COOKIE Issue 16: Glaucoma Ophthalmology-Optometry Crossover Issue

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GLAUCOMA OPHTHALMOLOGY-OPTOMETRY CROSSOVER ISSUE

July 2024

cookiemagazine.org

First Line of Defense Optometrists play a crucial role in reducing undiagnosed glaucoma cases globally—bridging the gap between primary and specialized eye care p10

Letter to Readers

Tech Navigating Tools, and Optometric Glaucoma Disparities T he fields of glaucoma diagnosis and management are rapidly evolving, resulting in an expansion of our glaucoma toolkit—with more instrumentation, added skills, and expanded experience.

Asian countries, optometrists are not even allowed to use slit-lamps at all. The disparity is significant, considering 80% of patients diagnosed with glaucoma are from Asian countries.

Throw in artificial intelligence (AI) in the mix and it radically transforms into a different practice landscape altogether.

Accurate screening techniques, which are crucial in glaucoma diagnosis, are severely hampered or limited by restricted access to eye care, especially in resource-poor regions of Asia. There is a need to develop sustainable healthcare infrastructure to screen, monitor and treat this debilitating disease.

Measuring IOP the old way—through the not-so-reliable applanation tonometry—doesn’t cut it anymore. Air puff and iCare tonometers do a much better job. Optical coherence tomography (OCT) gave us the gold standard for early glaucoma diagnosis. The latest visual field apparatus, such as virtual reality (VR), is now a fixture in many practices. Their portability and practicality are definite pluses There's even a newer version where patients can actually measure their IOPs themselves.

Contact lenses are now able to accurately measure IOP 24/7 in all temperatures—warm or cold. This makes it easier to manage patients with fluctuating IOP. A procedure to increase aqueous outflow through the Schlemm's canal by viscodilation can now be performed in patients with any stage or type of glaucoma, including those with peripheral anterior synechiae, angle recession and neovascular glaucoma that are not active. The procedure is termed ABiC or ab interno canaloplasty.

Some states in the U.S. now allow optometrists to perform selective laser trabeculoplasty (SLT) and minimally invasive glaucoma surgery (MIGS). In contrast, in some

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COOKIE MAGAZINE | July 2024

My niece wants to get into the ophthalmology residency program, but it is proving to be quite a challenge. The institutions offering ophthalmology need (and want) the cream of the crop. So you have to be dead serious if you really want to get into ophthalmology. On the other hand, there seems to be an increasing number of schools opening up optometry programs.

The takeaway? To address glaucoma’s growing menace to global health, optometry must be seen as a key player.

Nothing short of a cross-disciplinary strategy can stem its dark tide.

Best, Dr. Carmen Abesamis-Dichoso

OD, MAT, FPCO, FIACLE, FBCLA, FAAO

In This Issue...

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Cool Optometry

Glaucoma Care: What To Expect?

New therapies, designed with innovative approaches to enhance patient outcomes, are reshaping the landscape of glaucoma treatment

Optics

08

A Breakthrough in Glaucoma Management?

Wireless smart contact lenses: Revolutionizing patient care with continuous IOP monitoring and enhanced treatment compliance

Cover Story

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First Line of Defense Optometrists play a crucial role in reducing undiagnosed glaucoma cases globally—bridging the gap between primary and specialized eye care

Enlightenment

Kudos

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Brilliance in Balance Dr. Jennifer Stewart has mastered the art of work-life balance while making groundbreaking strides in optometry and sports vision

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An Optometrist’s POV How can effective strategies be established to enhance glaucoma screening, treatments, and patient outcomes?

Innovation

16 Glaucoma and AI From diagnostic support to innovative screening methods, APGC 2024 explores AI's gamechanging potential in glaucoma care

Conference Highlights

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Guidelines for Glaucoma Care APGS launches the 4th edition of its glaucoma guidelines at APGC 2024

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PACS: On Spotlight at APGC 2024 Understanding and managing primary angle closure in Asian populations

COOKIE MAGAZINE | July 2024

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Advisory Board Members

Matt Young CEO & Publisher Hannah Nguyen COO & CFO

Dr. Carmen Abesamis-Dichoso Abesamis Eye Care & Contact Lens Center, Manila, Philippines

Dr. Joseph J. Allen

Doctor Eye Health, Minnesota, USA hello@doctoreyehealth.com

carmen.dichoso@gmail.com

Gloria D. Gamat Chief Editor Mapet Poso Editor

Matt Herman Associate Editor Maricel Salvador

Dr. Mark Eltis

Dr. Kristie Nguyen

Dr. Feenstra and Associates; Dr. Kristie Nguyen PLLC, Florida, USA

Graphic Designer

View Eye Care, Toronto, Canada drmarkeltis@vieweyecare.com

kristie817@gmail.com

Writers Andrew Sweeney Diana Truong Hazlin Hassan Tan Sher Lynn Ruchi Ranga Society Relations & Conference Manager

Dr. Monica Chaudhry

Learn Beyond Vision, New Delhi, India monica.rchaudhry@gmail.com

Dr. Elise Brisco

NearSight, California, USA elisebrisco@hollywoodeyes.net

International Business Development Brandon Winkeler Robert Anderson Sven Mehlitz

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COOKIE MAGAZINE | July 2024

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Cool Optometry |

Glaucoma Care: What To Expect New therapies, designed with innovative approaches to enhance patient outcomes, are reshaping the landscape of glaucoma treatment by Hazlin Hassan From minimally invasive surgeries to implantable drug delivery systems and groundbreaking genetic therapies, these advancements in glaucoma treatments promise safer procedures, faster recovery times, and potentially transformative outcomes for millions affected by this sightthreatening condition.

GLAUCOMA TREATMENTS

Chandrasekaran, an ophthalmologist from Columbia Asia Hospital, Puchong, Malaysia.

According to Dr. Sudhashini, MIGS techniques have become popular due to the fewer complications and quicker recovery times in comparison to conventional surgeries. “Often performed in combination with cataract surgery, MIGS procedures are playing an increasingly important role in glaucoma management. With careful patient selection, MIGS procedures may yield excellent results, which can reduce glaucoma progression and improve the glaucoma patient's quality of life,” she added.

Among the newer innovations in the MIGS category are the deviceless MIGS, such as laser trabeculotomy (the ELIOS, MLase GmbH; Germering, Germany, and ViaLase, ViaLase, Inc.; California, USA ), abinterno canaloplasty (the iTrack and iTrack Advance devices, Nova Eye Medical; Kent Town, South Australia), and the combined canaloplasty and trabeculotomy (the OMNI System; California, USA).

These procedures aim to enhance the natural outflow pathways of the eye without the need for implanted devices, hence reducing the risk of foreign body-related complications, such as endothelial cell loss, inflammation, and surgical trauma.

M

ost people of a certain age (or slightly younger) ought to be familiar with the 1968 classic by the British rock band The Beatles called ‘Revolution.’ But in case you aren’t, here are the opening lyrics: “You say you want a revolution Well, you know We all wanna change the world You tell me that it's evolution Well, you know We all wanna change the world…”

Well, it seems that, in recent years, ophthalmologists are seeing a revolution in the fight against glaucoma. But instead of

overthrowing a government, cuttingedge technological innovations are offering new techniques for delivering glaucoma medications to lower intraocular pressure (IOP), as well as minimally invasive glaucoma surgeries (MIGS). These approaches are relatively safe and effective with faster recovery time and better outcomes.

Here are our top 5 picks:

1. Deviceless MIGS “One of the most notable developments is the rise of MIGS procedures,” said Dr. Sudhashini

“The MIGS has been making its rounds in most countries, either as a bridging therapy for mild to moderate glaucoma using the trabecular bypass MIGS (iStent, Glaukos Corporation; California, USA, and Hydrus, Alcon; Geneva, Switzerland), or subconjunctival MIGS like the PreserFlo (Santen Pharmaceutical; Osaka, Japan) for severe glaucoma,” said Prof. Dr. Norshamsiah Md Din, an ophthalmologist and glaucoma specialist at the Faculty of Medicine, Universiti Kebangsaan Malaysia.

Prof. Norshamsiah has used all three devices and she noted that there is a steep learning curve to implant the Hydrus trabecular bypass. But with practice, it becomes easier.

COOKIE MAGAZINE | July 2024

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Cool Optometry |

GLAUCOMA TREATMENTS

These devices offer modest (trabecular bypass MIGS) to substantial IOP lowering (subconjunctival MIGS) results.

According to Prof. Norshamsiah, the advantages of these devices over traditional glaucoma surgery like trabeculectomy and glaucoma drainage device (GDD) include a shorter operating time, faster recovery, and safer surgery with minimal risks and complications.

“However, the biggest stumbling block to using these devices is the cost, especially the smaller trabecular bypass MIGS,” she noted.

2. Intracameral implantable drug delivery systems In addition to surgical advancements, pharmacological innovations are also making waves in the glaucoma scene.

The use of daily eye drops to lower IOP has been a mainstay in glaucoma therapy for decades. However, a 2018 study put the rates of nonadherence as high as 67%.1 This increases the risk of glaucoma progression and vision loss.

eye drops, a prostaglandin analog, which reduces pressure in the eye by increasing the outward flow of fluid from the eye. After 12 months of a clinical study, 81% of people were able to eliminate the burden of taking daily eye drops.2

prioritize their treatment with regular monitoring.

