Global Ophthalmology and Glaucoma Conference October 13-15, 2016 Kuala Lumpur, Malaysia

Sheena Balakrishnan has completed her Diploma in Ophthalmology from Madras Medical College and Diplomate of National Board from The Eye Research Foundation, Chennai. She then completed her Fellowship from the International Council of Ophthalmology. She has undergone Medical Retina training and training in Anterior Segment Surgeries mainly focusing Cataract Surgeries and Refractive Surgeries. She has worked with the World Diabetic  Foundation in screening and managing diabetic retinopathy patients over 2 years. She has performed retinal laser photocoagulation, intravitreal injections, photodynamic therapy and managed retinal diseases. She is vastly experienced in performing cataract surgeries including small incision cataract surgeries and phacoemulsification surgeries. She has performed more than 3500 LASIK, LASEK, PRK, Wave front guided treatment. She has published and presented various papers at national and international conferences. She was invited faculty for Medical management of age related macular degeneration in APAO Conference in Bali in 2009. She is one of the few Surgeons in India who is experienced in large volumes Implantable Collamer Lens (ICL) technique.

The most important aspect in the success of Lasik surgery is the proper selection of cases. It is important to understand that Lasik being a cosmetic procedure, the pre-operative evaluation of the Lasik patient in terms of history taking, detailed anterior segment evaluation including dry eye work up, correct selection on the basis of topography and aberrometry is very significant in deciding the selection of procedure and outcomes of the Lasik. The role of pupil size diameter, occupation and visual demand of the patient also plays a significant role in the outcomes of Lasik. After the entire evaluation is completed, the most important thing is giving proper counseling to the patients for e.g., denying Lasik with large pupil size in people who work in radiology and other professions of dim light is essential. Discussion of the detailed realistic outcomes of the Lasik patients in relation to the day to day activities in counseling has better satisfaction rate post Lasik. In this presentation, I would like to share my compilation of significant points to be covered in the counseling and evaluation of the patients.

Enrique Suarez graduated as Medical Doctor from Universidad de Los Andes. He has obtained Internship and Ophthalmology Residency at Military Hospital (Caracas, Venezuela) and Cornea, External Diseases and Anterior Segment Fellowship with Dr. Herbert Kaufman at Louisiana State University, USA. He is the Head of Cornea Division at Military Hospital, Director of Cataract and Refractive Surgery & Clinic Ophthalmology Service at Centro Medico Docente La Trinidad Private Foundation (Caracas, Venezuela) for 20 years. Currently, he is the Senior Academic Consultant at King Khaled Eye Specialists Hospital (Riyadh, Saudi Arabia). He has over 40 publications to his credit and presented 450 lectures in international meetings. He also serves as the Board of Directors of International Ophthalmological Societies and Editorial Board Member of Ophthalmological Journals.

Purpose: The Verus ring is a silicone ring-shaped intraocular device that can be injected onto the anterior lens capsule that can assist with sizing and centration of the capsulorhexis. Capsulorhexis during cataract surgery in patients with corneal scars can be challenging. In this study, we determine the safety and efficacy of the Verus ring during anterior capsulorhexis.

 

Methods: Eyes with mild to moderate corneal scars undergoing cataract surgery (n=18) were subjected to implantation of the Verus ring during capsulorhexis by a single surgeon. Outcome measures included complications during the capsulorhexis procedure and time taken to complete the capsulorhexis and surgeon feedback. Historical and surgeon controls (n=18) for capsulorhexis in patients with clear cornea were used as a comparative group.

 

Results: There were no complications related to the insertion and removal of the device. Anterior capsular extensions were not observed in any of the cases with corneal scarring. The capsulorhexis was well centered in all the eyes. Surgeon feedback indicated that the insertion of the device did not require steep learning curve other than careful following the instructions as noted in the instruction video and was of the opinion that it greatly enhanced safety and efficiency during the capsulorhexis process.

 

Conclusion: The Verus ring appears to be a useful device in performing safe and efficient capsulorhexis in patients with corneal scars undergoing cataract surgery.

