New Horizons in Glaucoma Medical Therapy

Barbara Cvenkel

Department of Ophthalmology, University Medical Centre Ljubljana

Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia

Recent advances in glaucoma treatment have focussed on improving efficacy, reducing side effects and providing more convenient treatment options. Several new approaches and emerging therapies for the treatment of glaucoma show promise, particularly in the areas of novel drugs, delivery systems and neuroprotection strategies.

Rho-kinase inhibitors, a new class of drugs, consist of 3 agents (ripasudil, netarsudil and fasudil) that are available in some countries. They lower intraocular pressure by reducing the resistance to the outflow of aqueous humour from the Schlemm's canal by relaxing the trabecular meshwork. In addition, the Rho-kinase inhibitors reduce the synthesis of reactive oxygen species in the trabecular meshwork cells, which contributes to the death of these cells. Netarsudil 0.002% ophthalmic solution is the only Rho-kinase inhibitor approved in Europe with similar efficacy to timolol but a higher rate of ocular side effects. There are several Rho-kinase inhibitors currently under investigation. Nitric oxide donors are another class of agents that not only lower IOP but may also increase blood flow and anti-inflammatory activity. The only preparation available (not in Europe) is Latanoprostene Bunod, which releases latanoprost and a NO-donating molecule, butanediol mononitrate. A nitric oxide-donating bimatoprost is currently in phase III development. The development of novel prostaglandin receptor agonists that lower IOP by stimulating EP2 and EP3 receptors in addition to FP appears promising. Omidenepag isopropyl 0.002%, a prostanoid EP2 receptor agonist, lowers IOP by increasing trabecular and uveoscleral outflow and has comparable efficacy to latanoprost. The novel fixed combinations, of which netarsudil/latanoprost is available in some European countries, have shown high efficacy due to their effect on episcleral venous pressure. Fixed combinations in the pipeline include Rho-kinase inhibitors (ripasudil) with brimonidine and sepetaprost (an FP/EP3 receptor agonist). Adenosine receptor modulators are another group currently under investigation. Their effect on IOP depends on binding to the receptor subtype. Trabodenoson is a selective A1 receptor agonist that increases aqueous humour outflow via the matrix metalloproteinase-2 signalling pathway and has the potential for a neuroprotective effect.

The side effects of topical treatment and treatment adherence are an important issue in glaucoma treatment. Novel approaches focus on increasing drug absorption from the ocular surface through the use of mucoadhesive polymers, slow-release implants and nanoformulations, none of which are available for clinical use. The enhancement of drug delivery by injection of sustained-release bimatoprost has only been approved by the FDA for a single application for safety reasons. Studies on the intracameral and intraocular use of latanoprost, travoprost and ciliary neurotrophic factor are ongoing.

Home monitoring of IOP, Diurnal Curves and Water Drinking Tests. Are they Trustworthy and/or Necessary?

Barbara Cvenkel

Department of Ophthalmology, University Medical Centre Ljubljana

Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia

Intraocular pressure (IOP) remains the only modifiable factor in the development and progression of glaucoma. Although it is important to measure IOP at diagnosis and after IOP-lowering treatment, the evaluation of IOP-lowering therapy is usually based on a few IOP measurements during the consultation time. Studies have shown that IOP fluctuates throughout the day and over longer periods of time and that a single measurement of IOP in the office may not be representative of most of the day. There is no consensus on which IOP parameter (mean IOP, peak IOP, IOP fluctuation) is the most important risk factor for glaucoma progression. The lack of IOP data is an important limiting factor in glaucoma management. Twenty-four hour IOP monitoring can provide the most accurate measurements, but is hospital dependent, inconvenient and costly. A daytime curve may be an option, but it is questionable whether the pattern of IOP remains similar over subsequent days or over longer periods of time. Collecting more IOP readings at home has led to the development of self-tonometers and continuous pressure measurement devices. The iCare HOME tonometer has been shown to be accepted by the majority of patients and is easy to use. It allows the measurement of IOP in the usual position (i.e. supine position during the night). Home monitoring of IOP may be suitable for motivated patients who appreciate being actively involved in their treatment. The water-drinking test, which tests the eye’s outflow facility after drinking 800-1000 ml in a short time, could be an alternative to diurnal IOP monitoring, as a strong positive correlation between peak IOP values from the water-drinking test and diurnal IOP monitoring has been found in glaucoma patients.  In some patients, visual field loss progresses with apparently controlled IOP at office visits. In these selected patients, obtaining further IOP data may be helpful to modify and/or adjust treatment to prevent progression.