“As with any new invention, the use of these devices is limited at the moment by their cost and availability.

But they are definitely a promising option for glaucoma treatment in the near future,” said Dr Chandrasekaran.

This test also removes the onesize-fits-all approach in glaucoma management where high-risk patients are managed by a glaucoma specialist, while patients at a lowand intermediate-risk level can be managed safely and less frequently in a primary care setting, she added.

3. Glaucoma polygenic risk score A new genetic test for glaucoma could hold the key to identifying and prioritizing the treatment of those at high risk of losing their sight due to the disease. Until recently, there was no way of determining who will develop vision loss and how to better manage individuals at risk of developing glaucoma.

While the biodegradable Durysta was approved by the U.S. Food and Drug Administration in March 2020, the iDose TR was approved in December 2023 and is the first eye implant to deliver medication 24/7 for an extended period.

The iDose TR treats glaucoma by automatically releasing the same type of medication used for decades in the most commonly prescribed

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4. eyeWatch In severe and recalcitrant glaucoma, a GDD is often the treatment of choice as it offers better long-term IOP control. However, the early hypertensive phase and hypotony, especially in non-valved GDD, often limit its use. New devices to titrate the flow through the GDD are now available to overcome these problems.

The new eyeWatch (HomeBrite Corp.; CA, USA) implant is said to be the world’s first adjustable GDD. The unique and innovative mechanism using a small magnetic device inside the eyeWatch allows surgeons to titrate the aqueous outflow postoperatively, and therefore lowers or increases the patients’ IOP in an efficient, painless, and non-invasive inoffice manner.

Two intracameral implantable drug delivery systems aim to address this.

The iDose TR (travoprost intracameral implant, 75 mcg; Glaukos Corporation; California, USA) and the Durysta (bimatoprost implant, 10 mcg; Allergan; Dublin, Ireland) are minuscule implants that release potent glaucoma medications continuously over several months, ensuring consistent therapeutic levels.

“Its use has been approved in Australia and we hope it will soon be available worldwide,” said Prof.

Norshamsiah.

Ophthalmologists at Flinders University and The Council of the Queensland Institute of Medical Research have devised a glaucoma polygenic risk score that identifies individuals at high risk of losing their sight.

The deceptively simple saliva-based test kit can strongly predict severe and sight-threatening glaucoma and therefore identify patients at high risk of losing their sight. This helps

COOKIE MAGAZINE | July 2024

More than 90% of patients have a successful treatment after one year, meaning that their pressure is effectively managed.3 On average, anti-glaucoma medications are reduced to about one-third after one year.4

5. Gene therapies While gene therapies are in various stages of development, they hold great potential in transforming glaucoma management in the future.

The hope is that gene therapy for glaucoma provides a new treatment option for a disease that is incurable.

Early treatment may prevent damage, but it is yet unknown if gene therapy

can reverse damage that has already occurred.

to screen the therapeutic efficacy of the gene therapy approach.

In April 2023, scientists at Trinity College Dublin in Ireland announced a significant development towards a new treatment of glaucoma.5 While topical eye drops are critical in preventing disease progression, up to 10% of patients become treatmentresistant, putting them at risk of permanent vision loss.

Dr. Jeffrey O’Callaghan, a postdoctoral research fellow at Trinity and first author of the study, also said in the news release: “We are now hopeful that this therapy will pave the way for the development of treatments for other forms of blinding eye diseases.”

The College noted in its news release that a team at the Smurfit Institute of Genetics, in collaboration with biotechnology company Exhaura Ltd. (Dublin, Ireland), has shown that a gene therapy-based approach can decrease IOP in pre-clinical models of glaucoma.

A single injection of a viral vector can increase the flow of aqueous fluid from the front of the eye and thereby decrease pressure in the eye. The key instructions are for cells to produce an enzyme matrix (metalloproteinase-3, or MMP-3) that helps kick this process into gear.

“This exciting project allowed us to bridge the gap between academia and industry and work very closely with a gene therapy company to develop a cutting-edge therapy that we believe holds immense promise for patients in the future,” said Dr. Matthew Campbell, professor of genetics at Trinity College Dublin in the news release.

The study used multiple models of disease as well as donor human eyes

A remarkable year for glaucoma management

less burdensome treatment options.

Perhaps, there may even come a day when vision loss may be reversed.

For this, the lyrics of Imagine by John Lennon come to mind: “You may say I'm a dreamer But I'm not the only one…”

Contributors

“Glaucoma is one of the most rapidly evolving fields in ophthalmology. Traveling back in time to just a few decades ago, the progress we see today would have been unimaginable,” Dr. Chandrasekaran said.

Although the mechanism of the disease remains unclear, 2024 is a remarkable period for glaucoma management with the rapidly evolving advancements happening in the field, she noted.

The vast number of treatment options available today has transformed how the treating doctor approaches glaucoma. “This paradigm shift aligns well with the changing expectations of patients today, who seek beyond just eye drops, even in the early stages of the disease,” she added.

The year 2024 brings much hope to glaucoma patients, with safer, more efficient, and

References 1. Robin, AL, Muir, KW. (2019). Medication adherence in patients with ocular hypertension or glaucoma. Expert Rev Ophthalmol. doi.org/10.1080/17469899.2019.1635456.

2. Glaukos Transforming Vision. Glaukos announces positive topline outcomes for both phase 3 pivotal trials of iDose TR, achieving primary efficacy endpoints and demonstrating favorable tolerability and safety profiles. Available at https://investors.glaukos.com/investors/news/news-details/2022/ Glaukos-Announces-Positive-Topline-Outcomes-for-Both-Phase-3-Pivotal-Trials-of-iDose-TRAchieving-Primary-Efficacy-Endpoints-and-Demonstrating-Favorable-Tolerability-and-Safety-Profiles/ default.aspx. Accessed on June 22, 2024.

3. Roy S, Villamarin A, Stergiopulos C, et al. Initial Clinical Results of the eyeWatch: a New Adjustable Glaucoma Drainage Device Used in Refractory Glaucoma Surgery. J Glaucoma. 2019;28(5):452458.

4. Roy S, Villamarin A, Stergiopulos C, et al. Comparison Between the eyeWatch Device and the Ahmed Valve in Refractory Glaucoma. J Glaucoma. 2020;29(5):401-405.

5. Trinity College Dublin. Scientists develop novel gene therapy for glaucoma. Available at https:// www.tcd.ie/news_events/articles/2023/scientists-develop-novel-gene-therapy-for-glaucoma/.

Accessed on June 22, 2024.

Dr. Sudhashini Chandrasekaran is a consultant ophthalmologist from Columbia Asia Hospital, Puchong, Malaysia. She is the founder and immediate past president of the Malaysian Young Ophthalmologists Group. She is currently a committee member of the Malaysian Society of Ophthalmology. Dr Sudhashini obtained her medical degree from the National University of Ireland and her Master of Ophthalmology followed by a fellowship in glaucoma from the University of Malaya, Malaysia. She is passionate about the field and enjoys teaching and imparting her knowledge to younger doctors as well as the public. sudhashini@gmail.com Prof. Dr. Norshamsiah Md Din is a consultant ophthalmologist and glaucoma specialist in the Faculty of Medicine, Universiti Kebangsaan, Malaysia. She received her ophthalmology training from the National University of Malaysia in 2007 and obtained a Ph.D. from the University College London in 2014. She was also a clinical and research fellow at Moorfields Eye Hospital in uveitis and glaucoma from 2010 to 2013. Prof. Norshamsiah has more than 80 journal article publications under her name and is actively conducting research in glaucoma and uveitis. Her research interests are in the management of secondary glaucoma, minimally invasive glaucoma surgery, and glaucoma imaging. nsd@ppukm.ukm.edu.my

COOKIE MAGAZINE | July 2024

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Optics | CONTACT LENSES

lenses do not have a clear, universally accepted mmHg equivalence, highlighting the need for further refinement and standardization.4,5

A Breakthrough in Glaucoma Management?

Wireless smart contact lenses: Revolutionizing patient care with continuous IOP monitoring and enhanced treatment compliance

by Tan Sher Lynn

Managing and monitoring intraocular pressure (IOP) is crucial for preventing vision loss in glaucoma patients.

Traditional methods, such as the air puff test, have limitations, prompting a quest for better solutions. Enter the ‘smart’ contact lens—a promising technology that could revolutionize how we detect and manage glaucoma.

A

ccording to Dr. Carmen Abesamis-Dichoso, an optometrist and orthokeratology practitioner in the Philippines, IOP is the single most important modifiable risk factor in the development and progression of glaucoma.1 If there is increased variability in IOP, there is increased ganglion cell complex, which is an objective measure of macular structural damage.2 Current methods, such as the air puff test, have notable drawbacks, including higher IOP readings, which compromise the accuracy of the readings.3 “The air puff test has been found to yield higher IOP results than other methods. It can also induce corneal deformation or irregularity,” Dr. Abesamis-Dichoso said.