Amit Solanki has been in ophthalmic field for more than 12 years. He has done his Undergraduate & Post-graduate Training from the reputed B J Medical College, Ahmedabad (Gujarat). During two years of Senior Residency tenure at renowned Aravind Eye Hospital, Tamil Nadu, he was awarded the Diplomat of National Board in Ophthalmology (DNB) by the National Board of Examinations. He also completed Special Training in Glaucoma at Aravind Eye Hospital, Coimbatore. He has presented his work at national & state conferences and received many awards. He has also delivered many lectures (more than 55) at various conferences being a guest faculty.

Glaucoma is a leading cause for irreversible blindness in the world. It is estimated that currently nearly 70 million people are affected by glaucoma worldwide. Treatment for glaucoma is widely available and blindness from glaucoma can be prevented if the disease is detected early and treatment is given on time. However, the main challenge in glaucoma facing our country is that nearly 90% of glaucoma in the community is undetected. There is also a need for improving training for ophthalmologists for diagnosis of glaucoma, as there is poor diagnostic rate for those who undergo a routine ophthalmic evaluation. Still there are many missed out cases of glaucoma and also over diagnosed cases of either normal or glaucoma suspects or ocular hypertension or miss diagnosis of open or closed angles. When a patient is evaluated in the outpatient department, it is crucial for the eye surgeon to evaluate the optic disc to detect early changes, to view the anterior chamber to identify open or closed angles. Once there is a suspicion of glaucoma, standard automated perimetry should be performed and repeated in case a visual field defect is seen. This is an interactive session where I have put the real cases photographs (clinical & investigations) and it will be discussed with panelists about glaucoma diagnosis and management. Finally the take home message for each case will be given to audience.

Ashraful Huq Ridoy is now working as Junior Consultant at Bangladesh Eye Hospital Ltd. He has completed basic Medical degree MBBS in 2007 and accomplished FCPS (Fellow of College of Physicians and Surgeons, Bangladesh) in Ophthalmology in 2015; as well as he had 4 years Professional Training on Ophthalmology. He has completed Fellowship in Cataract Surgery. His working fields of interests are cataract, glaucoma and refractive surgery. He is the Life Member of Ophthalmological Society of Bangladesh and Executive Director of Bangladesh Eye Donation Society & Eye Bank.

Purpose: To assess the change in thickness of retinal nerve fiber layer and macula, after trabeculectomy, by using optical coherence tomography. Materials & Methods: A total of 25 patients with primary open angle glaucoma undergoing trabeculectomy were selected. Average and quadrant RNFL thickness, macular thicknesses were measured by OCT within a month before surgery and 1 and 3 months postoperatively. Main outcome measures were changes in average and quadrant RNFL, macular thickness with respect to post-operative intraocular pressure change. Results: Average and quadrant RNFL thickness increases post-operatively after reduction of IOP from 28.12±7.92 mmHg (mean±SD) to 11.40±2.71 mmHg at 1 month and 11.68±2.61 mmHg (P=<0.0001) at 3 months. A significant increase was observed in superior (18.33±5.55 μm, P=0.0085) and inferior (16.04±6.54 μm, P=0.0178) RNFL thickness at 3 months post-operatively. Average (10.89±5.55 μm, P=0.0555), nasal (13.12±8.16 μm, P=0.1146) and temporal (1.64±3.17 μm, P=0.6069) RNFL thickness increase were not statistically significant (P=>0.05). Macular thickness increases from 229.82±9.99 μm pre-peratively to 243.88±8.89 μm at 1 month and 233.52±7.95 μm at 3 months (P=0.1547) post-operatively, both were not significant. Conclusion: A significant increase in superior and inferior RNFL thickness was observed due to reduction of IOP after trabeculectomy

Khalid Qadha has 14 years of experience as an Ophthalmic Technician in the field of Ophthalmics at King Khaled Eye Specialist Hospital. He has 2 years of experience at Cleveland Clinic Abu Dhabi and has 9 years of experience as an Ophthalmic Ultra-sonographer with wide experience in Ophthalmic Pathology.

