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Message SEPTEMBER 2022 NEWSLETTERDoctor, I Have a Question : Treatment OptionsLiving With GlaucomaA Discussion With a Patient and TherapistNew Study From New York Eye and Ear Inrmary of Mount Sinai
Newsletter September, 2022 MESSAGE FROM THE PRESIDENTDear Readers,As summer nears its end, so does our 3rd Annual TGF Art Challenge to Celebrate Vision. But there is still time to participate. Through September 16th you can share a digital copy of your artwork with us, your friends, family, colleagues, and other viewers, and ask them to honor your artistic vision by making a gift on TGF’s Art Challenge page. Or, you can make a gift in honor of one of our artists! Remember -- every gift supports promising new glaucoma research, and every gift to the Challenge is being matched up to a total of $30,000. We are delighted that, this year, three glaucoma patients are among the participating artists. Each is sharing a vision and asking you to bring it into focus with your gift. We continue to expand our eorts to present educational programming – aimed both at our growing interested public and the medical community. We hope you’ll join us on Tuesday, Sept 27 for a talk with Dr. Barbara Wirostko and glaucoma patient Rebecca Vilender about the benets of measuring your IOP at home, and how you can access an aordable home-monitoring device. .And coming up on October 22 is a CME Glaucoma Symposium organized by TGF on “The Future is Now: Translating New Information into Clinical Practice.” Featuring a distinguished panel of glaucoma experts, the symposium is presented in conjunction with Evolve Medical to provide accredited continuing education for health care professionals. As always, we thank you for your generous support of all we strive to accomplish. We are most grateful! With all best wishes,Elena Sturman
DOCTOR, I HAVE A QUESTIONI was just diagnosed.What are my treatment options today?Jai G. Parekh, MD, MBA, FAAOClinical Associate Professor of OphthalmologyThe New York Eye & Ear Inrmary of Mt. SinaiThe Icahn School of Medicine, NYSenior Anterior Segment Eye SurgeonCo-Founder, EyeCare Consultants of NJTraditionally, people always thought of glaucoma treatment as eyedrops. Today there are a lot more options that we can oer to our patients. That’s why an early and accurate diagnosis is so important – because that’s where you can modify the course of the disease with all the options now available. The earlier you are in the disease course, especially with mild to moderate disease, the more options there are. Patients need to know that it’s perfectly reasonable to talk to their eye care professional about that.Drops are still the rst line of therapy. There are multiple modes of action for the dierent types of drops out there and they all work very well. In general, the rst line of defense tends to be a prostaglandin. “Polypharmacy,” where patients are prescribed several dierent drops (usually more than two), taken several times a day, is being used less today because the more you have to take drops, the more likely you are to forget and your chances of compliance are less than 70 percent.Therefore, other options, such as selective laser trabeculoplasty (SLT), are a wonderful option for people who have POAG, (primary open-angle glaucoma), the most dominant form of glaucoma. A landmark study a couple of years ago reported that in many parts of the world SLT is oered as a rst-line therapy. Here in the U.S., it’s oered usually after one or more drops but much of this depends on the discussion between the patient and physician; some patients may opt for it rst-line versus the trouble of using a drop daily.Today, there are dierent MIGS (minimally invasive glaucoma surgeries) that we oer to our patients in their glaucoma treatment journey. In addition to being used in conjunction with cataract surgery, some MIGS can be used as stand-alone surgeries– even 15-20 years before cataract surgery is necessary. We are very excited about that. Most MIGS are covered by insurance. So, patients have the choices of (1) drops – there are newer action drops and dierent combination drops out there; there are (2) lasers; and now we have (3) MIGS. In the pipeline, there are companies working on some drops with new mechanisms of action, new MIGS procedures, and newer lasers that may aect areas of the eye -- like the trabecular meshwork – that impact glaucoma. Of course, if a patient is diagnosed with end-stage glaucoma, or near end-stage glaucoma, then the options are limited. Perhaps the rst-line drop, the laser, and some of the MIGS won’t work as well and more traditional incisional surgery, such as a trabeculectomy, or tubes for draining the eyes are necessary –which is why it’s so important to get diagnosed early.
Newsletter September, 2022I’m very bullish about the therapies for glaucoma overall. Eye pressure is still the only way we can diagnose glaucoma. With a newly diagnosed patient, we check eye pressure a couple of times a year in the morning and a couple of times a year in the afternoon due to variations based on the time of day. And then we very often start them o on a drop. If patients do not want to take drops, we can start them o with an SLT laser procedure – that’s a conversation between the doctor and patient. We do visual eld tests as well, and OCT imaging, and sometimes an ERG retina/glaucoma test. At the beginning, we may do these tests more frequently just to chart the progression of the glaucoma.If the tests show the glaucoma is stable, we’re good to go. If not, we add a drop or do a laser, or sometimes a stand-alone MIG. What’s most important is to talk to your eye care provider about your options. Understand what your options are for where you are. The journey of glaucoma can last for decades if you’re diagnosed early. It’s not a one-shot deal. It’s like any other disease. If you are going to have heart disease, don’t you want to know earlier? Don’t you want to know earlier with diabetes? Glaucoma is no dierent in that respect.LIVING WITH GLAUCOMAMeet Greg AlterAfter 26 challenging years, most recently losing all his vision in one eye, Greg Alter believes that people who live with glaucoma shouldn’t give up. He has hope, he says, that one day soon lost vision can be restored and people with glaucoma will get their vision back.With the loving support of his family, and the ongoing advocacy and activism of his mother, Lela, Greg has courageously faced the issues of his life. He was born prematurely at 23 weeks, weighing only one pound. After spending 10 months in intensive care, and another four months in a rehab unit, he came home for the rst time at 14 months. In an article he wrote while in high school, Greg thanks the doctors who saved his life and the therapists who helped him learn how to talk, walk, and use his hands. Because prematurity can also cause vision problems, he had a laser procedure as an infant and eye examinations annually.One of the issues his parents advocated for was regular education. “We always wanted Greg to be mainstreamed,” Lela says. Greg agreed. He did well, nishing high school in New Jersey with good grades and a regular diploma. “We were planning for college,” says Lela Alter.“But we weren’t aware that Greg had a spinal issue, a result of his prematurity,” she explains. When he returned from a trip to Israel in the summer of 2017 – a lifelong dream – the pain was excruciating. That led to paraplegia, and very dicult spinal surgery to avoid total paralysis.”