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The potential of smart contact lenses Smart contact lenses, specifically wireless measuring contact lenses (WMCL), offer a non-invasive way to continuously monitor IOP. These lenses could provide significant benefits, including convenience and diurnal measurements, according to Dr. Abesamis-Dichoso. “Continuous monitoring of IOP using smart contact lenses is helpful in the management of glaucoma patients due to the convenience they offer for patients and clinicians, especially in taking diurnal measurements. They enable at-home monitoring without disrupting daily routines or sleep,” she explained.

Dr. Abesamis-Dichoso noted, however, that despite these advantages, current sensors in smart

COOKIE MAGAZINE | July 2024

Studies have shown that atmospheric pressure and temperature can influence IOP fluctuations. She mentioned that individuals in warmer climates tend to have lower IOP compared to those in colder environments.6 This variability underscores the importance of a monitoring device that can adapt to different environmental conditions.

Dual LCR technology in smart contact lenses A recent development may just solve the issue. Dengbao Xiao, along with colleagues from the Institute of Advanced Structure Technology at Beijing Institute of Technology, China, had succeeded in creating an intelligent WMCL that incorporates a dual inductor-capacitor-resistor (LCR) resonant system, enabling temperature self-compensation for quantitative IOP monitoring in various application environments.7 Xiao and his team developed the smart contact lens by designing two miniature spiral circuits with unique vibration patterns that change with the eye's pressure and diameter. These circuits were embedded between layers of polydimethylsiloxane, a common contact lens material. The lens' vibrations were wirelessly read using a coil connected to a computer, with signals unaffected by simulated eye movements, moisture, and wear.

In laboratory tests on pig eyes, the lenses monitored and transmitted pressure data across a range of temperatures (50 to 122 degrees F).

Single-circuit readings deviated up to 87% from true values, but dualcircuit readings differed by only 7%, eliminating temperature-related errors. This dual-circuit design shows promise for accurate early detection and monitoring of glaucoma across various temperatures.8 “The dual inductor capacitor-resistor (LCR) resonant system achieves temperature self-compensation

for quantitative IOP monitoring in different application environments.

This means it can monitor IOP in any temperature situation that enables early diagnosis and better management of glaucoma regardless of temperature or environmental factors,” Dr. Abesamis-Dichoso said, commenting on this innovation.

where patients are alerted to peaks or spikes in their levels, reminding them to take their medication or see their doctor immediately. The same is true for glaucoma patients.

Since the condition is potentially blinding, consistent monitoring of IOP would be very helpful in delaying its progression,” she continued.

Challenges in clinical adoption

Emerging frontiers in glaucoma care

However, she highlighted challenges in integrating this technology into everyday clinical practice, citing concerns over maintenance costs, hygiene, and corneal safety. Factors such as corneal base curve and thickness are critical in ensuring accurate fitting, centration, and comfort of the contact lens device on the eye.

In addition to smart contact lenses, Dr. Abesamis-Dichoso mentioned three areas of research that are currently being investigated to improve glaucoma diagnosis, treatment, and management: Gene therapy, neuroprotective agents, and artificial intelligence (AI) in diagnostics.

“Also, anything novel takes time for the consumer or public to accept, resulting in a ‘waiting time’ for people to see if it is effective,” shared Dr. Abesamis-Dichoso. “Another drawback is the hygienic maintenance required to keep the cornea healthy while wearing the device. While we understand the sophistication of the material and design, as well as the biocompatibility of this device with the eye, it is still a foreign body that needs to be closely monitored to ensure it can effectively monitor the IOP,” she remarked.

In addition, she suggested that the device should be tested in a larger number of individuals living in countries with warm and cold temperatures to make it more wearable. The device should also be designed with simpler parameters for clinicians to choose from, including base curve, diameter, and, if possible, incorporating power.

Nevertheless, if the WMCL does take off, it will be a game-changer in glaucoma management.

“Patient compliance in the timely administration of IOP-lowering drops has been a challenge for both clinicians and patients,” said Dr. Abesamis-Dichoso. “If the IOP can be continuously monitored, it would be similar to blood sugar and blood pressure monitoring devices,

“Gene therapy aims to identify genetic factors that contribute to the development of the condition.

By targeting specific genes, treatments can be implemented that can potentially prevent or reverse the damage caused by glaucoma.

Neuroprotective agents aim to protect the optic nerve from damage to slow down or halt the progression of the disease,” she shared. “Last but not least, AI algorithms can now analyze complex datasets and assist eye care professionals in early detection and personalized treatment plans. AI can also provide patients with valuable advice on how to better comply with the regimen prescribed, offering a good foundation to both clinician and patients in glaucoma care,” Dr. Abesamis-Dichoso concluded.

Contributor

References 1. Van de Veire S, Germonpre P, Renier C, et al. Influences of atmospheric pressure and temperature on intraocular pressure. Invest Ophthalmol Vis Sci. 2008;49(12):53925396.

2. Mahmoudinezhad G, Moghimi S, Nishida T, et al. Association of long-term intraocular pressure variability and rate of ganglion complex thinning in patients with glaucoma.

Am J Ophthlamol. 2024:264:104-119.

3. Piffaretti F, Barrettino D, Orsatti P. Rollable and implantable intraocular pressure sensor for the continuous adaptive management of glaucoma. Annu Int Conf Proc IEEE Eng Med Biol Soc. 2013;2013:3198-3201.

4. Bhartiya S, Gangwani M, Kalra RB, et al. 24hour Intraocular pressure monitoring: the way ahead. Rom J Ophthalmol. 2019;63(4):315320.

5. Downs JC, Burgoyne CF, Seigfreid WP. 24-Hour IOP telemetry in the nonhuman primate: implant system performance and initial characterization of IOP at multiple timescales.

Invest Ophthalmol Vis Sci. 2011;52:7365– 7375.

6. Hartmann A, Grabitz SD, Hoffmann EM, et al.

Intraocular Pressure and Its Relation to Climate Parameters-Results From the Gutenberg Health Study. Invest Ophthalmol Vis Sci. 2023;64(7):15.

7. Li X, Chen W, Xiao D, et al. Temperature SelfCompensating Intelligent Wireless Measuring Contact Lens for Quantitative Intraocular Pressure Monitoring. ACS Appl Mater Interfaces. 2024;16(17):22522-22531.

8. American Chemical Society. 'Smart' contact lenses could someday enable wireless glaucoma detection. Discover Chemistry PressPacs. Available at https://www.acs.org.

Published on May 9, 2024. Accessed July 5, 2024.

Dr. Carmen AbesamisDichoso earned her Doctor of Optometry in 1989 and her Master of Arts in Teaching in 2001 from the Central Colleges of the Philippines. She specializes in special contact lens design for keratoconus, children and high astigmatism, and visual assessment for individuals with mental challenges, autism, ADHD, cerebral palsy and learning disabilities. Practicing orthokeratology since 2005, she has had a private practice at Medical Plaza Makati since 1998.

She was named Outstanding Optometrist of the Year in 2017 by the Optometric Association of the Philippines. Currently, she chairs the International Affairs Committee of the Optometric Association of the Philippines and holds roles such as director of Special Olympics Opening Eyes in the Philippines and program manager of the Vision Screening Program. Dr. AbesamisDichoso is a fellow of the American Academy of Optometry, a founding fellow of the Philippine College of Optometrists, a fellow of the International Association of Contact Lens Educators and holds positions with the Asia-Pacific Council of Optometry. carmen.dichoso@gmail.com

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Cover Story

First Line of Defense Optometrists play a crucial role in reducing undiagnosed glaucoma cases globally—bridging the gap between

by Diana Truong primary and specialized eye care As the primary gatekeepers for eye care, optometrists often shoulder the responsibility of detecting glaucoma.

Dr. Michael Chaglasian, the executive vice president of the Optometric Glaucoma Society, sheds light on the pivotal role optometrists play in glaucoma screening, the challenges they face, the emerging tools at their disposal and why their expertise is more important than ever.

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laucoma, the leading cause of irreversible blindness worldwide, presents a major public health challenge. In 2020, around 52.7 million people were diagnosed with glaucoma, while a staggering 43.8 million went undetected. By 2040, these numbers will rise to 79.8 million detected and 67.1 million undetected cases.1 Optometrists, often the first line of defense against glaucoma, play a critical part in detecting the disease.

Despite their essential role, the capacity for accurate diagnosis can vary significantly among practitioners.

Fortunately, new tools—such as home testing, wearable devices and artificial intelligence (AI), can help optometrists quickly and consistently identify high-risk changes, easing the challenges of traditional screening methods. These advancements make early and accurate detection more accessible, bolstering optometrists’ ability to fight glaucoma effectively.

A tag-team approach According to an Oxford Eye Hospital study, for decades, optometrists have played a fundamental role in

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screening for glaucoma, initiating over 90% of glaucoma-related referrals to hospital eye services.

Despite the heavy reliance on primary care eye providers in early glaucoma detection, the relationship between optometrists and ophthalmologists has historically been complex.2 Back in the 1940s, it was unlawful for U.S. optometrists to use diagnostic and therapeutic drugs. This changed in 1971 when Rhode Island passed a bill allowing optometrists to use drugs for diagnostic purposes, blurring the lines between optometry and ophthalmology.

To address the rising number of glaucoma patients amidst a growing Since then, debates about expanding shortage of ophthalmologists, optometrists' roles have persisted, optometrists must take on more with inconsistent collaboration responsibilities, such as screening between the two fields. In the United and early detection.