Prof. Julián García-Feijóo is Chairman of the Department of Ophthalmology of the San Carlos Clinical Hospital and Professor of Ophthalmology at Complutense University of Madrid. He has produced 387 articles (MEDLINE), with more than 150 of the manuscripts published in journals from the first quartile of their category (h-index (ISI) = 35; Google Scholar = 55, i10 index: 287) and directed 57 Thesis (8 International PhD¸5 awarded with the University Complutense special merit prize) in the areas of glaucoma and degenerative ocular pathologies. Additionally, he has been editor of 28 books and author of 77 book chapters in other books. Prof. García-Feijóo has been an invited professor in more than 400 conferences and round tables, and in more than 600 national and international courses, participating in 30 public (including 2 EU Grants) and more than 160 private financed projects, acting as principal investigator (PI) in 110 of them. In addition, is Past-President of the Spanish Glaucoma Society, served on the Executive Committee of the European Glaucoma Society is Co-chair the EGS Surgical Special Interest Group and was member of the Glaucoma Committee of the ESCRS (2019-2023). He was General Secretary of the Spanish Society of Ophthalmology and is now its Vice-President. He also served as Editor of the Journal Archivos de la Sociedad Española de Oftalmologia for 8 years. He is currently President of the Madrid Society of Ophthalmology

Positioning of bleb forming….

Bleb forming devices, Less Invasive Glaucoma Surgery or Minimally Penetrating glaucoma surgery are positioned as a less invasive surgical option for patients with moderate to advanced open-angle glaucoma who have insufficient intraocular pressure (IOP) control despite maximally tolerated medical therapy or previous laser procedures. Some years ago these surgeries where considered as an intermediate step between traditional filtering surgeries, such as trabeculectomy, and less invasive interventions like SLT or MIGS. Its design allows for a controlled and sustained reduction in IOP, with a lower risk of complications compared to conventional filtering surgery. However the indications have evolved and now, in my opinion, are gaining acceptance as a viable alternative to trabeculectomy, especially in cases where long-term IOP reduction is needed but the patient or surgeon wishes to avoid the higher risk profile of traditional surgery. It is particularly considered for patients who may not be ideal candidates for trabeculectomy due to comorbidities, previous surgeries, or patient preference. Moreover they can be used as an alternative to glaucoma drainage devices after failed conventional filtering procedures. However, long-term data and comparative studies are still evolving to fully establish its place in glaucoma management guidelines

Premium IOLS in patients with glaucoma. Yes or No

We will discuss the different Premium IOLs and the potencial indications in patients with glaucoma. There are no contraindications for monofocal Toric IOLs or monofocal Plus IOLs other than the possibility of IOL decentration and tilt. However, the use of Multifocal IOLs  (MIOLs) in patients with glaucoma and even ocular hypertension (OHT) requires careful consideration due to potential effects on contrast sensitivity and  overall visual quality. For multifocal IOL Moderate and Advanced  glaucoma are very well stablished contraindications. In my opinion even patients with early glaucoma are not good candidates for MIOLs as contrast sensitivity could be affected even in early stages with minor VF defects. Moreover OHT patients could progress unexpectedly and rapidly so even in this case, patients have to be informed and should understand the potential risks and benefits, especially if their life expectancy is long. In PSX glaucoma or even PSX syndrome MIOLs should not be used due to the long term IOLs stability complications.

