OSWI Times Volume 2 -Glaucoma

Go Green Caribbean
for Glaucoma

OSWI Times Volume II

www.oswinet.org



OSWI Times Volume II

Go Green Caribbean for Glaucoma

Editor at Large

THANK YOU OSWI FOR THE PRIVILEGE

Thank you OSWI for the privilege of being able to review the towards such initiatives. It has also given me an opportunity to
articles of the OSWITimesVolume 2 - Glaucoma Issue. I commend wear a new cap. I would like to encourage the entire OSWI
the initiative of OSWI Times as it provides a forum for our community to continue to support this initiative so that we can
community interact and integrate. The experience has given me build stronger ties within our professional community.
an appreciation of the time and energy that needs to be dedicated

Dr. Shailendra Sugrim

CONTENTS EDITOR CREDITS
Dr. Shailendra Sugrim
02 Dr. Arindel S.R. Maharaj
“Re ections of a Glaucoma Surgeon” GRAPHIC DESIGN & LAYOUT CONSULTANT
Judith Young Ruiz
03 Dr. Micheal Siban
“Glaucoma in the Republic of ASSISTANT EDITOR
Suriname” Shannon Hoo Fatt

05 Dr. Donald Cameron-Swaby PUBLISHED BY
“The Jamaican Glaucoma Experience” The Ophthalmological Society of the West Indies
www.oswinet.org
06 Dr. Dawn Grosvenor
“ Twelve Years of World Glaucoma If you would like to advertise with us or would like to contribute to our editorial,
Week Activities in Barbados” please email us at [email protected]

08 Dr. Anthony Realini
“Glaucoma Laser in the West Indies”

09 Dr. Ciara Ramnarine
“How can we optimize Screening For
Glaucoma Patients?”

11 Dr. Lyle Newball
“Subliminal Cyclophotocoagulation”

13 Dr. Carla Bourne
“So, You want to be a MIGS Surgeon
– A Bootcamp Guide to Angle
Surgery.”

15 Dr. Shailendra Sugrim
“Treating Glaucoma in Guyana”

17 Mrs. Marilyn Watkins – Ramdin
“CAOTP NEWS (Caribbean
Association of Ophthalmic Technical
Personnel)”

FIND US ON @oswinet @oswinet The Ophthalmological Society www.oswinet.org
of the West Indies (OSWI)
Ophthalmological Society
of the West Indies

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OSWI Times Volume II

Go Green Caribbean for Glaucoma

Re ections of a Glaucoma Surgeon

Dr. Arindel S.R. Maharaj I have been an attending glaucoma specialist at the future glaucoma specialists and this mutual interaction
Bascom Palmer Eye Institute, University of Miami, with fellows and attending physicians has allowed me
Dr. Maharaj is an since 2014. During my time pursuing my PhD in to continue to innovate surgical and clinical
Assistant Professor, blood vessel biology, I became interested in applications of glaucoma care – by both teaching and
Clinical Ophthalmology, neuroprotection and regeneration medicine. learning from my trainees; as well as collaboration with
at the Bascom Palmer Eye industry in clinical trials and development of surgical
Institute, University of The eye was an excellent model to study blood vessels, tools.
Miami. He specializes in as visualization was possible, and the effect of
glaucoma and cataract neurotrophic factors could be studied both functionally Photo of Dr. Maharaj during surgery.
and histologically. It was during residency however,
management. that I became fascinated in glaucoma management Photo of Ahmed Glaucoma Valve Implant during
After leaving Trinidad at including both the clinical and surgical management of surgical implantation by Dr. Maharaj.
the age of 16 he completed the disease. The potential to, one day, deliver
medications or neurotrophic factors to regenerate the The eld of glaucoma is growing quickly as more
a dual undergraduate optic nerve was appealing to the eld. Moreover, even research and industry efforts are placed on innovation
degree at SUNY in Stony during my residency the eld was rapidly evolving to of both medicines and medical advancements, as well
now offer less invasive glaucoma surgeries. The as surgical advancements. With the aged population
Brook, followed by popularization of Micro/Minimally Invasive Glaucoma increasing, the need for skilled glaucoma specialists is
an MD and PhD at Surgery (MIGS) would not only preserve vision in increasing. Internationally, you will still nd large
Harvard Medical school. advanced cases, but also allow lifestyle modi cations pockets of areas where specialists in glaucoma are
He did his ophthalmology to decrease medication burden. Additionally, sparse. A glaucoma specialist in these areas can
residency at Baylor College glaucoma specialists are skilled anterior segment function in additional roles including comprehensive
of Medicine and glaucoma surgeons; one of the most rewarding aspects of eye care, as well as, physician advocate. I'm excited to
fellowship at the Bascom ophthalmology is the satisfaction of restoring sight bepartofandacontributortothis eld.
Palmer Eye Institute. with cataract surgery. Being able to do cataract surgery
as a specialist was an important factor for me.
Moreover, modern glaucoma patients also demand
high quality lifestyles and vision, and thus also bene t
from accommodating lenses and astigmatism
correction.

The glaucoma patient and physician develop a long-
term relationship – I have several patients that I have
known now for almost 8 years. I share the joy of visual
restoration with them and feel their suffering with
visual loss or deterioration of their disease. With this
longevity of care, I have also now developed
friendships with patients outside of the clinic. As a
physician of Caribbean heritage (Trinidad andTobago),
practicing as a glaucoma specialist in South Florida has
also allowed me to take care of many patients of
Caribbean background, both here in the US as well as in
the Caribbean.

As an academic specialist, I'm involved also in training

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Glaucoma in the
Republic of Suriname

Dr. Michael Siban, MD Glaucoma is a group of progressive optic neuropathies Eye care is provided only at the Suriname Eye Center of the
characterized by a degeneration of retinal ganglion cells Academic Hospital Paramaribo – the main referral hospital
and the retinal nerve bre layer that results in changes in locatedinParamaribo(thecapitalcityofSuriname). Duplicationof
the optic nerve head. Glaucoma is the leading cause of irreversible resources (both human and equipment) is very expensive and
blindness worldwide; is associated with a reduced quality of life; inefficient. Eye care in the districts and hinterland is provided on
andhasasigni cantimpactonpublichealth. regular bases by outreach (mobile) programs.

Dr. Michael Siban started his There are two major types of glaucoma: primary and secondary Photo of Map of the Republic of Suriname
residency in Academic Hospital glaucoma, which can be further subdivided into open-angle and
closed-angle. Primary Open Angle Glaucoma (POAG) is the most
Paramaribo in July 2007. common type of glaucoma. An estimated 57.5 million people
worldwide are affected by POAG with a global prevalence of 2.2%.
From July 2010- July 2012, Risk factors include increased intraocular pressure (IOP), positive
family history, race (African descent), myopia, age, genetics,
he did part of his residency at the smoking, systemic hypotension and hypertension, vasospasm,
Rotterdam Eye Hospital in the use of systemic or topical steroids, migraine and obstructive sleep
Netherlands where he also did apnea syndrome.
As a glaucoma specialist I would like to share my experience with
a glaucoma fellowship. Glaucoma in Suriname.

