Glaucoma in Focus

Ophthalmologists tackle the 'silent thief of sight’ at APAO 2023

by Chow Ee-Tan

At the Asia-Pacific Academy of Ophthalmology Congress (APAO 2023), held on February 23 to 26 in Kuala Lumpur, Malaysia, ophthalmologists turned the spotlight on glaucoma, the silent thief of sight, during an informationpacked glaucoma symposium, entitled Epidemiology, Risk Factor, Lifestyle and Genetics.

Prof. Dr. Liza Sharmini Ahmad Tajudin from the Department of Ophthalmology and Visual Science, Universiti Sains Malaysia, took on the topic Is Lifestyle Modification in Glaucoma as Important as in Cardiovascular Diseases?

She cited findings from a two-phase Malay Glaucoma Eye Study (20172020 and 2021-ongoing), which included 250 primary glaucoma and 250 controls to identify modifiable risk factors for the development and progression of glaucoma, with intervention on diet, exercise, navigation, and reading rehabilitation.

She concluded that the impact of lifestyle modification, which is proven to be effective in cardiovascular disease primary and secondary prevention, is not as powerful in glaucoma patients.

“However, there is a potential big impact on patients’ daily living. Patients should keep themselves active and eat healthily,” she said.

Glaucoma home monitoring, is it feasible?

Assoc. Prof. Dr. Jemaima Che Hamzah, senior consultant ophthalmologist/deputy dean (undergraduate), Faculty of Medicine, Universiti Kebangsaan Malaysia, posed the question: Home Monitoring in Glaucoma: Can it be a Reality?

Answering the question affirmatively, she said various devices have been designed to measure intraocular pressure (IOP) at home for 24 hours. For instance, a self-measuring tonometer is easy to use and does not require the use of topical anesthesia.

“Several tablet-based devices and head-mounted displays have been developed to measure visual field (VF) and can be performed potentially by patients without direct supervision of a healthcare professional,” Prof. Hamzah shared. “Invention of newer ’smart’ technology allows home monitoring of glaucoma by providing a better understanding about the effects of treatment to patients and improve patient care.”

Such tools can also increase patient engagement and help in patients’ adherence to their medication, which can lead to more affordable diagnostic tests available to individuals with limited access to healthcare.

Let’s talk about JOAG and mental health

Meanwhile, Dr. Azhany Yaakub from the Department of Ophthalmology, Universiti Sains Malaysia, presented his talk, Psychosocial Impact of Juvenile Open Angle Glaucoma (JOAG) in Adolescence: A Neglected Area.

She quoted a Singapore study on Young Population with Mental Disorders which shows that the vulnerable age groups for mental disorders are 18 to 34, followed by 35 to 49. A 2017 local survey in Malaysia among adolescents shows that one in five adolescents had depression, two in five were anxious, and one in 10 was stressed.

“JOAG patients are trapped in a chronic and life-long disease. They have to adapt to living with the disease daily and face treatmentrelated issues, such as medications, procedures, and surgeries, as well as the uncertainty of the future and career undertaking,” Dr. Yaakub shared.

Factors associated with depression, anxiety, and stress in JOAG are severe VF defect, higher numbers of medication, higher level of education, unemployment, and poor income.

“Holistic management of JOAG should include the psychological aspect, which is often neglected,” she added.

The need for cost-effective glaucoma screening

Dr. Ronnie George, director of Glaucoma Service at Sankara Nethralaya Chennai in India, explored the topic, Can We Effectively Screen for Angle Closure? and asked three important questions: “Do we have a good enough test? Is it practical? Is it cost-effective?”

He said none of the tests evaluated achieved the combination of specificity and sensitivity needed for population-based screening, as their current capacity does not realize the objective of case detection in the setting of an ophthalmology clinic.

“An incremental cost-effectiveness ratio value of $90 per qualityadjusted life-year was calculated for a community-screening program for glaucoma in rural India,” he shared, adding that the screening would treat an additional 2,872 cases and prevent

2,190 people years of blindness over 10 years.

On the other hand, the costeffectiveness and cost-utility of population-based glaucoma screening in China combined screening for POAG and PACG in rural China, both of which were below the WHO cost-effectiveness threshold of one to three times rural gross domestic product.

A study on 300 POAG patients

In her talk, Personalized Medicine in Oscular Fibrosis: Myth or Future Biomarker, Dr. Cynthia Yu Wai-Mun, MRC clinician scientist at King's College London, quoted a multicenter prospective longitudinal study by Glaucoma BioResource UK, which involved 300 POAG patients.

She said a Moorfields safer surgery system has identified the following high-risk patients: Afro-Caribbean, previously failed trabeculectomy, cataract surgery within the last six months, inflammatory eye disease, aphakia, and neovascular glaucoma chronic topical medication, among others.

“A large-scale biobank of tissue samples and detailed phenotyping were carried out from 300 patients and we were looking at the surgical risk, progression study, and therapeutic targets for new drugs and devices,” she shared.

She added that the longitudinal study will determine which test displays the strongest association with glaucoma progression and any correlation with IOP and multi-omics molecular data. It will also support the development of new glaucoma therapeutics, implants, and tests.

Editor’s Note

The 38th Asia-Pacific Academy of Ophthalmology Congress (APAO 2023) was held on February 23 to 26 in Kuala Lumpur, Malaysia. Reporting for this story took place during the event.