States, this is further complicated by varying state laws governing the “Baby boomers in the United scope of optometry practice.

States are aging and have a greater likelihood of having glaucoma. Many Adding to the challenge is will become glaucoma suspects the dwindling number of and that’s going to overwhelm ophthalmologists. One study ophthalmologists,” said Dr. projected a 12% decline in Chaglasian. “Optometry has a huge ophthalmologists and a 24% increase role as the primary contact point to in demand between 2020 and 2035, identify those at risk for glaucoma,” revealing a significant 30% gap in helping to reduce the burden on workforce adequacy.3 ophthalmologists.

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Collaboration between optometrists and ophthalmologists enhances coordination and efficiency in eye care services, ultimately improving the quality of care for patients.

“Communication between the two providers is essential for optimal patient care,” noted Dr. Chaglasian.

“They should share data about the patient and communicate about what’s in the patient’s best interest.

That’s what we should focus on.”

This integrated approach allows each professional to focus on strengths, resulting in a more effective treatment plan. “Optometry excels at many things, and ophthalmology excels at others,” Dr. Chaglasian said.

Optometrists can identify potential cases early and manage nonthreatening conditions. They can refer patients to ophthalmologists for further evaluation and treatment for more serious cases. This referral system ensures that patients receive appropriate care based on the severity of their condition, effectively bridging the gap between primary and specialized eye care.

Slipped between the cracks Typically, a comprehensive eye exam includes several diagnostic

procedures to identify early signs of glaucoma. “It starts with a family history and includes a microscopic examination of the front of the eye and the back of the eye, focusing on the optic nerve head for early glaucoma changes,” Dr. Chaglasian explained. “It also involves measuring intraocular pressure (IOP).”

A study by Wong et al. found that 66% of missed glaucoma cases involved patients with an enlarged cup-to-disc ratio on OCT images, often overlooked due to the difficulty of assessing the optic nerve head.

A New Zealand study comparing glaucoma-accredited optometrists and glaucoma specialists showed agreement in most areas assessed but less so in interpreting OCT images.4,5

Optometrists will conduct additional tests if any risk factors are identified during the exam. “A follow-up visit will cover scanning of the optic nerve Continuous training, as shown in head and retina with an OCT device, a study by Patel et al. significantly measuring the visual field with a boosted community glaucoma perimeter, further detection investigation into rates. Similarly, “Optometry excels the intraocular research in pressure, and Scotland at many things, and various other tests suggested ophthalmology excels used in glaucoma that additional at others.” diagnosis,” said Dr. training, Chaglasian. more clinical experience, and clearer guidelines Despite these thorough examinations could improve diagnostic accuracy for and significant improvements in accredited glaucoma optometrists.6,7 the field of glaucoma screening, a 2021 study revealed that the Standardized guidelines exist, like proportion of undetected glaucoma the American Optometric Association has remained high over the past five (AOA) Care of the Patient with decades. “Glaucoma diagnosis isn’t Primary Angle Closure Glaucoma, always clear-cut. Patients can be written in a consensus, evidencesuspects for years without evident based manner by optometrists. changes that confirm glaucoma.” Dr. A 2018 study showed that retailChaglasian explained.1 based optometry clinics followed guidelines for glaucoma care well, “A true diagnosis of glaucoma but there were gaps in performing generally means evidence of certain tests including dilated fundus histological changes to the optic exams, central corneal thickness nerve head and retinal nerve fiber measurements, visual fields (VF) layer consistent with glaucoma tests, gonioscopy, and setting target pathology,” he said.

IOP.8 Integration of OCT technology in optometry practices also has challenges. While OCT devices are now more available to optometrists, interpreting the images can be problematic. “Reading the results is a hurdle for some optometrists because they’re not black and white.

There could be subtle signs of early disease, it could be random noise, or it could be an erroneous piece of information that comes back in the test results,” noted Dr. Chaglasian.

VF testing is a crucial tool for spotting glaucoma and should ideally be done more than twice a year, with experts suggesting a minimum of three times annually to catch any variability in test results. The Wong et al. study also underscored the importance of regular testing, showing that nearly half of the glaucoma cases were undiagnosed due to missed VF screenings. These findings highlight a critical point: Infrequent testing can lead to missed diagnoses, allowing glaucoma to progress unchecked.4,9

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Cover Story

Glaucoma care: Beyond the clinic Traditional in-clinic testing often falls short, offering only a snapshot of a patient’s condition and consuming significant time and resources.

Additionally, the challenges brought on by the COVID-19 pandemic, combined with the increasing number of glaucoma patients, have pushed the eye care community to prioritize telemedicine and improve practice efficiency.

tabs on vision health without frequent clinic visits.11

eliminates user error and the need for self-testing.16

Portable perimeters are now allowing frequent at-home visual field testing.

The Melbourne Rapid Fields (tabletbased, GLANCE Optical; Melbourne, Australia), the IMOvifa™ (VR-based, CREWT; Tokyo, Japan), the VisuALL (VR-based, Olleyes; Summit, NJ, USA), and the re:Vive 2.0 (VRbased, Heru; Miami, FL, USA) are four notable options. Studies show these portable tests provide reliable results, often matching the traditional Humphrey Field Analyzer used in clinics.12,13

However, at-home testing and wearable devices have yet to be fully implemented in most optometry practices due to their high cost.

“They’re not fully implemented yet.

We’re making headway, but it’s slow,” said Dr. Chaglasian. “Most devices can be thousands of dollars, so it’s somewhat impractical at this point.”

Inspired by home monitoring advancements in other fields, like portable blood pressure cuffs and glucose meters, glaucoma Smartphone adapters and dedicated care is evolving beyond the clinic. self-imaging systems, like the Portable testing is changing the way SCANLY® Home OCT (Notal Vision; optometrists think Manassas, about glaucoma VA, USA), are “Home tonometry is detection, offering paving the way effective screening for at-home now available, and it’s that rivals traditional optic nerve quite good." methods. imaging. While nondilated Home testing. Home tonometry, eyes captured by smartphones may with devices like the iCare Home not always match the precision of tonometer (iCare; Vantaa, Finland), conventional fundus photography, lets patients monitor IOP outside they still show strong agreement in clinic hours. It is quick, comfortable, optic disc cup assessment compared and closely matches the accuracy to professional graders.14,15 of traditional Goldmann applanation tonometry. Since IOP fluctuations Wearable tech. One promising often occur when clinics are closed, approach to making glaucoma home monitoring provides essential screening easier and more effective data, helping practitioners to monitor is the use of wearable devices.

IOP accurately.10 These nifty gadgets offer continuous monitoring, addressing the challenge “Home tonometry is now available, of getting patients into the office to and it’s quite good,” noted Dr. take their IOP measurements.

Chaglasian. “The patient can use it at home, five or six times a day for a two- Take the FDA-approved Triggerfish® week period, giving us much more (SENSIMED; Lausanne, Switzerland), information about their fluctuation in for instance. This innovative device intraocular pressure.” is a contact lens with a built-in microsensor that measures tiny, Home visual acuity tests have spontaneous changes in the also become a promising tool for eye's shape to estimate IOP. The monitoring glaucoma. A systematic data collected by the lens is sent review of more than 1,000 studies wirelessly to an adhesive antenna highlighted three standout remote placed around the eye, which then visual acuity tests—DigiVis® transmits it to a portable recorder (Cambridge Medical Innovation; worn by the patient. From there, Cambridge, UK), iSight Test the information is transferred via Professional (Kay Pictures; Tring, Bluetooth to the practitioner's device, UK), and Peek Acuity (Peek Vision; making the whole process smooth London, UK)—comparable to in-clinic and convenient. Studies show that assessments. These apps offer an Triggerfish is safe, well-tolerated, and accessible and efficient way to keep

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A glimpse into the future Artificial intelligence is making significant strides in glaucoma detection, offering promising advancements for diagnosing this sight-threatening condition. These algorithms can identify progression risk and disease stage, and recommend referrals.

Perimetry. Since as early as 1994, researchers have used AI to diagnose glaucoma using VF testing datasets.

Noteworthy algorithms have outperformed glaucoma experts, distinguishing between normal and glaucomatous visual fields. When trained with both OCT images and standard automated perimetry (SAP) VF results, these algorithms achieve even greater accuracy making them excellent tools for identifying patients with glaucoma.17 Fundus photographs. AI reduces variability in the assessment of optic nerve head and retinal nerve fiber layer changes. Using segmentation and structured learning, AI models achieve impressive accuracy (94% to 98%) in diagnosing glaucoma from fundus photos. One exciting study showed how an OCT-trained deep learning model applied to fundus photographs can track glaucomatous changes over time.

Given the complexity of OCT imaging, this technology could be deployed in community settings, such as kiosks, to make glaucoma screening more accessible.18 OCT. Since 2005, studies have demonstrated the effectiveness of deep learning models in analyzing OCT imaging data to detect glaucoma optic neuropathy. These models offer

a quick and objective way to manage glaucoma.19 Despite these advancements, significant barriers remain before AI can be widely adopted in primary healthcare. Poor image quality can lead to false positives and increased healthcare costs, while privacy concerns may deter patients from participating.20 AI also needs to prove its efficacy in the real world. “There’s still a lot of testing that needs to be done, and

we’re still in the early days,” said Dr. Chaglasian. “We’ll see what happens in the next couple of years.”