He returned to Suriname in Suriname

July 2012 and completed his The Republic of Suriname is located on the northeast Atlantic
residency in December 2012. Coast of South America and is the smallest sovereign country in
this continent (163.821 km ). It is considered to be culturally, a
He started working as an Caribbean country. Its borders are French Guiana (East), Guyana
Ophthalmologist in January 2013 (West), Brazil (South) and the Atlantic Ocean (North).

at the Suriname Eye Center Suriname has a population of approximately 575,990 and is
ethnically diverse. The Indians are the largest ethnic group which
(Academic Hospital Paramaribo). form 27.4% of the population. The largest group of people are
Currently, he also works as a rotating however the Afro-Surinamese (37.4%). They can be divided into
two cultural/ethnic groups: the Maroons and the Creoles. The
Ophthalmologist at the St Maarten Maroons, whose ancestors are mostly runaway slaves that ed to
Medical Center in St Maarten. the interior comprise 21.7%, whereas the Creoles (mixed people
descending from African slaves and mostly Dutch Europeans) form
Dr. Siban also did a three months 15.7% of the population. The other ethnic groups are Javanese
observership on pediatric glaucoma (13.7%), Indigenous Amerindian (3.8%), Chinese (1.5%),
European (1%) and others (1.8%). 90% of the population live on
at Bascom Palmer Eye Institute the coastal area whereas 10% live in the interior. The main
(Miami, Florida) in 2017. languages spoken are Dutch and Sranan.

Glaucoma in Suriname

Suriname has a high prevalence of glaucoma (mostly due to the Photo of Map of South America
fact that the majority of the population is of African descent) and with Suriname on the North-East Coast (Green)
as expected, glaucoma is a major cause of visual disability. A Rapid
Assessment of Avoidable Blindness (RAAB) survey, that was done
in Suriname (2013-2014), showed that Glaucoma is the 3rd cause
of avoidable visual impairment in Suriname (after Refractive Error
and Cataract).

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OSWI Times Volume II

Go Green Caribbean for Glaucoma

At the Suriname Eye Center, currently 10 general Nd:YAG laser capsulotomy/iridotomy is available in our underestimate the emotional impact pediatric
ophthalmologists are employed, who also provide center but SLT is as yet not available. The current glaucoma has on parents and/or caretakers.
different subspecialties such as glaucoma; retina surgical options are Glaucoma drainage implants
including vitreoretinal surgery; strabismus and (Baerveldt), trabeculectomy, ab interno/externo In 2019, the Pediatric Preventable Blindness Study
pediatric ophthalmology; cornea; and oculoplastic and trabeculotomy and cyclo-cryocoagulation. Some types (PPB) was initiated in collaboration with the Bascom
orbital surgery. of glaucoma surgery are only partly reimbursed by Palmer Eye Institute. The main goal of this study is to
Health Insurance companies which is a signi cant calculate the disease burden of ophthalmic diseases
There are currently 3 glaucoma specialists at the nancial limitation to treat patients. and syndromes in the children of Suriname and
Suriname Eye Center. Many of the glaucoma patients in ultimately to be able to implement a screening tool for
Suriname are seen by these 3 specialists. All A point of concern is the people of African descent who the early detection of eye disease in children.
ophthalmologists are currently treating glaucoma live in isolated villages in the interior of the country. Unfortunately, this study has been temporarily halted
patients but if glaucoma surgery is needed these Many of these villages can only be reached by airplane due to the Covid-19 pandemic.
patients are referred to one of the glaucoma surgeons. or boat. This limits the accessibility of eye care for the
tribal people. Another important issue is the Future Goals
Glaucoma drugs are not always readily available in insufficient awareness of glaucoma in our population.
Suriname due to economic and nancial crisis. The Unfortunately, it is not rare that a patient visits the The Suriname Eye Center is currently being renovated
glaucoma drugs most frequently used are the clinic with end-stage glaucoma. Therefore, increasing and expanded with modern offices and surgery
prostaglandin analogues (Latanoprost and Travaprost), awareness of glaucoma is a major tool in the early facilities. This will increase our capacity to provide
beta-blockers (Timolol), carbonic anhydrase inhibitors detection of this potentially blinding disease. services and to have more ophthalmologists being
(Dorzolamide and Acetazolamide), trained. Our goal is to become a center of excellence in
parasympathomimetics (Pilocarpine) and alpha2- In 2017, I did a clinical observership in Pediatric the Caribbean. The current economic and nancial
adrenoceptor agonists (Brimonidine and Glaucoma at the Samuel & Ethel Balkan International crisis that Suriname is going through unfortunately
Apraclonidine). The IOP lowering drops or Pediatric Glaucoma Center (Bascom Palmer Eye poses many challenges for glaucoma care. Hopefully,
combinations that are currently covered by Health Institute in Miami, Florida). This observership was these challenges will be dealt with in the near future.
Insurance are Timolol, Latanoprost, Pilocarpine, made possible by the Global Eye SITE program. After
Dorzolamide and Dorzolamide/Timolol. All other drops this observership, I treated a few cases of congenital
(including preservative free drops) are either not and juvenile glaucoma. The treatment of this speci c
available or have to be paid for by the patient. group of patients is challenging. One should not

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OSWI Times Volume II

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The Jamaican Glaucoma Experience

Dr. Donald Cameron-Swaby Glaucoma was the second leading cause of blindness at the over the single plate valves and this has been abandoned.
start of my residency and has remained in that position. It
Dr. Cameron-Swaby graduated from has a greater incidence in the black race and is associated The two groups that make their initial presentation with the most
King's College Medical School, with a worst prognosis. We run a large Glaucoma Service at our advanced glaucoma and have been the most difficult to manage
London, and undertook institution and have been faced with many challenges in the are the low tension glaucoma and juvenile glaucoma patients.
constant battle to prevent blindness. Primary open-angle These two groups require careful attention and early surgery is
ophthalmology residency training at glaucoma causes painless visual loss with a negative scotoma. indicated if they fail to achieve target pressures or if they have
the Birmingham and Midland Eye Patients are not aware of visual loss until the disease is advanced. progressive deterioration of their visual eld or RNFL thickness.
Center, Birmingham UK. They can offer the greatest challenges, especially when associated
He completed fellowships in One of the biggest challenges with managing glaucoma in with a central corneal thickness of fewer than 475 microns.
Cornea and Glaucoma at Jamaica has been dealing with patient compliance. The Jamaican
government launched the National Health Fund program (NHF) in I have implanted several Express shunts both 50 and 200-micron
St Georges Hospital, London UK, and 2003.The NHF subsidises the cost of drugs used to treat a selection sizes. The results and complication pro le were comparable to
Moor eld's Eye Hospital, London UK. of chronic diseases, including glaucoma. Patients at public trabeculectomy with over 70% success rates. The only signi cant
hospitals can receive their glaucoma medication free of cost at advantage I found was the fact that a surgical peripheral
He moved to Jamaica in 2004 and participating pharmacies. This has helped to improve patient iridectomy was not required with the express shunt. I now favour
currently manages the glaucoma compliance. trabeculectomy over the express shunt.