Francisco Javier Goñi. Barcelona, Spain

Francisco Javier Goñi, obtained MD and PhD degrees at Navarra University, Spain, in 1985 and 1994 respectively. He qualified as an ophthalmologist in 1991. Since then he has been an Associated Professor at Universitat Politecnica de Catalunya (UPC) and Head of SIOVO-VOR ((Integrated Ophthalmology Department at Hospital de Granollers, Mollet del Vallès and Sant Celoni, and Valles Oftalmologia Research, associated to Universitat Internacional de Catalunya). He is currently chief of the Ophthalmology Department of Hospital Universitari de Mollet del Vallès, and glaucoma consultant at CTIG, Hospital Quiron-Teknon, Barcelona. He has been a member of the executive committee of the European Glaucoma Society from 2008 to 2012, and a board member of the International Perimetric Society from 2004 to 2012. His main area of interest is in diagnosis and treatment of glaucoma.

Of course I took my drops, doctor

When asked directly and in a straightforward manner, the patient will answer yes, I'm using the drops. Treatment adherence is difficult to assess. This presentation reviews key concepts to better identify possible barriers for treatment nonadherence and strategies for recognizing and improving it.

When enough is enough

In our clinical practice, it is not uncommon to face terminal situations related to glaucoma as a disease, to the patient as a suffering human being, and to the doctor as the leader of therapeutic decisions. This presentation reviews shortly the defining characteristics of each of the parties in this three-way relationship, leading to a situation that ultimately results in a difficult decision such as "enough is enough."

Dr Hari Jayaram is a Consultant Ophthalmic Surgeon and Clinician-Scientist based at Moorfields Eye Hospital NHS Foundation Trust where is the Director of the Glaucoma Service, with an honorary academic appointment as an Associate Professor at the Institute of Ophthalmology, University College London. He is a previous NIHR Academic Clinical Lecturer at Moorfields and a Fulbright Scholar having spent two years at the Casey Eye Institute in Portland, Oregon, USA studying new experimental glaucoma models. He currently serves as Co-Chair of the Research Management Committee, New Technologies Committee and Chair of the Consultants Committee at Moorfields Eye Hospital in London. He is an investigator for glaucoma surgical trials and innovations in healthcare delivery through high volume diagnostic hubs. His laboratory research focuses on the development of strategies to protect the optic nerve in glaucoma using extracellular vesicles and stem cells.

Abstract #1

“Does Advanced Age Affect the Surgical Procedure of Choice?”

The prevalence of glaucoma continues to increase with an ageing population and consequently we frequently have to address the challenging of progressing glaucoma in an ageing population, This talk will address the challenges of performing glaucoma surgery in an older population, whilst balancing the benefits of surgical intervention against the risk associated with surgery in this vulnerable group of patients, their willingness to undergo ocular surgery.

Abstract #2

“EBM - How do (should) Landmark Trials Affect Our Practice In Advanced Open Angle Glaucoma?”

The management of Advanced Open Angle Glaucoma has been a clinical challenge with prior evidence based upon clinical practice derived from a prior era. This talk will discuss the available contemporary evidence that can influence the clinical decision making of glaucoma specialists caring for this challenging cohort of patients. 

Current: Full Professor

Head of Glaucoma division of the University Ophthalmology Department

Head of German Childhood Glaucoma Center

Managing Senior Physician

2021               Managing Senior Physician

2017               Full Professor             

2015               Continuing Education Officer

2014                Assistant Professor, Chair of Glaucoma department

2006                Consultant, Senior Physician

Research projects

Since 2023                 DFG-funded, international research project (Ho 3277/7-1): Surgical success in congenital and secondary glaucoma: Conventional probes trabeculotomy versus catheter-based 360° trabeculotomy (prospective randomized clinical trial with Cologne (Prof. Dietlein) and Leuven (Prof. Stalmans)

Since 2023                 European Glaucoma Society Screening Task Force: European Expert Panel: genomic risk profiling, AI and cost effective screening strategies for glaucoma.

