NEW CONCEPTS IN GLAUCOMA CARE TREATMENT Proceedings of the Fifteenth Annual Meeting & of the Optometric Glaucoma Society INSIDE: • Virtual Reality Uses in Glaucoma • Questions Glaucoma Patients Ask • Pathogenesis of Glaucoma • Glaucoma Progression • Real-Time Aqueous Humor Outfl ow Imaginging APRIL 2017 REVIEW OF OPTOMETRY/APRIL 2017 1 0217_OGS_ja_3.22.indd 1 3/24/17 3:36 PM ro0417ogs_vyzulta.indd 1 3/20/17 1:57 PM NEW CONCEPTS IN GLAUCOMA CARE TREATMENT TABLE OF CONTENTS INTRODUCTORY REMARKS The 15th Annual Scientifi c Meeting of the Optometric Glaucoma Society (OGS), held Nov. 15 and 16, 2016, in Anaheim, Calif., brought 3 together some of the country’s top luminaries INTRODUCTORY REMARKS in the areas of glaucoma diagnosis, treatment, Highlights From the Annual Scientifi c assessment, and management. These individu- Meeting als shared groundbreaking research and the BY MURRAY FINGERET, OD latest clinical knowledge about glaucoma—con- sidered to be the top global eye burden by the World Health Organization. 4 Kicking things off in the President’s Lecture, PRESIDENT’S LECTURE Felipe A. Medeiros, MD, PhD, highlighted potential clinical applications for More Than a Video Game: Virtual virtual reality devices. These devices, being tested in simulation laboratories, Reality and Its Uses in Glaucoma could one day assist clinicians in assessing patients at risk for glaucoma and BY FELIPE A. MEDEIROS, MD, PHD in danger of falls and motor vehicle accidents due to visual fi eld loss. Make no mistake: These cutting-edge tools are not your techie’s virtual reality. Dr. Medeiros, in a separate lecture about glaucoma progression, unveiled 6 an innovative metric developed by his research group to measure functional PATIENT CARE and structural vision loss in glaucoma patients. The RGC Index may offer Questions Glaucoma Patients Ask clinicians a more cohesive picture of disease progression to better manage BY GEORGE A. CIOFFI, MD glaucoma. In his talk on glaucoma pathogenesis, Derek S. Welsbie, MD, PhD, over- viewed our current understanding about disease development and where our 12 knowledge falls short. Profound genetic discoveries being made by his sci- SCIENTIFIC DISCOVERIES entifi c team could lead to game-changing therapies that target specifi c gene Pathogenesis of Glaucoma mutations to actually prevent RGC axon degeneration and cell death. BY DEREK S. WELSBIE, MD, PHD The limitations of existing imaging methods to visualize the anterior seg- ment has sparked the promise of real-time aqueous humor outfl ow imaging in the clinical setting. Alex A. Huang, MD, PhD, introduced a technique devised 14 by his research group known as aqueous angiography, which provides a com- ASSESSMENT STRATEGIES prehensive, real-time view of the anterior chamber. The goal is to help sur- Glaucoma Progression: What’s New and What’s Best geons customize minimally invasive glaucoma surgery (MIGS) for improved BY FELIPE A. MEDEIROS, MD, PHD surgical outcomes. And George A. Cioffi , MD, offered clinicians indispensable strategies for fi elding queries from concerned patients about topics ranging from drop instil- lation to more serious issues such as: Will I go blind? 17 I hope you fi nd the enclosed information useful, knowing that research IMAGING TECHNIQUES & GLAUCOMA Real-Time Aqueous Humor on glaucoma happening today will be translated to the clinical realm to help Outflow Imaging clinicians take aim at this progressive and potentially devastating disease. BY ALEX A. HUANG, MD, PHD This supplement, developed by Review of Optometry, was made possible with generous support from Bausch + Lomb. Please visit the OGS website (www.optometricglaucomasociety.org) 19 and consider signing up for our free, quarterly e-journal to keep up with the About the Optometric group’s latest happenings and developments in glaucoma treatment and Glaucoma Society management. Murray Fingeret, OD Past President, Optometric Glaucoma Society Editor, Proceedings of the Thirteenth Annual Scientifi c Meeting of the Optometric Glaucoma Society 0217_OGS_ja_3.22.indd 3 3/24/17 3:37 PM NEW CONCEPTS IN GLAUCOMA CARE TREATMENT President’s Lecture in response to visual light stimuli through the use of an electro- More Than a Video Game: Virtual Reality encephalogram (EEG) placed on the scalp over the occipital and Its Uses in Glaucoma cortex. However, this approach is limited by cumbersome set-up Felipe A. Medeiros, MD, PhD and equipment (e.g., wet-gel-based electrodes) and a relatively low signal-to-noise ratio.5,6 Using state-of-the-art EEG technology and VR goggles, my hough the term “virtual reality” often brings to mind images research group recently developed a portable brain-computer Tof video gamers wearing high-tech goggles, immersed in an interface (BCI) that acquires and