During this live webinar, the audience will be able to identify advanced glaucoma patients, how to diagnose and follow up, the role of different diagnostic technologies, and how to treat either medically or surgically. Questions received during registration and during the webinar will be discussed.
Lecturer: Prof. Mohamed A. E. Mahdy, MD, PhD, Al-Azhar University, Cairo, Egypt
Dr. Mahdy: Good evening everybody, you you are welcome, all my colleagues in this prestigious website for continuous education. It’s my honor and pleasure to be here and to present this interesting topic with you. Today you are going to talk about advanced glaucoma, what is the current management and practice. This topic before we start, we have to highlight some points in a poll here. Regarding the advanced glaucoma, how are we going to define these cases? We have options like here. Please select your choice. We have options like here, please select your choice and test your knowledge before we start the session. I see now from the poll that most of you, I think, about 53% have defined those patients with total cupping of the optic nerve head with severe visual loss, and about 33% choose all the above, but the most important point here to clarify is definition are those with near total cupping of the optic nerve with or without severe visual field loss, as some cases with normal pressure glaucoma presents with advanced visual field damage, despite the fact that they lose a lot of the optic nerve head. Go to the second question, please. The second question: How are you going to follow up such a kind of advanced glaucoma patients? We have four choices. Imaging modalities, visual field exam, all of the above or none of the above. I think we have chosen all of the above, but during the I think we have chosen all of the above, but during the course the exam we’ll learn that despite all the advance now, it is not enough to follow up this kind of patient, as nothing remains from the structure to follow up with. And the most important is to concentrate in the optic nerve head — sorry, in the visual field. The third question: What is the best manage many of the advanced glaucoma patient. We have several modalities of treatment, like medications, lasers trabeculotomy with adjutants or all of the above. Waiting for your answers, because it’s very important to test the current practice in different parts of the world and the different … We see that 54% of the audience chose to do all of the above, a mixing of all the above medication, which is close to be right, and the next consensus comes 34% choose to do trabeculotomy with adjuvant medication, which is the most important part in management in this kind of advanced glaucoma patient. Lasers and medication plays a very little roll, as we will clarify later on in the course of the presentation. The last question will be: If you are encountered with a new case of advanced with a new case of advanced glaucoma what is your first option? Medications? Laser therapy, minimally invasive glaucoma surgery? Or to do a trabeculotomy? Waiting for your answers. I see that I see that 32% choose to do trabeculotomy, and 46% choose to do medication, which is not — we hope at the end of this preparation to get out of this percentage, and to transfer it toward the trabeculotomy or the minimally invasive glaucoma therapy, but medication has of course a very limited role in this kind of management. Now we go: Advanced glaucoma, what is the magnitude of the problem? And why is this group of patients are important? Simply you could say that this group — this increased morbidity and mortality of this group of patients, they are at great danger of losing the remaining vision, and this disease affects their daily activities with very socioeconomic and health challenges, with increased difficulties including depression. If we come to the annual cost of glaucoma patient in the United States, we could see here it varies in different stages. For example, in advanced glaucoma, we could see it costs 2 and a half thousand in comparison to half thousand, to 1.5 thousand in early stages. And you can see costs of the new modalities of treatment comes in the advanced glaucoma and you can see how much it differs in the cost and the management shifts in this presentation between the early, which is very limited, the blue ones here, and the late stage of glaucoma, which is that much larger in the advanced of glaucoma in that stage. If we come to the advanced glaucoma, we could see that there’s a significant proportion of glaucoma patients presents late in the advanced stage of disease, in the developing and developed world. For example, in the United Kingdom 38% of patients were in the advanced stage of glaucoma, while in South Africa, 45% of those patients with glaucoma were blind in at least one eye at the time of presentation. What about in underdeveloped world? We should under the percentage of patients with advanced glaucoma is very large. We should define this disease, how to diagnose and follow up, what are the challenges, what are the target intervention in these cases, how to treat, medical, laser, or surgery or a mix of both? What kind of surgery are you going to do for these patients and why? If we come to the definition, we could say that patients with advanced glaucoma are those with near total cupping of the optic nerve head, with or without severe visual field loss. And these patients tend to have a worse visual and overall prognosis. Based on the Hoddap and Parrish Anderson criteria, we should know this is the definition of advanced glaucoma. 