma Surgery
B. Corneal epithelial “honeycombing” edema due to
A. Corneal endothelial decompensation after tube vs. netarsudil
trab surgery
C. Challenges of treating ocular surface disease in
1. 2012 Tube Versus Trab (TVT) study found patients with glaucoma
16% of tube patients and 9% of trab patients
IV. Glaucoma due to Treatment of Corneal/External
developed persistent corneal edema (no
Disease
statistically significant difference).3 Persistent
corneal edema was the most common cause for A. The need for topical and periocular steroids for
reoperation for a complication in both groups. corneal/external diseases such as scleritis
2. 2022 Primary Tube vs. Trabeculectomy study B. The effect of scleral lenses on IOP
found no difference in persistent corneal edema
after tube vs. trab and a lower overall incidence
References and Selected Readings
of corneal decompensation (possibly due to
younger age at enrollment compared to TVT 1. Saini C, Davies EC, Ung L, et al. Incidence and risk factors
study).4 for glaucoma development and progression after corneal
transplantation. Eye (Lond). 2023; 37(10):2117-2125.
B. Mechanisms of corneal edema after glaucoma
2. Baltaziak M, Chew HF, Podbielski DW, Ahmed IIK. Glaucoma
intervention5
after corneal replacement. Surv Ophthalmol. 2018; 63(2):135-
1. Mechanical trauma: Faster decline of 148.
endothelial cells after anterior chamber tube vs. 3. Gedde SJ, Herndon LW, Brandt JD, Budenz DL, Feuer WJ,
sulcus/pars plana tube Schiffman JC; Tube Versus Trabeculectomy Study Group.
2. Anterior chamber inflammation Postoperative complications in the Tube Versus Trabeculectomy
(TVT) study during five years of follow-up. Am J Ophthalmol.
a. Peripheral anterior synechiae leading to 2012; 153(5):804-814.e1.
endothelial cell decompensation 4. Gedde SJ, Feuer WJ, Lim KS, et al; Primary Tube Versus
b. Increased cytokines after glaucoma surgery Trabeculectomy Study Group. Postoperative complications in
leading to endothelial cell damage the Primary Tube Versus Trabeculectomy study during 5 years of
follow-up. Ophthalmology 2022; 129(12):1357-1367.
Subspecialty Day 2024  |  Glaucoma Section III: Glaucoma Unscripted 25

5. Mehta AA, Tu EY, Vajaranant TS. Beyond mechanical trauma—

why the cornea may decompensate after glaucoma surgery. JAMA
Ophthalmol. 2019; 137(5):479-480.
6. Beatson B, Wang J, Boland MV, et al. Corneal edema and
keratoplasty: risk factors in eyes with previous glaucoma drainage
devices. Am J Ophthalmol. 2022; 238:27-35.
7. Aguayo Bonniard A, Yeung JY, Chan CC, Birt CM. Ocular
surface toxicity from glaucoma topical medications and associated
preservatives such as benzalkonium chloride (BAK). Expert Opin
Drug Metab Toxicol. 2016; 12(11):1279-1289.
8. Andole S, Senthil S. Ocular surface disease and anti-glaucoma
medications: various features, diagnosis, and management
guidelines. Semin Ophthalmol. 2023; 38(2):158-166.
9. Moumneh K, Sheybani A, Fellman RL, Godfrey DG, Grover DS.
Reticular corneal edema or corneal honeycombing in eyes treated
with netarsudil: a case series. J Glaucoma. 2020; 29(7):607-610.
10. Rososinski A, Wechsler D, Grigg J. Retrospective review of pars
plana versus anterior chamber placement of Baerveldt glaucoma
drainage device. J Glaucoma. 2015; 24(2):95-99.
26 Section III: Glaucoma Unscripted Subspecialty Day 2024  |  Glaucoma

Retina
Alice Yang Zhang MD

I. Association Between Intravitreal Injections and II. Considerations of Glaucoma Surgery in a Patient With
Glaucoma Retinal Disease
A. Review of IOP increase differences between anti- A. Risk of glaucoma with scleral buckles and with
VEGF injections and corticosteroid implants— pars plana vitrectomy
newer steroid implants may last up to 3 years:
B. Considerations of tube shunt implantation surgery
1. Fluocinolone acetonide 0.19 mg for diabetic in the setting of:
macular edema
1. Combined vitrectomy for pars plana tube
2. 0.18 mg for uveitis insertion
B. Evidence of anterior chamber paracentesis 2. Risk of retinal detachment and other
performed at the time of intravitreal injections complications for scleral buckle or segment
removal
C. Review volumes of new intravitreal injectable
medications 3. Silicone oil placement
1. Anti-VEGFs such as bevacizumab, ranibizumab, III. Incidental Macular OCT Findings
aflibercept: 0.05 cc
Review of urgent vs. nonurgent findings
2. Anti-VEGF and Ang2 inhibitor: faricimab,
6 mg/0.05 cc
Selected Readings
3. Newer anti-VEGF: aflibercept HD,
1. De Vries VA, Bassil FL, Ramdas WD. The effects of intravitreal
8.0 mg/0.07 cc injections on intraocular pressure and retinal nerve fiber layer: a
4. Complement inhibitors: pegcetacoplan, systematic review and meta-analysis. Sci Rep. 2020; 10:13248.
15 mg/0.1 cc; avacincaptad pegol, 2 mg/0.1 cc 2. Bach A, Filipowicz A, Gold AS, et al. Paracentesis following
intravitreal drug injections in maintaining physiologic ocular
perfusion pressure. Int J Ophthalmol. 2017; 10(12):1925-1927.
3. Mansoori T, Mohan GP, Agraharam SG, et al. Incidence and risk
factors for intraocular pressure rise after scleral buckle surgery for
retinal detachment. J Curr Ophthalmol. 2021; 33(4):444-448.
Subspecialty Day 2024  |  Glaucoma Section III: Glaucoma Unscripted 27

Uveitis
Careen Yen Lowder MD PhD and Jonathan Eisengart MD

I. Uveitic Glaucoma Prevalence C. Long-term effects of chronic inflammation

(hypotony) outweigh benefits from lower IOP.
A. 10%-46% develop secondary glaucoma.
IV. Medical Management of Glaucoma
B. Depends on type of uveitis
Aqueous suppressants, first line
C. Age at presentation
A. Beta blockers
D. Chronicity and severity of uveitis
1. Alpha agonists
E. 26%-79% of uveitis patients develop cystoid
macular edema (CME). 2. Carbonic anhydrase inhibitors
F. 48.8% of CME patients treated with intravitreal B. Prostaglandin analogs, second line: Stable, well
triamcinolone develop IOP >5 mmHg. controlled uveitis may be cautiously treated with
prostaglandin analogs.
G. 27.9% develop IOP >10 mmHg.
V. Management of Pupillary Block Glaucoma
II. Mechanisms of Glaucoma in Uveitis
A. Active uveitis with fibrin: inject intracameral tissue
A. Open angle mechanisms
plasminogen activator 12.5 μg
1. Steroid response
B. Argon or Nd:YAG laser iridotomy
2. Clogging of trabecular meshwork (TM) by
C. Surgical iridectomy may be required if iridotomies
inflammatory cells, proteins, debris, or fibrin
close due to inflammation.
3. Scarring and obliteration of TM or Schlemm
VI. Management of Neovascular Glaucoma
canal
A. Neovascular angle closure is usually a result of
4. Trabeculitis
retinal ischemia.
B. Steroid-induced glaucoma
B. Treated with pan retinal photocoagulation
1. One-third normal population increase of 6-15
VII. Surgical Management of Glaucoma
mmHg
A. Indicated when IOP is uncontrolled on maximal
2. 5% normal population high response >15
medical therapy
mmHg
B. Argon laser trabeculoplasty is contraindicated:
3. Takes several weeks (in primary open-angle
ineffective (80% failure), causes recurrence of
glaucoma, within 4-8 hours)
uveitis (60%).
4. Children, earlier response
VIII. Minimally Invasive Glaucoma Surgery (MIGS)
5. Biochemical and morphological changes in the
A. Procedure of choice in uveitis patients
TM
B. In steroid-response and uveitic glaucoma with an
C. Closed angle
open angle, IOP is up largely due to TM damage
1. Pupillary block due to 360 posterior synechiae and dysfunction.
or complete pupillary membrane
C. Traditional glaucoma surgery artificially bypasses
2. Nonpupillary block angle closure due to the TM.
inflamed ciliary body rotating forward leading
D. Goniotomy and GATT (gonioscopy-assisted
to angle closure
transluminal trabeculotomy) directly address the
3. Peripheral anterior synechiae site of outflow obstruction.
4. Neovascular glaucoma E. Broadly effective for inflammatory and steroid
response
III. Medical Management of Uveitis
F. Can be effective in failed tubes and
A. Topical, periocular, intravitreal, or systemic
trabeculectomies
steroids + immunomodulatory therapy
G. Hypotony almost never occurs with these
B. Undertreating uveitis to minimize IOP elevation at
procedures.
the expense of good IOP is not recommended.
28 Section III: Glaucoma Unscripted Subspecialty Day 2024  |  Glaucoma

IX. Tubes are an effective second choice.

A. When MIGS is not a good choice
B. When prior MIGS have failed

Selected Readings
1. Netland P, Foster S. Uveitic glaucoma: an update on how to
manage these patients. Glaucoma Today, Jan/Feb 2006:17-19.
2. Rothova A. Medical treatment of cystoid macular edema. Ocul
Immunol Inflamm. 2002; 10:239-246.
3. Estafanous M, Lowder CY. Patterns of macular edema in patients
with uveitis. Ophthalmology 2005; 112:360.
4. Goldstein D, Godfrey DG, Hall A, et al. Intraocular pressure in
patients with uveitis treated with fluocinolone acetonide implants.
Arch Ophthalmol. 2007; 125(11):1478-1485.
5. Bollinger K, Kim J, Lowder CY, Kaiser PK, Smith SD. Intraocular
pressure outcome of patients with fluocinolone acetonide
intravitreal implant for noninfectious uveitis. Ophthalmology
2011; 118:1927.
6. Chen RI, Purgert R, Eisengart J. Gonioscopy-assisted
transluminal trabeculotomy and goniotomy, with or without
concomitant cataract extraction, in steroid-induced and uveitic
glaucoma: 24-month outcomes. J Glaucoma. 2023; 32(6):501-
510.
Subspecialty Day 2024  |  Glaucoma Section III: Glaucoma Unscripted 29

Neuro-Ophthalmology
What Neuro-Ophthalmology Can Teach Us About Glaucoma
Julie Falardeau MD