clinic at the University Hospital The patients have generally not been receptive to incisional The OCT has revolutionized our investigation for glaucoma and has
of the West Indies. glaucoma surgery and would rather rely on maximum medical an important role alongside automated visual eld analysis and
treatment including oral Diamox, with its multitude of side corneal pachymetry. Initially, our patients had to travel to Miami
effects. Patients are in general more willing to try one of the for scans. There are now several OCT machines on the island and
various laser treatments for glaucoma. Initially, we offered ALT, patients can have scans locally at an affordable price.We now have
however, this has been superseded by SLT and MLT. We have also the armamentarium to monitor our mild to moderate glaucoma
offered Micropulse transcleral cyclophotocoagulation since and detect any worsening of their condition.
August 2019, which has also been successful in the short term
management of glaucoma. In my experience laser treatment has The ability to show patients their OCT scans helps to explain the
been useful in mild to moderate cases. The main limiting factor is fact they are losing vision despite having few symptoms. It has also
the effect wears off over time. become invaluable in monitoring the progression of glaucoma.
Unfortunately, it is not so useful for patients with advanced
My experience with MIGs has been limited and I have been trained disease and thin RNFL.
to implant the iStent and certi ed to use the trabectome. The
published results with MIGS have been good in various studies, The medical treatment of glaucoma has not changed much since I
however, the cost of devices has been a negative factor and the use completed my glaucoma fellowship. We have moved towards
of MIGS in Jamaica has not gained traction.The Kahook Dual Blade combination therapies rather than novel drugs. We are looking
will soon be added to our treatment option. Several reports have forward to the arrival of the rho kinase inhibitors in Jamaica. The
been favourable with success rates exceeding 60% in severe use of Vitamin B3 supplements has been advocated as a possible
glaucoma and approaching 80% in mild to moderate glaucoma. method to reverse apoptosis. To date, we have not seen any visual
improvement with these supplements.
We manage a large number of congenital glaucoma patients and
ourresultshavegenerallybeenverygood. Wehaveachievedmore We are always looking forward to new therapies. One very bright
than 78% success with trabeculotomy combined with light on the horizon has been the use of gene therapy by Dr. David
trabeculectomy as a primary surgical procedure. The preferred Sinclair et al. His team has reversed glaucomatous nerve damage
treatment option for children with failed primary surgery has been in mice.
the implantation of the Ahmed valve, which also has an overall
80% success rate. These have been implanted in babies as young as One of biggest challenges with
6 months without any problems. The only treatment option managing glaucoma in Jamaica has
offered to those with failed Ahmed valve has been the been dealing with patient compliance.
implantation of a second Ahmed valve in another quadrant. We are
planning to try the Baerveldt valve in the future as a large number
of our adult patients have been off all anti-glaucoma mediation
following implantation of this valve, without any complications of
hypotony or visual loss. We had a phase of implanting double
plated Ahmed valves however the success rates were not improved

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OSWI Times Volume II

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Twelve Years of World Glaucoma
Week Activities in Barbados

Dr. Dawn Grosvenor, As we had our rst virtual commemoration of World
MBBS, MRCOphth, GlaucomaWeek in Barbados in March 2021, I hearken back
to where it all started in 2010, and take a look back at the
FRCS(Glasg), FRCOphth developments through the years.

An Auspicious Start

Consultant Ophthalmologist & The call to action came out of the blue. I was in the second half of Figure 2. From L-R, Ms. Kia Zmuda of The Glaucoma Foundation,
Glaucoma Specialist, Barbados. my Glaucoma fellowship at Moor elds Eye Hospital in London in Dr. Dawn Grosvenor and Dr. David Callender at the Barbados
February 2010, when I got an email from Dr. David Callender, Glaucoma Week Awareness Walk in 2010.
Miss Grosvenor is a graduate of the Paediatric Ophthalmologist in Barbados, indicating that his office
University of the West Indies, Faculty was coordinating the launch of the rst ever commemoration of Figure 3. Participants at the rst Glaucoma Week Awareness Walk
of Medicine, Class of 2000. She went World Glaucoma Day (as it was called at the time) in Barbados, in Barbados in 2010
planned for March 2010. I was being invited to return to take part
on to complete her Ophthalmology in the activities. This was going to be a big deal: The President & Raising the Bar
training in the UK. She completed her CEO, Chairman and the Director of Research Programs of The
Glaucoma Foundation in NewYork were all coming down to assist
Glaucoma Fellowship at Moor elds with the launch. Moor elds' staff and colleagues rallied round to
Eye Hospital in London, with an cover my clinics and theatre, and I was off to Barbados. We had an
auspicious start, driven by Ms. Eugene Holder and the rest of Dr.
emphasis on surgical management Callender's staff at the Regional Eye Clinic in Barbados.There was a
of complex glaucomas. She has a full week of activities including free screenings at private offices; a
keen research and teaching interest public lecture by eminent local ophthalmologist – Mr. Clive
and is involved in several projects on Gibbons; public relations television slots; a dinner evening and
lecture with our partners from The Glaucoma Foundation (Figure
glaucoma in the region. She is a 1); and an awareness walk on the Saturday at the end of the week
Lecturer for the University of the (Figures 2 and 3). The response from our Optometry and
West Indies. At present she works in Ophthalmology colleagues who joined in the screening was
private practice, and as a Consultant phenomenal. The response from the public was overwhelmingly
Glaucoma Specialist at the Queen positive, and they wanted more…it was clear we had to make this
an annual event.
Elizabeth Hospital.

How could we top that start? Over the next few years, we kept the
core events that had been so popular, and aimed bigger and better
every year, always with the central focus to raise awareness and
educate the public about glaucoma. The World Glaucoma
Association expanded World Glaucoma Day to World Glaucoma
Week,andthat tinwithourexpansion.

Figure 1. Dinner Evening & Lecture with The Glaucoma Foundation We extended our partnerships to involve a wide swath of partners
at the rst Barbados Glaucoma week in 2010. and sponsors from the eye care community, the pharmaceutical
community and beyond, and they joined us in an Annual
Glaucoma Expo (Figure 4) with information booths featuring all
aspects of eye care. We partnered with the Ministry of Health's
Health Promotion Unit, and everyWeek started with an inaugural
church service and a message from the Minister of Health on
glaucoma. The Lions Clubs of Barbados became a strong partner
overtheyears,anda xtureatourevents(Figure5).

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OSWI Times Volume II

Go Green Caribbean for Glaucoma

As we look ahead to the future, a new generation of
ophthalmologists-in-training were featured in last
year's events – taking over press slots and coordinating
the hospital's screening programme for staff.

Pivoting for the Pandemic

Figure 4. Barbados Glaucoma Week Expo Figure 7. UWI Screening and education session during GlaucomaWeek 2020 was completed just in the nick of
Barbados Glaucoma Week. time before the pandemic hit Barbados: the last day of
Figure 5. Chief Medical Officer of Health (left) Dr. Joy St. the week of activities was March 14th, and Barbados
John and Lions Clubs of Barbados members at Barbados We continued the tradition of partnering with special recorded its rst case less than a week later. In 2021, as
guests over the years: The British High Commission we approached March, we were in the midst of a
Glaucoma Week partnered with us in 2012 and hosted Dr. Maria second wave of the pandemic. Of necessity, we pivoted
We increased our screening programme to include Papadopoulos, an eminent Paediatric Glaucoma to virtual events. With all the technological awareness
large scale public screening, alternatively utilizing Specialist from Moor elds, and guests from the that has emerged in the last year of living through the
large venues and the island's hospital clinic to Ministry of Health in a dinner reception and discussion pandemic, with con dences we continued to engage
accommodate the crowds. Nurses, doctors, University with the British High Commissioner. Dr. Richard the public in this new normal. We pushed our public
of the West Indies medical students and allied health Wormald, a proli c researcher from Moor elds Eye awareness campaigns through our well subscribed
professionals in the public sector rallied every year to Hospitaland the London School of Hygiene andTropical social media pages on Instagram, Twitter and
make these events a success (Figure 6). Private Medicine and the Cochrane Vision and Eyes Group Facebook. We also utilized our social media pages to
optometry and ophthalmology practices continued to joined us for a research-focused week in 2013 (Figure join the OSWI“Go Green”campaign for GlaucomaWeek
offer free screening during the week of activities 8). 2021. Press engagements were done virtually via
annually, and ophthalmic assistants and technicians For the ten-year anniversary of Barbados Glaucoma teleconference interviews on television and radio. We
were at the forefront of coordinating their practices' Week in 2019 we launched Umbra: An Exquisite Dining engaged the public via the same media, as well as a
efforts. in the Dark Experience.This was a fundraising event for new podcast engagement, and lectures this year via
Our annual lectures touched on various areas of paediatric glaucoma (Figure 9), which we hope to Zoom. Because of physical distancing protocols, there
glaucoma, from breaking down myths, to glaucoma reprise with a second edition when the pandemic is will be no mass screening, but our team is using this as
research, to glaucoma surgery. We partnered with the over. motivation to focus our attention on how we can create
University of the West Indies who hosted and pathways for persons to access screening later in the
publicized the annual lectures, and in 2018 we Figure 8. Guest Lecturer Dr. Richard Wormald (second left) year when we emerge from the second wave of the
conducted a dual screening and education session on at research-themed Barbados Glaucoma Week in 2013. pandemic.
site at Cave Hill Campus (Figure 7).
Figure 9. Dr. Grosvenor and celebrity singer Ch'An at Our team is using
Figure 6. Barbados Glaucoma Week Screeners celebrate Umbra Dining In the Dark fundraiser for Barbados
at the end of a long day. Glaucoma Week 2019. the physical