50% of the points are depressed at P less than 5%, over 20% of point at P less than 1%. At least 1 point in the central 5 degrees with a sensitivity of 0 decibels, and at least 5 degrees of sensitivity of decibels in both hemi fields. And this applies in very advanced glaucoma, but we have a number these patients with normal visual field glaucoma in which the break through appears later in the course of the disease. What are the risk factors in advanced glaucoma? We have to know that we have ocular and ocular risk factors gun the ocular risk factors, we have those with strong evidence and those with moderate strengths. Those with strong evidence of advanced glaucoma, advanced structural and or functional loss at initial presentation of the disease, and also the patient with high or marked visit to visit intraocular pressure fluctuation, these patients are at great danger of advancement of the disease. Also, we should know soc economic condition and the background are important in addition to other factors, these are the most important points to highlight. How are you going to detect in full ocular glaucoma? Depends on the symptoms. Identify of any secondary causes, imaging devices how are we going to use? Visual field changes, how are you going to use it and long-term follow-up. We could say that the subsequent visit for advanced glaucoma, with stable glaucoma, it should be between 3 and 4 months and it could be more frequent if unstable condition, in order to detect changes and to deal with it swiftly. If we come to the patient symptoms, we have to listen carefully to the patient and to compare his previous and past experience with the current experience. Sometimes the patient will describe they aren’t able to see part of the words I used to see earlier. I’m missing part of the words that I’m reading. I bump into things more often than earlier, transient visual field loss and visual hallucinations are a very important symptom and we have to listen to the patient hand it’s very important to know is this patient progressing or stable? Stable patient usually don’t miss words more than often and don’t bump into things more than previous, and progressing ones are losing. If we are going to use the structural changes in the optic nerve and nerve fiber layer to follow up such a kind of pay during our clinical exam, we could say that we have to see if the changes are present in the neural layer — we could say it is difficult to assess, because simply is sudden change in the optic nerve it remains, because the retinal area, only a limited part is left and it is hard to find sudden changes in this part and visual changes are less correlated with the structural changes in such a disease. If we are going, we have to carefully exam the zone beta atrophy, if we could compare if this is the issue in both eyes and we could compare the defect and the zone beta how large, is it getting enlarged from the left picture to the right, we could see that it is enlarging with advancing disease. If we come to the most important spectral domain all CT machines which you can measure besides the optic nerve head and neurofibrillary and even the ganglionic cells, we could say that. If the despite the fact that these two patients are closely similar, if we exam the optic nerve and nerve fiber parameters, but if we go to the visual field, we see that the left one is more healthier than the right one. So it is not likely to be helpful to use such an advance in machines as is minimal area and minimal neuro. We could understand from this graph here that early in the disease, while the visual field changes from 0 loss to 3, some patients will lose between — an amount of the ganglion cells between 100, 40 to 60. This is early in the disease. Early in the disease the structural changes is very helpful and you can use the ganglion cells to detect. Because the changes in the structure is more than the change in the function. Later on in the disease, in the moderate and severe glaucoma cases, you could see that the changes in the moderate cases between 3 and 10 and 3 or 12 loss, we could use both a combination of both. But later on on the disease, we could see the changes from 12 to 30, this is only a limited range of ganglion cells loss between 