UBM is almost universally defined as an optical science, the human eye is by nature light-sensitive; UBM permit complete imaging of deep ocular structures. UBM is perfect for glaucoma screening, determining lens and cornea pathologies and more. This presentation will help to show what UBM can change in clinical practice when to request it and when to request anterior segment OCT.

Prashant S Agnihotri was a Lecturer at Govt Medical College 1980 till 1985. He has worked at the Retina Care Hospital since 1985. He was a Visiting professor and the Head of the Department of Ophthalmology at the Siddhartha Institute of Medical Sciences, Vijayawada, India.

Internal limiting membrane removal has become a standard of care for various retinal surgeries specially, vitreomacular traction. Various methods and rational for this intricate important step shall be hallmark of this presentation.

Enrique Suarez was graduated as Medical Doctor from Universidad de Los Andes. He has obtained Internship and Ophthalmology Residency at Military Hospital (Caracas,Venezuela) and Cornea, External Diseases and Anterior Segment Fellowship with Dr. Herbert Kaufman at Louisiana State University, USA. He is the Head of Cornea Division at Military Hospital, Director of Cataract and Refractive Surgery & Clinic Ophthalmology Service at Centro Medico Docente La Trinidad Private Foundation (Caracas, Venezuela) for 20 years. Currently, he is the Senior Academic Consultant at King Khaled Eye Specialists Hospital (Riyadh, Saudi Arabia). He has over 40 publications to his credit and presented 450 lectures in international meetings. He also serves as the Board of Directors of International Ophthalmological Societies and Editorial Board Member of Ophthalmological Journals.

As more surgeons explore the possibility of femtosecond laser cataract surgery (in which the incision, capsulotomy and nucleus fragmentation are accomplished by the laser), the focus on the details of the surgery’s advantages and pitfalls has become more intense. And as with any surgery, one of the most important details is potential complications. Pearls to perform the different surgical steps of this technique will be presented from the pupil dilatation, incision, capsulorhexis, hydro dissection and phacoemulsification of the lens with practical tips to avoid complications as the posterior capsule blown and vitreous lens drop.

Mita Joshi is a leading Ophthalmologist at Indore. She finished her MBBS and DOMS from Surat, Gujarat in 2000. Further to enhance her career, she went to

Agrawal Eye Hospital, Chennai and did her DNB in Opthalmology followed by FERC and FICO [Fellowship of International Council of Ophthalmology] where she was awarded as international scholar. She had a keen interest in cornea so she did a prestigious fellowship of cornea at RIOGOH, Chennai. Later she finished FRCS [UK] and became one of the very few FRCS at Indore. After acquiring adequate experience, she moved to Apollo Rajshree Hospital and simultaneously became Asst. Professor at SAIMS College and Mohak Hospitals due to her keen interest in teaching.

Intraocular pressure (IOP) measurement is an important investigation which forms a part of routine checkup in ophthalmology. Instruments of IOP measurement range from the Schiotz tonometer to ocular response analyzers which include corneal hysteresis in their pressure calculations. Goldmann applanation tonometry remains the gold standard for intraocular pressure measurement. This technique though is not without its pitfalls but with this short educational presentation, we will attempt to demonstrate the same and try to make this test a part of every ophthalmologist’s routine.

 Ashok Kumar M has completed his MBBS in 1994 from Sri Ramachandra Medical College, Chennai, Tamil Nadu Dr. MGR Medical University. He obtained Diploma in Ophthalmology (2001 – 2003) from Regional Institute of Ophthalmology, Madras Medical College, Chennai and a Diploma from National Board New Delhi during 2003 – 2007. He is a Fellow of International Council of Ophthalmology and fellow of Royal College of Physicians and Surgeons (Glasgow) 2007. He has presented his work at Navkar I Care, India & state conferences and received many awards. He has also delivered many lectures various conferences being a guest faculty.