distancing

protocols, as

motivation to focus

our attention on

how we can create

pathways for

persons to access

screening.

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OSWI Times Volume II

Go Green Caribbean for Glaucoma

Glaucoma Laser
in the West Indies

Dr. Tony Realini, MD, MPH Readers of this article are acutely familiar with the advances in sustained-release drug delivery and minimally
crushing burden of glaucoma within the Caribbean invasive glaucoma surgery, our goal is to extend the
Dr. Anthony D. Realini population and with the challenges of managing medication-free survival of glaucoma patients receiving
is an ophthalmologist in this potentially blinding disease with limited resources. Ten primary SLT, as a step toward a drop-free lifetime for
Morgantown, West Virginia years ago, my research team from West Virginia University glaucoma patients.
and is affiliated with multiple in the United States forged a collaborative partnership with
hospitals in the area, including the Saint Lucia Ministry of Health and the Saint Lucia Blind Simultaneously with the launch of COAST, I am developing
West Virginia University Hospitals Welfare Association to explore the role of selective laser a consortium of stakeholders throughout sub-Saharan
and Louis A. Johnson Veterans trabeculoplasty (SLT) as sole therapy for glaucoma in Saint Africa (SSA) to identify and implement strategies to reduce
Lucia. Our preliminary study bore ripe fruit. In a study the enormous burden of glaucoma and glaucoma-related
Affairs Medical Center. report published in JAMA Ophthalmology in March 2013, vision loss and blindness in that hard-hit region. Many of
He received his medical degree from we described the key outcomes of our early work: among the barriers to care in SSA are similar to those in the
61 subjects undergoing bilateral SLT to replace existing Caribbean, and the lessons I've learned over a decade of
University of North Carolina at medical therapy, 93% attained lower intraocular pressure time spent treating glaucoma in Saint Lucia and Dominica
Chapel Hill School of Medicine (IOP) after SLT on no medications by an average of 4.5-5.0 will inform our future work in Africa.
mmHg at 12 months.
and has been in practice I'm grateful to the many people who made our work in the
for more than 20 years. Encouraged by these ndings, we successfully attained West Indies possible over the past decade—especially our
additional funding from the US National Institutes of patients who I miss dearly. I'm equally grateful to OSWI for
Health to conduct a more robust evaluation of SLT in the providing the opportunity for eye care providers
Caribbean. Partnering with Darra Burt, MD, of Eye Care throughout the Caribbean to come together, share
Saint Lucia, and Hazel Shillingford-Ricketts, MD, of experiences, and learn from one another.
Dominica (and pro led in the last issue of this periodical),
we undertook the West Indies Glaucoma Laser Study Photo below of Dr. Realini performing SLT on a patient in
(WIGLS). To date, 4 publications have described the results the West Indies.
of the now-completed WIGLS study. To summarize, WIGLS
con rmed the outcomes seen in our preliminary study,
with mean IOP reductions of 30% without medical therapy
at 12 months. Importantly, the results were similar in Saint
Lucia and Dominica, supporting the generalizability of
these ndings to broader populations of African-derived
people throughout the world. WIGLS also revealed that
postoperative in ammation was minimal and resolved
without therapy in nearly all eyes, and that 3-year
longitudinal analysis revealed no progressive lens changes
or cataractogenesis following SLT therapy.

The lessons we learned in both the preliminary study and
WIGLS has informed our next steps in SLT research. My
research team was recently awarded a seven-year,
multimillion dollar grant to conduct the COAST trial.
COAST—Clarifying the Optimal Application of SLT
Therapy—will explore the role of low-energy SLT and
annual repeat SLT compared to standard energy SLT
repeated as needed when its effect wears off. Coupled with

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How can we optimize Screening
for Glaucoma Patients?