40 and 0, which is complete loss of the ganglion cells which is not present or never exist in reality. So early in the disease, we could use both structure changes and machines used to image the ganglion cells and the neurofibrillary and the ganglion cells. Later on in the disease we have to resort to visual field which can give us a better idea. If we are going to use the visual field, what kind of visual field are you going to use? Might be the only possible way to follow up such a kind of patients, in addition to the clinical symptoms of the patient. We have to resort to central 10 degrees of visual field examination, use Goldman sighs V instead of III to clarify the defect, examine the cardinal points around fixation and use a quadrant total sensitivity and we will come to it. If we are using the SITA24-2, we are examining 12 points which is 6 degrees apart as you see here. If we use the central 10 degrees, we are examining 68 points with 2 degrees apart, with more details, with a more detailed examination as we could see, and what you are missing in the standard visual field. If we come to this graph, we see here that if we are examining central 10 degrees, we are at the spread marked points as you can see here and nothing in the grayscale examination. If we examine with the central 10 degrees, we could see that the defective points is residing in between the examined central point in the central 24-2, and we could find the defect, so every patient with advanced glaucoma, whether he has a central island or not, we have to do, or even every patient with glaucoma, we should do central visual field 10 degrees exam, as this patient which has no defect at all, it I shall shows a central defect in the central 10 degrees. If you look at the grayscale, it’s a very limited box, if you look at the top figures, it’s very limited, you could have more view down as you see here. If you use similar size what are you going to follow up with? Nothing to see. You will neglect it. But if you magnify it with central 10 degrees and use stimulus size V instead of stimulus size III, you could find more details to follow this patient? A numeric and objective manner later on. Also you have to resort either to examine the quadrant total sensitivity here, which is a very important point in central 10 degrees, which is existing in visual field, or to compare pointwise comparisons, this was defective by 5, now it is defective by 30 or so, so to compare by pointwise as you can see here. What are the challenges in advanced glaucoma? We have several challenges here for sure. One of them is the low-target intraocular pressure and we need to decrease the intraocular pressure postoperatively. Such patient is typically characterized by anxiety fear and sometimes hopelessness and depression. Also the physician might also feel that they are in a difficult position managing such a kind of patient. So we have to avoid a lot of the remaining portion of the vision, in addition to maximally control of the intraocular pressure, which is a very difficult task. But it could reach it no problem. In advanced glaucoma, lowering the intraocular pressure to the low teens, 12, 11, 13, or even single digit, 9 or 8 is very important. Both of these two factors, low intraocular pressure, and no or little fluctuation has the strongest evidence of protecting the optic nerve and remaining visual field later on. Other strategies such as enhancing blood flow and neuroprotection may be helpful for sure the and how are we going to increase the ocular blood flow? Our capabilities are limited. What is our mechanisms of neuroprotection? Our mechanisms are very limited. Soap the only neuroprotective mechanism here is lowering the intraocular pressure and reducing the fluctuation of the intraocular pressure. If we are talking about the management strategies, we have several points, one of them is bio psycho socio spiritual profile is important. If we come to the bio sociospiritual profile of the patient. We should talk work on the mechanism of glaucoma. General health and systemic conditions and other ocular affects of like cardiac disease, and patient with bronchial asthma should be addressed, because it will affect our choice of medication and our conditions if we are going to submit the patient for surgery. Age and life expectancy of the patient is very important, psychological condition, socioeconomic status, patient’s care and partners should be counseled carefully and to counsel them about the danger of disease and its importance. Aggressive lowering of intraocular pressure is important. It is the only proven treatment in preserve visual function in glaucoma. No other ways we could assess it carefully. In the advanced glaucoma intervention study, patients that didn’t progress had the mean intraocular pressure of 12mm, very low intraocular pressure was needed in order to maintain the intraocular pressure over a long period