### 3.1 - General Principles of Glaucoma Treatment

The purpose of this chapter is to give a summary overview and it is not meant to be an all-inclusive text



Figure 3.1. 
THE WHOM -TO -TREAT GRAPH The rate of ganglion cell loss and resulting functional decay is very different among different glaucoma eyes. Quality of life is clearly reduced when visual field defects become severe, cf. the severe functional impairment. Line A represents the effect of aging alone. In glaucoma loss of visual function is often much more rapid. An older patient, diagnosed late in life, with a moderate rate of progression (B) has a much lower risk of developing severe functional impairment than a younger patient with the same amount of field loss at diagnosis and rate of progression (C). A very slow rate of progression may be tolerated by the patient and treatment left unchanged (D), while a rapid rate of progression (E) needs a considerably lower target pressure .

It needs to be remembered that it is the extent of binocular visual field or the field of the better eye that largely determines the patient’s quality of life, while the rates of progression of each eye separately are needed to determine treatment .



To assess the likely Rate of Progression (RoP) is an important part of patient management and the measured rate is a very important factor that should determine target pressure and treatment intensity (See Ch. Introduction) [I.D]. Many studies have found that progression is usually linear1-4, but the goal of intensifying treatment is to decrease rate of progression.

Please observe that perimetric printouts of progression using the MD or VFI indices are age-corrected, so that a normal eye would not show any age-related deterioration over time.

The goal of glaucoma treatment is to maintain the patient’s visual function and related quality of life, …

/pdf/european-glaucoma-society-terminology-and-guidelines-for-35j13md8bp.pdf

European Glaucoma Society Terminology and Guidelines for Glaucoma, 4th Edition - Chapter 3: Treatment principles and optionsSupported by the EGS Foundation: Part 1: Foreword; Introduction; Glossary; Chapter 3 Treatment principles and options

Background Comprehensive literature reviews of historical perspectives and evidence supporting cannabis/cannabinoids in the treatment of pain, including migraine and headache, with associated neurobiological mechanisms of pain modulation have been well described Most of the existing literature reports on the cannabinoids Δ9 -tetrahydrocannabinol (THC) and cannabidiol (CBD), or cannabis in general There are many cannabis strains that vary widely in the composition of cannabinoids, terpenes, flavonoids, and other compounds These components work synergistically to produce wide variations in benefits, side effects, and strain characteristics Knowledge of the individual medicinal properties of the cannabinoids, terpenes, and flavonoids is necessary to cross-breed strains to obtain optimal standardized synergistic compositions This will enable targeting individual symptoms and/or diseases, including migraine, headache, and pain Objective Review the medical literature for the use of cannabis/cannabinoids in the treatment of migraine, headache, facial pain, and other chronic pain syndromes, and for supporting evidence of a potential role in combatting the opioid epidemic Review the medical literature involving major and minor cannabinoids, primary and secondary terpenes, and flavonoids that underlie the synergistic entourage effects of cannabis Summarize the individual medicinal benefits of these substances, including analgesic and anti-inflammatory properties Conclusion There is accumulating evidence for various therapeutic benefits of cannabis/cannabinoids, especially in the treatment of pain, which may also apply to the treatment of migraine and headache There is also supporting evidence that cannabis may assist in opioid detoxification and weaning, thus making it a potential weapon in battling the opioid epidemic Cannabis science is a rapidly evolving medical sector and industry with increasingly regulated production standards Further research is anticipated to optimize breeding of strain-specific synergistic ratios of cannabinoids, terpenes, and other phytochemicals for predictable user effects, characteristics, and improved symptom and disease-targeted therapies

Medicinal Properties of Cannabinoids, Terpenes, and Flavonoids in Cannabis, and Benefits in Migraine, Headache, and Pain: An Update on Current Evidence and Cannabis Science

Background
The use of cannabis, or marijuana, for medicinal purposes is deeply rooted though history, dating back to ancient times. It once held a prominent position in the history of medicine, recommended by many eminent physicians for numerous diseases, particularly headache and migraine. Through the decades, this plant has taken a fascinating journey from a legal and frequently prescribed status to illegal, driven by political and social factors rather than by science. However, with an abundance of growing support for its multitude of medicinal uses, the misguided stigma of cannabis is fading, and there has been a dramatic push for legalizing medicinal cannabis and research. Almost half of the United States has now legalized medicinal cannabis, several states have legalized recreational use, and others have legalized cannabidiol-only use, which is one of many therapeutic cannabinoids extracted from cannabis. Physicians need to be educated on the history, pharmacology, clinical indications, and proper clinical use of cannabis, as patients will inevitably inquire about it for many diseases, including chronic pain and headache disorders for which there is some intriguing supportive evidence.