Since 2020                 Establishment of a European network to improve treatment strategies and treatment options for childhood glaucoma.

Since 2017                  Establishment of a clinical-epidemiological registry for congenital glaucoma in Germany.

2016                           DFG-funded International Scientific Congress with "live surgery" (Ho 3277/4-1)

2014                           DFG-funded International Scientific Congress

(Ho 3277/3-1)

2012-2016                   DFG Research Grant (Ho 3277/2-1) Role of intraocular pressure fluctuations in the development and progression of glaucoma disease

Since 2007                  Founding member and investigator of the Gutenberg Health Study

2004/2005                   DFG research and clinical fellowship USA (Ho 3277/1-1): Prospective longitudinal study on "structure and function relationship in glaucoma"

Since 2000                  Investigator and cooperator with the clinical trial center of the eye clinic and the IMBEI

Experience in the field of empowerment

• Active mentor in the mentoring program of the Johannes Gutenberg University Mainz
• Active mentor for female habilitation physicians at the Medical Faculty of the University of Cologne and Germany-wide.
• Development of a Mainz Ophthalmology Curriculum for Continuing Education
• Establishment of the Journal Club since 2008 for doctors in further training
• Reviewer as part of the Clinician Scientist Fellowship Program at the Mainz University Medical Center
• Supervision of doctorates/habilitations/professorships
• Director of international fellowship

Title

Advances in laser treatment for glaucoma

Abstract

The presentation includes new recommendations for first line treatment for glaucoma and an objective view on the future treatment for glaucoma

Title

Glaucoma isn´t the only optic neuropathy. How do I avoid getting into trouble?

Abstract

The talk will present differential diagnoses of glaucoma including various non-glaucomatous optic neuropathies. Identification comparison to glaucoma optic neuropathy will be discussed. 

Anthony qualified from University College Galway in 1987 and undertook his ophthalmology postgraduate training in the UK. He was awarded an MD from the University of Leicester and undertook fellowship training in Glaucoma in London at the Western Ophthalmic and Anterior Segment and Cornea in Nottingham.

He is currently a consultant ophthalmologist with a subspecialist interest in glaucoma at Nottingham University Hospital and an Honorary Professor of Ophthalmology at the University of Nottingham. His primary research interest is in the clinical management of glaucoma particularly advanced glaucoma. He has received research funding support from the NIHR-HTA program, Glaucoma UK and Fight for Sight. He is currently the Chief Investigator of the NIHR funded Treatment of Advanced Glaucoma Study (TAGS).

He has published over 100 glaucoma peer reviewed papers in glaucoma and lectured extensively. He is a past President of the UK & Eire Glaucoma Society. Currently he is a member of the European Glaucoma Society Scientific Committee, Clinical lead for the East of England Ophthalmology Clinical Research Network and the Chairman of Glaucoma UK a patient support charity.

Anthony King Program

Friday 4^th April.

Session 11:00 - 12:00

Primary or secondary open angle glaucoma in a young patient – what do I do differently

Abstract

The treatment approach for open angle glaucoma may vary according to the underlying aetiology of the condition and the age of the patient.  While the treatment options remain the same for all open angle glaucoma patients the order in which these options are undertaken may vary and age may influence the treatment pathway adopted.  We will explore the options that exist and important considerations in deciding treatment and evidence that exists to support treatment choices.

Session 17:30 – 18:30

The patient is in late disease but early in life. What do I do differently

Abstract

The treatment approach for glaucoma may vary according to the severity of disease and the age of the patient.  Patients presenting early in life with advanced disease have longer to become severely visually impaired during their lifetime and this may influence the treatment pathway adopted. We will explore the options that exist and important considerations in deciding treatment and evidence that exists to support treatment choices.

Greek Glaucoma Society 2025

Stefano Miglior

Glaucoma suspects and ocular hypertensives. Are we wasting resources in this group of individuals…?