By providing more accurate and consistent diagnoses, AI has the potential to significantly reduce the burden of glaucoma, ensuring early detection and better management of this chronic eye disease. “If it works, it’s only going to enhance my ability to take care of patients and hopefully make things more efficient so I can spend more time face-to-face with them,” said Dr. Chaglasian.

References 1. Soh Z, Yu M, Betzler BK, et al. The global extent of undetected glaucoma in adults: A systematic review and meta-analysis. Ophthalmology. 2021;128(10):1393-1404.

2. Bowling B, Chen SDM, Salmon JF. Outcomes of referrals by community optometrists to a hospital glaucoma service. Br J Ophthalmol. 2005;89(9):1102–1104.

3. Berkowitz ST, Finn AP, Parikh R, et al. Ophthalmology workforce projections in the United States, 2020 to 2035. Ophthalmology. 2024;131(2):133-139.

4. Wong EY, Keeffe JE, Rait JL, et al. Detection of undiagnosed glaucoma by eye health professionals. Ophthalmology. 2004;111(8):1508–1514.

Jump in but proceed with caution Optometrists play a crucial role as the first line of defense against glaucoma.

Dr. Chaglasian noted, "Because glaucoma can lead to vision loss, optometrists naturally approach it with caution, which is wise. But I also think caution prevents them from jumping in and taking care of these patients, which is what we really need to do,” said Dr. Chaglasian. “We have to get optometry on board, and we need to do the right thing for our patients.”

As glaucoma screening technologies continue to develop and become more accessible, optometrists have increased potential to reduce the global prevalence of undiagnosed glaucoma, preserving the vision of millions worldwide.

Contributor

5. Green S, Ng RJ, Phillips G, et al. Glaucoma Agreement in New Zealand (GAINZ). Clin Exp Optom. 2024;107(2):204-212.

6. Patel UD, Murdoch IE, Theodossiades J. Glaucoma detection in the community: Does ongoing training of optometrists have a lasting effect? Eye. 2006;20(5):591-594.

7. Azuara-Blanco A, Burr J, Thomas R, et al. The accuracy of accredited glaucoma optometrists in the diagnosis and treatment recommendation for glaucoma. Br J Ophthal. 2007;91(2):16391643.

8. Stanley J, Huisingh CE, Swain TA, et al. Compliance with primary open-angle glaucoma and primary open-angle glaucoma suspect preferred practice patterns in a retail-based eye clinic. Journal of Glaucoma. 2018;27(12):1068-1072.

9. Chauhan BC, Garway-Heath DF, Goñi FJ, Rossetti L, et al. Practical recommendations for measuring rates of visual field change in glaucoma. Br J Ophthalmol. 2008;92(4):569-573.

10.Liu J, De Francesco T, Schlenker M, Ahmed II. Icare Home tonometer: a review of characteristics and clinical utility. Clin Ophthalmol. 2020 Nov 23;14:4031-4045.

11.Thirunavukarasu AJ, Hassan R, Limonard A, et al. Accuracy and reliability of self-administered visual acuity tests: systematic review of pragmatic trials. PLOS ONE. 2023;18(6):e0281847.

12.Kang J, De Arrigunaga S, Freeman SE, et al. Comparison of perimetric outcomes from a tablet perimeter, Smart Visual Function Analyzer, and Humphrey Field Analyzer. Ophthalmol Glaucoma.

2023;6(5):509-520.

13.Tsapakis S, Papaconstantinou D, Diagourtas A, et al. Visual field examination method using virtual reality glasses compared with the Humphrey perimeter. Clin Ophthalmol. 2017 Aug 7;11:14311443.

14.Wintergerst MWM, Brinkmann CK, Holz FG, et al. Undilated versus dilated monoscopic smartphonebased fundus photography for optic nerve head evaluation. Sci Rep. 2018;8(1):10228.

15.Stratton S, Luna J, Roh S, et al. Smartphone-based fundus photography for remote glaucoma assessment in a low resource setting. Invest Ophthalmol Vis Sci. 2021;62(8):1616.

16.Dunbar GE, Shen BY, Aref AA. The Sensimed Triggerfish contact lens sensor: Efficacy, safety, and patient perspectives. Clin Ophthalmol. 2017 May;11:875-882.

17.Bizios D, Heijl A, Bengtsson B. Integration and fusion of standard automated perimetry and optical coherence tomography data for improved automated glaucoma diagnostics. BMC Ophthalmol.

2011;11:20.

18.Medeiros FA, Jammal AA, Thompson AC. From machine to machine: An OCT-trained deep learning algorithm for objective quantification of glaucomatous damage in fundus photographs.

Ophthalmology. 2019;126(4):513-521.

19.Gutierrez A, Chen TC. Artificial intelligence in glaucoma: Posterior segment optical coherence tomography. Curr Opin Ophthalmol. 2023;34(3):245-254.

20.Zhu Y, Salowe R, Chow C, et al. Advancing glaucoma care: Integrating artificial intelligence in diagnosis, management, and progression detection. Bioengineering (Basel). 2024;11(2):122.

Dr. Michael Chaglasian is an associate professor at the Illinois College of Optometry and chief of staff of the Illinois Eye Institute.

He is a graduate of the State University of New York College of Optometry and completed a residency in Primary Eye Care/ Ocular Disease at the Pennsylvania College of Optometry. He is a founding member and currently the executive vice president of the Optometric Glaucoma Society.

Dr. Chaglasian’s clinical practice is focused exclusively on patients with glaucoma and related conditions, while co-managing surgical care as well. His research interests include perimetry and OCT technology, particularly in the collection of reference databases.

Dr. Chaglasian has completed many research projects within the glaucoma field and remains actively engaged with new devices and treatments. Dr. Chaglasian has a number of published articles and is passionate about teaching fellow clinicians on the care and management of patients with glaucoma. mchaglas@ico.edu

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Kudos |

WOMEN IN OPTOMETRY

Brilliance in Balance Dr. Jennifer Stewart has mastered the art of work-life balance while making groundbreaking strides in optometry and sports vision

by Andrew Sweeney

Being able to pursue a career you love is remarkable, but achieving a healthy work-life balance takes it to another level.

Dr. Jennifer Stewart, the latest optometrist featured in our Women in Optometry series, has successfully achieved both goals and more in her career.

H

ave you ever thought about those rare moments in life when one little event or a chance encounter ends up having a profound influence on the course of your life? These little random moments are what make life worth living, proving that life isn’t predetermined and we don’t have to conform to societal roles.

For Dr. Jennifer Stewart, the founder of Look New Canaan (New Canaan, Connecticut, USA) and a prominent figure in the American sports vision industry, one such chance encounter led to an exceptional career.

“I was pre-med in college and was having trouble deciding what career I wanted to pursue.

I looked at veterinary medicine, physical therapy, medical school, chiropractic school, but not optometry! A chance encounter with my next-door neighbor (who was my OD) turned into an opportunity to shadow him—and the rest is history,” shared Dr. Stewart.

A chance encounter leads to a stellar career Dr. Stewart is internationally recognized as a speaker, writer, consultant, and educator. She also serves as the editor of Independent Strong and is an adjunct assistant professor at the New England College of Optometry (NECO). Her private practice and professional career all trace back to one serendipitous encounter.

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“I then started at NECO in 2003 and absolutely loved optometry school! The coursework was rigorous but I had amazing professors and classmates and really enjoyed learning,” she continued. “At that moment, it seemed to take forever, but I felt well prepared and excited

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to start seeing patients once I graduated!”

the NECO Performance Vision Club, which has now grown significantly.”

Optometry is an incredible, wonderful field for women. “I have been so fortunate in my private practice to build a business that supports me financially, professionally, and personally,” Dr. Stewart enthused.

“Women can feel pulled in many directions, especially as mothers, and we don’t often get the flexibility other careers have. That’s why building a private practice that is focused on the work-life balance has been so powerful.”

After optometry school, Dr. Stewart kept her interest in sports vision but was busy learning to see patients.

Then she joined her former practice as an associate and, eventually, partner. “But I always had put sports vision on the back burner,” she added. “And in 2015, I decided it was time to start Performance 20/20, my sports vision practice.”

Empowerment through balance The search for finding the ideal work-life balance is something that challenges many women in optometry. While the field is close to achieving gender equality overall, cultural expectations still predominantly favor a male-centered definition of the ideal work-life balance in wider society.

However, Dr. Stewart has been able to achieve this. According to her, the key is finding the right optometric specialty A self-confessed sports fanatic, Dr. Steward realized that there wasn’t much support for people like herself who wanted to specialize in sports vision.

Highlighting her rolled-up sleeves and can-do attitude, she dedicated herself to developing sports optometry as a specialized field. An old adage, ‘If you love your job, you never have to work again,’ is something that Dr. Stewart exemplifies.