I. Introduction B. Central scotoma or visual field respects the vertical

meridian.
Optic nerve cupping is widely recognized as a
feature of glaucoma. However, multiple congenital C. Optic disc pallor > cupping or surviving neural rim
or acquired entities not associated with elevated shows pallor.
IOP or glaucomatous optic nerve disease may result
D. Optic nerves are symmetric in appearance to each
in pathologic optic nerve excavation. Furthermore,
other, but 1 visual field is very different.
congenital optic disc anomalies and acquired
nonglaucomatous optic neuropathies can also present E. Marked relative afferent pupillary defect
with visual field defects that are typical of glaucoma.
F. Color vision loss is disproportionate to reduction in
Differentiating glaucomatous from nonglaucomatous
visual acuity.
optic neuropathy can be challenging, even for
experienced clinicians. A detailed history, thorough G. Optic disc appearance and/or the OCT of the optic
assessment of visual function (visual acuity, afferent nerve does not correlate with the visual field defect.
pupillary function, color vision, and visual field
H. Papillomacular bundle loss on OCT
testing), close observation of disc appearance and
vasculature, and ancillary testing such as OCT I. Macular ganglion cell complex on OCT
of the retinal nerve fiber layer and ganglion cell demonstrates a homonymous or bitemporal pattern
layer–inner plexiform layer will aid in the diagnosis of ganglion cell loss.
of glaucomatous versus nonglaucomatous optic
J. Presence of concerning ocular/orbital signs in
neuropathy.
addition to the suspicious optic disc
II. Optic Disc Mimickers (Nonglaucomatous Cupping)
1. Proptosis
A. Compressive optic neuropathy
2. Ptosis/lid edema
B. Traumatic optic neuropathy
3. Dilated episcleral vessels
C. Demyelinating optic neuritis
4. Chemosis
D. Arteritic ischemic optic neuropathy
5. Ocular motility disorder
E. Hereditary optic neuropathy
V. MRI Findings Commonly Seen With Advanced
F. Toxic optic neuropathy (methanol toxicity) Glaucoma
G. Hypoxic ischemic encephalopathy A. MRI may show optic nerve T2 hyperintensity
without associated optic nerve enhancement in
III. Visual Field Mimickers
patients with advanced glaucoma.
A. Congenital optic disc disorders: Optic disc drusen
B. The radiologist typically brings up the possibility
are the most common congenital cause of visual
of prior ischemia or, more frequently, will
field mimicker. While B-scan ultrasonography,
mention potential sequela of optic neuritis, which
fundus autofluorescence, and fluorescein
universally will lead to neuro-ophthalmology
angiogram can be greatly helpful in the assessment
referral.
of optic disc drusen, enhanced depth imaging OCT
(EDI-OCT) can reliably and quickly be used to C. Studies have demonstrated significant differences
diagnose buried optic disc drusen and is becoming in the optic nerve volume on MRI in the severe
a top-choice diagnostic imaging modality among glaucoma group compared with the mild and
neuro-ophthalmologists. control groups.
B. Ischemic optic neuropathy 1. Furthermore, advanced disease is often
associated with loss of volume involving the
C. Branch retinal vein/artery occlusion
entire length of the optic nerve. This loss of
IV. “Glaucoma”: Indications for Neuroimaging and/or volume can be associated with abnormal signal
Additional Neuro Workup on T2-weighted images (T2 hyperintensity), but
no contrast enhancement should be noted in
A. Acute or rapidly progressing vision loss
glaucomatous optic neuropathy.
30 Section III: Glaucoma Unscripted Subspecialty Day 2024  |  Glaucoma

2. Mosleh and colleagues recently published on Selected Readings

glaucoma as a cause of optic nerve abnormalities
1. Piette SC, Sergott RC. Pathological optic-disc cupping. Curr Opin
on MRI. Their conclusion is that optic nerve T2 Ophthalmol. 2006; 17:1-6.
hyperintensity and MRI optic nerve atrophy are
nonspecific findings that can be found in severe 2. Fraser CL, White A JR, Plant GT, Martin KR. Optic nerve
glaucomatous optic nerves and should not cupping and the neuro-ophthalmologist. J Neuroophthalmol.
2013; 33:377-389.
systematically prompt investigations for another
cause optic neuropathy. 3. Waisberg E, Micieli JA. Neuro-ophthalmological optic nerve
cupping: an overview. Eye Brain. 2021; 13:255-268.
D. The patient’s history, assessment of afferent
function with visual acuity, color vision, and 4. Senthil S, Nakka M, Sachdeva V, et al. Glaucoma mimickers:
visual field, as well as careful evaluation of the a major review of causes, diagnostic evaluation, and
recommendations. Semin Ophthalmol. 2021; 36:692-712.
optic disc, remain essential before concluding that
such an MRI finding is in fact due to advanced 5. Mosleh R, Alvarez F, Bouthour W, et al. Glaucoma as a cause of
glaucomatous optic neuropathy. optic nerve abnormalities on magnetic resonance imaging. Eye
(Lond). 2024; 38(9):1626-1632.
Subspecialty Day 2024  |  Glaucoma Section III: Glaucoma Unscripted 31

Low Vision
The Importance of Addressing the Visual Impairment
Caused by Glaucoma
John Shepherd MD

A patient presented to my low vision practice with advanced For more information for both patients and practitioners on
glaucoma. A review of her ophthalmologist’s notes demon- empowering the lives of patients through vision rehabilitation,
strated stable IOPs in the target range and stable visual fields. go to this link: https://www.aao.org/education/low-vision-and-
Her increasing tendency to trip and fall was not noted or dis- vision-rehab. The Academy is very supportive of vision rehabili-
cussed. Her primary care provider completed a thorough medi- tation, which is now the standard of care for all who experience
cal workup to evaluate this tendency to trip and fall, but no vision loss. Through this link, you can find a wonderful hand-
cause was found. The primary care provider referred the patient out you may print and give to your patients with low vision.
to me to determine if the vision loss from the glaucoma might be There is also a directory of services for the practitioner wanting
the problem. It was. to find low vision resources in the community, in addition to
As ophthalmologists, we know that despite our best efforts opportunities for continuing education.
glaucoma can cause irreversible vision loss. This can create
challenges for our patients with reading, taking a walk at the
Selected Readings
mall, or even driving. Safety and ability to live independently
can be significantly compromised. 1. Crabb DP, Smith ND, Glen FC, et al. How does glaucoma look?
Vision rehabilitation addresses these very challenges. Patient perception of visual field loss. Ophthalmology 2013;
Although the potential benefits of vision rehabilitation are 120(6):1120-1126.
known, many patients never benefit from these services because 2. Deemer AD, Goldstein JE, Ramulu PY. Approaching
they are not referred by their ophthalmologist. rehabilitation in patients with advanced glaucoma. Eye (Lond).
One of the challenges we face as ophthalmologists is iden- 2023; 37(10):1993-2006.
tifying the patient who may benefit from vision rehabilitation. 3. Haymes SA, Leblanc RP, Nicolela MT, et al. Risks of falls and
The Academy’s Vision Rehabilitation Preferred Practice Pattern motor vehicle collisions in glaucoma. Invest Ophthalmol Vis Sci.
(PPP) guidelines suggest offering referral to vision rehabilita- 2007; 48(3):1149-1155.
tion for patients with BCVA less than 20/40, visual field loss, a
4. Jackson ML, Virgili G, Shepherd JD, et al. Vision rehabilitation
scotoma, or contrast sensitivity loss. A screening questionnaire
Preferred Practice Pattern. Ophthalmology 2023; 130(3):271-335.
may be helpful. For example, the Glaucoma Activity Limitation
questionnaire consists of 9 questions and can be administered 5. Kaleem MA, Rajjoub R, Schiefer C, et al. Characteristics of
by office staff in a glaucoma practice. Perhaps the simplest way glaucoma patients attending vision rehabilitation services.
to identify an appropriate patient is to ask any patient with Ophthalmol Glaucoma. 2021; 4(6):638-645.
irreversible vision loss this one question: “Does your vision loss 6. Kaleem MA, Swenor BK, Shepherd JD, et al. Low vision services
make it difficult for you to participate in your favorite activi- and the glaucoma patient [editorial]. Ophthalmol Glaucoma.
ties?” A “yes” response should prompt a referral. 2019; 2(3):127-129.
Vision rehabilitation providers need to be seen as partners 7. Kaleem MA, West SK, Swenor BK, et al. Referral to low
with comprehensive ophthalmologists and glaucoma specialists vision services for glaucoma patients: referral patterns and
in the holistic care of glaucoma patients. Truly comprehensive characteristics of those who refer. J Glaucoma. 2017; 26(2):115-
patient care aims to protect the remaining vision through con- 120.
sistent care, restore what is lost through medical and surgical
8. Kaleem MA, West SK, Swenor BK, et al. Referral to low vision
treatments, and build on what remains through rehabilitation.
services for glaucoma patients: referral criteria and barriers. J
The Academy’s mission and motto is “Protecting sight. Empow- Glaucoma. 2018; 27(7):653-655.
ering lives.” While it is important to protect the sight of our
patients through appropriate medical and surgical treatments, 9. Khadka J, Pesudovs K, McAlinden C, et al. Reengineering the
it is equally important to empower their lives by providing the glaucoma quality of life-15 questionnaire with Rasch analysis.
Invest Ophthalmol Vis Sci. 2011; 52(9):6971-6977.
tools, counseling, and training needed to live as well as they can
despite irreversible vision loss. 10. Spaeth G, Walt J, Keener J. Evaluation of quality of life for
patients with glaucoma. Am J Ophthalmol. 2006; 141:S3-S14.
32 The American Glaucoma Society Subspecialty Day Lecture Subspecialty Day 2024  |  Glaucoma

The Unknowable Truths of Glaucoma: Dealing With

Uncertainty in Clinical Practice
Pradeep Y Ramulu MD PhD

I. Goals of Glaucoma Care VI. Uncertainty in OCT Imaging

II. Why do we get so many tests in glaucoma? A. Variability in different OCT measures
III. Trustworthiness of Testing B. Strategies for dealing with OCT variability
A. What does trustworthiness mean? C. Distinguishing OCT change from age-related
change
B. How do we incorporate trustworthiness in testing?
VII. Symptoms as a Tool for Glaucoma Evaluation
IV. Uncertainty in IOP Measurement
A. What words best capture glaucoma severity?
A. Interobserver variability of applanation tonometry
B. Can words meaningfully help us understand
B. Variability across different measurement methods
disease presence/severity?
(iCare, Tono-Pen)
C. Can symptoms help distinguish glaucoma from
C. Deviation of in-clinic and home tonometry
other diseases? How well?
D. Which measurement is “best”?
D. How to use symptoms in clinical practice
E. Do all IOP measurements need to be by
VIII. Making Decisions in the Context of Uncertainty
applanation?
V. Uncertainty in Visual Field Assessment
A. Test-to-test fluctuation in visual fields
B. Can you explain fluctuation with reliability
metrics?
C. Should we filter out “unreliable” tests to judge
progression?
D. Strategies for dealing with visual field variability
Subspecialty Day 2024  |  Glaucoma Section IV: Medication and Laser Innovations 33

Chicago Rx: New Medications, New Formulations

Douglas J Rhee MD

NOTES
34 Section IV: Medication and Laser Innovations Subspecialty Day 2024  |  Glaucoma

The Rise of GLP-1 Receptor Agonists

Qi N Cui MD

I. Introductions Selected Readings

A. Setting the stage: The burden of glaucoma 1. Sterling JK, Adetunji MO, Guttha S, et al. GLP-1 receptor agonist
NLY01 reduces retinal inflammation and neuron death secondary
B. Current glaucoma treatments and their limitations to ocular hypertension. Cell Rep. 2020; 33(5):108271.
C. Introduction to GLP-1R agonists and dual-agonists 2. Lawrence ECN, Guo M, Schwartz TD, et al. Topical and systemic
GLP-1R agonist administration both rescue retinal ganglion cells
1. What are they?
in hypertensive glaucoma. Front Cell Neurosci. 2023;17:1156829.
2. Insights from diabetes and weight management 3. Sterling J, Hua P, Dunaief JL, Cui QN, VanderBeek BL.
II. GLP-1RA: Mechanisms and Therapeutic Potential in Glucagon-like peptide 1 receptor agonist use is associated with
Glaucoma reduced risk for glaucoma. Br J Ophthalmol. 2023; 107(2):215-
220.
A. Neuroprotective mechanisms in CNS and relevance
4. Niazi S, Gnesin F, Thein AS, et al. Association between glucagon-
to glaucoma
like peptide-1 receptor agonists and the risk of glaucoma in
B. Evidence linking GLP-1R agonists to individuals with type 2 diabetes. Ophthalmology. Epub ahead of
neuroprotection print 2024 Mar 13. doi: 10.1016/j.ophtha.2024.03.004.