Individuals with Ocular Hypertension (OHT) are about the 4% of the general population above the age of 40.  Glaucoma Suspects (individuals with a suspicious optic disc and a normal or borderline visual field and a normal IOP) should be added to the group of OHT, thus increasing the number of functionally normal individuals with a higher risk to develop POAG over time and/or already affected by a very early stage of the disease.

They have a potentially high impact on the amount of resources (economical, human and logistic) that should be allocated in order to provide the correct diagnosis and to organize the proper follow up and clinical management. Today we have adequate indications for an Evidence Based (EB) management of OHT, which may simplify the whole process and considerably limit the waste of resources in this area. We do not have yet EB indications for the best management of glaucoma suspects, but a proper knowledge of basic ophthalmological signs, and a correct interpretation of Imaging and Visual Field test results may help in simplifying the overall diagnostic and management processes.

It is not possible to foresee the impact of a correct clinical practice on the possible saving of economical, human and logistic resources. On the other hand, however, it has to be kept in mind that during the last decades a very strong and continuously repeated message concerning “early diagnosis of glaucoma” has been spread out all over general ophthalmologists and general population. The result is that today potential patients tend to be extremely anxious for a potentially blinding disease and ophthalmologists tend to over-diagnose and over-treat.

The presentation will try to highlight these concepts and to update present findings to better elucidate the whole context.

Stefano Miglior

How do I approach the relevant co-morbidities in this (late disease/late in life) age group…?

The management of glaucoma in the elderly, when glaucoma may be advanced or even end-stage, needs a very challenging clinical approach, which should take into account a number of significant variables: stage of the disease, binocular functional status, life expectancy (which does not simply depend on the crude age, but also on the presence/absence of systemic co-morbidities, the psychological status of the patient, the assessment of IOP and of the local and systemic impact of topical therapy, and, whenever possible, the assessment of visual field rate of progression.

Among these, co-morbidities represent a significant problem, either if they are ocular or if they are systemic.

If they are ocular (age-related macular degeneration, retinal vascular diseases, ocular inflammation, advanced cataract, severe corneal diseases…) the ophthalmologist should be aware of the functional impact of the ocular co-morbidities on the proper assessment of the glaucomatous eye. At the same time the ophthalmologist should be well aware that a proper management of glaucoma must be titrated in order to treat the disease and limit the impact of whatever glaucoma treatment on the ocular co-morbidities.

If they are systemic, the ophthalmologist should consider the possibility of under-treating, in case of significant diseases that may significantly shorten life expectancy of the patient. In other situations, such as neuro-degenerative diseases, which affect the accurate diagnosis and follow up of glaucoma, the ophthalmologist should consider to try to simplify the medical treatment or to decide for surgery.  In case of systemic vascular diseases the approach to glaucoma surgery should be accurately planned in order to reduce the risk of interference of systemic medications on the surgery itself and during the first period of post-op follow up.

The presentation will try to highlight these concepts and to update present findings to better elucidate the whole context.

Giovanni Montesano is a practicing ophthalmologist and Clinical Glaucoma Fellow at Moorfields Eye Hospital in London. He previously served as a Research Fellow at City, University of London (2019–2021), working with Prof. David P. Crabb in collaboration with Prof. David F. Garway-Heath, and in 2023, he earned a PhD in Vision Science from City, University of London. His research focuses on clinical psychophysics, perimetry, retinal and optic nerve imaging, artificial intelligence, and structure-function relationship in glaucoma and retinal diseases. He has worked on advanced statistical methods for detecting and measuring glaucoma progression and their applications them to clinical trials. Currently, he is supported by Glaucoma UK grants to develop predictive models of glaucoma progression in response to treatment, integrating data from clinical trials and real-world datasets. He actively collaborates with international research groups, frequently presents at national and international conferences, and has published in high-impact, peer-reviewed journals, earning multiple awards for his contributions to the field.