of time. Fluctuations should be considered whenever a patient with apparently lower office measurement of intraocular pressure demonstrates progression of the disease. If you find that the intraocular pressure is stable and the patient is pressure, you should think about fluctuation of the intraocular and you could do a care every now and then. And also there is other factors like how is he going to use the medications for his blood pressure and so on. Medical therapy. Is medical therapy indicated for advanced glaucoma patient? We could say yes. In some patients it has a place to be applied specifically in patients who are progressing slowly and may have longevity such as they might not be blind during their lifetime. And patients who can afford the medication, medical therapy may be an appropriate therapy, but patients who cannot afford the patient, if the medication is not available and the patient with long life expectancy and the progression of the disease is rapid, these patients are not candidates for medical therapy. How are you going to prescribe medication for these patients? We have to prescribe medication with intraocular pressure, like prostaglandins, and beta blockers. Brimonidine and like medications could play a role here, but not that much. Laser treatment. We have a lot of weapons here from the laser trabeculotomies, transsclerral and the new laser like micropulse laser and subthreshold laser and endoscopic. We could say that any type of laser that has the potential to increase intraocular pressure should be avoided. Transscleral photocoagulation could be employed in some cases, especially advanced glaucoma cases with with morbid conditions. Micropulse laser could have a place, and endoscopic photocoagulation could have a place and should be part of other surgeries. What are the other surgical option? S are you going to do minimally invasive glaucoma surgery or tra traditional trabeculotomy? We could say we have a lot of surgical modalities available, the newer surgeries do not appear to consistently achieve a low intraocular pressure required for patients with advanced glaucoma and traditional trabeculotomy is one of the most important if we have a chance to do it once, otherwise, we have to resort shunts. Filterrering surgery you could see it here from wound leak, with anterior chamber, and molecular folds which you can see here which is a very drastic complication. Shallow AC with lenticulocorneal touch was found to be the main reason of opacification in several studies, we should be careful to avoid such complications especially to wipe out as a cause of postoperative loss of visual acuity. However, it does exist, what is the wipeout it is the loss of the central visual field in the absence of other explanation as a cause of postoperative loss of visual acuity. We should keep it in mind and know that it could happen with anyone. With other the guidelines suggest? The guidelines suggest that trabeculotomy remains the conventional primary surgery for advanced glaucoma, but technique has evolved to include the use of wide application of mitomycin C, ememployment of releasable sutures, controllable sutures with extensive postoperative manipulations. This is to do two things: To improve the outcome of surgery and to make the trabeculotomy as safe surgery in advanced glaucoma. The National Institute for health and clinical excellence guidelines in the UK has recommended that patients who present with advanced glaucoma should be offered primary glaucoma surgery and don’t wait and give medication, because you are losing time and progressing later these patients are progressing and put yourself and the patient in a difficult situation later on. But if we are doing trabeculotomy, there are several tips we have to put in our mind. If we are doing trabeculotomy. Preoperatively, we have to consider the risk of any form of surgery should be explained to the patient in advance, in addition to the patient’s care-giver and his relatives for sure. They should listen that we are going to many miles or to stop the progression of the disease, we are not going toin crease the patient’s vision. We are going to preserve or try to preserve or try to delay the patient’s visual loss. Patients will be told that the risk of loss of their remaining field, wipe-out phenomenon, could exist. But never, never, ever discourage the patient from doing surgery. Consider the use of topical steroids preop tively for a week? , lower the intraocular pressure is high if you need T lower intraocular with mannitol or acetazmide. Such patients are usually elder, so general anesthesia is better to be avoided, but it might be indicated in some patients. Topical anesthesia is preferred. We have to keep the volume of anesthetic to a minimum and use adrenaline-free medications, avoid all with orbital compression with balloons and other devices. Antimetabolite use, these should be used with every