III. Preclinical Evidence Supporting GLP-1R Agonists for 5. Hallaj S, Halfpenny W, Chuter BG, Weinreb RN, Baxter
SL, Cui QN. Association between glucagon-like peptide
Treating Glaucoma
1 (GLP-1) receptor agonists exposure and intraocular
A. Mechanisms of action in the context of glaucoma pressure change. medRxiv. Preprint 2024 May 6. doi:
10.1101/2024.05.06.24306943.
IV. Retrospective Studies Supporting GLP-1R Agonists
for Treating Glaucoma 6. Guo M, Schwartz TD, Dunaief JL, Cui QN. Myeloid cells in
retinal and brain degeneration. FEBS J. 2021; 289(8):2337-2361.
V. Clinical Insights: Potential Pathway Linking GLP-1RA
Therapy to IOP Lowering
VI. Exploring Other Factors
A. Weight loss
B. Insulin pathways
VII. Implications for Future Research and Clinical Practice
VIII. Concluding Remarks
Subspecialty Day 2024  |  Glaucoma Section IV: Medication and Laser Innovations 35

Next-Gen Neuroprotection With Nicotinamide

Qing Wang MD PhD

NOTES
36 Section IV: Medication and Laser Innovations Subspecialty Day 2024  |  Glaucoma

Practical Ways to Help Patients With Adherence

Paula Anne Newman-Casey MD MS

I. Glaucoma Medication Adherence—Why Is It Selected Readings

Important?
1. Sleath B, Blalock S, Blalock S, et al. The relationship between
A. Association with glaucoma severity glaucoma medication adherence, eye drop technique, and visual
field defect severity. Ophthalmology 2011; 118(12):2398-2402.
B. Impact on field loss over time
2. Newman-Casey PA, Niziol LM, Niziol LM, et al. The association
II. Glaucoma Medication Adherence—Is It Really a between medication adherence and visual field progression in the
Problem? Collaborative Initial Glaucoma Treatment Study. Ophthalmology
2020; 127(4):477-483.
A. Persistence with different classes of glaucoma
medications 3. Nordstrom BL, Friedman DS, Mozaffari E, Quigley HA, Walker
AM. Persistence and adherence with topical glaucoma therapy.
B. Who persists with glaucoma medications over Am J Ophthalmol. 2005; 140(4):598-606.
time?
4. Newman-Casey PA, Blachley T, Lee PP, et al. Patterns of
III. Glaucoma Medication Adherence—Why Is It So glaucoma medication adherence over four years of follow-up.
Hard? Ophthalmology 2015; 122(10):2010-2021.

IV. Glaucoma Medication Adherence—How Can We 5. Newman-Casey PA, Robin AL, Blachley T, et al. The most
Improve? common barriers to glaucoma medication adherence: a cross-
sectional survey. Ophthalmology 2015; 122(7):1308-1316.
A. Expanding the glaucoma care team
6. Nieuwlaat R, Wilczynski N, Navarro T, et al. Interventions for
1. Medication Adherence in Glaucoma to Improve enhancing medication adherence. Cochrane Database Syst Rev.
Care (MAGIC) trial 2014; 20:CD000011.

2. Support, Educate, Empower (SEE) trial 7. Muir KW, Rosdahl J, Hein AM, et al. Improved glaucoma
medication adherence in a randomized controlled trial.
3. Lumata Health Ophthalmol Glaucoma. 2022; 5(1):40-46.

B. Helping patients feel heard 8. Newman-Casey PA, Niziol LM, Lee PP, et al. The impact of the
Support, Educate, Empower personalized glaucoma coaching
1. Asking open-ended questions pilot study on glaucoma medication adherence. Ophthalmol
2. Reflecting Glaucoma. 2020; 3(4):228-237.
9. Miller WR, Rollnick S. Motivational Interviewing: Helping
3. Asking permission to provide advice
People Change, 3rd ed. New York, NY: Guilford Press; 2013.
C. How can physicians help?
1. Assessing adherence on all patients
2. Addressing cost/side effects/complex drop
regimens
3. Assessing ability to instill drops
4. Organized ophthalmology can support
expansion of the glaucoma care team.
Subspecialty Day 2024  |  Glaucoma Section IV: Medication and Laser Innovations 37

Transforming Treatment: Novel Drug Delivery

Platforms
Robert M Kinast MD

Many patients struggle with eye drop adherence, including with

self-administration. Up to 90% of glaucoma subjects instill
drops incorrectly, either missing the eye, contacting the eye with
the bottle tip, or wasting drops. There are many novel drug
delivery platforms that can potentially improve adherence.

Intraocular Injectables
1. Bimatoprost sustained release (Durysta, Allergan)*
2. Travoprost sustained release (Paxtrava, Ocular Therapeu-
tix)
3. Travoprost sustained release (Travoprost XR, Alcon)
4. Travoprost intracameral implant (iDose TR, Glaukos)*
5. IOL drug delivery (Spyglass IOL, Spyglass Pharma)

Extraocular Implants
1. Punctal plugs (Evolute, Mati Therapeutics)
2. Contact lenses (LL-BMT1, MediPrint Ophthalmics)
3. Ocular inserts (Topical Ophthalmic Drug Delivery
Device, Amorphex Therapeutics) and rings (Bimatoprost
Ocular Ring, Allergan)
4. Subconjunctival injections and implants (VS-101, ViSci)

Eye Drop Sprays

1. Microdose spray (Optejet, Eyenovia)*

* Commercially available.
38 Section IV: Medication and Laser Innovations Subspecialty Day 2024  |  Glaucoma

Glaucoma Lasers: What’s New?

Sarah Van Tassel MD

I. Device Update II. Data Update: Clarifying the Optimal Application of

SLT Therapy (COAST) Trial Glaucoma Study
A. Excimer laser
A. Randomized clinical trial
1. Features
B. Either standard or low-energy SLT4
a. Implant free
C. At 12 months, patients will undergo repeat SLT
b. Safety similar to phaco alone
either annually at low energy or as needed at
c. Rapid learning curve due to similarity to initially assigned energy.
existing MIGS
D. 48-month success rates will be compared.
2. Supporting data: Multiple peer-reviewed
publications1
References
B. Femtosecond laser image-guided high-precision 1. Durr GM, Tötenberg-Harms M, Lewis R, Fea A, Marolo P,
trabeculotomy Ahmed IIK. Current review of excimer laser trabeculostomy. Eye
1. Features Vis (Lond). 2020; 7:24.

a. Treatment access in 4 quadrants 2. Nagy ZZ, Kranitz K, Ahmed IIK, De Francesco T, Mikula
E, Juhasz T. First-in-human safety study of femtosecond laser
b. No hand-held gonioprism image guided trabeculotomy for glaucoma treatment: 24-month
outcomes. Ophthalmol Sci. 2023; 3(4):100313.
c. Nonincisional delivery
3. Geffen N, Ofir S, Belkin A, et al. Transscleral selective laser
2. Supporting data: First-in-human safety data at trabeculoplasty without a gonioscopy lens. J Glaucoma. 2017;
24 months2 26(3):201-207.
C. Direct selective laser trabeculoplasty (SLT)3 4. Realini T, Gazzard G, Latina M, Kass M. Low-energy selective
laser trabeculoplasty repeated annually: rationale for the COAST
1. Features trial. J Glaucoma. 2021; 30(7):545-551.
a. No gonioprism
b. May enable SLT when angle view is poor or
positioning challenging
2. Supporting data: GLAUrious trial
Subspecialty Day 2024  |  Glaucoma Section V: The Latest Diagnostics for Glaucoma, and All That Jazz 39

Home Is Where the Jazz Is, But Is Home Testing

Ready for Prime Time?
Rachel Simpson MD

I. Review of Existing Home IOP Testing Technology The patient opts for home eye pressure monitoring.
Home IOP monitoring reveals IOP that frequently
Easy and accurate home eye pressure monitoring
spikes to the mid 30s and then slowly descends
is the dream of glaucoma clinicians and glaucoma
throughout the day to a nadir of 18. After
patients alike. With increasing availability of home eye
reviewing the iCare HOME data, the decision is
pressure monitoring systems, this dream may soon be
made to perform SLT. Post-SLT monitoring shows
reality.
significantly reduced IOP variability.
iCare HOME represents the first commercially
C. Case 3: Did it work?
available home eye pressure monitoring unit. The
device represents a significant advance in patient Patient is a 78-year-old male with POAG, with
monitoring of IOP. Home pressure monitoring has IOP of 25 OS on maximum medical therapy. iCare
always been limited by its relative dependence on the HOME monitoring shows an IOP range of 16-28
skill of the person performing the pressure reading. OS, with a mean IOP of 23. The patient undergoes
The iCare HOME has been shown to have similar Xen Gel Stent OS. His mean postop pressures
reliability indices to Goldmann applanation.1 in clinic are 14; however, his HVF continues to
progress. iCare HOME monitoring reveals an
II. Applying and Integrating Home IOP Monitoring Into
IOP range of 14-28, with a mean IOP of 23. The
Practice
decision was made to perform trab after Xen. His
A. Case 1: Well controlled with progression mean postop IOP is 12. Home IOP monitoring
reveals a range of IOP from 8 to 13.
Patient 1 is a 67-year-old male with a history of
severe primary open-angle glaucoma (POAG) with III. Limitations of Current Technology
progressing Humphrey visual fields (HVF) despite
Home IOP monitoring shows significant promise as a
IOP at his goal of low teens. The typical workup
key decision metric for glaucoma treatment. However,
for progressing glaucoma despite low IOP includes
there are still a number of issues limiting its use:
nocturnal hypotension and an obstructive sleep
apnea (OSA) evaluation. Adding iCare HOME A. Accessibility
testing to the workup reveals the patient is spiking
B. Affordability
into the 50s at 4:00 each morning.
C. Reliability
Without the iCare HOME testing data, clinical
decision-making would have been guided by IV. The Future of Home IOP Monitoring
negative OSA and hypotension testing, leading
A. Contact lenses
many to assume the patient needed a very low
pressure, possibly single digits. And most glaucoma B. Implantable barometric sensors2
surgeons would have been tempted to surgically
intervene. By revealing the early morning IOP
References
spikes, we know treatment should be aimed at
blunting his spikes, which are likely the cause of his 1. Ogle JJ, Soo Hoo WC, Chua CH, Yip LWL. Accuracy and
progression. reliability of self-measured intraocular pressure in glaucoma
patients using the iCare HOME tonometer. J Glaucoma. 2021;
The patient had selective laser trabeculoplasty 30(12):1027-1032.
(SLT), and post-SLT home testing showed blunting
2. Wu KY, Mina M, Carbonneau M, Marchand M, Tran SD.
of his previously noted spikes. His HVF has since
Advancements in wearable and implantable intraocular
stabilized. pressure biosensors for ophthalmology: a comprehensive review.
B. Case 2: To treat or not to treat Micromachines (Basel) 2023; 14(10):1915.

