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Peril to the Nerve

Glaucoma and Clinical Neuro-Ophthalmology

edited by: B.J. Leader & J.C. Calkwood

Price: € 74.00 / US $ 92.50

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Publication details: Book. 1998. xiii and 283 pages. Publication date: 1998-03-27. 50 figures of which 3 in full color, and 21 tables. Hardbound.

ISBN: 978-90-6299-153-2 (ISBN 10: 90-6299-153-X; Kugler Publications)
This publication is part of the New Orleans Academy of Ophthalmology series
Also available as ebook


For half a century the New Orleans Academy of Ophthalmology has been dedicated to providing an annual in-depth evaluation of an important clinical topic in ophthalmology. These symposia have always been a combination of relevant clinical thought, based on outstanding knowledge, and current research. In 1996 this tradition was continued with the symposium "Peril to the Nerve - Ophthalmology". From the latest discussions in the literature to provocative round tables and clinical controversy presentations, the participants discussed clinically useful topics in these fields. The panelists in the glaucoma segment were Drs Michael Kass, Donald Minckler, Paul Palmberg, Harry Quigley, George Spaeth and Thom Zimmerman; those in the neuro-ophthalmology section were Drs Ronald M.Burde, Joel S. Glazer and Normal J. Schatz. This volume contains the updated papers and reports of the round table discussions at this meeting. It can be considered a "state-of-the-art" publication.



"You don't see what you don't know"
George Spaeth

For a half century the New Orleans Academy has been dedicated to providing an annual in depth evaluation of an important clinical topic in ophthalmology. Our symposia have always been a combination of relevant clinical thought based on outstanding knowledge and current research. In April, 1996, this tradition continued with the symposium "Peril to the Nerve" - Glaucoma and Clinical Neuro-ophthalmology. From the latest discussions of the literature to provocative round table and clinical controversy presentations, the participants discussed clinically useful topics in these fields. For four days the nearly two hundred physicians in attendance were treated to innovative thinking from speakers who were chosen for their lively approach to science and teaching. The panelists in the glaucoma segment were a wonderful combination of acerbic wit and clinical insight. Doctors Michael Kass, Donald Minckler, Paul Palmberg, Harry Quigley, George Spaeth and Thorn Zimmerman are some of the great names in this field. They enjoy teaching, are critical of each other, and like to have fun. This was a wonderful mix, which shows in their presentations. The neuro-ophthalmology section included Doctors Ronald M. Burde, Joel S. Glazer, and Norman J. Schatz. This was a reunion of sorts for these physicians as, exactly twenty-five years previously, they appeared on the panel of the New Orleans Academy discussing neuro-ophthalmology. Although a little older, these three gentlemen used their additional wisdom and experience to make the neuro-ophthalmology section interesting and informative. Any reader needing a refresher in clinically relevant neuro-ophthalmology will find this section particularly helpful. New Orleans has always been a fun place to visit and once a year, the New Orleans Academy makes it a fun place to learn. The more detailed presentation of each topic in this monograph expands on the oral presentations given during the symposium. As editors, we would like to thank the president of the New Orleans Academy, Dr. William Rachal, and the executive secretary, Mrs. Emily Busby, for their tremendous help in organizing this symposium. The editorial expertise of Kugler Publications is also gratefully acknowledged. The success of this symposium, however, would not have been possible without the enthusiastic and continuing support of the ophthalmologists of New Orleans and South Louisiana who are members of the New Orleans Academy. To them we give our appreciation.

Barry J. Leader, MD
Jonathan C. Calkwood, MD

Table of Contents

Table of Contents



Glaucoma and the nerve

The progression of open-angle glaucoma: it isn't what you think
Harry A. Quigley

The pathophysiology of visual field injury in glaucoma: correlating anatomy and tissue alterations with clinical field analysis
Don Minckler

The clinical impact of new optic nerve imaging techniques
Harry A. Quigley

Glaucoma management dilemmas

Ocular hypertension: does treatment work?
Michael A. Kass

Racial differences affecting glaucoma management. Does glaucoma discriminate?
Harry A. Quigley

Clinical controversies: the trials of treating glaucoma progression
Don Mirickler, Moderator

Grand Rounds I
Kenneth Haik, Moderator

The treatment of normal-tension glaucoma
Michael A. Kass

Medical management of glaucoma
Thorn J. Zimmerman and Robert D. Fechtner

Clinical controversies: target pressures - what are they?
Paul Palmberg, Moderator

Glaucoma: where have we been, where are we now, and where should we be going?
George L. Spaeth

Surgical treatment of glaucoma

Surgery: realities, expectations and indications
George L. Spaeth

Grand Rounds II
Katherine Loftfield, Moderator

How to suspect, detect, and treat a person with angle-closure glaucoma
George L. Spaeth

Argon laser trabeculoplasty
Michael A: Kass

Cyclodestructive procedures: are newer approaches better?
Don Minckler

Clinical controversies: cataracts and glaucoma
Thorn J. Zimmerman, Moderator

Glaucoma: surgical challenges

Filtering surgery with antimetabolites
Paul Palmberg

Early complications after glaucoma filtering surgery (the 'dirty dozen')
Harry A. Quigley

