EnVision Summit 2025: Glaucoma with co-existing ocular co-morbidities

Poonam Misra, an assistant professor at Manhattan Eye Ear and Throat Hospital, discussed the management of corneal transplantation in patients with glaucoma. She emphasized the importance of understanding the patient's pre-existing conditions, including angle anatomy and degree of glaucoma, to effectively manage increases in intraocular pressure after transplantation. Misra explained that different types of transplants can have varying responses in terms of intraocular pressure elevation, and monitoring pressure is crucial due to the challenges posed by corneal shape and thickness. Misra outlined the treatment approach, starting with SLT and medical therapy, followed by milder glaucoma surgeries like canaloplasty or goniotomy, depending on the optic nerve health. In severe cases, she noted that more aggressive interventions such as trabeculectomy or tube shunt surgery may be necessary, with tube shunt surgery often preferred to avoid the corneal graft.

Alcina Lidder, an assistant professor of ophthalmology at the Northwestern University Feinberg School of Medicine, then discussed the diagnostic dilemma of glaucoma in myopic eyes. She referenced a 100-year-old paper by Dr. Arnold Knapp, which highlighted the difficulty in diagnosing glaucoma in myopic patients. Lidder emphasized that myopia, especially high axial length and high myopia, is a significant risk factor for glaucoma, and patients may be underdiagnosed despite having glaucomatous visual field changes.

Lidder stressed the importance of screening and educating patients with myopia about the increased risk of glaucoma. She outlined various risk factors, including family history, central corneal thickness, prior trauma, surgical history, refractive surgery history, current refractive error, corneal curvature, and axial length. Lidder emphasized the need for a multi-modal approach to diagnosing glaucoma in myopic eyes due to the potential for testing artifacts. She discussed the limitations of OCT RNFL, which may lead to over or underdiagnosis of glaucoma, and the importance of considering other OCT modalities, such as OCT GCIPL, to monitor changes over time. Lidder also highlighted the significance of optic nerve photos, fundus exams, and visual field patterns in the diagnosis of glaucoma in myopic eyes. She mentioned the temporal raphe sign on GCIPL, fundus tessellation, and the crescent moon sign on the optic nerve exam as indicators of a higher risk of glaucoma.

Finally, Lidder discussed the potential role of artificial intelligence in the future to aid in the diagnosis of glaucoma in myopic eyes, particularly in areas with a high prevalence of myopia. She emphasized the urgency of this issue, as projections estimate that by 2050, half of the world's population will be affected by myopia, and 10% by high myopia.