How do we evaluate the results of a trial. Common sources of bias

Evaluating the results of a clinical trial requires a critical understanding of potential biases that can influence outcomes. This presentation will introduce common strategies to minimize bias, focusing on the gold standard: randomized, placebo-controlled, double-masked clinical trials. It will then systematically explore how bias can arise when deviations from this protocol occur. Recognizing that the gold-standard approach is not always feasible—such as in surgical trials—alternative measures to mitigate bias in these cases will also be discussed. The presentation will also explore how the choice of outcome can change the interpretation of the results, specifically focusing on the difference between intraocular pressure control and disease progression control.

Minimal Clinical Important Differences in Glaucoma Trials

In glaucoma trials, defining meaningful treatment effects is essential for both clinical decision-making and patient care. This presentation will focus on the concept of Minimal Clinically Important Differences, emphasizing disease progression as a key outcome measure, primarily assessed through visual field monitoring. While intraocular pressure (IOP) reduction remains the main modifiable risk factor in glaucoma management, its correlation with long-term visual field preservation is imperfect. We will explore the relationship between visual field loss and vision-related quality of life, highlighting why disease progression—rather than IOP alone—should be the primary measure of treatment efficacy. The limitations of IOP-based outcomes and the need for clinically relevant, patient-centred measures will also be discussed.

Winifred Nolan MBchB, FRCOphth, MD (Research)
Winnie Nolan is a Consultant Ophthalmologist in the Glaucoma service at Moorfields Eye Hospital, and Clinical Associate Professor at the International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London.   Her ophthalmology training was at Moorfields and she worked as a Consultant at the Birmingham and Midland Eye Centre for 3 years from 2007-2010 before coming back to Moorfields .

Winnie spent 2 years conducting research into the epidemiology of angle closure in Mongolia and 18 months as a clinical and research fellow in Singapore investigating the role of anterior segment OCT in detecting angle closure.   She is currently working with colleagues at the International Centre for Eye Health and the African Glaucoma Network on a programme of work aimed at prevention of glaucoma blindness in Sub-Saharan Africa.  Her clinical interests and case mix include complex primary and secondary glaucomas and primary angle closure glaucoma.  She spent 3 years as Clinical Director for Moorfields south 2013-16.

Winnie is on the Board of Governors for the World Glaucoma Association and was the Chair of the Programme Planning Committee for the 2019 World Glaucoma Congress.  She is Glaucoma Section Editor for EYE journal.

She is also on the Board of Glaucoma UK and Chair of the Research Panel for the Charity. 

Winnie Nolan - Abstracts for talks

4^th April:

Imaging of the anterior segment:  Do we still need gonioscopy?

Over the last decade the use of anterior segment imaging has become a more established part of the diagnostic work up for glaucoma patients.   Where it used to be an adjunct to gonioscopy in helping confirm the presence and mechanisms of angle closure, it now is used more routinely for excluding angle closure in ‘virtual clinic ‘ settings or as a replacement for gonioscopy.   However, gonioscopy is still an important examination technique which requires skill and practice.   In this talk there will be discussion of the role of imaging and the advantages and disadvantages of the two types of angle examination techniques.

5^th April:

How should landmark trials affect our practice in angle closure?

The ZAP and EAGLE studies are the two key trials which have changed practice in the management of patients with narrow angles and primary angle closure disease.  The ZAP study showed a small benefit of prophylactic laser iridotomy for narrow angles and this talk will discuss how in the UK we now suggest limiting this intervention to patients thought to be at higher risk of acute angle closure.  The EAGLE trial showed that clear lens extraction achieves better control of IOP in patients with PAC and PACG compared with iridotomy.   This talk will discuss the exclusion criteria for EAGLE and the importance of counselling patients on CLE and identifying those who may be at higher risk of complications following surgery.  This will be illustrated with case example(s).