Patient 2 is a 56-year-old female glaucoma suspect

with myopic nerves and borderline thinning on
OCT. She has a positive family history and central
corneal thickness of 600 μm. She was referred due
to suspicious optic nerves. Her IOP is 20 OU. The
clinical question is, treat or observe?
40 Section V: The Latest Diagnostics for Glaucoma, and All That Jazz Subspecialty Day 2024  |  Glaucoma

Razzle Dazzle 2.0: Is OCT Angiography Clinically

Useful?
Sasan Moghimi MD

Optical coherence tomography angiography (OCT-A) is a OCT-A can detect progression in advanced glaucoma.
noninvasive, 3-dimensional imaging method for visualizing
■ In eyes with advanced glaucoma, there is a stronger rela-
and quantifying microvasculature throughout the retina. For
tionship between VD and VF than between retinal nerve
glaucoma evaluation, OCT-A provides quantitative assessment
fiber layer (RNFL) thickness and VF. The rate of macula
of vessel density (VD) in the peripapillary retina, the superficial
VD loss increases as glaucoma worsens. In contrast, there
and deep layers of the macula, and the choroid. The measure-
is no correlation between the rate of GCC thinning and
ments have good short-term and long-term repeatability and
VF severity.5
reproducibility. While the reproducibility is acceptable and bet-
■ In advanced glaucoma, particularly when VF mean devia-
ter than visual field (VF), variability of OCT-A is greater than
tion is worse than −14 dB, parafoveal VD is a promising
OCT.1
tool; macula VD does not have a detectable measurement
floor, whereas the RNFL typically reaches a floor at a
OCT-A and OCT are complementary. visual sensitivity loss of −10 to −12 dB.6
■ OCT-A and OCT measurements show similar efficiency
in detecting early glaucoma. However, one-third of early OCT-A can help assess risk of glaucoma progression.
glaucoma eyes showed greater percentage loss of VD than
■ Lower baseline macula and optic nerve head VD is asso-
ganglion cell complex (GCC) thickness.
ciated with a faster rate of OCT RNFL thinning in mild
■ VD loss is faster than GCC thinning in half of suspect
to moderate glaucoma.2,7
eyes. Moreover, 20% of suspect eyes had only significant
■ Choroidal VD dropout (corresponding to perfusion
loss of VD, and also faster VD loss than GCC thinning.2
defects on indocyanine green angiography) also has been
■ VD loss is more pronounced in senile sclerotic pheno-
suggested as a biomarker for VF deterioration or RNFL
types compared to generalized enlargement eyes and eyes
thinning, especially in eyes with disc hemorrhage. More-
with disc hemorrhage.3
over, it has been associated with faster central VF pro-
■ The effectiveness of using multimodal imaging to detect
gression and GCC thinning.8
glaucomatous progression has been established. Event-
■ OCT-A-measured VD changes during the initial period
based methods for examining glaucoma progression with
have shown superior predictive performance for future
OCT and OCT-A reveal that OCT-A identified 22%
VF progression compared to OCT.9,10 Fast OCT-A pro-
as progressors, while OCT identified 17%. Combining
gressors have double risk of VF progression.10 Further-
OCT and OCT-A increased the detection rate of progres-
more, combining OCT-A and OCT allows for a higher
sors to 34%.4
frequency of detecting future VF progression, indicating
their complementary roles in assessing the risk of glau-
coma progression (Figure 1).

Figure 1. Proportions of eyes with visual field

(VF) progression at the end of follow-up (5.7
years) from guided progression analysis using
OCT/OCT-A slopes during initial period (2
years).
Subspecialty Day 2024  |  Glaucoma Section V: The Latest Diagnostics for Glaucoma, and All That Jazz 41

Recommendations 4. Wu JH, Moghimi S, Nishida T, Mahmoudinezhad G, Zangwill

LM, Weinreb RN. Detection and agreement of event-based OCT
■ OCT-A is complementary to OCT and can be used spe- and OCTA analysis for glaucoma progression. Eye (Lond). 2024;
cifically for early glaucoma diagnosis, eyes with disc 38(5):973-979.
hemorrhages, risk assessment for prediction of glaucoma,
5. Hou H, Moghimi S, Zangwill LM, et al. Association between
and monitoring of glaucoma. This approach improves the
rates of retinal nerve fiber layer thinning after intraocular
accuracy and reliability of detecting disease progression, pressure–lowering procedures and disc hemorrhage. Ophthalmol
leading to better-informed clinical decisions and more Glaucoma. 2020; 3(1):7-13.
effective management of glaucoma.
■ Peripapillary VD metrics perform better than macula VD 6. Moghimi S, Bowd C, Zangwill LM, et al. Measurement floors
and dynamic ranges of OCT and OCT angiography in glaucoma.
in early glaucoma. Eyes with advanced glaucoma benefit
Ophthalmology 2019; 126(7):980-988.
from OCT-A imaging. In these eyes, superficial macular
VD using larger scans (6×6 mm) is advantageous to OCT 7. Kamalipour A, Moghimi S, Hou H, et al. Multilayer macula
as there is no detected floor. vessel density and visual field progression in glaucoma. Am J
■ Evaluation of peripapillary VD and choroidal drop-out is Ophthalmol. 2022; 237:193-203.
recommended to detect patients at high risk for glaucoma 8. Micheletti E, Moghimi S, Nishida T, et al. Rates of choroidal
progression. microvasculature dropout and retinal nerve fiber layer changes in
■ Testing 2 times per year may provide good information glaucoma. Am J Ophthalmol. 2022; 241:130-138.
for detecting progression in these patients.11 9. Nishida T, Moghimi S, Wu JH, et al. Association of initial optical
■ Up to 25% of OCT-A scans (using the SSADA algorithm) coherence tomography angiography vessel density loss with
have artifacts and poor quality, in comparison with less faster visual field loss in glaucoma. JAMA Ophthalmol. 2022;
than 3% of OCT scans.2,12 A systematic scan review is 140(4):319-326.
needed to ensure appropriate interpretation of OCT-A
10. Tansuebchueasai N, Nishida T, Moghimi S, et al. Rate of initial
images. optic nerve head capillary density loss and risk of visual field
progression. JAMA Ophthalmol. 2024; 142(6):530-537.
References 11. Mahmoudinezhad G, Moghimi S, Proudfoot JA, et al. Effect of
1. Wu JH, Moghimi S, Nishida T, et al. Evaluation of the long-term testing frequency on the time to detect glaucoma progression with
variability of macular OCT/OCTA and visual field parameters. Br optical coherence tomography (OCT) and OCT angiography. Am
J Ophthalmol. 2024; 108(2):211-216. J Ophthalmol. 2023; 245:184-192.

2. Hou H, Moghimi S, Kamalipour A, et al. Macular thickness and 12. Kamalipour A, Moghimi S, Hou H, et al. OCT angiography
microvasculature loss in glaucoma suspect eyes. Ophthalmol artifacts in glaucoma. Ophthalmology 2021; 128(10):1426-1437.
Glaucoma. 2022; 5(2):170-178.
3. Ekici E, Moghimi S, Bowd C, et al. Capillary density measured by
optical coherence tomography angiography in glaucomatous optic
disc phenotypes. Am J Ophthalmol. 2020; 219:261-270.
42 Section V: The Latest Diagnostics for Glaucoma, and All That Jazz Subspecialty Day 2024  |  Glaucoma

Glamour, Glitz, and Glaucoma Genetics:

When to Order Genetic Testing
Anthony P Khawaja MBBS

I. Glaucoma is one of the most genetic of all common 2. This can cost as low as $50 per sample and
human diseases. is the basis for low-cost direct-to-consumer
genotyping (eg, 23andMe, Ancestry).
A. Heritability estimates for glaucoma have been as
high as 70%, making glaucoma one of the most 3. A computational process called “imputing”
heritable of all common human diseases. can effectively map out all common variations
across the genetic code (>10 million variants)
B. While family history is a strong risk factor,
from genotyping data.
genetic tests can provide much more accurate risk
assessment for individuals. 4. Genotyping can be used to identify the genetic
risk variants for common, complex POAG.
II. Simple and Complex Forms of Primary Open-Angle
Glaucoma (POAG) 5. All common genetic risk variants can be
combined into a single risk score, commonly
A. In up to 4% of POAG, disease may be caused by a
referred to as a polygenic risk score (PRS).
single rare mutation in 1 gene.
B. Sequencing of the genetic code is also coming down
1. This “simple” form of POAG is inherited in a
in cost.
Mendelian fashion.
1. Sequencing involves reading the full genetic
2. The most frequent form of Mendelian glaucoma
code across the genome, or in specified parts.
is due to mutations in the myocilin gene and
inherited in an autosomal dominant fashion. 2. Unlike genotyping chips, sequencing identifies
rare variants in the genetic code which can cause
3. The single mutation is of such strong effect that
Mendelian forms of glaucoma.
we would expect the majority of people with
that mutation to develop disease. 3. Whole-genome sequencing aims to read the
whole genetic code.
B. The majority of POAG (likely >95% of cases) is
complex in nature. 4. Exome sequencing aims to read only the parts of
the genetic code that encode proteins.
1. Each individual risk factor (genetic or
environmental) for complex disease is not by 5. It is possible to sequence just a single gene if we
itself sufficient to cause disease, but rather are looking for a risk variant in that specific
increases risk by an incremental amount. gene only.
2. The majority of people with each individual risk 6. It is also possible to sequence a panel of genes
factor will not develop glaucoma. that are known to harbour variants that cause
a particular disease or type of disease (eg,
3. The cumulative effect of multiple risk factors
sequencing genes for Mendelian glaucoma or for
can reach a threshold when disease is caused.
inherited retinal dystrophies).
4. The genetic risk variants that contribute to
IV. Genetic Testing for Mendelian Glaucoma
complex glaucoma tend to be common variants
(ie, not rare mutations, but common variations A. Identifying a known disease-causing mutation can
in the genetic code). help confirm the diagnosis of early-onset glaucoma.
III. Types of Genetic Testing B. Screening of relatives for a known disease-causing
mutation that runs in a family can inform future
A. Genotyping of common genetic variations
management strategy.
(markers) across the whole genetic code is
increasingly available and affordable. 1. For relatives that carry the mutation, close
screening should be carried out to ensure timely
1. Genotyping “chips” can cheaply and accurately
treatment if early signs of disease manifest.
measure approaching 1 million points of the
genetic code at which we commonly vary. 2. For relatives without the mutation, they can be
reassured that they are at the general population
level of risk for glaucoma and close screening
may not be required.
Subspecialty Day 2024  |  Glaucoma Section V: The Latest Diagnostics for Glaucoma, and All That Jazz 43

3. This type of testing is particularly valuable V. Genetic Testing for Common, Complex POAG
for severe, autosomal dominant, early-onset
A. Polygenic risk scores (PRS) have been robustly
disease.
shown to predict the prevalence of glaucoma in the
4. More general “cascade testing” of relatives general population.
of patients with myocilin mutations has been
1. The evidence is predominantly in European
shown to potentially be of benefit.
populations, with the AUROC reaching 76%-
C. Screening all patients with POAG for myocilin 80% when considered together with age and
mutations is generally not advised as the yield of sex.
positive results will be too low.
2. This can help identify people at high risk of
D. However, the yield may be high enough with POAG, independently of a family history.
certain criteria (young age of onset, high maximum
3. Evidence is still required to know whether
IOP and strong family history). Identification of
screening of individuals with a high PRS in the
a myocilin mutation could then prompt cascade
general population would significantly prevent
genetic testing and early treatment of family
vision loss in a cost-effective manner.
members at high risk.
4. A glaucoma PRS is already widely available
E. There is also case report evidence that patients with
through the 23andMe platform, and clinicians
myocilin glaucoma may have particularly high
should be able to interpret and counsel patients
success rates with 360 degree trabeculotomy.
regarding their individual risk score.
F. Deciding whether to test patients or family
B. Early evidence suggests PRS may provide a degree
members for myocilin mutations may not be
of information regarding the risk of disease
straightforward, and genetic counselling should be
progression and the risk of requiring incisional
provided.
surgery. However, PRSs have not been formally
G. In the U.S., an example service testing for validated prospectively to assess their potential
known glaucoma-causing mutations genes is clinical utility, and further studies are required.
available from the Ocular Genomics Institute at
C. A PRS can be ordered by glaucoma specialists in
Massachusetts Eye and Ear (GEDi-O panel).
some countries (eg, Australia).
H. In the UK, whole-genome sequencing is available
D. Observational studies have suggested that genetic
in the National Health Service if patients fulfill
risk informed by a PRS can be modified by some
certain criteria such as a juvenile age of onset.
lifestyle modifications (eg, caffeine, alcohol, and
salt intake).
44 Section V: The Latest Diagnostics for Glaucoma, and All That Jazz Subspecialty Day 2024  |  Glaucoma