translates brain signals in interactive, three-dimensional world created by software devel- tandem with an internet-of-things (IoT) device that collects and opers, virtual reality (VR) devices hold a great deal of promise exchanges the information. The system is capable of objectively for applications in the clinical ophthalmic realm. measuring visual function loss in glaucoma. In fact, discoveries by our research group at the Visual Per- formance Laboratory are helping to pave the way for using vir- A Portable Brain-Computer Interface to Assess tual reality strategies to assess visual function and the visual fi eld Glaucoma Damage (VF) at earlier stages of glaucoma. These developing technolo- Our portable platform to assess functional loss, the gies may improve upon or offer alternatives to existing methods nGoggle, is housed in a head-mounted display coupled with of disease assessment such as standard automated perimetry a dry-electrode, wireless EEG system. Designed to capture (SAP) exams, which are burdened by a host of clinical and natural-response signals known as steady-state visual evoked logistical obstacles explained below. potentials (ssVEPs) in response to visual stimuli sent by the EEG, SAP exams are the mainstream for determining functional the device can collect and convey information to the cloud via glaucomatous loss and progressive damage. However, SAP— wireless or Bluetooth capabilities.7 which typically involves the projection of a white stimulus onto We have compared the diagnostic performance of the a white background to determine threshold values via software nGoggle and SAP in detecting eyes with glaucomatous neu- algorithms—is limited by factors including the dependency on ropathy in recent investigations. A pilot study including 54 patient cooperation and highly trained technicians, subjectiv- eyes of glaucoma patients and 28 eyes of healthy individuals ity of fi ndings, a tendency to produce false-positive and false- revealed that the nGoggle performed at least as well if not bet- negative patient responses, a lack of portability, the need for ter than SAP in detecting eyes with glaucoma, with the potential sometimes expensive perimeter devices, and a limited ability to advantages of objective assessment and portability.8 collect data over time.1-3 In addition, VFs only become clearly Future clinical applications for the nGoggle could include abnormal in many patients once a substantial number of gan- home-based testing for functional loss. This would enable the glion cells have been lost.4 We must strive to do better than this, acquisition of many more tests over time, potentially improv- given the irreversible nature of vision loss in glaucoma. ing detection of progression compared to what is possible with Previous investigations have attempted to objectively assess standard perimetry today. However, the feasibility of such an visual function loss in glaucoma with techniques such as visual application would require further investigations. evoked potentials (VEP), which measures brain electrical activity Assessing Postural Responses in Glaucoma Patients A man wears the Photos: Felipe A. Medeiros, MD, PhD Falls are an important cause of morbi-mortality in the older nGoggle, a portable device incorporat- population, and studies reveal that glaucoma patients have an ing head-mounted increased likelihood of falling. In fact, glaucoma patients are equipment with three times more likely to suffer a fall compared with healthy goggles, a wire- 9 less EEG, and an subjects. At our laboratory, we have investigated the use of adapted Samsung VR-based tests that might improve our ability to predict which VR device, designed glaucomatous patients are at a higher risk for falling. by researchers to objectively assess One assessment strategy involves the use of immersive visual fi eld loss. dynamic visual stimuli presented on a VR headset (e.g., the Oculus Rift) to induce postural responses in glaucoma patients. So, for example, the system might elicit the sensation of rotation or of being in a tunnel. Specialized software then measures the degree of force of the patient’s movement. This approach has enabled us to assess patient postural responses to dynamic visual stimulation in a manner that more 4 REVIEW OF OPTOMETRY/APRIL 2017 0217_OGS_ja_3.22.indd 4 3/24/17 3:37 PM The driving simulator in the Visual Performance Laboratory at UCSD helps researchers assess factors associated with driving ability in glaucoma patients and assists the team in developing functional tests that can better evaluate task performance. closely represents real-world visual responses to everyday tasks. We found that a VR-based test was better able to predict risk of falls than SAP.10 Determining Glaucoma Patients’ Risk of Motor Vehicle