case with trabeculotomy with any kind of glaucoma except with contraindicated like if we have subconjunctively or scarring. Place this antimetabolites away from the limbus to create a small diffuse bleb. Technical mod indication of trabeculotomy should be employed decome press the eye slowly. Temporal paracentesis, do to proficient intraor your preferred place either intraoperative or later, postoperative if you develop a lot of — Keep the Cheraw flap relatively thick to permit closure without excessive flow. Use fluorescein to conduct Seidel test to assure that we don’t have leakage, preplace sutures may be employed for easy and rapid closure. Application of releasable controllable or laserrable sutures to facilitate control of the intraocular pressure is very important. Operate early in the morning with a fresh mind and consider checking the intraocular pressure later in the day before sending the patient home. Don’t operate on the glaucoma patient late in the day. You should be fresh and your stuff should be ready and concentrating. If a monocular patient is there, consider same day admit and be may need to be treated as blind. Monitor carefully to avoid excessive IOP spikes, or complications with hypotony, Releasable suture is very important to be released just on the slit lamp in the office, and to do little massage. It will enhance the flow and don’t forget to close the conjunctiva securely to avoid any postoperative wound leak. In another case, we are going to do trab with PHACO I’m doing the same sides. I’m employing we could say controllable suture, this is then I am applying the condition to the controllable sutures, to avoid — the aim of these two types of sutures, the releasable suture is to avoid early postoperative hypotony, and to release the pressure later on with modification. And also to securely close the conjunctiva, because we do have a large wound here and I’m tucking the conjunctiva into the grooves with a sutures here in a — fashion so nothing is there. Thank you for your kind attention and this is the end of my slides. It’s not that much. Time. And now it’s time to listen to my colleagues for any questions. > Thank you, Dr. Mahdy, so you can go ahead and stop your screenshare. We have about four questions. >> OK, I will stop it. >> OK. Now, I stopped my screenshare now. Now we’ll go to the questions. Raised by our attendees. Can we go now? >> Yes, so if you open the Q & A, you should see those questions. >> Yeah, I opened the question and answer box, and anyone who is joining us here, we could see what the — giving now. The first question, can medical measures improve vision with people with glaucoma? For sure, this is the first question. There’s a lot of things about this, but in advanced glaucoma, for sure, don’t lose time with such kind of things. We have to concentrate in such kind of patients with something that will help them immediately. What intraocular patient eye can be operate? Ed for sure we cannot operate in an eye with high intraocular pressure. Otherwise it will explode in our face. We have to decrease the pressure through paracentesis or give medication intravenously, this is very important. In advanced glaucoma, I’m not using selective laser, I’m using these kind of lasers in moderate glaucoma cases or in early advanced glaucoma cases. In order to minimize the use of medication. The other question: When do you order visual field, central 10 degrees, how severe visual field the center 24-2 that I should order? No. 1, every case with advanced glaucoma, we should do central 10 degrees. This is very important. Any new case with advanced glaucoma, even without advanced glaucoma, we should do both, as I show in the example that early cases, in which no visual field loss was seen in the advanced: In the 24-2, we could find some defects in central part of the visual field with central 10 degrees. Another question: Can trabeculotomy be done under anesthesia? For sure, but our patients are usually elder. If you can avoid general anesthesia, this is very important, but you should do a careful local anesthesia and it should be tailored to the patient. How often do you order visual field, oct, disc photos, in advanced glaucoma? We should say that visual field, as long — if you review the — you know for advanced glaucoma patients, especially the elderly, it is very time-consuming and very difficult to do, but if you reviewing the patient’s symptoms and you are assessing that the patient is stable, you could do it every 6 months, but usually we follow up these cases every three to four months. So not every visit you have to do, but disc photos, it adds nothing to our things, because disc photos, we have near-total optic nerve cupping, nothing to be seen. Early in the disease, you can control and do OCT and do photos and everything. But later on, visual field is the only valuable modalities of following up such a kind of vision. What about