Objective
To review the history of medicinal cannabis use, discuss the pharmacology and physiology of the endocannabinoid system and cannabis-derived cannabinoids, perform a comprehensive literature review of the clinical uses of medicinal cannabis and cannabinoids with a focus on migraine and other headache disorders, and outline general clinical practice guidelines.

Conclusion
The literature suggests that the medicinal use of cannabis may have a therapeutic role for a multitude of diseases, particularly chronic pain disorders including headache. Supporting literature suggests a role for medicinal cannabis and cannabinoids in several types of headache disorders including migraine and cluster headache, although it is primarily limited to case based, anecdotal, or laboratory-based scientific research. Cannabis contains an extensive number of pharmacological and biochemical compounds, of which only a minority are understood, so many potential therapeutic uses likely remain undiscovered. Cannabinoids appear to modulate and interact at many pathways inherent to migraine, triptan mechanisms ofaction, and opiate pathways, suggesting potential synergistic or similar benefits. Modulation of the endocannabinoid system through agonism or antagonism of its receptors, targeting its metabolic pathways, or combining cannabinoids with other analgesics for synergistic effects, may provide the foundation for many new classes of medications. Despite the limited evidence and research suggesting a role for cannabis and cannabinoids in some headache disorders, randomized clinical trials are lacking and necessary for confirmation and further evaluation.

Comprehensive Review of Medicinal Marijuana, Cannabinoids, and Therapeutic Implications in Medicine and Headache: What a Long Strange Trip It's Been …

Botulinum Toxin Therapy

PURPOSE Dosimetric studies show that proton therapy can reduce the low/intermediate radiation dose to uninvolved tissue in children with low-grade glioma (LGG). For this reason, LGG is the fourth most common pediatric tumor treated with proton therapy, yet clinical outcome data on efficacy and toxicity are limited. METHODS AND MATERIALS We reviewed the medical records of 174 children (≤21 years old) with nonmetastatic LGG enrolled on a prospective protocol and treated with proton therapy between 2007 and 2017. We assessed clinical outcomes and toxicity and analyzed patient, tumor, and treatment-related variables. RESULTS The median age was 10.2 years (range, 2-21). Fifty-eight percent of tumors were World Health Organization grade 1 and 30% were grade 2; 12% were diagnosed on imaging characteristics alone. The most common histology was pilocytic astrocytoma (47%). The most common tumor subsites were diencephalon/optic pathway (52%), caudal brainstem (16%), and cerebellum (13%). Forty-two percent received chemotherapy before radiation therapy. The median follow-up was 4.4 years. The 5-year actuarial rates of local control, progression-free survival, and overall survival were 85% (95% confidence interval [CI], 78%-90%), 84% (95% CI, 77%-89%), and 92% (95% CI, 85%-95%), respectively. On univariate analysis, brainstem/spinal cord tumor location (62% vs 90% elsewhere) and dose <54 GyRBE (67% vs 91% for 54 GyRBE) were associated with inferior local control (P < .01 for both). Twenty-two patients (12.6%) experienced acute nausea or vomiting requiring ondansetron; 2 patients (1.1%) required corticosteroids. Serious toxicities (4% of patients) included brainstem necrosis requiring corticosteroids (n = 2), symptomatic vasculopathy (n = 2), radiation retinopathy (n = 1), epilepsy (n = 1), and death from radiation-induced high-grade glioma (n = 1). Thirty-nine patients (22%) developed new-onset central hormone deficiency. Pseudoprogression was observed in 32.1%. CONCLUSIONS Compared with modern photon series, proton therapy reduces the radiation dose to developing brain tissue, diminishing acute toxicities without compromising disease control.

Outcomes Following Proton Therapy for Pediatric Low-Grade Glioma.

Purpose: To perform a systematic review of the complications of strabismus surgery, focusing on incidence and risk factors. Material and Methods: A systematic literature search was performed using the Medline and Cochrane databases. Results: Local complications, such as conjunctival injection and mild scarring, are almost universal but only rarely have long-term clinical significance. There are several important complications that are uncommon but associated with significant long-term sequelae, including slipped muscles, lost muscles, stretched scars, incarcerated muscles, pulled-in-two syndrome, periocular infections, orbital cellulitis, scleral perforations, retinal detachments, endophthalmitis, anterior segment ischemia, and surgical errors. Discussion: Strabismus surgery is associated with a number of common and serious complications, and it is important for both surgeons and patients to be aware of the risks.

Complications of Strabismus Surgery: Incidence and Risk Factors

Comparison of Botulinum Toxin With Surgery for the Treatment of Acute-Onset Comitant Esotropia in Children

Visual Outcomes in Pediatric Optic Neuritis

Survey of Complementary and Alternative Medicine Use in Glaucoma Patients

The Effect of Botulinum Toxin Augmentation on Strabismus Surgery for Large-Angle Infantile Esotropia

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