Gonioscopy or study of the angle of the anterior chamber forms an important part of glaucoma diagnosis and management. This presentation aims to put forward the salient features of gonioscopy and methods of performing the same. The angle of the anterior chamber does not allow direct visualization due to total internal reflection. Use of a gonioscope allows us to overcome this and visualize the angle. Different types of gonioscopes are in use to aid in diagnosis and management. Those can be classified as direct and indirect. Direct goniolenses are: Koeppe and Swan Jacob; and indirect goniolenses are Goldmann and Zeiss. It has both diagnostic and surgical uses. The angle has been graded according to the structure visible on gonioscopy and help to manage glaucoma. There are various methods of grading angle width. Identification of angle structures like: Schwalbe’s line, trabecular, Schlemm’s canal, sclera spur and ciliary body are important. Indentation gonioscopy is very important aspect by which potential angle closure glaucoma patients can be identified. Recording the various findings and use of imaging camera devices are now available. Thus, gonioscopy is an important tool in management of diagnosis and management of glaucoma.

Pratik Mahajan obtained MS in Ophthalmology and MBBS in Ophthalmology. He is a known Retina Surgeon with 11 years of experience working as a Chief Vitreoretinal Consultant and Surgeon at Shri Swaminarayan Gurukul Eye Institute, Rajkot. He pursued his long term Vitreoretinal Fellowship from the same institute at Rajkot, Gujarat. He underwent a clinical and research fellowship at Dr. Nagpal’s Retina Foundation, Ahmedabad. Under the able guidance of Dr. P N Nagpal, he learned and mastered the skills of the Retinal Detachment surgeries. He completed a fellowship in Retinopathy of Prematurity at L V Prasad Eye Institute, Hyderabad and got wide exposure to pediatric vitreoretinal diseases and surgeries under Dr. Subhadra Jalali. He was honored Master’s in Surgery (MS) in Ophthalmology by the reputed Saurashtra University, Rajkot, and pursued the training at the recognised Pandit Dindayal Upadhyay Medical College, Rajkot. He did his MBBS from Mahatma Gandhi Memorial Medical College, Indore and pursued clinical internship from Maharaja Yashwantrao Hospital, Indore. Presently, he is associated with Retina Speciality Hospital. Earlier, he was at Vasan Eye Care Hospital Indore.

Primary open-angle glaucoma is a progressive optic neuropathy involving loss of retinal ganglion cells and their axons at the level of the optic nerve head. This change manifests as thinning and excavation of the neural tissues and nerve fiber layer. The structural appearance of the optic nerve head is paramount to both glaucoma diagnosis and to the detection of progression. Hence, careful and systematic clinical examination of the optic nerve remains a cornerstone of glaucoma management. This presentation highlights various conditions which can co-exist and makes the diagnosis and assessment of glaucomatous optic disc difficult. There is a large degree of variability in the size of the normal optic nerve. Focal defects in neuro-retinal rim may be present and may indicate glaucoma, even in the presence of a “normal” cup to disc ratio. Myopic nerves are difficult to interpret, due to optic nerve tilt that makes evaluation of the temporal region, as well as the superior and inferior poles, difficult. Peripapillary atrophy can make determination of the optic disc margin difficult and can be misinterpreted as neuroretinal rim. Congenital colobomas of the optic nerve head are easy to diagnose because of their typical appearance. Optic nerve

pit and conus of the disc can sometimes cause diagnostic difficulties. Pallor disproportionate to cupping, normal intraocular pressure or unusual history of onset, progression and age should arouse suspicion of a neurological cause for the disc changes. Blurring of the disc margin can be due to papilledema, AION, papillitis or optic nerve head drusen.

Amit Solanki has been in ophthalmic field for more than 12 years. He has done his Undergraduate & Post-graduate Training from the reputed B J Medical College, Ahmedabad (Gujarat). During two years of Senior Residency tenure at renowned Aravind Eye Hospital, Tamil Nadu, he was awarded the Diplomat of National Board in Ophthalmology (DNB) by the National Board of Examinations. He also completed Special Training in Glaucoma at Aravind Eye Hospital, Coimbatore. He has presented his work at national & state conferences and received many awards. He has also delivered many lectures (more than 55) at various conferences being a guest faculty.