the primary surgery for advanced glaucoma patients? I could say that for every patient with advanced glaucoma, I advise primary trabeculotomy. Specifically if he didn’t have any contraindication. I don’t — I usually don’t lose time with medication. Glaucoma is primarily a surgical disease, if you are treating a patient with medication, for sure you should resort to surgery later on, don’t put yourself and the patients in a difficult situation. There’s another question about the in which stage of glaucoma. For micropulse. Micropulse, for sure it’s very important, if we can do it, in patients with very limited visual field, with advanced stages of glaucoma, and who are not going to live enough. With short life expectancy. Can can laser … help in preventing — well nothing can prevent it, but it because we do not know exactly what brought it into the field. Nothing could be done to avoid t but you should be aware that it exists and should put it in your mind. How many cases of) syndrome in your practice. Luckily enough to today, I have one. But I will not be happy to see it again. It’s very difficult and I made a hard time to see a patient who loses vision while I’m trying to help him. What are you: Of use of the 24-2 — ([unclear] For sure, visual field is very important for our basic glaucoma management, but here we should concentrate on the central 10 degrees, which gives you more details and more objective follow-up. The question: By Angela Peron … would you advise doing trabeculotomy in eyes with vision worse than hand movement? I could say I did not only trabeculotomy in a patient with worse than hand motion, if you see that the patient see hand motion, this type of vision and this amount of vision is very helpful to preserve his dignity and to let him see ghosts and not to be in a dark world. I could do trabeculotomy in such a kind of patient for sure. But we should warn the patient who are you going to do. Can we replace trabeculotomy with laser, cyto photocoagulation? For sure until now no, because cyclophoto coag, you don’t know if it is going to work or not, it doesn’t behave the same for every patient, trabeculotomy is tested surgery. In your clever hand or in the good hand, it could give a better result than any kind of surgery later on. What is the best medical treatment with patients with drug allergy, but doesn’t want to do surgery or lasers? We say that prostaglandin, and beta blockers, but what kind of allergy, I don’t know, but it depends, because nothing could replace surgery. It is selected in some patients to do certain medications because they are not going to live enough, is so don’t general conditions don’t permit to do surgery, or usually they don’t — they are not able to do surgery. Full obstruction advance glaucoma, you could say usually for stable patients every three to four months. Don’t be late. Otherwise you lose. We should see these patients more often, but if we have progressing disease, we could see it more often than 3 months. If the patient’s 260 vision with the near-total cupping, which should normal intraocular pressure with regular checkup, how to do medical management in such cases? If you have a patient with 2/60, which in my point of view is a very useful vision to allow the patient to go to the toilet and to eat and to know to whom he’s talking, it’s very important to preserve this vision and sometimes you have patients with less vision than 260 who have to do surgery and don’t submit to medical surgery except in the selected patient with the conditions that that we said in the presentation. How to choose medications for advanced glaucoma? We go to the safest, and safer. Advanced glaucoma patient, most of them are elder and have cardiac disease and lung disease, as well, so beta blocker is the third choice. The first choice is prostaglandins, and second choice is carbonic anhydrase inhibitors. Mid teens and high teens like 18 or 19, are there any other things that you use? For sure we could resort here if he’s aversive to surgery completely, you could use — it could be used here as an adjuvant with quotient to avoid any intraocular pressure spikes. As an adjuvant for medication for those who are refusing to do surgery. Why the first choice surgery for the primary glaucoma? Why can not follow under medication? No, it’s clarified enough that under medication, if the patient is losing his vision while observing him to lose while doing medication. If you catch the patient with advanced glaucoma, what are you going to wait for? Nothing to be lost. If you — you’ll be met with complete loss of vision and not target to be saved here. Are there any possibilities to improve vision with patients with advanced glaucoma nowadays? I could say for the time being no known way to improve the vision, but for sure, those who went to the moon and Mars will find gene therapy and these things to improve these kind of patients. My patients had 40, 