Perimetry Pizzazz: Latest Updates on Visual Fields

Andrew E Pouw MD

I. Improvements to Conventional Test Strategies: 4. Other study compared tablet MRF to

Humphrey/Zeiss: SITA-Faster Humphrey Field Analyzer over 4 visits during 6
months with good results and comparability.
A. Description of the strategy changes (Heijl et al.
PMID 30336129.1) IV. Optimizing the Signal From the Noise: Investigating
Optimal Frequency/Timing of Testing
B. Assessing the switch in clinical practice (Pham et
al. PMID 33798655.2) A. Frontloading fields investigations (Phu, Kalloniatis.
PMID 3477983613 and 33951444.14)
II. Test Modality Innovations: Virtual Reality
Two field tests per visit instead of 1 (used SITA-
A. Thresholding strategies: A variety of companies,
Faster) noted to have comparable reliability indices
products, and initial literature
and comparable identification repeatability of
1. Custom approaches (Stapelfeldt, et al. PMID deficits; simulations of 2 tests per visit vs. 1 test
34614166.3) every 6 months suggested superior detection rates
for 2 tests/year.
2. C3 analyzer (Mees, et al. PMID 31790067.4)
B. Fast-PACE: clustering fields (Medeiros, et al. PMID
3. VisuALL (Olleyes) (Razeghinejad, et al. PMID
38160883.15)
32941320.5)
1. 125 eyes of 65 patients: 2 sets of 5 weekly visits
4. SmartSystem (M&S) (Najdawi, et al. Citation
(cluster 1 and 2), 6 months apart, then single
pending. Full disclosure: This is what I’m
visits every 6 months after that
working on.)
2. Of the 35 eyes noted to progress, 25 had such
5. Radius XR (Glaukos; no published literature so
progression detected between the first 2 clusters
far.)
(71% sensitivity).
6. Virtual Field (Hu, et al. PMID 35577312.6)
7. Maybe more if I find out about them between References
now and November!
1. Heijl A, Patella VM, Chong LX, et al. A new SITA perimetric
B. Oculokinetic strategy threshold testing algorithm: construction and a multicenter
clinical study. Am J Ophthalmol. 2019; 198:154-165.
Historical concept (Damato. PMID 4084485.7),
2. Pham AT, Ramulu PY, Boland MV, Yohannan J. The effect of
now in VR perimeter (Vivid Vision, Greenfield, et
transitioning from SITA Standard to SITA Faster on visual field
al. PMID 36276927.8)
performance. Ophthalmology 2021; 128(10):1417-1425.
C. Open source initiatives/smartphones 3. Stapelfeldt J, Kucur SS, Huber N, Hohn R, Sznitman R. Virtual
Also thresholding, but unique: smartphones plus reality−based and conventional visual field examination
open source programming: Iowa Head Mounted comparison in healthy and glaucoma patients. Transl Vis Sci
Technol. 2021; 10(12):10.
Perimeter/OPI Interface (Wall, et al. PMID
37747414.9 Turpin, et al. PMID 35385053.10) 4. Mees L, Upadhyaya S, Kumar P, et al. Validation of a head-
mounted virtual reality visual field screening device. J Glaucoma.
III. Teleglaucoma 2020; 29(2):86-91.
A. VR perimeters? Would depend on price point, I 5. Razeghinejad R, Gonzalez-Garcia A, Myers JS, Katz LJ.
think. Preliminary report on a novel virtual reality perimeter compared
with standard automated perimetry. J Glaucoma. 2021; 30(1):17-
B. Tablet-based perimetry
23.
1. Melbourne Rapid Fields (MRF) on tablet 6. Hu GY, Prasad J, Chen DK, Alcantara-Castillo JC, Patel
computers (Prea, et al. PMID 35893408.11 Also VN, Al-Aswad LA. Home monitoring of glaucoma using a
29550190.12) home tonometer and a novel virtual reality visual field device:
acceptability and feasibility. Ophthalmol Glaucoma. 2023;
2. Tested patient compliance with weekly home-
6(2):121-128.
testing with MRF fields using tablets and
checking proportion of tests with adequate 7. Damato BE. Oculokinetic perimetry: a simple visual field test for
reliability indices, over 12 months. use in the community. Br J Ophthalmol. 1985; 69(12):927-931.

3. 75% compliance rate, 2/3 reliable 8. Greenfield JA, Deiner M, Nguyen A, et al. Virtual reality
oculokinetic perimetry test reproducibility and relationship
to conventional perimetry and OCT. Ophthalmol Sci. 2021;
2(1):100105.
Subspecialty Day 2024  |  Glaucoma Section V: The Latest Diagnostics for Glaucoma, and All That Jazz 45

9. Heinzman Z, Linton E, Marín-Franch I, et al. Validation of

the Iowa head-mounted open-source perimeter. Transl Vis Sci
Technol. 2023; 12(9):19.
10. Marín-Franch I, Turpin A, Artes PH, et al. The Open Perimetry
Initiative: a framework for cross-platform development for the
new generation of portable perimeters. J Vis. 2022; 22(5):1.
11. Prea SM, Vingrys AJ, Kong GYX. Test reliability and compliance
to a twelve-month visual field telemedicine study in glaucoma
patients. J Clin Med. 2022; 11(15):4317.
12. Prea SM, Kong YXG, Mehta A, et al. Six-month longitudinal
comparison of a portable table perimeter with the Humphrey
Field Analyzer. Am J Ophthalmol. 2018; 190:9-16.
13. Phu J, Kalloniatis M. The Frontloading Fields study (FFS):
detecting changes in mean deviation in glaucoma using multiple
visual field tests per clinical visit. Transl Vis Sci Technol. 2021;
10(13):21.
14. Phu J, Kalloniatis M. Viability of performing multiple 24-2 visual
field examinations at the same clinical visit: the Frontloading
Fields study (FFS). Am J Ophthalmol. 2021; 230:48-59.
15. Medeiros FA, Malek DA, Tseng H, et al. Short-term detection of
fast progressors in glaucoma: the Fast Progression Assessment
through Clustered Evaluation (Fast-PACE) study. Ophthalmology
2024; 131(6):645-657.
46 Section V: The Latest Diagnostics for Glaucoma, and All That Jazz Subspecialty Day 2024  |  Glaucoma

Is Anterior Segment OCT Alluring? Practical Tips to

Incorporate Into Your Practice
Lauren S Blieden MD

Objectives
1. Learn the alphabet soup of anterior segment OCT (AS-
OCT)
2. Applications of the results: Is the angle open or closed?
3. Practical applications: How to use this information in a
practical way

Abstract
After this brief presentation, the learner should be able to dis-
tinguish between open and closed angles on AS-OCT imaging,
discuss the role of AS-OCT vs. gonioscopy in patient evalua-
tion, and allow the AS-OCT findings to guide clinical manage-
ment and/or treatment of glaucoma patients.
Subspecialty Day 2024  |  Glaucoma Section V: The Latest Diagnostics for Glaucoma, and All That Jazz 47

OCT Onstage: Updates on Diagnostic Imaging

Rithambara Ramachandran MD

I. The Past: Brief History of OCT D. Role for Bruch membrane opening–minimum rim
width?
Timeline of OCT advancement from 1976 onward.
III. On the Horizon: Advances in OCT technology
II. The Present: Pearls for Optimizing OCT in Clinical
Practice A. OCT angiography: Evaluations of vessel density,
microvascular dropout, peripapillary perfusion
A. It is important to move beyond cursory glances at
the color quadrants. B. OCT adaptive optics: Increased resolution
of images, visualization of retinal nerve fiber
1. Often misses focal defects due to averaging
layer bundles and areas of dropout, improved
effect
understanding of the lamina cribrosa’s
2. Common causes of red disease (false-positive microstructure
disease diagnosis)
C. Vis-OCT: Increased resolution of images by using
a. Poor signal strength visible wavelength of light
b. High myopia D. Intraoperative OCT: Application to both MIGS
and traditional glaucoma surgery
c. Tilted discs
E. Portable OCT: Handheld devices, at-home devices,
d. Vessel displacement
phone- and tablet-based devices
e. Peripapillary atrophy
IV. The Future: OCT and AI
3. Common causes of green disease (false-negative
A. Disease detection: Feature-dependent vs. feature-
disease diagnosis)
agnostic approaches
a. Peripapillary traction
B. Mapping structure to function: Predicting visual
b. Hyaloid thickening field changes from OCT images
c. Edema C. Progression prediction
d. Optic nerve head drusen 1. Forecasting visual field changes
e. Thicker than average baseline 2. Differentiating “slow progressors” from “rapid
progressors”
4. We need to expand our OCT normative
databases to include large sample of individuals
of more varied ages, refractive statuses, Selected Readings
geographic origins, systemic conditions, and life
1. Song G, Jelly ET, Chu KK, Kendall WY, Wax A. A review of low-
experiences. cost and portable optical coherence tomography. Prog Biomed
B. Always examine the B-scan. Eng (Bristol). 2021; 3(3):032002.

