Saturday, June 23, 2018


The Asia Pacific Glaucoma Guidelines (APGG) were first released in 2003. The third and latest edition was unveiled in 2016 during the Asia Pacific Glaucoma Congress at Chiang Mai. 

The guidelines follow the “easy-to-read” format seen in previous editions. Information is provided in the form of “why”, “what”, “when” and “how” questions and answers.

The guidelines consist of an Introduction as a prologue, 3 main sections and an epilogue of appendices, definition of terms, abbreviations and references.

The main sections consist of:
1. Assessment
2. Treatment
3. Follow-up

Section 1 on patient assessment broadly deals with evaluation of a glaucoma suspect. There are also short notes on gonioscopy; optic nerve head and retinal nerve fiber layer assessments; optic disc photography and imaging; and finally visual field examination. This section also deals with risk categories and treatment targets.

According to the APGG, intraocular pressure should be reduced by 40%, 30% and 20% from baseline in glaucoma with high risk, moderate risk and glaucoma suspects with moderate risk of visual loss respectively.

Regarding central corneal thickness (CCT), the APGG provides the following statement: “While correction nomograms based solely on corneal thickness are neither valid nor useful in individual patients, the clinician needs to put the measured IOP into context”.

Section 2 starts with initiation of treatment. An important recommendation here is to treat the mechanism causing glaucoma (page 33). Another highlight is the emphasis on choosing the most appropriate medication with respect to the patient. Section 2.3 deals with laser treatments in glaucoma. While, Section 2.4 is on surgical techniques; touching on trabeculectomy, non-penetrating glaucoma surgery, glaucoma drainage devices and minimally invasive glaucoma surgery.

Section 3 is on follow-up. This section deals with reasons why follow-up is required; the points to be looked at during follow-up and timing of the follow-ups. Section 3.2 highlights screening for glaucoma and other relevant issues.

The appendix provides concise information on a number of topics such as: medical treatment of childhood glaucoma; treatment in pregnancy and lactation; systemic medications that may induce angle closure; calibration of Goldmann tonometers; tonometer mires; gonioscopy; goniogram/gonioscopic chart; modified Van Hedrick grading; how to optimize patient performance in subjective perimetry; common artifacts for visual field measurements; principles of management of secondary glaucomas; side-effects of glaucoma medications; laser trabeculoplasty; trans-scleral cyclophotocoagulation; glaucomatous optic neuropathy; imaging devices; field progression; glaucoma quality of life-15 questionnaire; and other topics.

The APGG 3rd edition is available for download from the following link:

Wednesday, June 20, 2018

NICE Guidelines

The National Institute for Health and Care Excellence (NICE) has published guidelines in November 2017 for diagnosis and management of glaucoma in individuals aged 18 years and over.

The guidelines include the following recommendations:

1. Case finding: These recommendations are targeted to primary eye-care professionals in order to detect cases and refer them to specialists for further management. 

2. Diagnosis: This is based on certain tests such as visual field, optic nerve and anterior chamber angle assessments, as well as measurements of intra-ocular pressure and central corneal thickness.

3. Standard practice for all assessments: Records pertaining to previous tests, images, past medical history, glaucoma medication record, current medications and drug allergies and intolerances should be accessed. The machines and instruments for the tests should be regularly calibrated and maintained as per manufacturer specifications.

4. Reassessment: Certain examinations and tests have to be repeated on each visit for confirmation or monitoring.

5. Treatment: When management decisions are to be undertaken, the healthcare professional should take into account any cognitive and physical impairment, relevant co-morbidities or potential drug interactions.

6. Organization of care: Glaucoma suspects should be referred to specialists for confirmation of the condition. The healthcare professionals should understand the principles of diagnosis of ocular hypertension and chronic open angle glaucoma and be able to perform and interpret the previously mentioned tests and procedures. A management plan should be established.

7. Providing information: The individuals who come for glaucoma assessment should be offered the opportunity to discuss their diagnosis, referral, prognosis, treatment and discharge and provide them with relevant information in an accessible format at initial and subsequent visits.


Thursday, June 14, 2018


Two years have passed since I took up the challenge to share my thoughts on glaucoma with a larger audience. I neither have any experience blogging, nor could I have access to any professional help in developing a website/blog. This is just an attempt to share some knowledge I have gained on a purely amateur level.

As before, I have made some changes to the glog. Foremost, I have changed the name to "Glaucoma Specialist Club", this will improve online search of the glog. Hopefully, these changes will bring a fresh impetus to our efforts to make the study of glaucoma simple and comprehensive at the same time. During the past 1 year there have been around 7000 visits to the glog. I got some comments from visitors also. They have helped me improve the glog.