50mm mercury, he feels not much pain, refractive to medical patient. What should I do next? Laser surgery or just let him be. This is 40, 50mm mercury are not going to be treated with any kind of laser. You should do trabeculotomy for these kind of patient, even if he sees light, this is enough for him. But don’t lose time and try to do medication or laser for these kind of patients. Because the window for laser work is very limited. It is not like — trabeculotomy can reduce the intraocular pressure postoperatively from 40 to 10, in a controllable way. If you employ here a controllable solution and releasable suture, you could preserve — can Can I ask for a patient 36, female who’s left-only eye, left eye blind to glaucoma, this is typical for advanced glaucoma, left eye has two failed trabeculotomy and one Hammett valve done 10 years ago, intraocular pressure now raised to 10 to 26mm with all medications available. I’m not sure, if it is 10, it’s OK. But if it’s 26 for sure it needs surgery. Cup-disc ratio is 0 over 7, ([unclear] transient effect, what was the next choice? Second degree implant? It’s possible or to use a valve. If you have a working valve, for sure there’s something either the valve is obstructed or is — or something like this, you should review the valve, the existing valve and to ensure that there’s no [unclear] valve space. What is the best nonsurgical treatment in advanced glaucoma? We could say there there’s no best nonsurgical, but we could say that we have a nonsurgical way in the patients who refuse to do surgery. Traditional trabeculotomy would be the best answer for that but glaucoma twices in [unclear] Are there a pick risks of endothelial incompetency with subsequent bowl in (reading) I operate a lot of combined surgery, usually the lens and the endothelium is affected, but you should utilize copious amount of Visco elastics and with a minimal manipulation. For sure. How can I get an anterior segment in glaucoma. My email is present here and I can send to you, anyone who wants to contact me, you are most welcome and you can join me any time here in Egypt. If the patient — I don’t know if I can send this in a chat in public, or — OK, I will panelist, shall I send — I will send the email for everyone. I will write it down now. All of you are most welcome to get in touch with me. If the patient is medical treatment and he did have surgery, how we can arrange his medical treatment after surgery? If we did try for any patient, you should ask him to stop all the old medications, specifically his anti-glaucoma and start a new one. Don’t start with the — if we don’t have to be successful trabeculotomy and we think that this patient is going to fail, you have to resort to early to revive this bleb earlier. Either with laser suturelizeis or digital massage or to do the revision of the bleb with needling and the revision of 5 fluoro — but if we don’t succeed to get this bleb into function again, we might give him Rho kinase inhibitors, or later if there is no — we could give him prostaglandins or beta blockers if there is no contraindication. Yes, very limited as adjuvant, not as a primary treat treatment. Used as an adjuvant, specifically if we need to decrease the intraocular pressure by very few mm mercuries. But high intraocular pressure this is not a candidate for this patient. If I have a female patient 19 years old with glaucoma vision loss, right eye, left eye with tunnel and visual acuity, 618 being managed with medication. Would you advise trabeculotomy for such a patient? Do it immediately. Don’t hesitate. I do think that the one who will be blamed for advance advancement of the glaucoma medication is an inexperienced one who is hesitant to take a decision to do surgery. If you try to do surgery for a patient with glaucoma earlier, you you will try to avoid loss and control him earlier. To inform the patient before surgery, do you have the incidence of wipe-out after surgery? I don’t have the incidence for sure, but I know that I’m telling the patient exactly what are we going to do for you is to try to preserve your vision. Or to delay loss of your vision. If you choose not to do, and your intraocular pressure is still high, you will completely lose your vision. You should say it loudly. For sure, you’ll lose your vision. If we do surgery, the outcome might be you will be preserved or you lose a little, or in very few cases and rare cases you might lose completely. So you have to share your decision. Tell him that he’s going to lose his vision if he didn’t do. If he did, he will get one of three. In rare cases he will lose, but now after months or something, or might still the same as he is now. Without any problem. Or might decrease the vision a little bit, but remains. Would you advise trabeculotomy in eye with no — only I do it in no light perception in a painful eye. No painful eye, no surgery. This is malpractice. Only indication for