Dr. Ciara Ramnarine Glaucoma is the leading cause of irreversible blindness globally waves of the COVID-19 pandemic, telemedicine became an
with approximately 60 million people being affected by the important part of how doctors manage their patients. Although it is
Dr. Ramnarine graduated disease.¹ The same applies to Trinidad and Tobago. A study not as simple, teleophthalmology is no myth. Mobile applications
from medical school in 2010 done in 2014 unexpectedly found that glaucoma was the leading have been developed in India that can automatically quantify the
then later went on to qualify as an cause of blindness (26.6%).² Ethnically, persons of African descent peripheral anterior chamber depth upon uploading an optic disc
ophthalmologist in July 2018. have the highest prevalence of Primary Open Angle Glaucoma photo. This, plus off-site assessment of optic disc photography by
Her hobbies include traveling, (POAG) while the Asian population has the highest prevalence of trained readers, can assist in detecting cases while reducing risk of
reading and playing with dogs. Primary Angle Closure Glaucoma (PACG).¹ Trinidad and Tobago is spread of COVID-19.
blessed to have a multi-ethnic population and as such sees
approximately 37% of its people falling into these high-risk Fortunately, glaucoma is a disease that once detected and treated
categories.³ This, coupled with an ageing demographic pro le, early can prevent vison impairment and irreversible blindness.Thus,
makes it necessary to develop efficient screening methods to screening of this disease must take precedence if we want to reduce
improve glaucoma detection rates and minimize visual morbidity. the burden of avoidable vison loss. Multiple, combined, low-cost
screening techniques, targeted screening and education, making
A screening test is considered suitable if it possesses a high speci city screening tools readily available in the community and introduction
and sensitivity, be cost effective, safe to administer, readily available of technological assistance or teleophthalmology are some of the
and lead to early detection and treatment of the disease. There is, ways that we can optimize screening of glaucoma and reduce the
unfortunately, no one glaucoma screening method that ts all these global burden of the disease.
criteria. Some of the common screening tests relied upon are: optic
disc assessment, intraocular pressure measurement and anterior Optimise Screening by
chamber depth measurement. Done solely, intraocular pressure targeting populations
measurement demonstrates a speci city of 95% and optic disc at risk
photography carries a speci city of 89%. However, combined these
two screening tests have a speci city of 99.5%.⁴ This gives credit to References
the strategy of combining screening tests in order to improve the
validity of screening. 1. Tham et al.: Global prevalence of glaucoma and projections of
glaucoma burden through 2040: a systematic review and meta-
Screening tests need to be readily available and easily accessible. analysis (Ophthalmology 2014;121:2081-90) Ophthalmology Vol.
Providing low-cost equipment such as hand-held tonometers, 122 Issue 7
fundus photographers and visual acuity charts to community health
centres can allow us to screen a larger number of persons at a faster 2. Braithwaite T, Bartholomew D, Deomansingh F, Fraser A,
rate. Training of staff at the community level such as district health Maharaj V, Bridgemohan P, Sharma S, Singh D, Ramsewak S, Bourne
nurses, medical officers and primary care physicians in the use of R, NESTT. (2015). The prevalence and causes of blindness and vision
equipment as well as identifying those patients that need impairment in Trinidad and Tobago.
comprehensive eye exams would go a long way in detection of
undiagnosed glaucoma patients. 3. Wikipedia contributors. (2021, February 24). Demographics of
Trinidad and Tobago in Wikipedia, The Free Encyclopedia.
It is estimated that, even in developed countries, 50% of glaucoma
sufferers go undetected.⁵ Another tactic that can be employed to 4. Mowatt G, Burr JM, Cook JA, et al; OAG Screening Project. Screening
optimize screening is to target populations at risk such as those with tests for detecting open-angle glaucoma: systematic review and
a family history of glaucoma and ethnic populations that are at meta-analysis. Invest Ophthalmol Vis Sci. 2008;49(12):5373-5385.
greater risk of developing glaucoma. Conducting mass population
screenings for glaucoma is expensive and unreliable. Targeted 5. Holló, G., Kóthy, P., Géczy, A., and Vargha, P. Health anxiety in a
screening of family members of POAG patients has been shown to non-population-based, pre-publicised glaucoma screening exercise.
increase detection rates.⁶ Not only screening of these groups but Eye. (2010): 699-705. Accessed on 1 October 2010.
targeted education and insistence on routine eye examinations
despite normal results can reduce cost and prove to be a more 6. Rajendrababu S, Gupta N, Vijayakumar B, Kumaragurupari R,
accurate approach to public glaucoma screening. Krishnadas SR. Screening rst degree relatives of persons with primary
open-angle glaucoma in India. J Curr Glauc Pract. 2015;8(3):107-112.
Since March of 2020, we have not been able to go a day without
hearing about the global pandemic. It has certainly permitted
technology to play an even greater role in our lives as technology
allows us to safely live the 'new normal'. During the early days and

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OSWI Times Volume II

Go Green Caribbean for Glaucoma

Subliminal Cyclophotocoagulation

Dr. Lyle Newball, MD Glaucoma is a leading cause of irreversible blindness mW,“on”time 0.63 ms,“off”time 1.9 ms, and 25% duty cycle per
affecting approximately 60 million people globally 40 years 100 seconds to each eye. The results proved that SubCyclo at 25%
Dr. Lyle Newball, of age and older. Glaucoma is a disease that cannot be duty cycle was safe and effective for reducing IOP. SubCyclo was
is a Colombian Ophthalmologist ignored, and the need for signi cant changes in how we diagnose, also reported to be safer than conventional transscleral
with sub-specialization in Glaucoma, manage, and treat must be examined and applied whenever cyclophotocoagulation.
Cornea and Refractive Surgery. possible. With currently available advancements, it is simply
He is a national and international unacceptable to wait fora patient'svision to deteriorate to operate Setting the duty cycle between 31.3 and 25% allows the use of the
speaker, President of the Colombian because traditional glaucoma surgical methods have not met laser in cases of advanced or terminal glaucoma. We have seen
acceptablerisk-to-bene tassessments. many multifaceted patient cases where SubCyclo is determined to
Association of Cataract and be the safest and most efficient surgical treatment plan. These
member of the board of directors of Fortunately, advancements in how we approach surgical cases include patients with ocular surface disease, patients who
protocols, such as the SubLiminal cyclophotocoagulation are intolerant to drugs, or patients where previous medical or
the Colombian Society of (SubCyclo) procedure (Quantel Medical), have changed the surgical interventions have failed and there is a need to quickly
Ophthalmology SOCOFTAL and treatment landscape. I have been using the SubCyclo procedure for reduce IOP.
nearly 2 years, and my experience has been very positive. It is
multiple Ophthalmological important to outline how we utilize SubCyclo and compare it to In our own practice, when presented with cases where there is no
Associations. Co-founder and other options, including traditional cyclophotocoagulation and associated disease or in ammation, we set the duty cycle to
Director of the Lyle Newball Clinic cyclodestructive procedures (and its varying modalities) used in 31.3%. For patients who may have already been treated, and who
and the Lyle Newball Foundation, in the treatment of glaucoma. we want to treat again, or for patients who have a history of ocular
which humanitarian work has been in ammation but good VA, we recommend using the 25% duty
done through the donation of SubCyclo is one of the latest technologies that uses a non- cycle. The SubCyclo's wavelength is 810 nm with a power of 2000
Ophthalmological surgeries in destructive 810-nm laser to treat open-angle, angle-closure, and mW. Depending on the case and the outcome you target,
different countries and activities even neovascular glaucoma. The technology is speci cally adjustments should be made to the duty cycle rather than power.
that promote development of designed to reduce the production of aqueous humour, selectively
destroying the pigmented ciliary body, resulting in minimal Treatment duration lasts 80 seconds for each half of the eye: 80s
the potential of the coagulative necrosis. Another bene t of the technology is that it below and 80s above, giving us a total of 160 seconds. This is very
Caribbean population. undertakes uveoscleral remodeling, which increases out ow important and what I personally recommend. Additionally, I prefer
Financial disclosures: Abbott, through the unconventional pathway. to use transillumination to mark the limbus, giving me the exact
Johnson & Johnson Vision, position of the ciliary body. This process is also effective in cases
Glaukos,Quantel Medical SubCyclo is based on pulse technology that delivers a continuous where there is disorganization of the anterior segment (i.e. corneal
wave of repetitive short pulses with cooling breaks, which controls transplant,etc.),andwecannot identifythelocationofthelimbus.
levels of thermal elevation and preserves the structures of the With a phaco transilluminator, you can put it on the eye surface
ciliary body. The“cool-off”period between pulses, called the Duty and look for the shadow. This means we have found the ciliary
Cycle, eliminates the risk of overheating, which causes coagulative body, and it gives us a target for the laser treatment (Photo 1).
necrosis in the eye and minimalizes the likelihood of patients
developing phthisis bulbi or ocular hypotension (Figure 1). I have found that using sub-Tenon block in place of topical
anesthesia reduces patient discomfort and pain. Peribulbar or
retrobulbar are also acceptable anesthesia for this procedure. The
bottom line is that we always perform SubCyclo under sedation.