Gordana Sunaric Mégevand is a glaucoma specialist in Geneva, Switzerland. Her career started at the University Hospital Geneva, followed by a 3 years fellowship in glaucoma and anterior segment surgery in Capetown, South Africa. At return she headed the Glaucoma unit at the University Hospital in Geneva, then founded in 2013 the Centre Ophtalmologique de Florissant (COF) and the Clinical Research Centre Foundation A de Rothschild.  She served as president of the EBO (European Board of Ophthalmology), and was awarded the Peter Eustace medal in 2020 for contribution towards upgrading education in ophthalmology in Europe.  She was an Exco – member of the EGS (European Glaucoma Society ) and has actively contributed in the elaboration and realisations of the EGS – FEBOS Glaucoma exam and the EGS Glaucoma Fellowship.

To MIGS or not to MIGS, this is the question

Gordana Sunaric Mégevand MD; FMH, FEBO

Who is the ideal patient for filtration surgery

Gordana Sunaric Mégevand MD; FMH, FEBO

Since its description, over 50 years ago, Trabeculectomy has remained the Gold Standard in the surgical management of uncontrolled and progressive glaucoma but concerns about bleb-related complications have contributed to an expanded use of tube shunts and of newer, safer surgeries.  However most comparison of these alternative surgeries have confirmed the superiority of Trabeculectomy in reducing IOP but at the expense of potential post-operative complications. When planning surgery, It is important to evaluate the risk- benefit in the given patient, to adopt an individualized approach balancing potential complication with long term efficacy. 

Andrew is a consultant glaucoma surgeon at Princess Alexandra Eye Pavilion Edinburgh. He is the NHS Research Scotland National Lead for Ophthalmology, Honorary Reader at University of Edinburgh, and is the current president of the UK and Eire Glaucoma Society (UKEGS). He completed glaucoma fellowship training at Moorfields Eye Hospital, London and Shiley Eye Institute, University of California San Diego. He is a past member of the EGS executive committee and co-chair of the EGC scientific committee and currently co-chairs the examination committee. He is a past recipient of the ARVO Innovative Research Award, Pfizer Ophthalmic Fellowship, Royal College of Ophthalmologists’ Fauld’s Trophy and Tenovus Scotland Lady Illingworth Award. In 2023 he was awarded a master’s degree in medical statistics and in his spare time is a qualified classifier for the British Paralympic Association. 

Abstract 1: My best to go glaucoma biomarkers in OCT

Optical coherence tomography (OCT) has transformed glaucoma diagnosis by providing objective, high-resolution imaging of key structural biomarkers. The most important OCT parameters include retinal nerve fibre layer (RNFL) thickness, retinal ganglion cell layer (GCL) and Bruch’s membrane opening-minimum rim width (BMO-MRW), all of which help detect glaucomatous damage at an early stage. However, several challenges persist, particularly regarding the reliability of normative databases, the presence of artifacts, and difficulties in high myopia.

Beyond diagnosis, OCT plays an important role in monitoring glaucoma progression by detecting structural changes over time. However, challenges such as the "floor effect"—where RNFL and GCL measurements become too thin to detect further progression—can limit its utility in advanced disease. Additionally, measurement variability, scan quality issues, and the need to account for normal age-related change remain important considerations. Despite these limitations, OCT remains an indispensable tool, complementing functional tests.

Abstract 2: Does everybody with well controlled early glaucoma need a trabecular MIGS procedure at the time of cataract surgery?

Minimally invasive glaucoma surgery (MIGS), particularly trabecular bypass procedures, has become an attractive option for patients undergoing cataract surgery who have coexisting glaucoma. These procedures offer a favourable safety profile and can reduce medications and provide additional intraocular pressure reduction. However, whether or not  all patients with mild to moderate glaucoma should be offered a trabecular MIGS procedure at the time of cataract surgery remains controversial. Not all patients require additional pressure lowering and cataract surgery alone has been shown to lower IOP. Overtreatment may also expose patients to unnecessary risks and the patient and healthcare system to unnecessary costs. While MIGS may be beneficial for many, a tailored approach is necessary and patient-specific factors, such as target IOP, disease progression and medication burden should guide decision-making. 