“I have always been and still am an athlete, so I was always interested in finding a way to combine my love of sports with a profession,” she said. “I was excited to learn about the field of sports vision as a first-year student at NECO. I was also the co-founder of

Over the years, Dr. Stewart’s involvement in sports vision has also evolved, keeping it both fun and interesting. “I’m no longer working with athletes in person but I have developed a comprehensive online sports vision practice for optometrists, teach a sports vision course at NECO, and continue to advocate and promote the field,” she shared.

An incredible field, an exciting future Her ability to strike the ideal worklife balance has allowed Dr. Stewart to focus on another passion of hers: Public speaking. While she loves discussing her work in sportsfocused optometry, Dr. Stewart is also passionate about speaking on day-to-day operations, optical success, contact lens sales, practice management, and other related topics. No matter the subject or particular engagement, she retains the same goal: Making a positive change among her audience.

“I always hope that attendees leave with one pearl of wisdom or are inspired to make one change after hearing me speak. If you’ve ever been to one of my presentations, you know I love to give homework! For me, it’s not enough just to provide information. I want attendees to have real, concrete steps and action items for when they get back to their practices,” Dr. Stewart enthused.

Attitudes like Dr. Stewart’s highlight the bright future for optometry, both for herself and the broader field.

At 43 years old, she has already received considerable recognition

from her peers, including the Emerging Leader Award from the OWA, the GameChanger Award from Eyecare Business, and the Theia Award for Innovation from Women in Optometry.

New Look Canaan, her newly opened boutique optical studio, is performing very well. Her enthusiasm for both her current accomplishments and her future plans is palpable.

“I opened Look New Canaan in February 2024, so I look forward to seeing what we are capable of!

I am excited to continue providing advisory and consulting work through my firm, OD Perspectives, and while I may be traveling a bit less this year, I never know what events I’ll be at, especially if they are located at Disney World,” she enthused.

Optometry continues to be such an incredibly rewarding field and is always evolving. “Women have such an opportunity to carve out the career we want, and that brings us joy and purpose. My best advice for those looking to enter optometry school is to do it and don’t look back,” concluded Dr. Stewart.

Contributor Dr. Jennifer Stewart, OD, is an optometrist, internationally recognized speaker, writer, consultant, and entrepreneur. She is the founder and chief vision officer of Look New Canaan, a boutique private practice in New Canaan, CT, USA. She helps optometrists and organizations with operations, sales success, practice management, and sales team training through her advisory and consulting firm, OD Perspectives. Dr. Stewart is the co-founder and chief vision officer for Performance 20/20, which provides services for sports and performance vision training.

She serves on the Executive Board of the International Sports Vision Association and provides consulting for sports vision practitioners around the world. jen.stewart@perform2020.com

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Innovation |

GLAUCOMA AND AI

Glaucoma A and AI

I is all the rage in many fields, and ophthalmology and optometry are no exception.

A symposium held recently at APGC 2024 in Manila, Philippines, highlighted the latest breakthroughs in AI for glaucoma care and management.

AI in clinical practice

From diagnostic support to innovative screening methods, APGC 2024 explores AI's gamechanging potential in glaucoma care

by Diana Truong

Experts at the 7th Congress of the Asia-Pacific Glaucoma Society (APGC 2024) discussed artificial intelligence’s (AI’s) promise in glaucoma management while addressing challenges such as data biases and integration into clinical workflows.

Integrating AI into clinical practice for glaucoma diagnosis and management presents unique challenges and opportunities. Dr. Leopold Schmetterer from the Singapore Eye Research Institute (SERI) shared his insights on this topic, exploring the potential and pitfalls of AI in everyday clinical settings.

“Increasingly, AI applications in ophthalmology are popping up in MEDLINE searches,” Dr. Schmetterer noted, highlighting the growing interest in this technology. Yet, he pointed out a significant lag in realworld clinical adoption. “When it comes to real clinical applications, we are rather at a much lower pace,” he said. This discrepancy stems from several challenges that need to be addressed.

One major hurdle is the nature of the data used to train AI models.

“Many of the studies are published on pre-selected patient populations, not on real clinical applicability,” explained Dr. Schmetterer. This makes it difficult to apply these models to diverse patient groups seen in primary or secondary care settings. He emphasized the risk of “data set shifts, accidental fitting of confounders, and unintended discriminatory bias.”

Logistical issues also play a significant role. Implementing AI requires sophisticated technical infrastructure and seamless integration into existing workflows, which can be daunting for many clinics. “It’s a question of costeffectiveness that needs to be clarified,” Dr. Schmetterer added.

Moreover, there’s a sociocultural aspect to consider: How will patients and healthcare providers accept AI as part of the diagnostic process?

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AI’s potential for glaucoma care

Schmetterer mused, opening the floor to innovative ideas.

Dr. Schmetterer outlined several key applications where AI could make a substantial impact:

AI-driven gait analysis

Screening Tool: AI can be a powerful tool for screening undiagnosed glaucoma cases. “There is a need for a screening tool,” Dr. Schmetterer emphasized, noting that AI could help identify cases that might otherwise go undetected. However, he cautioned about the issues of false positives and false negatives, which could overwhelm the healthcare system if not managed correctly.

Imagine a future where a simple walk down a hospital corridor could help screen for glaucoma. Dr. Xiaofei Wang from Beihang University in China is pioneering just that with innovative AI-driven gait analysis research. His goal is ambitious yet straightforward: To make glaucoma pre-screening more accessible, especially in regions where advanced diagnostic tools are scarce.

“Conducting pre-screening is very crucial for glaucoma,” Dr. Wang emphasized. Traditional diagnostic tools like OCT and fundus imaging aren’t always available to everyone.

His approach uses AI to bridge this gap, analyzing how people walk to spot potential visual impairments.

Diagnostic Support: While AI is unlikely to replace clinical diagnosis, it can certainly support it. AI can assist in analyzing optical coherence tomography (OCT) scans, intraocular pressure measurements, and visual field tests. “AI for screening has nothing to do with AI for Dr. Wang’s method is refreshingly diagnosis,” Dr. Schmetterer clarified, simple yet effective. Instead of emphasizing relying on the different expensive motion “Based on a single requirements capture systems fundus photograph, for these or attaching we can predict future applications. AI in sensors to diagnosis would patients, his team progression with work alongside uses everyday approximately 80% traditional technology— accuracy.” methods, mobile phones. enhancing their “Any mobile phone — Dr. Leopold Schmetterer accuracy and that has a video efficiency. recording function can perform this task,” he explained.

Precision Medicine: Another exciting area is precision medicine. AI can In their study, participants walked a help tailor treatments to individual six-meter path in a hospital corridor, patients, optimizing therapeutic drug performing three tasks: Walking monitoring and potentially improving normally, walking while performing outcomes. “Based on a single fundus a mental subtraction task, and photograph, we can predict future walking over obstacles. The videos progression with approximately 80% captured during these tasks were accuracy,” Dr. Schmetterer shared, then analyzed using a deep learning underscoring the potential of AI to model to extract gait parameters like personalize glaucoma care. walking speed, stride length, and gait cycle.

Looking ahead, AI could also play a role in population health Under normal walking conditions, management and clinical trial design. there was no significant difference in Enhancing patient education through gait parameters between glaucoma large language models and using AI patients and those without the to draft clinical guidelines are other condition. However, when tasked intriguing possibilities. “Should we with walking and performing a mental maybe use ChatGPT in the future subtraction simultaneously, the for drafting such guidelines?” Dr. differences became apparent.

The glaucoma group walked more slowly and had longer gait cycles and shorter strides. “Patients with visual field damage need great cognitive effort to maintain a normal gait and are unable to do so on certain tasks,” Dr. Wang noted.

Interestingly, when crossing obstacles, both groups showed similar walking speeds, suggesting that simple gait analysis might be more revealing under mentally challenging conditions.

The real breakthrough comes from the AI’s ability to classify patients based on their gait. By feeding the gait parameters into a machine learning model, Dr. Wang’s team could distinguish between glaucoma patients and healthy individuals.

Although the sample size was small, the results were promising.

The next step? Scaling up the study to include more participants, which could solidify AI-driven gait analysis as a reliable pre-screening tool for glaucoma.

Besides Dr. Schmetterer’s insights into the integration of AI in clinical practice and Dr. Wang’s innovative AI-driven gait analysis, symposium attendees enjoyed a range of AI topics in ophthalmology, including applications of AI in angle closure, surgical navigation of ab interno trabeculotomy based on deep learning, revolutionizing glaucoma management with large language models, and more.

With continued research and collaboration, these advancements could soon become invaluable tools in the fight against glaucoma, making early detection and tailored treatment more accessible than ever.

Editor’s Note The 7th Congress of the AsiaPacific Glaucoma Society (APGC 2024) was held from May 24 to 26, 2024, in Manila, Philippines.

Reporting for this story took place during the event. A version of this article was first published on cakemagazine.org.

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17

Enlightenment |

GLAUCOMA CARE

An Optometrist's

POV

How can effective strategies be established to enhance glaucoma screening, treatments, and patient outcomes? by Andrew Sweeney Glaucoma often leads to a significant deterioration in the patient’s quality of life—all the more so when they already have low vision. As optometrists, developing a strategy to focus on this group should help you better manage your optometry clinic and improve patient outcomes.

G

laucoma is one of the most prevalent diseases that eye care professionals encounter.