On a personal level, I have seen changes happening in my life. That affected the regularity of the posts on the glog. Hopefully, I shall update you all once things settle. 

As always, please guide me and show me ways to improve this glog.

With best wishes



(Dr Syed Shoeb Ahmad)

Tuesday, June 5, 2018


Glaucoma suspects are controversial clinical dilemmas. These individuals harbor certain risk factors or demonstrate some clinical features suggestive of an increased probability to develop glaucomatous optic atrophy in the future. These characteristics range from high intraocular pressure; optic disc, visual field, or retinal nerve fiber layer abnormalities; or abnormal angles to a positive family history of glaucoma and other risk factors. Individuals having these characteristics should be assessed diligently before a diagnosis of glaucoma is made. Glaucoma is a chronic, lifelong condition, having a negative impact on the quality of life, with an increased risk of medication-related side-effects, adverse economic impacts, and the need for lifestyle changes in the patient. Overdiagnosis and unnecessary treatment of such individuals is bereft of any advantage. 

My article on Glaucoma suspects has been published in the latest issue of Taiwan Journal of Ophthalmology. This review aims to provide a practical blueprint for the proper diagnosis and management of such glaucoma suspects. I hope it will be of interest to the general ophthalmologists and residents dealing with Glaucoma patients.

Saturday, May 26, 2018

ICE vs Axenfeld-Rieger Syndrome

                                            ICE                      ARS
Manifestation.                 Unilateral             Bilateral
Endothelium.                   Dystrophy.           Normal
Angle.                          Goniosynechiae      Iris strands
Iris stroma.                      Abnormal.           Abnormal
Ectropion uveae.                   +.                      +
Glaucoma.                       100% cases.         60% cases
Age.                                 20-30 years.         Congenital
Sex.                                Mostly females.     Equal distribution
Inheritance.                    Sporadic.               Autosomal dominant

Friday, May 18, 2018

Aerie Pharmaceuticals Submits New Drug Application to U.S. Food and Drug Administration for RoclatanTM (netarsudil/latanoprost ophthalmic solution) 0.02%/0.005%
DURHAM, N.C.--(BUSINESS WIRE)--May 15, 2018-- Aerie Pharmaceuticals, Inc.(NASDAQ:AERI), an ophthalmic pharmaceutical company focused on the discovery, development and commercialization of first-in-class therapies for the treatment of patients with open-angle glaucoma and other diseases of the eye, today announced the submission of its New Drug Application (NDA) to the U.S. Food and Drug Administration (FDA) for RoclatanTM(netarsudil/latanoprost ophthalmic solution) 0.02%/0.005%. RoclatanTM is a once-daily eye drop designed to reduce intraocular pressure (IOP) in patients with glaucoma or ocular hypertension. It is a fixed dose combination of Aerie’s Rhopressa®, which is currently available in the United States, and the widely-prescribed PGA (prostaglandin analog) latanoprost. RoclatanTM successfully achieved its primary efficacy endpoint in two Phase 3 registration trials, named Mercury 1 and Mercury 2, and also achieved successful 12-month safety and efficacy results in Mercury 1, the results of which are included in the NDA submission.
The expected FDA review period for RoclatanTM NDA is only ten months instead of twelve months because Aerie’s submission is filed under Section 505(b)(2) of the Federal Food, Drug and Cosmetic Act, since RoclatanTM is a fixed dose combination of two previously approved drugs in the United States.
“The RoclatanTM NDA filing represents another significant achievement for Aerie this year, on top of our recent commercial launch of Rhopressa® in the United States. Since RoclatanTM is being filed through the 505(b)(2) regulatory pathway, in which both active ingredients, netarsudil and latanoprost, are already approved in the United States, we expect a ten-month FDA review. We believe, if approved, RoclatanTM has the potential to be the most efficacious therapy in the market for the reduction of IOP, which makes this submission all the more exciting for our valued employees, eye care professionals, and most importantly, patients who suffer from glaucoma or ocular hypertension,” said Vicente Anido, Jr., Ph.D., Chief Executive Officer and Chairman at Aerie.

Tuesday, May 15, 2018


Iridocorneal Endothelial Syndromes (ICE) are characterized by the following:

Common features of the three ICES:

1. Corneal endothelial dystrophy
2. Distorted pupil
3. Ectropion uveae
4. Goniosynechiae
5. Secondary synechial glaucoma

Characteristics which distinguish between the three ICES:

1. Iris naevus syndrome (Cogan-Reese)=
Multiple small or a few larger iris nodules.

2. Chandler’s Syndrome=
Corneal oedema at normal or mildly elevated IOP.

3. Essential iris atrophy=
Progressive iris atrophy with iris hole formation (opposite to the side of goniosynechiae).