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We have asked a few questions to Prof. Shlomo Melamed of Tel Aviv University to understand the state of the art and the future perspectives in glaucoma management. For his professional expertise he can be for us an excellent guide to the latest technological and scientific developments.
We can start our interview with your opinion about the importance of technological research. No doubt that technological research and development are essential for improved diagnosis and treatment of Glaucoma.
Could you explain to our readers the recent applications of the use of laser in penetrating and nonpenetrating glaucoma surgery? I am actively involved in the development and evaluation of the CO2 laser Sclerectomy which is a minimally invasive procedure aimed at the un-roofing of Schlemmâs canal ab-externo. This may fit into your definition of âNon-Penetratingâ surgery, although I donât think we should use this term, as all of our procedures are somehow âpenetratingâ.
There were several attempts in the past to use various lasers for full-thickness filtration surgery. We tried the Flash-Lamp Pulsed Dye Laser for creating a sclerectomy Ab-Interno after staining the Trabeculum with Methylene Blue, but the hypotensive effect was short lived. Holmium Laser and even Excimer laser (by Prof. Carlo Traverso) were used as well, but due to practical issues as well as complications related to full-thickness surgery â all of them have not materialized into routine procedures for Glaucoma.
Do you think that surgical expertise will maintain a central importance with the development of more and more precise lasers? It is a hard question. On one hand, refining lasers and improved precision of laser systems will enhance our abilities to be more accurate while focusing on miniature structures (such as Schlemmâs Canal). However, the more advanced tools we shall have, we shall dare more by aiming at targets which have been out of the scope of our abilities to treat, and this may require additional surgical expertise.
Which are the main advantages and limits of innovative techniques compared with traditional trabeculectomy? The main advantage is getting rid of the filtration bleb, which is a source for so many troubles such as: foreign body sensation, pain, discomfort, Dellen formation, hypotony, blebitis and endophthalmitis.
The limits may be the more complex and complicated technologies required for new methodologies which make the surgery more demanding.
When laser trabeculoplasty can be recommended in the management of early glaucoma or even as primary treatment? Selective Laser Trabeculoplasty (SLT) should be recognized as an option for Primary Glaucoma treatment in cases of OHT, Primary open angle glaucoma and PXF Glaucoma. We published in 2004 the 1st paper on use of SLT as primary Rx, with 31% reduction of IOP . This âmagic numberâ of 30-31% IOP reduction was also reported by Mcintyre, Nagar, and the multi-center study comparing SLT to Medical Rx (Katz et al.). I routinely explain to these patients the option of SLT vs. start of Medical Rx, and many patients prefer the SLT due to these advantages: superb safety profile, 92% efficacy for 3 years, quick and easy procedure, no need for drops and cost issue (SLT was found to be cost effective over drugs after 2 years).
Pigmentary and pseudoexfoliation glaucoma require which kind of specific approach? Both require more careful energy delivery due to excessive pigmentation in the angle.
The research concerning the mechanisms of retinal ganglion cell death will change our approach to glaucoma diagnosis and treatment? This is a key issue in Glaucoma research. Once we understand better what triggers RGCâs death and how the apoptotic route can be modified â we shall be able to come up with a Neuroprotective approach which will hopefully âsaveâ the optic nerve from further damage.
Do you think that glaucoma screenings should be recommended and are worth their costs? Screening for Glaucoma is not an easy task. Screening should be based not only on measurement of IOP, but also on collecting historical and clinical data, evaluating optic nerves and performing visual field tests. These requirements may limit large scale population screening for Glaucoma .
At the present state of scientific knowledge are there reliable bio-markers for glaucoma risk-patients? At the current state of the art, there are no âacceptableâ and reliable bio-markers evaluating risks for Glaucoma which we can use routinely. I have no experience in this intriguing new field of research, and can only refer you to our colleague Prof. Stefano Gandolfi, who is actively involved in studying a variety of bio-markers for Glaucoma risk.