In 2019 Greg started to complain about ashes in his right eye,” Lela recalls. “We took him to three specialists who changed his eyeglass prescription, but there was no mention of glaucoma or the need to see a glaucoma specialist. Then Covid struck. In June of 2021, Lela noticed that the right lens of Greg’s eyeglasses was slightly cracked, which, to her dismay, Greg hadn’t noticed. After just a few minutes at the ophthalmologist, the doctor said, “Your son does not have vision in his right eye.” Greg was diagnosed with closed-angle glaucoma. “At that time, we knew nothing about glaucoma and I assumed his vision would return when his pressures lowered. Since then, Greg has seen ‘tons’ of glaucoma specialists– I’ve reached out to doctors all over the United States looking for hope. We have had to change college plans. Greg took a class at Bergen Community College this summer – but it’s very dicult for him with his eyes right now given all the reading he has had to do. It has been daunting.”For Lela’s part, she has become an ardent advocate for glaucoma awareness and intensied research so that vision restoration can be achieved. She prays it will happen during her son’s life span. She wants to make sure that children are tested for glaucoma at the earliest age possible – too many people still believe glaucoma is a disease of the elderly, she says. She asks others to speak up, to support research, and to urge research centers around the world to work together. “I have to believe that vision restoration can be accomplished,” she says. She looks to other diseases as examples of what advocacy and activism can achieve.Black Patients Six Times More Likely to Have Advanced Vision Loss After Glaucoma Diagnosis Than White PatientsAccording to a new study from the New York Eye and Ear Inrmary of Mount Sinai (NYEE), black patients have a dramatically higher risk of advanced vision loss after a new diagnosis of primary open-angle glaucoma (POAG) when compared to white patients.Louis R. Pasquale, MD, FARVO, senior author of the study, is deputy chairman for Ophthalmology Research at the Icahn School of Medicine at Mount Sinai and director of the NYEE Eye and Vision Research Institute. He co-chairs TGF’s Scientic Advisory Board.“This study has tremendous implications for glaucoma screening of Blacks, who we already knew were a population at increased risk of glaucoma,” Pasquale says. “Screening earlier in life could signicantly increase the chance of detecting glaucoma and slowing down progression before it reaches one of the advanced patterns shown in our research.”Within the study group of over 200,000 participants, 1,946 patients developed glaucoma. Researchers analyzed their earliest record of visual eld loss using archetype analysis, a form of articial intelligence.
Newsletter September, 2022The algorithm identied 14 archetypes: four representing advanced loss patterns, nine of early loss, and one of no visual eld loss.Black patients made up 1.3 percent of the study but had a nearly twofold increased risk of early visual eld loss archetypes, and a sixfold higher risk for advanced eld loss archetypes, when compared to white patients. “African descent is a risk factor for glaucoma blindness, and this work provides insight into why that might be the case,” Pasquale said. “We suspect that the reason why Blacks presented with more advanced patterns of loss compared to whites is that the disease starts one to two decades earlier in the former group compared to the latter group. This emphasizes the importance of early screening strategies in Blacks to identify early-onset glaucoma so that visual disability in this population is averted.” Navigating the Psycho/Social Aspects of GlaucomaJoe Lovett is a glaucoma patient, advocate, and documentary lmmaker, whose award-winning Going Blind was created to increase public awareness of blindness, vision loss, and the vision rehabilitation system. Going Blind is also Joe’s personal story of his struggle with glaucoma. The psycho-social issues of glaucoma that so dramatically aect a patient’s quality of life are rarely addressed in glaucoma care as they have been in other medical situations such as AIDS, cancers, and Alzheimer’s.On July 26 TGF presented a webinar during which Joe Lovett and New York-based clinical psychologist Deborah Waxenberg explored some of the issues that impact living with glaucoma.“Losing vision is a mourning process,” says Lovett, who has lived with glaucoma for some 30 years, and whose vision has recently worsened. “At rst you don’t take it too seriously, but then you start to notice the loss.”Lovett agrees with Deborah Waxenberg that therapy can create a space for dealing with loss and feelings of diminishment, and issues of independence and a sense of identity, which people often feel they have to protect. Therapy can also identify strategies for dealing with anticipatory anxiety, which Waxenberg likened to being chased by a tiger, and emphasizing what strengths people still have -- dierentiating low vision from low capacity as a person and acceptance from resignation. Losses in our lives can activate earlier experiences of loss and therapy is helpful in addressing that too.“You learn to use what you have,” says Joe. “That’s the best tip I got. You’ve got to deal with what is, not with what might be. It’s also super important to invite people in – let others know that they can only do what they can do.”
How can you nd a therapist? You can do an initial search online for a health psychologist in your area. But Deborah Waxenberg doesn’t think that is necessary – the ultimate question she says is one of t, of nding someone who can really listen and who won’t rush to solutions. In the New York area, two organizations that oer low vision support are Lighthouse Guild: https://www.lighthouseguild.org and Visions - Services for the Blind and Visually Impaired: https://www.visionsvcb.org.
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