surgery is to stop pain. What medication is preferable for a patient with asthmatic and cardiac cases? Asthmatic patients for sure you should avoid using beta blockers and cardiac, we should cooperate with the cardiologists and we have carbonic anhydrase inhibitors and prostaglandins, quell as well. Patient is myopic of both eyes minus 3. If you have a patient — these patients with 0.4, 0.5, it might be normal. We should see the patient’s family, No. 3, we have to do — and we have to put this patient as a suspect. Specifically if the patient cup is deep. Shallow cups, this is normal, but if the cup is bunching out, this means something is going on and might be an early glaucoma. When trabeculotomy fails, do you try it again in another site on the same eye or you move straight ahead to tubes? I do tube always with Hammett if I have no site to do trabeculotomy. I can do trabeculotomy once and twice and thrice if I can with mitomycin. If I don’t have displaced — still the same for — because once you open one quadrant, it is not only one quadrant it is one quadrant and bar to another quadrant, so you lose at least one one-third or one half of the subconjunctival space, you will not be able to do it and if he rides a flight of anti-glaucoma — he will not be back for trabeculotomy again, because the fail completely. But if you did trabeculotomy and if it fails, still we will have time for valve. As a follow-up in advanced glaucoma with light perception? How can you going to do light perception? It’s not possible to do [unclear] for a patient with light perception. Never do imaging modality in such a kind of patient. It will not be capable of doing baremetry, just listen to the patient’s perception and manage accordingly. The one he’s telling the similar — [mumbling] we will try to arrange with the — with have administrator for sure to be present with all of you again if I could delivered a useful message for you today. Do you use Hammett valve? For sure I use T I use it for more than 30 years now, since I was in — by the end of my residency, I started using Hammett valve. But not in advanced glaucoma, except if no place for trabeculotomy. Trabeculotomy is my preferred choice for glaucoma, even glaucoma with neurovascular — in neurovascular glaucoma I do trabeculotomy after control of the bleeders and the new vessels. If you control the new vessels enough, you could do trabeculotomy safely and to minimize to go to Hammett valve or other things. In other cases of advanced glaucoma with visual field 20/20, in case of advanced glaucoma with a visual field 20/20, with a tunnel vision, how can we encourage patients to do surgery with the possibility of losing that central vision. I said these are the most — if I catch a patient with 20/20, we have to do trabeculotomy now, not tomorrow, because this is the most important kind of patient for surgery who is going to be benefited. He has the maximum vision you need and he has the potential. And for sure, the structural integrity with a patient with 20/20 is higher than those with 2/60 or counting fingers. I managed to do a single-eyed kid with 7 years old with glaucoma surgery secondary to the cataract surgery, and luckily I managed. I was lucky with this patient, but this patient has 1/60 and he’s still in his school with vision aids. So it’s very important. If you have a patient with 20/20 vision, in a very important, can tell him and explain him explicitly his need for surgery and the benefits of getting surgery earlier. And the disadvantage of not going to surgery later. Should I start the medication on the first visit for 70 years old patient: And intraocular pressure 10mm of mercury without confirmation of visual field tests Usually we should try it if this patient 70 years old can do visual field tests is very important, otherize you should carefully characterize and do photos for the optic nerve head, as well, and it’s very important, intraocular pressure of 10mm of mercury is OK. Lasik and hard to obtain a level intraocular pressure, mesh intraocular pressure always 12 what should be done? This patient with advanced glaucoma with Lasik, and who have some ewe have some equations for assessing the patient with refractive surgery. Either Lasik or [unclear] this is very important to follow this patient carefully. The most important is not to consider only the intraocular pressure, but the symptomatology, intraocular pressure, visual field can I can do, and the optic nerve head and the visual field if you can see. Can we do many, many invasive surgeries in advanced glaucoma? Sure we have, we can do it in some cases but which cases? The cases that needs small mm mercury decreasement from the original one. If we have a patient who is a teen or 17, something like this, and we can’t afford minimally invasive glaucoma surgery and you are familiar enough to do t you can do minimally invasive glaucoma surgery for this kind of patient.