The leading principle of the activities of professor (emer.) Anja Tuulonen, MD, PhD, throughout her career can be summarized in one sentence: To promote the wellbeing of citizens and patients within an affordable health care system. She led two Finnish university eye departments for 25 years. After her retirement in 2019, she has continued to work for Tays Eye Centre as a developer and leader of a joint ecosystem aces-rwm (automation in care and evaluation of system with real-world monitoring) which represents collaborative work of all five Finnish university eye clinics. For glaucoma Tays has collected 2008-23 real-world data (RWD), including visual field data and over 200 000 images. All these as well as the Belgian/Singaporean AI algorithm are stored in secured Tays’s environment enabling also genetic analyses using the Finn Gen data. In addition to glaucoma, Tays has also collected RWD since 2008 for the three other ‘Big Four’ eye diseases (age-related macular degeneration, diabetic retinopathy and cataract).

Abstract

29th Greek Glaucoma Congress

Athens, Greece

Master Protocol for Evaluating Real-World Data

Anja Tuulonen, prof. (emer.)

Tays Eye Centre, Tampere, Finland

Based upon available literature, all systems suffer from the same challenges: huge variability of care practices (despite guidelines), simultaneous under- and over-care as well as unsustainable increase of costs. The Western world has already demonstrated that simply doing more what we currently do, i.e., more eye care and more spending cannot guarantee better access to care, nor to better quality, outcomes, or satisfaction with care.

Due to multi-fold variabilities within national and international ophthalmic subspecialities, it is obvious that all cannot be right. As nothing is intrinsically cost-effective, it is important to understand and measure the impact of the current work being done and benchmark our patient outcomes to other organizations.

The US National Institute of Health defines Master Protocol as a trial design that can test multiple subpopulations in parallel under a single protocol, without the need to develop new protocols for every trial. The metrics need to be   1) meaningful both for patients and clinicians, 2) easily and systematically recordable and available from structured electronic health records, and 3) understandable to aid decision making at different levels of health care. In addition, it is crucial to confirm that we measure, report and compare the same aspects of care using the same metrics and methods. These steps offer platforms for adapting trial designs using real-world data for multiple purposes. They require collaboration of clinicians with deep practice experience and questioning minds working closely together.

The digital platform of the Master Protocol is planned to work as a searchlight for scanning the similarly structured RWD data sets between clinics in peer-to-peer benchmarking. Both detected differences and similarities in data sets and outcomes may be valuable and guide to deeper understanding of care practices, including their impacts on outcomes.

Abstract

29th Greek Glaucoma Congress

Athens, Greece      

Screening for Glaucoma: Where Are We Today?

Anja Tuulonen, prof. (emer.)

Tays Eye Centre, Tampere, Finland

The benefits of screening should out-weigh any harms (such as under- and over-care, false positive, negative and uncertain findings) and be cost-effective. Systems outcome matter also in screening, not just test performance which ignores the steps that follow after the test. It is these steps that actually determine how much benefit and harms screening would bring.

For example, evaluation of fundus pictures by artificial intelligence (AI) is time-efficient compared to human evaluation. However, obviously AI, neither e.g., genetic testing, cannot guarantee high enough attendance to screening which has reported to be just above 10% even when screening for targeted high-risk glaucoma populations. In addition, when also Western health care systems are already suffocating with the current patient overflows, it does not seem justified to refer even more patients for their follow-up. However, even when the evidence does not support systematic screening (as is currently the case in glaucoma), screening may be interpreted justified as ‘at least we are doing something’.

A long list of questions still remains to be answered related to high-risk case finding/screening in order to balance between over and under referral and care, how to set a ‘good enough’ referral threshold, how to define test intervals, how to utilize and optimize the already existing systems, and how to deal with social-economic-cultural barriers preventing implementation.