Its impact can be severe, sometimes leading to vision loss. It is a silent killer, slowly yet steadily eroding the patient's eyesight, often without immediate symptoms.

For patients affected by conditions like myopia, presbyopia, and low vision, among others, glaucoma can represent a final ‘nail in the coffin.’ It not only affects their vision specifically but their quality of life as well. As such, having a strategy in place for glaucoma patients who require prescriptions is critical.

“With over 80 million people suffering from glaucoma worldwide, and 2% of the UK population over 40 affected by glaucoma, it is

impossible to avoid coming into contact with the disease in an optometric setting,” shared Mrs. Imogen R. Hawthorne, the deputy clinical lead for ophthalmology at Modality LLP (Birmingham, England).

“We have to be mindful of screening for it at every sight test for every patient, as well as making considerations for those who already have a formal diagnosis,” she added.

Look for the ‘glaringly’ obvious signs As a member of the British College of Optometrists who is qualified to prescribe medications to her patients, Mrs. Hawthorne has witnessed

the profound impact of glaucoma.

Based on her experience, she has a system in place to treat glaucoma patients with compromised baseline vision. This includes taking a broad view of the patient’s overall health and medical history.

“When prescribing a glaucoma patient with either spectacles or contact lenses, it can be helpful for community optometrists to have a full patient history from their ophthalmologist, including any details of field loss. Significant field loss, particularly in the inferior field would be a contraindication to recommending bifocal or multifocal spectacles,” Mrs. Hawthorne explained.

“Certain visual field defects or poor acuity in one eye may limit the success of certain contact lens modalities, such as multifocal or monovision,” she continued.

“Understanding a patient's surgical history or any drops they may be taking will also have a bearing on what contact lenses an optometrist may recommend,” That is, if, indeed, contact lenses are suitable for the patient at all.

“Up to 70% of glaucoma patients may complain of glare for which I would suggest a photochromic lens in the spectacles. There are also various brands of tinted spectacles with a specific tint designed to block the wavelengths of light, which more commonly causes glare symptoms in glaucoma patients,” she added.

Glaucoma: It is only going to get worse Glaucoma is an increasingly growing problem as most developed countries grapple with an aging population, highlighting the apparent strain on public health systems. The UK, well known for its National Health Service (NHS), is struggling with recruiting ophthalmologists and optometrists to deal with this challenge.

These issues will persist for a long time and, combined with growing rates of poor vision requiring prescriptions,

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glaucoma is a ticking time bomb. In the interim, Mrs. Hawthorne has solid recommendations for focusing on the fundamentals of glaucoma treatment, especially for those with poor vision.

“The vast majority of my clinical time is spent working in an ophthalmological setting, seeing and treating glaucoma patients. In the UK, more and more optometrists are working in glaucoma clinics to support the growing number of patients with the disease,” Mrs. Hawthorne said.

There is a deficit in NHS doctors to meet the demand. “However, we do have a nationally recognized training framework called the Ophthalmology Common Clinical Competency Framework, which guides optometrists, nurses, and orthoptists to upskill to deliver ophthalmology care, including glaucoma,” she continued.

“In the UK, we have moved towards offering Selective Laser Trabeculoplasty (SLT) laser as firstline therapy to patients with openangle disease. Not worrying about remembering to take eye drops or suffering their side effects may be life-changing for some patients. Each patient has their own unique set of circumstances, especially for those with poor quality vision,” she added.

Allies in community optometry and ophthalmology Another piece of advice that Mrs. Hawthorne can offer for managing prescription issues related to glaucoma is community monitoring.

Patients who require frequent eye exams have to be rigorously examined for signs of the disease.

According to Mrs. Hawthorne, this depends on effective communication between optometrists and ophthalmologists. If treatment is aided by community involvement and if patients who fall through the cracks are identified, then the impact of glaucoma can be mitigated.

“Community optometry plays a key role not only in identifying potential

new cases or at-risk patients but also as an ally to the ophthalmology clinic. ” Mrs. Hawthorne said.

She added that optometry can flag patients whose disease may be progressing or who have been lost to hospital clinic follow-up, as well as check drop compliance and signpost to charitable organizations who may be able to offer support.

“For those who are symptomatic, the clinic plays a vital role in ensuring a patient is making the most of their remaining vision by providing practical advice tailored to their vision loss and lifestyle,” she added.

Concern for cosmesis One of the main concerns Mrs. Hawthorne highlights from her practice is that patients with poor vision may not realize the extent of their glaucoma symptoms. This often occurs because they may mistake said symptoms for the degeneration of a pre-existing problem.

During the early to moderate stages of glaucoma, patients are often subjectively unaware of any field loss.

As such, Mrs. Hawthorne does not recommend any specific spectacle or contact lenses. In advanced stages of glaucoma, her advice depends on the patient's level of vision, lifestyle, and any other health challenges they may have.

“While magnifiers may be useful as a quick aid to pull from a pocket, many patients prefer to use magnification apps on their smartphones. Nonoptical aids may also prove useful, such as liquid level indicators, 'bump-ons' to help find commonly used buttons on devices in the home, and various kitchen appliances adapted for use by those with vision impairment,” Mrs. Hawthorne said.

Glare is another issue as it is one of the most common side effects experienced by patients. Mrs. Hawthorne said this often causes a diminishment in the reported quality of life of low-vision patients.

is important to focus on lenses that match their existing prescriptions and can also offer protection against light sensitivity. However, there are two issues at play here: Finding the right tool for their problem and the aesthetics of doing so.

“Some patients may opt for a fit-over glare shield, e.g., NoIR filter. However, these do not tend to be popular due to their poor cosmesis. I haven’t been approached for prescription sunglasses very often, but I have had many more inquiries for tinted lenses, again for cosmetic reasons,” Mrs. Hawthorne shared.

“Taking prostaglandin drops over many years can lead to darkening of the skin around the eyes, and in some cases, loss of periorbital fat, giving the eyes a 'sunken' appearance.

Some glaucoma surgeries can also leave the eyes looking 'redder' than before. In both cases, patients may be troubled by the cosmesis of their eyes. And I have been approached in the past for a tinted lens that hides the eyes or improves their cosmesis,” she concluded.

Contributor Mrs. Imogen R. Hawthorne is a UK-based optometrist advanced clinical practitioner with 15 years of experience working in extended roles within both NHS and private hospital ophthalmology services. A proven leader of multi-disciplinary clinical teams, Mrs. Hawthorne has built teams from inception, re-designed and re-established existing services, and led clinical groups in both local and national organizations. Her areas of specialist interest include glaucoma, cataracts, cornea, ophthalmic laser procedures, and pediatrics. She is currently the ophthalmology deputy clinical lead for Modality LLP, a communitybased ophthalmology provider, working in a variety of extended clinical roles as well as leading in operations, governance, and policy. imogen.hawthorne@nhs.net

As such, Mrs. Hawthorne believes it

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Conference Highlights |

GLAUCOMA GUIDELINES

for Glaucoma Care

APGS launches the 4th edition of its glaucoma guidelines at APGC 2024

by Diana Truong

The 7th Congress of the Asia-Pacific Glaucoma Society (APGC 2024) witnessed the launch of the 4th edition of the Asia-Pacific Glaucoma Guidelines (APGG4) by the AsiaPacific Glaucoma Society (APGS). The updated publication, unveiled during Symposium Eight on Day 2 of the conference, marks a step up in the standardization and optimization of glaucoma care across the Asia-Pacific region.*

“I

t’s really been a very close working relationship over the past 18 months to bring the 4th edition of APGG to you today. Where all of you can see, witness, and hold the physical copy of all the blood and sweat we endured over the last 18 months,” said APGG4 Co-Chair Dr. Tina Wong (Singapore) during the release symposium.

The Asia-Pacific population, with its vast ethnic and socio-economic diversity, presents unique challenges in managing glaucoma. “Asia alone accounts for 60% of glaucoma cases worldwide,” said APGG4 contributor Dr. Ching-Yu Cheng (Singapore). “And

20

3.6 million people are blind due to glaucoma in Asia alone.”

Recognizing these challenges, the APGS has meticulously crafted the APGG4 to serve as a comprehensive resource for ophthalmologists and healthcare providers. The guidelines aim to bridge gaps in knowledge and practice, providing a unified approach to glaucoma diagnosis and management while being sensitive to the varying healthcare infrastructures and resource availability across different countries.

The APGG4 reflects the latest in scientific research and expert

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consensus, but the guidelines are not only evidence-based. They are also practical and adaptable to the diverse conditions within the Asia-Pacific region.

New and improved edition The new edition of the APGG boasts an improved layout. The previous publication was divided into three chapters—assessment, treatment, and follow-up—with a number of appendices detailing specific topics, like gonioscopy and laser trabeculoplasty, at the very end.

The updated edition folds much of

the 3rd edition appendices into the following new chapters: Epidemiology of glaucoma in the Asia-Pacific region, diagnostic workup, management approach, medical treatment, and surgical and laser treatment.

For instance, gonioscopy is now included under Diagnostic Workup and laser trabeculoplasty appears in the Surgical and Laser Treatment chapter. This new structure offers a more intuitive presentation of information.

