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November 2022 NEWSLETTERDOCTOR, I HAVE A QUESTION : OPTIC NERVE REGENERATIONPATIENT PROFILE: HILLARY GOLDENGLAUCOMA AND SLEEP HANDS-FREE MAGNIFICATION Message
Newsletter November, 2022Message From The PresidentDear Readers,The fall season is in full swing at the Foundation. On October 22, The Glaucoma Foundation held its rst medical symposium oering continuing education credit to ophthalmologists and optometrists across the country. Eighty eye-care professionals joined us at the Harvard Club in New York City for a half day of presentations by experts from Harvard, Duke, Columbia, UC San Diego, University of Iowa, SUNY, Mount Sinai, and Johns Hopkins. Another 350 attended the symposium on Zoom.Titled The Future is Now: Translating New Information into Clinical Practice, the program explored new and developing science related to glaucoma and its impact on clinical care. The entire symposium can be viewed on YouTube, accessible on our website, and we will be spotlighting some of the talks in our newsletters, beginning in this issue with Dr. Thomas Johnson’s work on retinal ganglion cell transplantation. We would like to thank our partners AbbVie, Santen, Alcon, Glaukos, Heidelberg Engineering, Qlaris Bio, New World Medical, Ora, and Zeiss Meditec for supporting this special project. We have just awarded three new supplemental glaucoma fellowships to doctors from Columbia, Mount Sinai, and the Kresge Eye Institute at Wayne State University. And, this month, our scientic advisory board will be reviewing a record number of research grant applications, assessing which projects are ready for funding. In our next newsletter, we will tell you about the fellows, and the science we will be supporting in 2023. During this special season of Thanksgiving, I want you to know how grateful we are for you, our friends and supporters, who care about our mission and make our research and educational initiatives possible. The Foundation and I wish you and your loved ones a happy and healthy holiday season.Please remember us on Giving Tuesday, November 29th. You are vital to our work! With all best wishes,Elena Sturman
DOCTOR, I HAVE A QUESTIONWhen might optic nerve regeneration and vision restoration be a reality for glaucoma patients?Question Answered by:Thomas V. Johnson III, MD, PhD Shelley & Allan Holt Rising Professor,Wilmer Eye Institute, Johns Hopkins MedicineDr. Johnson’s answer reects portions of his talk, Restoring Vision in Glaucoma Patients: Retinal Ganglion Cell Transplantation, delivered at TGF’s October 22 Symposium. His presentation can be viewed in its entirety at the end of the event recording, available on our website and by this link to YouTube:THE FUTURE IS NOW: TRANSLATING NEW INFORMATION INTO CLINICAL PRACTICE - YouTubeOver the past 10 years, we have been working hard on the long road to nd cures for glaucoma patients who have already sustained severe and permanent damage to their optic nerve. Our desire is to go beyond what we can do now – which is to preserve vision and prevent future blindness – and to actually restore vision to people who have already lost it. Unfortunately, glaucoma is often diagnosed late after vision loss has already begun and, at this time, glaucoma vision loss is irreversible. We can do many things to lower eye pressure and, for most people, this can prevent vision loss from getting worse. Relatively soon, we’ll have neuroprotective therapies that will give us a second method to protect vision but won’t necessarily restore vision.Vision loss in glaucoma is caused by the death of retinal ganglion cells (RGCs). RGCs are complex types of nerve cells that play a crucial role in vision. RGCs receive and process visual information that begins as light entering the eye and is detected by rods and cones, and then transmit that information to the brain via their axons, which are long bers that make up the optic nerve. So, in order to restore vision lost in glaucoma we actually have to replace the retinal ganglion cells throughout the entirety of their visual pathway. That’s an incredibly tall order– the National Eye Institute has designated it as an “audacious goal.” First, we need to create RGCs from scratch. Recent scientic advances have enabled RGC production from human stem cell sources. But once we have created them in adish, we have to gure out how to transplant them into the eye in a way that allows them not only to survive, but to migrate into the correct part of the retina where they can receive accurate visual information about the world around us. And then they need to send an axon that goes all the way to
Newsletter November, 2022the optic nerve head through the optic nerve and then to one of several centers of the brain that are meant to receive visual input. Once there, they have to create synapses so they are able to deliver rapid signals.Thirty years ago, science would have looked at this list of obstacles and said this is completely impossible, it’s science ction. But enough work has been done in the past 10 years that this is now scientically possible.Regarding the major challenge of axon regeneration, quite a bit of work has actually been done and a number of molecular pathways have been identied that allow surviving RGCs not only to generate RGC axons but to grow axons that in some cases go all the way back to the brain – and actually arrive at structures in the brain that are meant to receive axonal input from RGCs.But relatively less work has been done on the feasibility of connecting the RGCs to the retina to tell us if that is feasible. We know we can coax them to structurally integrate if we disrupt the internal limiting membrane (ILM) which is a major barrier. But we still have a long way to go – functional integration is something that we are currently assessing. And neuroprotection is going to be really important – the survival rate of RGCs following transplantation needs to be improved.Knowing that there are a huge number of obstacles that still have to be overcome, we’ve organized a new consortium of more than 200 scientists worldwide to gure out how to actually put all the pieces of the puzzle together.The goals of the Retinal ganglion cell (RGC) Repopulation, Stem cell Transplantation, and Optic nerve Regeneration (RReSTORe) Consortium are to prioritize the most critical challenges and questions related to RGC regeneration over the next ve years, and to brainstorm approaches to meeting these challenges while fostering opportunities for collaborative scientic investigation.What do I tell my patients today? On the one hand, it is dicult to predict the future of optic nerve regeneration because there are quite a few questions that we don’t even know how to ask yet; we haven’t gotten the experimental systems far enough along to know all of the hurdles that lie ahead.On the other hand, as a clinician/scientist, it is incredibly meaningful that, especially for my younger patients – children and younger adults – I have something that can bring these patients hope. I condently think we’ll at least be doing clinical trials in those people’s lifetime. But one has to be realistic. I am not sure it’s likely to happen in less than 6 to 10 years.