1. Scan quality 2. Englmaier VA, Storp JJ, Leclaire MD, et al. Accuracy of Bruch’s
membrane opening minimum rim width and retinal nerve fiber
2. Segmentation errors layer thickness in glaucoma diagnosis depending on optic disc
size. Graefes Arch Clin Exp Ophthalmol. 2024; 262(6):1899-
3. Focal glaucomatous defects 1910.
C. Pay attention to the macula 3. Dong ZM, Wollstein G, Wang B, Schuman JS. Adaptive optics
optical coherence tomography in glaucoma. Prog Retin Eye Res.
1. Nerve fibers from the papillomacular bundle
2017; 57:76-88.
feed into the temporal quadrant of the disc,
and therefore this is an important predictor of 4. Rufai SR. Handheld optical coherence tomography removes
central visual acuity. barriers to imaging the eyes of young children. Eye (Lond). 2022;
36(5):907-908.
2. Integration of the macular ganglion cell–inner
plexiform layer and circumpapillary retinal 5. Hood DC. Improving our understanding, and detection, of
glaucomatous damage: an approach based upon optical coherence
nerve fiber layer maps aid in the detection of
tomography (OCT). Prog Retin Eye Res. 2017; 57:46-75.
true arcuate defects.
6. Ang BCH, Lim SY, Dorairaj S. Intra-operative optical coherence
3. Macular damage can be missed with over- tomography in glaucoma surgery—a systematic review. Eye
reliance on global averages and 24-2 HVF tests. (Lond). 2020; 34(1):168-177.
48 Section V: The Latest Diagnostics for Glaucoma, and All That Jazz Subspecialty Day 2024  |  Glaucoma

7. Rank EA, Agneter A, Schmoll T, Leitgeb RA, Drexler

W. Miniaturizing optical coherence tomography. Transl
Biophotonics. 2022; 4(1-2):e202100007.
8. Geevarghese A, Wollstein G, Ishikawa H, Schuman JS. Optical
coherence tomography and glaucoma. Annu Rev Vis Sci. 2021;
7:693-726.
9. Van Melkebeke L, Barbosa-Breda J, Huygens M, Stalmans I.
Optical coherence tomography angiography in glaucoma: a
review. Ophthalmic Res. 2018; 60(3):139-151.
10. Chopra R, Wagner SK, Keane PA. Optical coherence tomography
in the 2020s—outside the eye clinic. Eye 2021; 35(1):236-243.
11. Kotcharlakota D, Choudhari NS. Role of adaptive optics in
early diagnosis of glaucoma from a clinician’s perspective. Semin
Ophthalmol. 2023; 38(1):44-51.
12. Fujimoto J, Swanson E. The development, commercialization, and
impact of optical coherence tomography. Invest Ophthalmol Vis
Sci. 2016; 57(9):OCT1-OCT13.
13. Swaminathan SS, Chang TC. Use of intraoperative optical
coherence tomography for tube positioning in glaucoma surgery.
JAMA Ophthalmol. 2017; 135(12):1438-1439.
14. Song W, Zhang S, Kim YM, et al. Visible light optical coherence
tomography of peripapillary retinal nerve fiber layer reflectivity in
glaucoma. Transl Vis Sci Technol. 2022; 11(9):28.
Subspecialty Day 2024  |  Glaucoma Section VI: Great Debates From the Land of Lincoln 49

Tube/Trab Failed: What Next? I Vote for Second Tube

Marlene R Moster MD

Placing a tube has evolved into a first-line surgical approach for

glaucoma progression, challenging trabeculectomy as a “stan-
dard of care.” However, many tubes as well as trabs fail over
time. The 5-year treatment outcomes in the Tube vs. Trabecu-
lectomy (TVT) study showed that the cumulative probability of
failure during 5 years of follow-up was 29.8% in the tube group
and 46.9% in the trabeculectomy group (P = .002; hazard
ratio = 2.15; 95% CI, 1.30-3.56). The rate of reoperation for
glaucoma was 9% in the tube group and 29% in the trabecu-
lectomy group (P = .025).1 When this occurs, treatment options
include a repeat tube shunt, trabeculectomy (if there is sufficient
conjunctiva), cyclophotocoagulation, or on rare occasions, a
combination of MIGS. Each of these approaches has its unique
benefits and complications.
A second tube has proven to be an excellent approach to
decreasing the IOP when a tube fails and is at least as effective
as a cyclophotocoagulation.2

References
1. Gedde SJ, Schiffman JC, Feuer WJ, Herndon LW, Brandt JD,
Budenz DL; Tube versus Trabeculectomy Study Group. Treatment
outcomes in the Tube Versus Trabeculectomy (TVT) study after
five years of follow-up. Am J Ophthalmol. 2012; 153(5):789-803.
e2.
2. Feldman RM, Chuang AZ, Mansberger SL, et al; ASSISTS
Group. Outcomes of the Second Aqueous Shunt Implant
Versus Transscleral Cyclophotocoagulation Treatment study: a
randomized comparative trial. J Glaucoma. 2022; 31(9):701-709.
50 Section VI: Great Debates From the Land of Lincoln Subspecialty Day 2024  |  Glaucoma

Tube/Trab Failed: What Next? I Vote for Ciliary

Body Laser
Richard Lee MD

I. Why Cyclophotocoagulation (CPC) as Secondary References

Surgery After a Failed Tube or Trabeculectomy?
1. Feldman RM, Chuang AZ, Mansberger SL, et al; the ASSISTS
A. Prospective randomized clinical trial results1 Group. Outcomes of the Second Aqueous Shunt Implant
Versus Transscleral Cyclophotocoagulation Treatment Study: a
B. Short-term overall success rates were high with randomized comparative trial. J Glaucoma. 2022; 31(9):701-709.
either second glaucoma drainage device (SGDD) or
2. Duerr ERH, Sayed MS, Moster SJ, et al. Transscleral diode laser
CPC. However, SGDD was associated with more
cyclophotocoagulation: a comparison of slow coagulation and
clinic visits and an increased risk of additional standard coagulation techniques. Ophthalmol Glaucoma. 2018;
glaucoma surgery. 1(2):115-122.
C. CPC in study was with “pop” settings. 3. Khodeiry MM, Liu X, Lee RK. Clinical outcomes of slow-
Improved results with “slow burn” transscleral coagulation continuous-wave transscleral cyclophotocoagulation
cyclophotocoagulation (TS-CPC) laser.2 laser for treatment of glaucoma. Curr Opin Ophthalmol. 2022;
33(3):237-242.
II. Why TS-CPC?
4. Khodeiry MM, Sheheitli H, Sayed SS, Persad PJ, Feuer W,
A. CPC is the most versatile and minimally invasive Lee RK. Treatment outcomes of slow coagulation transscleral
glaucoma surgery.3 cyclophotocoagulation in pseudophakic patients with medically
uncontrolled glaucoma. Am J Ophthalmol. 2021; 229:90-99.
B. CPC does not affect the conjunctival real estate, so
all glaucoma surgery options are still possible. 5. Elhusseiny AM, Khodeiry MM, Liu X, Syed MS, Lee RK. Slow-
coagulation transscleral cyclophotocoagulation laser treatment
C. Rapid recovery with immediate return to activities for medically uncontrolled secondary aphakic adult glaucoma. J
of daily living, even day of surgery Glaucoma. 2023; 32(8):695-700.
D. Slow-burn TS-CPC is effective as a primary 6. Khodeiry MM, Lauter AJ, Sayed MS, Han Y, Lee RK. Primary
glaucoma surgery.4 slow-coagulation trans-scleral cyclophotocoagulation laser
treatment for medically recalcitrant neovascular glaucoma. Br J
E. Slow-burn TS-CPC is effective as a primary or Ophthalmol. 2023; 107(5):671-676.
secondary glaucoma surgery for complex and
recalcitrant glaucomas (ie, aphakic glaucoma,5 7. Khodeiry MM, Liu X, Sayed MS, Lee RK. Outcomes of primary
neovascular glaucoma,6 corneal transplant angle- surgical treatment of medically recalcitrant post-keratoplasty
glaucoma with transscleral cyclophotocoagulation. Eur J
closure glaucoma,7 silicone oil glaucoma,8 etc.)
Ophthalmol. 2023; 33(4):1658-1665.
8. Khodeiry MM, Liu X, Sheheitli H, Sayed MS, Lee RK. Slow
coagulation transscleral cyclophotocoagulation for post-
vitrectomy patients with silicone oil-induced glaucoma. J
Glaucoma. 2021; 30(9):789-794.
Subspecialty Day 2024  |  Glaucoma Section VI: Great Debates From the Land of Lincoln 51

We Can Successfully Treat Poor Adherence!

Intracameral Drug Delivery
Leonard K Seibold MD

I. Unrealistic Reliance on Eyedrops V. Intracameral Drug Delivery

Even when taken perfectly, IOP reduction is variable A. Two currently available options
with topical therapies.
1. Durysta
II. The Problem of Medication Adherence
a. Bimatoprost (10 mcg) sustained release,
A. Widely prevalent issue for glaucoma patients dissolvable
B. Associated with disease progression b. Approved for single use
C. Under-recognized by doctors, under-reported by c. 4-6 month duration, subset of patients with
patients 2+ years effect
D. Multifactorial causes d. Excellent clinical trial and real-world safety
data
1. Cost concerns/insurance coverage
e. Simple in-office procedure
2. Side effects/intolerance
2. iDose
3. Allergy, immediate or late onset
a. Travoprost (75 mcg) sustained-release
4. Poor patient understanding of disease and lack
titanium implant
of immediate benefit
b. Implant anchored to trabecular meshwork
III. Alternatives to Eyedrop Therapy
c. Two pivotal trials: noninferior to timolol at 3
A. Selective laser trabeculoplasty
months
B. Intracameral drug delivery
d. 81% of recipients medication free at 1 year
C. MIGS
e. Efficacy out to 36 months
D. Traditional surgery
VI. Future Directions With Intracameral Drug Delivery
IV. The Case for Intracameral Drug Delivery
A. The natural next step in therapy—why jump to Selected Readings
more invasive measures?
1. Berdahl JP, Sarkisian SR, Ang RE, et al. Efficacy and safety of the
B. Can be performed in office travoprost intraocular implant in reducing topical IOP-lowering
medication burden in patients with open-angle glaucoma or
C. Least invasive, with no tissue destruction ocular hypertension. Drugs 2024; 84(1):83-97.
D. Topical test to ensure treatment response 2. Bacharach J, Tatham A, Ferguson G, et al. Phase 3, randomized,
20-month study of the efficacy and safety of bimatoprost implant
E. Lowest risk option in patients with open-angle glaucoma and ocular hypertension
F. Can be done in any lens status; no need to pair with (ARTEMIS 2). Drugs 2021; 81(17):2017-2033.
phaco
G. Save MIGS/surgery for another day
52 Section VI: Great Debates From the Land of Lincoln Subspecialty Day 2024  |  Glaucoma

Poor Adherence? Just Operate!