Figure 1. SubCylco pulse technology graph. Photo 1

The Duty Cycle 11

The duty cycle is the relationship between the time we deliver the
laser and the time of the breaks in between. As this can be
adjusted, it is best used at 31.3 and 25%. This is evident in a study
of patients with evolving moderate-to-severe glaucoma who
were resistant to previous surgical treatments. In this particular
study, laser settings were programmed as follows: power 2000

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OSWI Times Volume II

Go Green Caribbean for Glaucoma

A Case Study Place the sub-Tenon block in the sub-Tenon space The other important postoperative protocol is to
other- wise chemosis will occur, and you will lose the discontinue all previous glaucoma drugs, so that you
A patient in our clinic presented with neovascular gap in which you marked the ciliary body. Slide the can assess the real effect of the SubCyclo treatment
glaucoma and signi cant in ammation. We probe over the upper 160° while keeping the probe procedure. Other physicians I know prefer to use ocular
determined that SubCyclo was the best course of completely perpendicular to the eyeball, so that you hypotensive drugs for 1 month before discontinuing. If I
treatment. To start, we marked the location of the can nd the ciliary body, approaching this step by need to start hypotensive drugs because the pressure is
ciliary body and mapped out the lower 160°, which quadrant (80°) is much more effective, and there is less high, I will start based on the IOP value. I also always
should provide an accurate eld. One of the most of a concern to keep your hands at an angle. Simply check for mydriasis and uveitis in the postoperative
important tips I have learned is to respect the 3 to 9 repeat for each quadrant (Photo 4). For this particular period.
meridians.This is where you will nd the neurovascular case, due to the neovascular glaucoma and
bundle. If this area is lasered, not only will you cause in ammation,wesettheSubCycloat25%dutycycle. Conclusion
more in ammation, but it may cause mydriasis in the
postoperative period. Be careful not to confuse the 3 to Postoperatively, we use steroids, which I typically taper My overall experience with SubCyclo has been positive,
9 meridian due to cyclotorsion that occurs when the down, reducing the dose each week. I start with a and it has proven to be a safe and efficient surgical
patient is in surgical position. I recommend using a steroid (Prednisolone 1%) four times per day for week treatment. We have seen results, on average, of IOP
pendulum marker (Photo 2). to ensure the line is at 1, three times per day for week 2, and so forth. It is reduction by 29%, and we have reduced the number of
180° and avoid cyclotorsion when the patient lay important to assess the in ammatory reaction in the drugs from 2.09 to 1.6 (Figure 2). These results include
down. (Photo 3). anterior chamber to adjust the steroid treatment patients with neovascular glaucoma, including painful
schedule accordingly. blind eyes that we have treated using both the 31.3 and
25% duty cycle.

In my opinion, SubCyclo

is just as efficient as

treatment based on

Photo2 cyclophotocoagulation

without the side effects

and complications.

Figure 2. Six-month results using This is primarily due to the rest periods and tissue
the 31.3 to 25% duty cycle. cooling period that do not risk destruction of the ciliary
body itself. This treatment option can also be repeated
to ensure the target result is met for each patient.

Photo 3 Resources.

01. Probability of blindness from glaucoma has nearly halved [news release]. American
Academy of Ophthalmology. Available at: https://www.aao.org/newsroom/news-
releases/detail/probability-of-blindness-from-glaucoma-has-nearly- September 20, 2019.

02. New laser therapy for advanced and end-stage glaucoma. Quantel Medical website.
Available at: https://www.quantel- medical.com/products/ophthalmology/laser/vitra-810.
Accessed September 20, 2019.

03. Benhatchi N, Bensmail D, Lachkar Y. Bene ts of subcyclo laser therapy guided by high-
frequency ultrasound biomicroscopy in patients with refractory glaucoma. J Glaucoma.
2019;28(6):535-539.

Photo 4 www.oswinet.org

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OSWI Times Volume II

Go Green Caribbean for Glaucoma

So, You want to be a MIGS Surgeon

– A Bootcamp Guide to Angle Surgery.

Dr. Carla I. Bourne Successful Minimally Invasive Glaucoma Surgery (MIGS) are variations of the Swan-Jacob model. There are many options
requires preparation. This guide will walk you through the e.g. disposable, reusable, handle, hands free, xation ring
Dr. Carla Bourne, MD is a steps to success. attachments.While most require tilting the patient's head and the
Glaucoma and Cataract Specialist operating microscope, a few companies manufacture prisms with
Angle Anatomy two mirrors enabling a view from above in primary position. It is
at the James A. Haley best if the lens chosen has a“cut out”to facilitate easy entrance via
Veterans Affairs Hospital, Tampa, FL. Groundwork begins in the clinic with knowledge of angle anatomy your corneal incision into the anterior chamber.
and variations. Ensure that you can correctly distinguish anatomic
Dr. Bourne completed residency challenges such as: • Acquaintyourselfwithhowtotiltyourmicroscope
at the Howard University Hospital. • Adjustyourchairand/orocularheighttokeepalignment
• Anatomyofalightlypigmentedtrabecular • Refocusgrosslybeforeusing nefocus
Dr. Bourne is board certi ed in meshwork using Schwalbe's line
Ophthalmology. She is an Assistant The patent's head will be tilted away from you and the microscope
• Peripheralanteriorsynechiaevs. irisprocesses tilted approximately 30-40 degrees towards you. The key to
Professor of Ophthalmology, successful MIGS surgery is visibility. Often, the beginning MIGS
University of Central Florida & Thewebsiteswww.gonioscopy.org isanexcellentresource. surgeon has angle visibility issues due to under rotation of the
University of Texas Galveston. patient's head or the scope. Placing a preset mark on the scope can
Patient Selection help avoid this issue (Figure 1 & 2). Smart phone apps can assist
with determining your degree of tilt. Rotating enough to have a
Patient selection is key for your rst cases. If possible, choose parallel approach to the iris plane (enface) creates the most
patients who are cooperative with your gonioscopy exam in clinic optimized view.
and who have:

• Mild-moderateglaucoma
• Clearcornea
• Well-de nedanglelandmarks

Initially, avoid patients on blood thinners or who have shallow
anterior chambers (unless cataract surgery is also being
performed).

Have realistic expectations for post-operative intraocular
pressures (IOP) and choose patients that match those
expectations. For example, patients with neovascular glaucoma,
angles closed with large areas of PAS or severe glaucoma with
markedly elevated pressures would not be ideal and somewhat
contraindicated.

MIGS can be performed with or without cataract surgery
depending on your practice location and reimbursement
limitations. Performing MIGS on a phakic patient is also an option.
However, it is best that the surgeon be very pro cient in
performing angle surgery on pseudophakic patients before
attempting this. The angle and anterior chamber depth are
shallower and the risk of damaging the lens and other structures
increasessigni cantly.

Surgery Preparation

Familiarize yourself with your direct gonioprism of choice. Ensure Figures 1 and 2 showing the tilt of the microscope
you are comfortable handling it in your non-dominant hand. Most during angle surgery. Note the present mark.