Glaucoma is the 2nd most common cause of blindness worldwide. It is the most common irreversible cause of vision loss. Definition of glaucoma has changed over a period of time. In 1960, glaucoma is a condition characterized by raised IOP, optic nerve head changes and visual field defects. In 1980, it is an optic neuropathy characterized by ONH changes, visual fields with IOP as a risk factor. In 2004, glaucoma is recognized and defined by changes in the optic nerve head and RNFL as a result of a characteristic acquired loss of retinal ganglion cells. Diagnostic tools such as Anterior segment evaluation, Gonioscopy,

Ophthalmoscopic examination, IOP, Stereoscopic ONH photograph, NFL photography, Fields, Imaging techniques are used. There are various disadvantages of each technique. C/D ratio is not reliable (tremendous variability in the size of normal disc), Photography has relatively high inter-observer and intra-observer variability: Subjective psychophysical test; Automated perimetry. It demands high degree of performance by patient. VF damage was a relatively late phenomenon, and has 30- 45% death rate of RGC to produce a demonstrable field defect. It is not sufficient to diagnose “Pre perimetric glaucoma”. So a technology that assesses the health, structure and thickness of RNFL is clearly the most appropriate choice to diagnose and follow glaucoma. In this presentation, I will be discussing the principle, techniques, interpretation, advantages and disadvantages of each imaging technique and also will compare each of them.

Ajit Kumar Poddar has completed his MBBS and MS in Ophthalmology in the year 1995 and 2002, respectively from Patna University, India. He is a Medical Director of Akhand Jyoti Eye Hospital, Bihar, India, which is the largest eye hospital in Eastern India with community eye care being its core strength. He has presented his papers at various state and national level conferences and has a surgical experience of over 100,000 surgeries. He has organized various CME and scientific seminars under his leadership.

Background: There is no recent evidence on the prevalence of blindness and visual impairment (VI) from rural Bihar.

 

Aim: To estimate the prevalence and causes of blindness and cataract surgical services in rural Bihar.

 

Subjects: Individuals aged ≥ 50 years were considered for this study.

 

Materials & Methods: We conducted a house-hold survey from January to March 2016 in randomly chosen Siwan district by using validated rapid assessment of avoidable blindness (RAAB) methodology.

 

Results: We enumerated 3476 and examined 3189 individuals (92% response rate). The overall prevalence of blindness, severe visual impairment (VI) and moderate VI was found to be 2.2% (95%CI: 1.6-2.8), 3.4% and 18.3%, respectively. Untreated cataract was the leading cause in all three categories including blindness (73%), severe VI (93%) and moderate VI (79%). Refractive error (71%) was the main cause in mild VI category. Cataract surgical coverage for the district was 78.1%, 79.4% for males and 77% for females. 30.6% eyes had borderline to poor outcome.

 

Conclusion: Untreated cataract continues to remain a major cause of avoidable blindness including both moderate and severe VI. This suggests a huge backlog of cataract cases among the marginalized populations of Bihar. In spite of good coverage, cataract surgical complications are also significant, that means quality needs to be improved. Focused community outreach services targeting the rural regions are required to address the problem.

Dr.Rajesh completed his under graduation from India and post graduation from university of London. Presently as director of Dr.Rajesh Hospitals, Bangalore and Medical Director of Dr.agarwal’s eye hospital with Dr.Rajesh eye hospital Bangalore. Dr.Rajesh is one among top eye surgeons who perform SMILE procedure in India.