LIVING WITH GLAUCOMAMeet Hillary GoldenUntil two years ago, Hillary Golden, a Louisianan living in Denver, didn’t know a lot about eyes, and even less about glaucoma. But what a dierence two years can make! Today, as a 53-year-old with severe glaucoma, her life is steeped in learning as much as she can and spreading the word about glaucoma, specically about normal-tension glaucoma (NTG).“I have been in medical sales my entire career,” Hillary explains – “from selling CT scan equipment to medical software.” She was training oral surgeons on computer-guided surgery in 2020 when elective surgeries were halted due to the Covid pandemic. She was furloughed for four months. It was during that period at home that she noticed a stye on her eyelid and decided to get it checked out.“I had the time, so I agreed to do a more comprehensive eye exam. The assistant dilated my eyes. Then the doctor came in and looked in my eye and says ‘hmmm, I don’t like the look of your nerve.’ At this point, I knew nothing about eyes. They seemed more concerned about the nerve than about my stye. I remember that at about 11:45 she said: ‘I think you might have glaucoma.’“I came back for a visual eld test and OCT imaging test which conrmed that I had severe glaucoma – they said it was normal-tension glaucoma. A few days later I saw a glaucoma specialist who started me on eye drops. That was the beginning of a whole learning process. I wanted to research the heck out of it – what is normal tension, what does it mean? I thought only old people got glaucoma!”Normal-tension glaucoma is a form of glaucoma in which the optic nerve is damaged even when the pressure does not exceed the normal range. “Because I was miserable on the drops, they said we could try SLT laser surgery, but that did not work. I had lost 40 percent of my visual eld in both eyes at my diagnosis. The loss is in the upper nasal quadrant, so thankfully, I can still see and can drive.“In 2021 I was traveling again, working for Allergan, selling a medical device for glaucoma. I got more involved with my eyes – I was talking to glaucoma doctors all day for work. This past February I changed jobs moving to Sight Sciences –working with the Omni MIGS surgical system for glaucoma. The reason I love my job is because I want to help other people through the doctors I call on every day. I also want people to know that normal-tension glaucoma (NTG) is dierent.I personally mentor a couple of glaucoma patients and I am in several glaucoma support groups where I answer questions the best I can and give support to whoever needs it. In the U.S. normal-tension glaucoma accounts for about 30 percent of all glaucoma cases.“I’ve done a lot of research on my own. There’s a prominent doctor in Switzerland who has done research on the role of vascular dysregulation in NTG and he’s been helping me. I also have a doctor in Denver and one in South Dakota. I’ve tried to seek out the gurus of normal tension…I have to try everything.“I have a home tonometer – I think this is going to be the norm – measuring IOP three or four times a
Newsletter November, 2022year in the doctor’s oce just isn’t often enough. It’s super important for my pressures to be super low – they need to be 9 or 10. I have a tech background. But not everyone is tech savvy – more doctors need to have a technician to help patients set up their tonometers.“I’ve also become a certied health coach. I know it’s going to help that I eat well and take care of myself in other ways, but it’s frustrating. I’ve lost so much vision and I sit in the waiting room with all these other patients who are 20 years older than me, and my eyes are worse than theirs. It’s stressful thinking about what my eyes will look like in 20 years. Losing vision is a scary thing -- I’m doing everything I can to preserve what I have left.”Glaucoma and SleepResearch indicates that sleep problems can be a contributing factor to glaucoma progression. Did you know that people with obstructive sleep apnea syndrome (OSAS) are more likely to develop glaucoma than those who do not have this sleep disorder? According to some studies, people suering from OSAS, which is characterized by episodes of paused and shallow breathing during sleep, are up to ten times more likely to develop glaucoma.While intraocular pressure (IOP) can rise during nighttime, this does not appear to be the primary link between sleep apnea and glaucoma as glaucoma progression occurs in some patients despite very low IOP. Worsening of the optic nerve in conjunction with low IOP may indicate normal-tension glaucoma (NTG), also known as low-tension glaucoma, and may also signal the presence of underlying sleep apnea. Recent studies suggest that certain types of glaucoma may result from insucient blood supply to the optic nerve. These studies show that there is decreased ocular blood ow in sleep apnea, and that normal-tension glaucoma is more prevalent in patients with sleep apnea. NTG is characterized by progressive optic nerve damage and visual eld loss with IOP levels that are usually considered to be within the normal range. Because sleep apnea can cause a worsening of glaucoma, it is particularly important to recognize its presence and to treat it appropriately. Another sleep-related question is whether sleep position is related to glaucoma progression. Research shows that IOP is higher when sleeping in the supine position (lying face up, horizontally) than other sleep positions, leading to recommendations that sleeping with the head elevated 20 to 30 degrees may lessen the eect of the supine position. Some studies indicate that sleeping on the same side of the body as the eye with the greater visual eld loss could also be a factor that contributes to glaucoma progression.
Thank you for being a TGF newsletter reader.Let us know what’s on your mind.info@glaucomafoundation.orgCopyright © 2024 The Glaucoma Foundation, All rights reserved.You are receiving this email as a friend of The Glaucoma Foundation.Our mailing address is:The Glaucoma Foundation80 Maiden Lane, Suite 700New York, NY 10038A Low Vision Specialists Talks About Hands-Free MagnicationOn November 15, Steven Schoenbart, OD will address the various ways to educate and assist patients who suer from vision loss, including the use of telescopic glasses for “hands free” magnication.