Andrew M Williams MD

I. Glaucoma medication adherence is suboptimal, and VI. Nonincisional surgical options could be considered,
lower self-reported adherence is associated with perhaps particularly for patients with inconsistent
increased risk of disease progression.1 follow-up. Emerging evidence suggests that “low
and slow” techniques of transscleral CPC can lead
II. For a patient who presents with poor adherence to
to long-term IOP control safely in eyes with good
topical medical therapy, there are several options:
visual function. And it generally requires less frequent
A. Counseling and education2 follow-up than incisional procedures and may be
performed in office settings.8
B. Office-based intervention, such as laser
trabeculoplasty or intracameral medication injection VII. Excellent surgical options are available for a patient
with poor adherence.
C. Surgery: MIGS, trabeculectomy, tube shunt,
transscleral cyclophotocoagulation (CPC) A. Even in mild or stable glaucoma, surgical
treatment can effectively lower IOP and reduce IOP
III. Surgery is an excellent choice because of the range
fluctuations.
of surgical options available. Choice of surgical
procedure would depend on 3 factors: B. Surgical options are repeatable if 1 procedure fails
over time.
A. The glaucoma (stability, severity, and type of
glaucoma) C. Intracameral drug delivery has possible promise in
the future, but absence of repeatability limits the
B. The lens status (visually significant cataract or not)
utility of this mechanism as long-term therapy.
C. Patient factors (expected follow-up adherence,
lifestyle considerations, and whether the goal is to
References
remain drop-free in the long run)
1. Newman-Casey PA, Niziol LM, Gillespie BW, Janz NK, Lichter
IV. Surgical Considerations for Different Glaucoma PR, Musch DC. The association between medication adherence
Characteristics and visual field progression in the Collaborative Initial Glaucoma
A. For low-target IOP and high motivation to be Treatment Study. Ophthalmology 2020; 127(4):477-483.
drop free, trabeculectomy has high success. In the 2. Muir KW, Rosdahl JA, Hein AM, et al. Improved glaucoma
Treatment of Advanced Glaucoma Study (TAGS), medication adherence in a randomized controlled trial.
primary trabeculectomy resulted in lower IOP Ophthalmol Glaucoma. 2022; 5(1):40-46.
compared to primary medication with similar 3. Bicket AK, Le JT, Azuara-Blanco A, et al. Minimally invasive
quality of life and safety outcomes. glaucoma surgical techniques for open-angle glaucoma: an
overview of Cochrane Systematic Reviews and network meta-
B. Less invasive options can achieve IOP goal across
analysis. JAMA Ophthalmol. 2021; 139(9):983-989.
the spectrum of glaucoma severity.
4. Vold SD, Williamson BK, Hirsch L, et al. Canaloplasty and
1. MIGS procedures can improve the probability trabeculotomy with the OMNI System in pseudophakic patients
of drop-free disease control compared to with open-angle glaucoma: the ROMEO study. Ophthalmol
cataract surgery alone.3 Glaucoma. 2021; 4(2):173-181.
2. MIGS procedures can provide an opportunity 5. Sarkisian SR Jr, Grover DS, Gallardo MJ, et al; iStent infinite
for IOP control even without concomitant Study Group. Effectiveness and safety of iStent Infinite trabecular
cataract surgery across glaucoma severity micro-bypass for uncontrolled glaucoma. J Glaucoma. 2023;
levels, as demonstrated for canaloplasty4 and 32(1):9-18.
trabecular bypass stent.5 6. Montesano G, Ometto G, Ahmed II, et al. Five-year visual field
outcomes of the HORIZON trial. Am J Ophthalmol. 2023;
3. MIGS procedures generally have a better safety
251:143-155.
profile than filtering surgery and generally
require fewer postoperative visits. More 7. Rothman AL, Chang TC, Lum F, Vanner EA. Intraocular
importantly, MIGS can reduce medication pressure changes following stand-alone phacoemulsification: an
burden and slow disease progression.6 IRIS Registry analysis. Am J Ophthalmol. 2023; 245:25-36.
8. Khodeiry MM, Sheheitli H, Sayed MS, Persad PJ, Feuer WJ,
V. Surgery provides an opportunity to address cataract.
Lee RK. Treatment outcomes of slow coagulation transscleral
A. Cataract surgery alone lowers IOP by about cyclophotocoagulation in pseudophakic patients with medically
2 mmHg among glaucoma patients.7 uncontrolled glaucoma. Am J Ophthalmol. 2021; 229:90-99.

B. Cataract surgery allows for intervention with 9. King AJ, Hudson J, Fernie G, et al; TAGS Study Group. Primary
MIGS procedures, some of which are approved for trabeculectomy for advanced glaucoma: pragmatic multicentre
randomised controlled trial (TAGS). BMJ. 2021; 373:n1014.
use only at the time of cataract surgery.
Subspecialty Day 2024  |  Glaucoma Section VI: Great Debates From the Land of Lincoln 53

Mild Glaucoma With Phaco: Nearly Always/Always

Offer Minimally Invasive Glaucoma Surgery With IOP
Controlled on 1 Med
Oluwatosin U Smith MD

Minimally invasive glaucoma surgery (MIGS) is being quickly

adopted by many as a treatment option for patients with mild
to moderate disease. This could be an option for treatment in
patients with poorly controlled glaucoma as well as those stable
on current topical medical therapy in combination with cataract
surgery.
Many of the surgical options in this category are safe and
involve angle-based surgery that allows opportunity for more
invasive surgical options in the future. The reasons for the deci-
sion to proceed with a MIGS at the time of cataract surgery
is varied and extends beyond control of IOP and number of
topical drops. The impact of this decision could be seen in the
course of a patient’s glaucoma journey and its long-term out-
comes.

Selected Reading
1. Jones L, Maes N, Qidwai U, Ratnarajan G. Impact of minimally
invasive glaucoma surgery on the ocular surface and quality of
life in patients with glaucoma. Ther Adv Ophthalmol. 2023;
15:25158414231152765.
54 Section VI: Great Debates From the Land of Lincoln Subspecialty Day 2024  |  Glaucoma

Mild Glaucoma With Phaco: Minimally Invasive

Glaucoma Surgery Not Necessary if IOP Controlled
on 1 Med
Cindy M Hutnik MD PhD

The goal of glaucoma management is to maintain the IOP

within a range at which visual field loss is unlikely to substan-
tially reduce a patient’s health-related quality of life over his or
her lifetime.1 Several options to lower IOP are now available
that have challenged the traditional treatment algorithm. This
has introduced an element of uncertainty as to what the best
options are for the patient in your office. Sharing decision-mak-
ing involving the patient is an expectation, with several factors,
such as stage of the disease, dosing, adherence, cost, accessibil-
ity, local and systemic comorbidities, and patient preference, all
needing to be considered.2
The last decade has witnessed the emergence of minimally
invasive glaucoma surgical (MIGS) procedures with reported
safety profiles that have prompted consideration of earlier adop-
tion in the management algorithm.3 The question is: Are we
ready to position MIGS at the beginning of the algorithm?

References
1. Chauhan BC, Garway-Heath DF, Goni FJ, et al. Practical
recommendations for measuring rates of visual field change in
glaucoma. Br J Ophthalmol. 2008; 92:569-573.
2. Singh K, Lee BL, Wilson MR; Glaucoma Modified RAND-
Like Methodology Group. A panel assessment of glaucoma
management: modification of existing RAND-like methodology
for consensus in ophthalmology. Part II: Results and
interpretation. Am J Ophthalmol. 2008; 145:575-581.
3. Ang BCH, Lim SY, Betzler BK, et. Recent advancements in
glaucoma surgery—a review. Bioengineering 2023; 10:1-27.
Subspecialty Day 2024  |  Glaucoma Section VI: Great Debates From the Land of Lincoln 55

Managing the Super Senior (>90 yo) With Advanced,

Progressive Disease: Observe
Kuldev Singh MD MPH

NOTES
56 Section VI: Great Debates From the Land of Lincoln Subspecialty Day 2024  |  Glaucoma

Managing the Super Senior (>90 yo) With Advanced,

Progressive Disease: Surgery
Jody R Piltz MD

I. Introduction C. Difficult to distinguish real glaucoma progression

from other ocular pathologies, artifact
Managing a super senior poses unique challenges.
As with every decision in medicine, the decision of D. May have greater difficulty with medical
whether to proceed with surgery in a progressing management
super senior “depends.” During this debate, the factors
1. Physical difficulties instilling drops: arthritis,
that need to be considered and the unique challenges
tremors
in this demographic will be addressed. Ultimately,
it will be clear that when the individual’s quality of 2. Memory issues: Forgetting to use drops or if
life (QoL) is at risk, we, as glaucoma surgeons, must they have already taken them
address the surgical option with the patient and
3. If dependent on others at care facility, risk of
family—no matter how old they are.
irregular use, increased stress of relinquished
II. Assess Life Expectancy and Current QoL control
A. Current health 4. More pronounced side effects of glaucoma
medications
B. Current QoL
V. Try conservative options first.
C. Life expectancy
A. Family assistance
D. Extent of glaucoma
B. Older meds
E. Degree glaucoma deficits impact QoL
C. Address non-IOP factors
1. Currently
VI. But if still progressing, move on to surgery if QoL
2. Anticipated in future based on decision to
balance indicates.
operate or not
VII. Be prepared for increased risk of complications.
III. Importance of Vision in Super Seniors
A. Suprachoroidal hemorrhage, intraop or delayed
A. As ambulation decreases, the importance of near
postop
vision for QoL increases.
B. Brittle blood vessels
B. Safety: Better vision helps to decrease risk of falls
and accidents, which is vitally important to health C. Increased use of anticoagulants
and QoL of super seniors.
D. Friable conjunctiva
IV. Super Seniors Are Not the Same as Younger Seniors,
E. Scarred conjunctiva from prior surgeries or years of
Age 65-85
topical therapy
A. Greater trouble assessing progression
F. Delayed wound healing
1. Less accurate visual field exams
G. Anesthesia issues
2. OCTs may already be at the floor.
VIII. Maximize laser first.
3. Optic nerves may be too advanced to assess for
A. Selective laser trabeculoplasty
change.
B. Consider cyclophotocoagulation in high-risk super
B. May have more rapid progression
seniors.
1. Sudden decompensation with acute IOP
1. Noninvasive procedure
elevations
2. Short anesthesia duration
2. Non-IOP factors may play an increasingly
important role. 3. Need for fewer postop drops and appointments
a. Vascular disease 4. Lower risk of postop complications
b. Impaired autoregulation 5. Individuals do not have to alter their activities.
c. Unstable BP
d. Other health issues
Subspecialty Day 2024  |  Glaucoma Section VI: Great Debates From the Land of Lincoln 57

C. Consider tube or Xen instead of trabeculectomy if Selected Readings

incisional surgery is needed.
1. Choi HG, Lee MJ, Lee SM. Mortality and causes of death in a
1. Decreased risk of hypotony population with blindness in Korea: a longitudinal follow-up
study using a national sample cohort. Sci Rep. 2020; 10:4891.
2. Possibly more controlled postoperative course
2. Haymes SA, Leblanc RP, Nicolela MT, Chiasson LA, Chauhan
D. MIGs is unlikely to be helpful. BC. Risk of falls and motor vehicle collisions in glaucoma. Invest
Ophthalmol Vis Sci. 2007; 48:1149-1155.
1. More likely to have scarred drainage outflow
systems 3. Siegfried CJ. Meeting the needs of the emerging ‘super senior.’ Rev
Ophthalmol. July 2014.
2. Prefer to avoid need for multiple trips to OR
4. Tseng VL, Chlebowski RT, Yu F, et al. Association of cataract
IX. Conclusion surgery with mortality in older women: findings from the
Women’s Health Initiative. JAMA Ophthalmol. 2018; 136(1):3-
It is important to remember that super seniors deserve
10.
to enjoy their years with the best possible QoL. It is
our responsibility to do whatever is in our arsenal to
facilitate this.
58 Section VI: Great Debates From the Land of Lincoln Subspecialty Day 2024  |  Glaucoma

Primary Angle Closure Suspect/Early Glaucoma:

Phaco
Nathan M Radcliffe MD

Patients with early primary angle-closure glaucoma and

primary angle-closure glaucoma suspects present a unique
dilemma for the clinician. Laser iridotomy provides a benefit
but does not entirely address the fundamental angle-closure
mechanism, which is induced by the enlarging cataractous lens.
That said, the Zhongshan Angle Closure Prevention (ZAP)
randomized controlled trial (RCT) demonstrated that although
iridotomy had a benefit, the overall likelihood of angle closure
disease was low.1 For patients with elevated IOP and angle clo-
sure, clear lens/cataract extraction has been shown to be supe-
rior in many aspects to laser in the EAGLE RCT.2 Therefore,
thoughtful and patient-tailored assessment of risk factors and
glaucoma staging is crucial to determine which angle-closure
suspects or those with early angle-closure glaucoma would best
benefit from clear lens extraction.