Late complications after glaucoma filtering surgery
Paul Palmberg

Glaucoma drainage devices: promise and problems
Don Minckler

Grand Rounds III
Clifford Hendricks, Moderator

Medical and surgical management of neovascular and uveitic glaucoma
Don Minckler

Clinical controversies: my toughest cases - what would you do?
Georg L. Spaeth, Moderator


Optic neuritis
Norman J. Schatz

The ischemic optic neuropathies: what's new?
Joel S. Glaser

Visual loss in Graves' disease
Jonathan C. Calkwood and Ronald M. Burde

Idiopathic intracranial hypertension
Norman J. Schatz

Round Table and Question and Answer Period. Undiagnosable progressive optic neuropathies -etiology, management and empiric treatment
Jonathan C. Calkwood

Round Table and Question and Answer Period. Clinical pearls from difficult cases
Jonathan C. Calkwood

Index of authors


Book reviews

Japanese Journal of Ophthalmology, Vol 43 (1)
By: Noria Ohba MD

PERIL TO THE NERVE: GLAUCOMA AND CLINICAL NEURO-OPHTHALMOLOGY is the proceedings of the 45th Annual Symposium of the New Orleans Academy of Ophthalmology which was held in New Orleans, April 1996. From the review of the latest literature to provocative round table and clinical controversy presentations this book provides a wonderful wit and teaching on clinically important topics in these fields

The panelists in the glaucoma section are Quigley, Kass, Zimmerman and Spaeth, some of the great names in this field. Quigley provides a comprehensive review of the progression and outcome of glaucoma, insisting that the prevailing view that all patients are going blind during lifetime is wrong and that the primary goal for glaucoma monitoring is to differentiate between those persons at greater risk for visual loss and those who are going to have no significant visual loss and to provide valid measures and prediction of glaucoma progression in a cost-effective manner. The reader will appreciate that a forthcoming practice is directed to assessment of the retinal ganglion cells and their axons and that a number of new approaches for monitoring the optic nerve structure are on-going, such as Topcon Imagenet system, Glaucoma-Scope, Scanning laser ophthalmoscope, Retinal thickness analyzer, Optical coherence tomography, Nerve fiber analyzer, which are hopefully to reach the point of proven clinical impact. It is needless to say that an ideal testing system should give comfort for the patient, low acquisition and maintenance cost, rapid analysis per eye, high reproducibility and high validity. Quigley also discusses racial differences in the prevalence of glaucoma in such a manner that estimated rates of open-angle glaucoma (OAG) and angle-closure glaucoma (ACG) vary substantially among the major ethno-geographic groups, OAG is more than four times as frequent among those of African descent, and ACG more prevalent than OAG in Asian persons.

Kass summarizes the current concept of ocular hypertension to note that its incidence i more prevalent than POAG, its conversion to POAG is about 3% per year, and major risk factors include elevated IOP, optic disk abnormality, increasing age, family history and vascular disease. However, the guideline for practical management awaits the ongoing scientific studies. Kass also describes the issues of normal-tension glaucoma and points out that, aside from controversy about its pathogenesis, it is still controversial whether lowering IOP helps to stabilize this condition and whether it is more common in women and myopic individuals.

Every ophthalmologist knows that non-compliance in glaucoma patients can be as high as 60-70% and very often has to be considered a reason for treatment failure. Zimmerman and Fechtner emphasizes that obtaining information regarding lifestyle, basic feelings and sentiments is useful in establishing compliance with medical therapy, a good time to consider compliance and related problems is prior to beginning therapy, and it is our responsibility to make sure the patient understands, accepts, and complies much depending on the education of patients. Impressively instructive is that the one-eyed trial process is useful for both education and reinforcing benefits of care early in the relationship with the patient. Also, nasolacrimal occlusion is recommended for the safest and most efficacious use of drug in patients undergoing a lifetime treatment.

Spaeth and others discuss how to suspect, detect and treat a person with angle-closure glaucoma and therapeutic measures including argon laser trabeculoplasty, cyclodestructive procedure, filtering surgery with antimetabolites, neovascular glaucoma, and complications after glaucoma surgery, all of which are instructive for the current management of glaucoma

About one fifth of this book deals with neuro-ophthalmological topics. This section reviews optic neuritis, the ischemic optic neuropathies, visual loss in Grave's disease, idiopathic intracranial hypertension. The contents are not related to the first section of this book, but provide the current concept, diagnosis, and management of relatively common, neuro-ophthalmological diseases. Two chapters are devoted to round table discussion with, case presentation and question and answer. Epidemiology or racial difference of these , diseases is not covered in this book. Ischemic optic neuropathy of giant cell arteritis type and idiopathic intracranial hypertension (pseudotumor cerebri) are fortunately extremely rare in , Japan.

Noria Ohba MD
Professor, Department of Ophthalmology
Kagoshima University Faculty of Medicine
Kagoshima, Japan

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