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OSWI Times Volume II

Go Green Caribbean for Glaucoma

MIGS surgery requires higher magni cation than seating the gonioprism. For some devices e.g. Hydrus Now you are on your
cataract surgery.Take the time to become acclimatized trabecular micro-bypass stent and using Ellex's I-track mark and set go to
to working under higher magni cation since your canaloplasty device, additional incisions need to be work in the angle!
depthof eldwillbedifferent. placed which are not in the typical cataract surgery
If you tape the patient's head, leaving a tab or another location.
quick release technique, allows you to rotate their head
quickly and easily. If your cataract incision is at a superior or inferior
temporal location and not 3 or 9 o'clock, you may need
Placing the bed in a slight reverse Trendelenburg can to turn your scope and adjust your seated position
also reduce blood re ux which can cloud the view slightly to gain equal access to both the superior and
especially in a patient on blood thinners. inferior angle. It is often easier to make your incision
directly temporally.
Intraoperative Considerations
Take care not to apply excess pressure with the
MIGS surgery has special considerations even for an gonioprism. This will cause striae and egress of
experienced cataract surgeon. viscoelastic from the anterior chamber which limits the
view. A cohesive or heavier molecular weight
• Tiltingthescopeandheadchanges viscoelastic helps maintain anterior chamber depth
the working angle during manipulations. In addition, a coupling agent for
the gonioprism such as viscoelastic or lidocaine gel is
• Onehandcontrolstheprismoutsidethe needed.
eye while the other manipulates inside
the anterior chamber Some surgeons prefer to perform their MIGS surgery
prior to performing phacoemulsi cation since the
• Thesurgicalspaceismuchsmaller– corneal view is optimal, however, the angle space is
limited to the area between the smallerandthesurgeondoesnotbene tfromthe ush
corneal endothelium and the iris plane of heme which appears in Schlemm's canal (SC) after
cataract extraction. This red ush creates a consistent
• Highermagni cationisneeded and clearly de ned landmark for even a lightly
pigmented TM. Trypan blue can also be used
Another item for consideration is an ocular block – peri intracamerally to stain the TM. Some surgeons will
or retrobulbar can assist with akinesia. However, release some viscoelastic from the AC to drop the
remember that the patient will no longer be able to pressure and induce re ux into Schlemm's canal to
cooperate with requests to look more nasally to get to create the demarcation of SC. Be careful not to cause so
the desired enface view. To accommodate this, use the much re ux that you get spill over into the AC which
prism to move the eye or turn the head more. would obscure your view.

Familiarity builds muscle memory. It is best to practice Use viscoelastic to clear heme and increase working
getting into position and performing maneuvers prior space. Place the viscoelastic while viewing with the
to your rst MIGS case. A simple exercise would be gonioprism so that it is directed to the speci c problem
explaining to our patient that after the cataract surgery area. If this maneuver is unsuccessful or the view
you would be turning their head to just examine their signi cantly obscured with heme, gentle irrigation and
anatomy or drainage area. aspiration to ush the anterior chamber works well. Be
sure to quickly reform the eye to prevent new heme
• Usingtheviscoelasticcanula,entertheeye re ux.
• Approachthetrabecularmeshwork(TM)
• Inject a small amount of viscoelastic and Device Matters

observe the chamber deepening
• GentlytouchtheTM

This will give you practice identifying the correct Familiarize yourself with your device of choice. Use your
working area in addition to performing two types of resources - call upon support from the device
single-handed maneuvers directly at your target representatives, experienced colleagues and surgical
location. videos. Plan a wet lab prior to your rst case and leave
time to review again if needed. Ensure comfort with the
It is also key to pay attention to your incision device mechanisms. Some have roller wheels to
placement. A wound which is too posterior will cause enable the canal to be cannulated, others use an
limbal vessels to bleed and obscure your view. injector model for stent deployment. Each device has
its own nuances. Also, make sure the surgical team staff
A wound which is too anterior may cause difficulty is trained on preparing the devices for use.

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OSWI Times Volume II

Go Green Caribbean for Glaucoma

Treating Glaucoma in Guyana

Dr. Shailendra Sugrim Introduction of diagnostic tools such as tonometry began ltering into offices.
Majority of eye-care practitioners use pneumotonometry since it
MBBS, Dip Ophth, ChM (Ophth) Based on empirical data and also from studies from individual is convenient and easily done.Though applanation tonometry has
countries in the Caribbean, primary open angle glaucoma (POAG) its disadvantage in that it needs special skill and experience and
Dr. Sugrim completed his Bachelors is the most common form of glaucoma in the Caribbean region. also regular supply of uorescein and topical anaesthesia, it is the
of Medicine and Surgery in 2001 Stuies of black West Indian populations in St. Lucia [Mason et al gold standard method of tonometry. The use of applanation
from the University of Guyana, 1989] and Barbados [Leske et al 1994] show a prevalence of 8.8% tonometry (such as Goldmann and Perkin's Tonometry) is being
School of Medicine. and 6.6%, respectively. It is the most common formof glaucoma in taught and promoted amongst all eye-care practitioners. The use
He went on to complete his three- the US (approx . 1.86% in adults over 40 years) [Friedman et al of Humphrey'sVisual Field (HVF) as a diagnostic tool and follow up
year Ophthalmology training in 2014]. Most literature contend that POAG varies signi cantly tool has been available however this tool needs to be carefully
Chittagong, Bangladesh and according to race and ethnicity. In Caucasians > 40 years in the US, interpreted by those trained and with experience. HVF
then completed a one year the prevalence is 1.69%. The Baltimore Eye Study concluded that measurement is found to be highly unreliable across the
Glaucoma Fellowship OAG is three times more prevalent among African Americans in the population usually due to difficulty in interpreting the instructions
in Bangladesh and New York. United States than among Caucasians. It is accepted that people of during the test. Also in elderly patients, apart from having
Asian descent are much more likely to suffer from angle closure difficulty in comprehending the instructions, response time
He completed Masters in Surgery in glaucoma (ACG), while those of African or European origin are affects their ability to give reliable readings.
Clinical Ophthalmology from the more likely to develop POAG. Population based studies in India
University of Edinburgh, Scotland. report prevalence of POAG between 2 to 13%. The Ocular Modern developments and research on glaucoma has enabled us
He is currently the Head of HypertensionTreatment Study (OHTS) showed that black race was also to consider other factors such as characteristics of the neuro-
Department of Ophthalmology, a risk factor for conversion from ocular hypertension to OAG. It also retinal rim, size of the optic nerve and the central corneal thickness
Georgetown Public Hospital and showed that corneal thickness and cup-to-disc ratio may present a (pachymetry). Over the past 5 years diagnostic use of pachymetry
the National Coordinator of Vision better means of evaluating risk factors. and Optical Coherence Tomography (OCT) are now a part of the
and Eye Health Services of the armamentarium of Guyanese eye care professionals in detecting
Ministry of Health, Guyana. Guyana Situation glaucoma at earlier stages.

In Guyana, our two major ethnic groups are of Indian origin and Open Angle Glaucoma
African origin. Minorities include Portuguese, Chinese, Indigenous
and mixed groups. Hence, in assuming the prevalence risks for In Guyana, POAG in the Afro-Guyanese population presents
Glaucoma in our country, looking at data from studies with similar usually with very advanced features and with patients already
ethnicity gives us an idea of what the dimension is like. In 2009, a having a tremendous loss of peripheral vision. This nding is
random sampling and analysis of data from records at Georgetown common in both the old and young age group. This presents a
Public Hospital showed that 9% of patients presenting to the Eye challenge because patients with advanced vision loss are at risk for
Clinic were likely to have a diagnosis of OAG with majority of further loss of vision if surgical intervention is needed. The usual
patients being of African ethnicity. approach is to try to initiate or maximise their topical glaucoma
medications until maximum tolerated medical therapy is
Diagnosis achieved. It is especially difficult to convince younger patients
with advanced eld loss (tunnel vision) with 20/20 central vision,
Diagnosis is straightforward in advanced cases with all the to undergo surgery. Typical pro le for these patients is
characteristic features – these are the stages in which you do not characterised by high IOPs (>30mmHg), deep excavated cups
want to be having rst encounters with patients. In Guyana, these with thin rims and C:D ratios – usually > 0.7. In the past, due to
advanced cases are easily diagnosed by all levels of eye care sparsity of eye care professionals, routine eye screenings were not
personnel and are immediately treated or referred for treatment. the usual practice of the population and hence, a reliable family
Diagnosis becomes more technical in early glaucoma cases or in history cannot be elicited. Though, the current practice is to
normal tension cases.These patients typically present in their late encourage relatives to have regular screening for glaucoma.
30s and early 40s. Normal tension glaucoma (NTG) seems to be more common in
Indo-Guyanese patients who are also prone to diabetes mellitus.
Up until 10-12 years ago, there was a sparsity of ophthalmologists These patients present in various stages from early disease to
in the country and eye care personnel had to resort to managing advanced disease. Their IOPs range from 10-14mmHg. Most NTG
and treating glaucoma cases diagnosed based purely on cup-disc cases are initialised on topical glaucoma eye drops and their IOPs,
ratios. As more ophthalmologists were trained, eventually the use Visual Fields and OCTs are monitored for effectiveness of
treatment.