From past 2 to 3 decades widely spoken refractive treatment option across the world is LASIK; after invention of newer possibilities by Femto seond laser applications I present to you all laser flap less laser vision correction beyond LASIK “Relex Smile”

 

RELEX SMILE (Small incision lenticule extraction) is flapless corneal refractive surgery only femtosecond laser used to complete the refractive surgery on intact cornea, potentially reducing surgical time and side effects. SMILE could potentially replace the current, widely practiced LASIK. The three main steps involved in Relex smile are first docking then Lenticule creation on intact cornea and last extraction of lenticule through a small access incision. Docing procedure performed after application of topical anesthesia, standard sterile draping, and insertion of the speculum, the patient’s eye will be centered and docked with the curved interface cone before application of suction fixation. Then Femto second laser will then be activated for photo-dissection in the following sequence: first the posterior surface of the refractive lenticule (spiral in), Then the lenticule border is created. The anterior surface of the refractive lenticule (spiral out) is then formed which extended beyond the posterior lenticule diameter by 1 mm to form the anterior cap Followed by an access rim cut of 4mm. I use the following FS laser parameters: 120 μm flap thickness, 7.0 mm cap diameter, 6.0 mm optical zone of lenticule, 170 nj of power with side cut angles at 90°. A superior access cut of 4mm. After the suction is released by manually the refractive lenticule is separated from the stromal bed then lenticule is then grasped with non-toothed serrated forceps through the small incision and extraction completed. Post operatively medication given for a period of 4 weeks and lubrication eye drops given for a period of 12 weeks.

Kareem B Elessawy has completed his Master’s degree in 2012 from Cairo University and MD degree from Cairo University School of Medicine in 2015. He is Assistant Lecturer in Ophthalmology Department, and he is promoted for Lecturer degree soon.

Purpose: To study the efficacy of scarless dacryocystorhinostomy through inferomedial transconjunctival approach in comparison to traditional external dacryocystorhinostomy.

 

Setting: Tertiary ophthalmic referral centre, Cairo, Egypt.

 

Design: Prospective randomized comparative interventional case series

 

Method: It included 40 eyes suffering from nasolacrimal duct obstruction that needed DCR. Patients were randomly divided into two groups. Group A included 20 eyes who underwent conventional DCR surgery via skin incision while group B included 20 eyes who underwent transconjunctival DCR.

 

Results: Tear meniscus height decreased in both groups after the surgery with more reduction in group A. Patient satisfaction improved in both groups after the surgery with more improvement in group A. In group A, total success was obtained in 19 cases while one case showed partial success. No failures were reported. On the other hand, group B had 17 cases with total success, 2 cases with partial success, and failure in only one case. No major intra-operative complications were encountered in external DCR group. However, complications were reported in 50 % of cases in transconjunctival approach.

 

Conclusion: External DCR remains the most successful surgery in the management of complete nasolacrimal duct obstruction. While, the trans-conjuntival approach may be considered as a new tool that can be used in specific patients as skin diseases, tendency

for keloid formation or patient preference with comparable results to external DCR. Also, it can be converted into external approach when needed.

Putri Pamulani is a Medical Student from Universitas Padjadjaran. Talk about ideas, interested in medical science and interpersonal skill, as well as social and cultural activity, guitar and amateur art and ceramic, opened to new things and dream to explore the earth!

Glaucoma affected about 66.8 million people worldwide. Primary open angle glaucoma (POAG) contributed to 70% cases of glaucoma. Of different genetic type discoveries in glaucoma, MYOC gene mutation has been considered as a single POAG-causing gene. This mutation caused production of mutant myocilin protein which was rarely observed in people without glaucoma. An exact pathogenesis of how mutant myocilin induced POAG is important for further intervention and treatment, meanwhile it remains unknown. This literature review is aimed to describe the pathogenesis of POAG related to mutant myocilin. Reviewed literatures revealed that turnover of mutant myocilin involved autophagy pathway, rather than ubiquitin-proteasome and lysosomal pathways which was involved in turnover of non-mutant Myocilin. Grp94 was found as a product of unfolded protein response to mutant myocilin. Grp94 bound mutant myocilin and directed its degradation to endoplasmic reticulum-associated degradation (ERAD). ERAD pathway degraded mutant myocilin inefficiently, which resulted in accumulation of mutant myocilin. The accumulation of mutant myocilin in trabecular meshwork (TM) cells led to ER stress-induced cell death. TM cell death interfered the outflow of aqueous humour therefore increased intra-ocular pressure. Another research revealed that mutant myocilin is consistently causing stress-induced cell death by increasing sensitivity towards oxidative stress. Knowledge of the mutant myocilin involvement in POAG can help further investigation strategies for myocilin-related glaucoma. In summary, the binding between Grp94 and mutant myocilin induced the death of TM cell and led to the development of POAG.