Staying current with the latest developments, the APGG4 has also incorporated detailed information on novel medications and techniques with proven safety and efficacy in glaucoma treatment, such as Rhokinase (ROCK) inhibitors and iDOSE (Glaukos).

Treatment algorithms, a useful feature from previous editions, appear every few pages in the APGG4. “It is for good reason.

I think it is pragmatic,” said APPG4 contributor Dr. Victor Koh (Singapore) at APGC 2024. “It is practical when you are using the algorithms and applying them to your patients.”

The APGG4 also features Key Messages and Frequently Asked Questions for every section, providing readers with quick summaries and additional useful information.

it remains a critical tool for ophthalmologists and healthcare providers, especially in the AsiaPacific region. By adapting these guidelines to local contexts and individual patient needs, healthcare professionals can ensure that they are providing the highest standard of care in the fight against glaucoma.

Reference * Asia-Pacific Glaucoma Society. Asia-Pacific Glaucoma Guidelines: 4th Edition. Amsterdam, the Netherlands: Kugler Publications, 2024.

History of the APGG The APGG has a rich history of evolving to meet the needs of glaucoma patients and healthcare providers. The first edition, released in 2003, set the foundation for subsequent updates in 2008 and 2016. Each edition has built on the last, incorporating new research findings and clinical insights to stay at the forefront of glaucoma care.

Editor’s Note The 7th Congress of the AsiaPacific Glaucoma Society (APGC 2024) was held from May 24 to 26, 2024, in Manila, Philippines.

Reporting for this story took place during the event. A version of this article was first published on cakemagazine.org.

As the APGG continues to evolve,

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Conference Highlights |

APGC 2024

PACS: On Spotlight at APGC 2024 Understanding and managing primary angle closure in Asian populations

by Diana Truong

Insights into the anterior segment among Asians took center stage during a dynamic session at the 7th Congress of the Asia-Pacific Glaucoma Society (APGC 2024). Specialists explored the anatomical peculiarities, risk factors and treatment options tailored to the Asia-Pacific demographic.

Different Asian subgroups show unique anatomical features. For instance, the Japanese have a slightly larger anterior chamber width, which offers some protection, while Koreans and Filipinos show higher risk traits but also have protective factors like smaller lens vaults.3,4,5 “A narrow-angle, thicker iris, and greater curvature of the iris are common in the Filipino population, but their smaller lens vault may be protective,” Dr. Lin explained.

Informed management of PACS Dr. Tin Aung from the Singapore National Eye Centre (Singapore) discussed managing primary angle closure suspects (PACS), drawing insights from the ZAP and ANALIS trials. Reflecting on research data from the two studies, Dr. Aung emphasized the low risk of PACS progression.6,7 “The prevalence of angle closure suspects is much higher than angle closure glaucoma, suggesting that most won’t progress,” Dr. Aung highlighted.

P

rimary angle closure glaucoma (PACG) poses a significant concern, particularly among Asian populations, who face a much higher risk. This was the key theme at an engaging plenary session on Day 3 of the APGC 2024 held recently in Manila, Philippines.

Asians and the anterior segment Dr. Shan Lin from the Glaucoma Center of San Francisco (USA) shared some intriguing insights into anterior segment findings among Asians, shedding light on why angle-closure glaucoma (ACG) is more prevalent among Asian populations.

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“Asians have more glaucoma, particularly angle-closure glaucoma, and we’re exploring why that is,” Dr. Lin noted.

He humorously prefaced his presentation with, “The only relevant disclosure here is that I’m Asian.”

He explained that anterior chamber depth and width are generally smaller in Asians compared to Caucasians, leading to a more crowded anterior segment and increased ACG risk. “When we looked at the anterior chamber volume and its area, it was smaller in Chinese,” he said. Additionally, the iris thickens more in the dark in the Chinese population, further narrowing the angle.1,2

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“Observation remains a viable option, especially for patients with minimal cataracts,” he added. However, he cautioned against complacency, likening it to Singapore’s low crime rate. “Low risk doesn’t mean no risk,” Dr. Aung emphasized, urging patients to understand the nuances before deciding.

The trials underscored the importance of informed decisionmaking. “We discuss with the patient the options of observation versus laser peripheral iridotomy, quoting the data on progression incidence,” Dr. Aung explained.

He also acknowledged cultural variations, citing London’s practice of discharging most PACS patients without laser intervention.

AS-OCT in PACS risk assessment Dr. Benjamin Xu from the University of Southern California (USA) provided insights into PACS risk stratification

and the role of ocular biometrics.

Despite its global prevalence, with three-quarters of cases occurring in Asia, PACS poses challenges in management and risk assessment.

Drawing from longitudinal studies like the aforementioned ZAP trial, Dr. Xu highlighted the limited progression rate of untreated PACS, suggesting that laser peripheral iridotomy may not be the most efficient use of resources. Instead, he emphasized identifying high-risk PACS eyes that warrant earlier intervention.

Patient history emerged as a valuable tool for risk assessment, with familial predisposition and older age being significant factors.

Dr. Xu also explored the potential of ocular biometrics, particularly anterior segment optical coherence tomography (AS-OCT), in predicting angle closure severity and progression.

“AS-OCT produces beautifully highresolution images,” said Dr. Xu. “We can quantitatively analyze AS-OCT images and derive measurements of biometric parameters that describe the size, shape, and configuration of the anatomical structures at the front of the eye.”

AS-OCT offers quantitative insights into anatomical structures, aiding in identifying eyes at higher risk.

“AS-OCT imaging provides us with information that is not available using gonioscopy,” he stated, highlighting its significance in evaluating PACS. Looking ahead, Dr. Xu outlined the need for longitudinal studies in diverse populations to refine risk assessment strategies. The ongoing Multiracial Angle Closure Progression Study (MAPS) aims to address these gaps by establishing OCT-based definitions of narrow angles and monitoring high-risk patients over time.

When lens extraction is not enough When faced with PACG, deciding between phacoemulsification (phaco) alone or combining it with trabeculectomy (phaco-trab) can feel

like choosing between a latte and a double espresso—both serve their purpose, but one packs a stronger punch.

Dr. Clement Tham from The Chinese University of Hong Kong (Hong Kong) discussed when lens extraction alone is enough.

He said that if you need only a modest drop in intraocular pressure (IOP), phaco might just do the trick. “If you only require a relatively small amount of IOP reduction, then probably lens extraction alone would be sufficient,” he explained. If you’re aiming for a dramatic decrease in IOP, adding trabeculectomy to the mix might be necessary. “If you need dramatic, substantial IOP reduction, then you probably need to add something else,” Dr. Tham advised.

So, while phacoemulsification can be a straightforward solution for mild cases, phacotrabeculectomy might be the go-to for those needing maximum pressure relief.

For those in the middle, a study by Dr. Isabelle Lai (Hong Kong) found that phaco-ECP offers a balanced approach with moderate IOP reduction and very few additional risks.8 Ultimately, the best choice depends on various factors like the preoperative IOP, the number of

medications the patient is on, the stage of glaucoma, and the patient’s overall health and preferences. As Dr. Tham put it, “It is very important that you sit down with your patient and go through the pros, cons, and risks of each surgical option.”

Managing refractory PACG Dr. Paul Healey from the University of Sydney (Australia) shared strategies for managing refractory PACG, a condition where angle-closure glaucoma persists despite attempted interventions. “Refractory PACG occurs when primary angle closure persists after angle rehabilitation measures have failed,” he explained.

To target a very high IOP and dysfunctional trabecular meshwork, Dr. Healey suggested medical therapy as well as promising new treatments like laser trabeculoplasty and intraocular stents.

Editor’s Note The 7th Congress of the AsiaPacific Glaucoma Society (APGC 2024) was held from May 24 to 26, 2024, in Manila, Philippines.

Reporting for this story took place during the event. A version of this article was first published on cakemagazine.org.

References 1. Wang D, Huang G, He M, et al. Comparison of anterior ocular segment biometry features and related factors among American Caucasians, American Chinese and mainland Chinese.Clin Exp Ophthalmol. 2012;40(6):542-549.

2. Wang D, He M, Wu L, et al. Dark-light change of iris parameters and related factors among American Caucasians, American Chinese, and mainland Chinese. Curr Eye Res. 2012;37:599-605.

3. Pekmezci M, Vo B, Lim AK, et al. The characteristics of glaucoma in Japanese Americans. Arch Ophthalmol. 2009;127(2):167-171.

4. Kang JM, Baek SU, Chansangpetch S, et al. Comparison of anterior segment parameters among Koreans, Chinese, and White persons. Ophthalmol Glaucoma. 2018;1(3):182-188.

5. Sales CS, Lee RY, Agadzi AK, et al. Open-angle glaucoma in Filipino and white Americans: a comparative study. J Glaucoma. 2014;23(4):246-253.

6. 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.

7. Baskaran M, Kumar RS, Friedman DS, et al. The Singapore asymptomatic narrow angles laser iridotomy study five-year results of a randomized controlled trial. Ophthalmology. 2022;129(2):147158.

8. Lai ISW, Chan NCY, Ling A, et al. Combined phacoemulsification-endoscopic cyclophotocoagulation versus phacoemulsification alone in primary angle-closure glaucoma: A pilot randomized controlled trial. Ophthalmol Glaucoma. 2021;4(6):589-596.

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