References
1. He M, Jiang Y, Huang S, et al. Laser peripheral iridotomy for
the prevention of angle closure: a single-centre, randomised
controlled trial. Lancet 2019; 393(10181):1609-1618.
2. Azuara-Blanco A, Burr J, Ramsay C, et al; EAGLE study group.
Effectiveness of early lens extraction for the treatment of primary
angle-closure glaucoma (EAGLE): a randomised controlled trial.
Lancet. 2016; 388(10052):1389-1397.
Subspecialty Day 2024  |  Glaucoma Section VI: Great Debates From the Land of Lincoln 59

Primary Angle Closure Suspect/Early Glaucoma:

Laser Peripheral Iridotomy ± Meds
Benjamin Y Xu MD PhD

In eyes with clear lenses, primary angle-closure suspect (PACS),

primary angle closure (PAC), and even mild primary angle-
closure glaucoma (PACG) can be managed primarily with laser
peripheral iridotomy (LPI) with or without drops. The Zhong-
shan Angle Closure Prevention (ZAP) Trial demonstrated that
most PACS eyes do not benefit from LPI, let alone clear lens
extraction. In addition, the Effectiveness, in Angle Closure
Glaucoma, of Lens Extraction (EAGLE) trial demonstrated that
LPI alone consistently produces robust IOP lowering in PAC/
PACG eyes, which buys time for patients to enjoy their good
vision. Finally, acute angle closure is exceedingly rare after LPI,
and patients can simply be monitored for evidence of progres-
sion before lens extraction.
Subspecialty Day 2024  |  Glaucoma Financial Disclosure 61

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62 Financial Disclosures Subspecialty Day 2024  |  Glaucoma

Financial Disclosures

Disclosure list contains individual’s relevant disclosures with ineligible companies.

All relevant financial relationships have been mitigated.

Jella A An MD MBA Gus Gazzard FRCOphth MA Robert M Kinast MD

AbbVie: C,L,S MB BChir MD Devers Drop Device: EO
Alcon Laboratories, Inc.: C Alcon Laboratories, Inc.: C,L GentleDrop: EO
Iridex: C Allergan, Inc.: C,L Rheon Medical: P
New World Medical, Inc.: C Bausch + Lomb: L
Santen, Inc.: C Belkin Laser Ltd: C Anthony J King FRCOphth MD
Sight Sciences, Inc.: C Carl Zeiss Meditec: C AbbVie: C
Elios: C,L Glaukos Corp.: L
Lauren S Blieden MD Ellex: L Théa: C,L
AbbVie: C Genentech: C
Alcon Laboratories, Inc.: C Glaukos Corp.: C,L Roman Krivochenitser MD
New World Medical, Inc.: C Haag-Streit Group: L Alcon Laboratories, Inc.: L
Ivantis, Inc.: C,L
Carla I Bourne MD Lumenis Vision: L Richard Lee MD
AbbVie: L McKinsey: C Mitsubishi Electronics: S
Sight Sciences, Inc.: L Merck & Co., Inc.: C,L Pfizer, Inc.: US
Reichert, Inc.: C
Larissa Camejo MD Ripple: C Ari Leshno MD
AbbVie: C,L Santen, Inc.: C Santen, Inc.: C
Alcon Laboratories, Inc.: C Sight Sciences, Inc.: C
Glaukos Corp.: L Théa: C,L Wendy W Liu MD PhD
Iridex: L ViaLase, Inc.: C None
Johnson & Johnson Vision: L Visufarma: C,L
Lumibird: L Careen Yen Lowder MD PhD
Nova Eye Medical: C,L Steven Gedde MD None
Sight Sciences, Inc.: C,L None
Jeffrey Ma MD
Yara P Catoira-Boyle MD Lauren E Hock MD None
None None
Steven L Mansberger MD MPH
Philip P Chen MD Cindy M Hutnik MD PhD AbbVie: S
None None Glaukos Corp.: C
IQVIA: S
Qi N Cui MD Anthony P Khawaja MBBS Nicox: C
Penn Center for Innovation: P Aerie Pharmaceuticals, Inc.: C ONL Therapeutics: C
Alcon Laboratories, Inc.: S Perfuse: C,S
Anna T Do MD Allergan, Inc.: C,L Tabia: C
AbbVie: L Google Health: C Théa: C,S
Heidelberg Engineering: L
Julie Falardeau MD Novartis Pharmaceuticals: C Sasan Moghimi MD
Stoke Therapeutics: S Reichert, Inc.: C None
Santen, Inc.: C,L
David S Friedman MD PhD MPH Théa: S,L Giovanni Montesano MD
AbbVie: C Topcon Medical Systems, Inc.: C Alcon Laboratories, Inc.: C
Glaucoma Research Foundation: C Centervue, Inc.: C
Life Biosciences: C Omikron, SpA: C
National Opinion Research Center: C Relayer: EO
Théa: L Théa: C

Disclosures current as of 10/3/24. Check the Meeting Guide for the most up-to-date financial disclosures.
Subspecialty Day 2024  |  Glaucoma Financial Disclosures 63

Marlene R Moster MD Balance Ophthalmics: C,PS Leonard K Seibold MD

AbbVie: C,L,S Bausch + Lomb: C,L Allergan, Inc.: C
Alcon Laboratories, Inc.: C,L,S Beaver-Visitec International: C New World Medical, Inc.: C
Allergan, Inc.: C,L,S Belkin Laser Ltd: C,SO Oculus Surgical, Inc.: C
ArcScan, Inc.: C Carl Zeiss Meditec: C
Bausch + Lomb: C,L,S Dompé: C Brian M Shafer MD
Glaukos Corp.: S Elios Vision: C,SO AbbVie: C,L
InnFocus, Inc.: S Ellex: C,L Alcon Laboratories, Inc.: C
MedEdicus: L EyePoint Pharmaceuticals: C Carl Zeiss Meditec: C
New World Medical, Inc.: S Glaukos Corp.: C,L CorneaGen: C
Regeneron Pharmaceuticals, Inc.: C ImprimisRx: C Dompé: C
Santen, Inc.: S Iridex: C,L Glaukos Corp.: C,L
Théa: C,L IrisVision: C,SO Tarsus Pharmaceuticals: C
W L Gore and Associates: C Iveric Bio: C
Kala Pharmaceuticals, Inc.: C,L John Shepherd MD
Paula Anne Newman-Casey MD Lumenis Vision: C,L None
MS New World Medical, Inc.: C,L
None Novartis Pharma AG: C,L Aakriti Garg Shukla MD
Ocular Therapeutix: C,S AbbVie: C
Yvonne Ou MD Ocusciences: C Alcon Laboratories, Inc.: C
Oculinea: C Omeros Corp.: C Théa: L
Orasis Pharmaceuticals: C Théa Laboratories: C
Regine S Pappas MD Quantel Medical: C
AbbVie: C Rayner: C,L Carla J Siegfried MD
Glaukos Corp.: C,L Reichert, Inc.: C,L None
Retina AI: SO Santen, Inc.: C
Sight Sciences, Inc.: C,L,SO Rachel Simpson MD
Jody R Piltz MD Spyglass Pharma: C,SO AbbVie: C
Alcon Laboratories, Inc.: C,L Tarsus Pharmaceuticals: C Glaukos Corp.: C
Nanoscope Therapeutics : C TearClear: C,SO Nova Eye Medical: C
Théa: C
Andrew E Pouw MD ViaLase, Inc.: C,SO Kuldev Singh MD MPH
M&S Technologies: S Viatris: C,L Advanced Ophthalmic Innovations: C
Alcon Laboratories, Inc.: C
Lorraine M Provencher MD Rithambara Ramachandran MD Allergan, Inc.: C
Alcon Laboratories, Inc.: C,L None Apellis Pharmaceuticals, Inc.: C
Allergan, Inc.: C,L Aurion: C
Beyeonics Surgical, Ltd.: C Pradeep Y Ramulu MD PhD Belkin Laser Ltd: C
Elios: C Alcon Laboratories, Inc.: C Centricity Vision, Inc.: C
Glaukos Corp.: C,L Dompé: C EyePoint Pharmaceuticals: C
MicroSurgical Technology: C,L,S Perfuse Therapeutics: S Glaukos Corp.: C
New World Medical, Inc.: C Topcon Medical Systems, Inc.: S Graybug: C
Radius: C,SO W L Gore, Inc.: C Ivantis, Inc.: C
ViaLase, Inc.: C jcyte: C
Douglas J Rhee MD Johnson & Johnson: C
Mary Qiu MD Aerie Pharmaceuticals, Inc.: L,C Novartis Pharma AG: C
Allergan, Inc.: C Alcon Laboratories, Inc.: C,L,S Ocular Therapeutix, Inc.: C
Allergan, Inc.: C,S Oculis: C
Nathan M Radcliffe MD Avellino Labs: C Radiance Therapuetics: C
Aerie Pharmaceuticals, Inc.: C,L Glaukos Corp.: S REGENXBIO: C
Alcon Laboratories, Inc.: C,L Iantrek: C Santen, Inc.: C
Alderya Therapeutics, Inc.: C Ivantis, Inc.: C,S Sight Sciences, Inc.: C
Alimera Sciences, Inc.: C,L Ocular Therapeutix: C,S U.S. Food and Drug Administration:
Allergan, Inc.: C,L,S C,S
Aquea: C,SO
Avellino Labs: C

Disclosures current as of 10/3/24. Check the Meeting Guide for the most up-to-date financial disclosures.
64 Financial Disclosures Subspecialty Day 2024  |  Glaucoma

Oluwatosin U Smith MD Richard D Ten Hulzen MD Qing Wang MD PhD

Alcon Laboratories, Inc.: C,L None None
Allergan Medical Affairs: C
Allergan, Inc.: C,L,S Ives A Valenzuela MD Andrew M Williams MD
Bausch + Lomb: C,L None None
Belkin Vision: C
Elios: C Sarah Van Tassel MD Benjamin Y Xu MD PhD
Glaukos Corp.: C AbbVie: C AbbVie: C
IrisVision: C Adverum: C Alcon Laboratories, Inc.: C
iSTAR Medical: S Alcon Laboratories, Inc.: C ArcScan, Inc.: C
New World Medical, Inc.: C Balance Ophthalmics: PS Ocular Therapeutix: S
Novaeye Medical: C,US Bausch + Lomb: C
Ocular Therapeutix: S Belkin Laser Ltd: C Alice Yang Zhang MD
Olleyes, Inc.: PS Carl Zeiss Meditec: C None
Sanoculis: C Character Bioscience: C
Glaukos Corp.: C Amy D Zhang MD
Joshua D Stein MD MS New World Medical, Inc.: C None
AbbVie: S Théa: C
Janssen Pharmaceuticals, Inc.: S
Ocular Therapeutix: S

Disclosures current as of 10/3/24. Check the Meeting Guide for the most up-to-date financial disclosures.
Subspecialty Day 2024  |  Glaucoma Presenter Index 65

Presenter Index

An, Jella A 13 Moster, Marlene R 49

Blieden, Lauren S 46 Newman-Casey, Paula Anne 36
Bourne, Carla I 15 Piltz, Jody R 56
Catoira-Boyle, Yara P 12 Pouw, Andrew E 44
Chen, Philip P 11 Provencher, Lorraine M 17
Cui, Qi N 34 Radcliffe, Nathan M 58
Falardeau, Julie 29 Ramachandran, Rithambara 47
Friedman, David S 2 Ramulu, Pradeep Y 32
Gazzard, Gus 4 Rhee, Douglas J 33
Hock, Lauren E 3 Seibold, Leonard K 51
Hutnik, Cindy M 54 Shafer, Brian M 21
Khawaja, Anthony P 42 Shepherd, John 31
Kinast, Robert M 37 Simpson, Rachel 39
King, Anthony J 9 Singh, Kuldev 55
Krivochenitser, Roman 19 Smith, Oluwatosin U 53
Lee, Richard 50 Valenzuela, Ives A 1
Leshno, Ari 5 Van Tassel, Sarah 38
Liu, Wendy W 8 Wang, Qing 35
Lowder, Careen Yen 27 Williams, Andrew M 52
Ma, Jeffrey 24 Xu, Benjamin Y 59
Moghimi, Sasan 40 Zhang, Alice Yang 26
Montesano, Giovanni 7 Zhang, Amy D 18