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OSWI Times Volume II

Go Green Caribbean for Glaucoma

Angle Closure Glaucoma Guyana at a private clinic. Enough cases of this As the Number 1
procedure are not available to determine the Worldwide leading
Cases of Primary Angle Closure Glaucoma (ACG) exist effectiveness of SLT in the population. Over the past 2-3 cause of irreversible
and they are found to be common in the indigenous years, Glaucoma Valve Surgery was introduced with a visual loss,
(Amerindian) population. However we do encounter few cases being done sporadically based on availability Glaucoma is a
cases in both Indo-Guyanese and Afro-Guyanese of consumables which are quite costly. pertinent issue for
patients. Secondary ACG cases are present in cases of Guyana and the
neovascular glaucoma, uveitic glaucoma and lens- Patient Education and Awareness Caribbean.
induced glaucoma. Management of these cases are
initially attempted medically. Facility for YAG Laser Patient education is a key issue in glaucoma
Peripheral Iridotomy is currently only present at two management. Careful counselling is important so that
locations in Guyana. Advanced cases not responding to patients are educated on the pattern of visual loss, their
medications eventually require surgical intervention. options for treatment and also the irreversibility of
glaucomatous optic neuropathy. Doctor-patient
Secondary Glaucoma cases are commonly due to counselling can be challenging in a public system
trauma (which has a male predominance), steroid where clinics are overcrowded and overtaxed with
induced, ocular in ammation and lens related. limited human resources. Patient counselling training
Congenital Glaucoma presents rarely and these cases sessions have been conducted with eye care staff.
are managed surgically with long-term follow-up at Glaucoma Awareness and Public Health Education
clinics. efforts in Guyana were forti ed in 2013, when the
Department of Ophthalmology at the Georgetown
Treatment Public Hospital began annual commemorative
activities in keeping with World Glaucoma Day and
Initialising treatment of glaucoma patients with World Glaucoma Week. Over the years, this annual
medical therapy (topical eye drops) is the current mode activity has shown tremendous response in the general
of management. For the past 15-20 years, the most public to have regular eye checks. Activities undertaken
economical eye drop used in our public system is Gutt over the years include: free public Glaucoma
Timolol 0.5% which gives about 10-20% decrease in Screenings, Media Publications and Appearances,
initial IOP reduction. It is a drug with good tract record, Social Media activities, pamphlets and poster
well tolerated and there are minimal side-effects. distribution and community outreaches and talks.
Lobbying by the newly trained ophthalmologists has
seen growth in provision of other classes of glaucoma Compliance
medications in the public system which are provided to
the general public free of cost. Patients now have the It is difficult sometimes for patients to understand
opportunity to access 2nd, 3rd and 4th drug therapies until visual loss from glaucoma if they aren't having a
maximum tolerated medical therapy is achieved noticeable scotomas or blurred vision.This affects their
(prostaglandin analogues, alpha-agonists, CA- compliance and hence, counselling is important.
Inhibitors). Availability and cost of medications is a Compliance is usually not an issue in patients with
pertinent issue. Due to the heavy demands on the advanced visual eld loss, who are willing to give
system and large patient numbers, there are some consentforanysurgical procedure.In2017,aglaucoma
occasions when the supplies are depleted. This forces medication compliance study was done at the
patients to purchase these drops (which presents a Georgetown Hospital which shows 26% of the study
dilemma for the elder patients who are primarily population having high compliance to their
receiving government pensions). medications. Level of education and knowledge of
glaucoma was shown to be a high determinant of
Surgery is recommended for patients who do not compliance.
respond to medical therapy. Trabeculectomy with
mitomycin-C is the usual procedure for young patients Conclusion
and older patients with clear lens. In older patients
with moderate-severe cataracts are recommended for As the Number 1 Worldwide leading cause of
combined procedures. Angle closure patients are irreversible visual loss, Glaucoma is a pertinent issue for
monitored after having laser peripheral iridotomy Guyana and the Caribbean.
done. Secondary glaucomas (especially in ammatory-
induced cases) are controlled with medications until Patients across all racial and ethnic divides are not
the need for surgical intervention arises. All congenital aware that they may be afflicted with glaucoma.
cases are recommended forsurgery (Trabeculectomy + Patient education, compliance and availability/cost of
Trabeculotomy procedure). Selective Laser medications are key issues that our communities have
Trabeculoplasty (SLT) was introduced in Guyana in to grapple with. A concerted and collaborative effort to
2015 and is currently available at one location in combat glaucoma in the region is essential.

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OSWI Times Volume II

Go Green Caribbean for Glaucoma

CAOTP NEWS
(Caribbean Association of
Ophthalmic Technical Personnel)

Marily Watkins-Ramdin After a late start, the CAOTP virtual weekly
President and Board Member, teaching sessions are now up and running with
the kind assistance of OSWI, Ms. Sergina
COATP Flaherty COMT OSC (Ophthalmic Seminars of San
Antonio - OSSA) and the doctors of the Caribbean Eye
Institute (CEI). We delivered (4) one hour sessions
during the month of April 2021.

Marilyn Watkins-Ramdin, COMT Sessions will continue to be held biweekly on Tuesday
ROUB, after completing her associate and Thursday evenings in preparation for COA, COT and
OSA IJCAHPO exams in August 2021. These virtual
degree in biology and Chemistry in sessions via Zoom have now replaced the face-to-face
1993 Marilyn became an classes that we have been coordinating in Barbados
and Trinidad since 2010. Out of the darkness of the
Ophthalmic assistant the same year. pandemic comes the light of being able to reach all of
After the requisite course of study our membership, as well as, nurses and technicians
she achieved her COA certi cation from Antigua down to Suriname! Recorded sessions are
from JCAHPO in 1996, and became available on the Caribbean Eye Institute YouTube
an ATPO member in 1996 also. channel.
Presenter for 1st OSWI technicians
This is our 10th anniversary of offering IJCAHPO exams!
programme 2008. She has also held CAOTP, along with OSWI, over the past 10 years have
roles such as Coordinator OSWI had the pleasure of collaborating with IJCAHPO to offer
technician programme 2009, these exams to our Caribbean Ophthalmic Assistants.

Coordinator IJCAHPO exams at OSWI IJCAHPO offers textbooks and ashcards for our
2011- present. Mrs. Watkins- programme at the JCAHPO bookstore on
www.jcahpo.org. Check out the IJCAHPO site for
Ramdin is the proud founder and monthly webinars with CME which can be used for
president CAOTP, and Coordinator of certi cation or recerti cation. Please note that, as of
August 2020, only IJCAHPO approved CME courses are
CAOTP technicians and nurses validforcerti cationorrecerti cation.
programme 2012- present.

In closing, CAOTP plans to continue our teaching
sessions when we begin the new teaching year
(September 2021 to July 2022), in preparation for
exams and general Ophthalmic knowledge of our
membership.

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