Hamoud Al-Shahrani completed his M.B., Ch, B from Alexandria University, Alexandria, Egypt. He is Ex- Director of Prince Sultan Military Medical City, Saudi Arabia. Earlier he was Director of Academic Affairs & Training Riyadh Military Hospital. He has published several papers in reputed journals. He is associated with several ongoing projects on genetic basis of dermatological diseases in Saudis.

Primary glaucoma (PG) refers to a diverse group of ocular disorders that are characterized by retinal neurodegeneration, visual field defects and blindness. The etiology of PG is attributed to multifactorial mechanisms. Increasing evidence indicates that oxidative stress (OS) plays a major role in ocular pathologies. Several molecules are able to regulate interaocular pressure (IOP). Adrenergic, cholinergic, serotonergic, and dopaminergic systems are all involved. Catechol-O-methyl transferase (COMT) may be a candidate gene for PG that encodes an enzyme involved in the metabolic inactivation of dopamine. We examined a possible association between the COMT Val158Met polymorphism and PG. Saudi subjects including 210 unrelated PG patients and 177 matched controls were analyzed for allele and genotype distribution of COMT Val158Met polymorphism. We found significant differences in allele and genotype frequencies between patients and controls. The frequencies of Met(158) allele (A) and genotype Val(158)Met (GA) were significantly higher in patients compared to those in controls. On the other hand, the frequencies of Val(158) allele (G) and genotype Val(158)Val (GG) were significantly higher in controls than those in patients. We found a significant association of the COMT Val158Met polymorphism with PG. Upon stratification of our results into POAG and PACG, the distribution of frequencies genotypes followed similar pattern in PAOG and PACG. These results provide evidence for a role of COMT Val158Met polymorphism in the etiopathology of PG (PAOG and PACG) in Saudi population. It appears that the association of COMT Val158Met polymorphism with PG is not mediated by gender.

Poundra Adhisatya Pratama is Medical Doctor graduated from Universitas Padjadjaran, Indonesia. He is now working at Majalengka District Hospital, West Java. He has a passion in medical research, especially ophthalmology. Currently he is running his Private Primary Health Care in Bandung, Indonesia and is a Founder of Global Health Alliance, a community that focused on strengthening the role of primary health care in Indonesia.

Glaucoma affected about 66.8 million people worldwide. Primary open angle glaucoma (POAG) contributed to 70% cases of glaucoma. Of different genetic type discoveries in glaucoma, MYOC gene mutation has been considered as a single POAG-causing gene. This mutation caused production of mutant myocilin protein which was rarely observed in people without glaucoma. An exact pathogenesis of how mutant myocilin induced POAG is important for further intervention and treatment, meanwhile it remains unknown. This literature review is aimed to describe the pathogenesis of POAG related to mutant myocilin. Reviewed literatures revealed that turnover of mutant myocilin involved autophagy pathway, rather than ubiquitin-proteasome and lysosomal pathways which was involved in turnover of non-mutant Myocilin. Grp94 was found as a product of unfolded protein response to mutant myocilin. Grp94 bound mutant myocilin and directed its degradation to endoplasmic reticulum-associated degradation (ERAD). ERAD pathway degraded mutant myocilin inefficiently, which resulted in accumulation of mutant myocilin.The accumulation of mutant myocilin in trabecular meshwork (TM) cells led to ER stress-induced cell death. TM cell death interfered the outflow of aqueous humour therefore increased intra-ocular pressure. Another research revealed that mutant myocilin is consistently causing stress-induced cell death by increasing sensitivity towards oxidative stress. Knowledge of the mutant myocilin involvement in POAG can help further investigation strategies for myocilin-related glaucoma. In summary, the binding between Grp94 and mutant myocilin induced the death of TM cell and led to the development of POAG.