In an episode of The Spotlight Series Podcast, hosted by Mario Nacinovich, Larissa Camejo, MD, speaks about patients with glaucoma and myopia. Dr. Camejo highlights the increased vulnerability of highly myopic eyes and the diagnostic challenges posed by atypical optic nerve anatomy and misleading imaging results. She outlines a practical management approach emphasizing careful monitoring, earlier intervention once progression is confirmed, and a stepwise treatment strategy.
Mario Nacinovich:
Welcome back to The Spotlight Series. I’m joined today by a very good friend, Dr. Larissa Camejo, a fellowship-trained cataract and glaucoma surgeon based in Palm Beach Gardens, Florida, and a recognized expert in medical and surgical glaucoma care. Larissa, thanks so much for joining me.
Larissa Camejo, MD:
Hi, Mario. Thank you so much for having me.
Mario Nacinovich:
Today, we’re tackling a challenging but common scenario: patients who have both glaucoma and myopia, especially high myopia. We’ll look at the association and the pathophysiology, how to diagnose glaucoma in those tricky eyes, and then focus on how you think about surgical management. When a myopic patient sits in your chair, how do you think about their baseline risk for developing glaucoma compared to an emmetropic patient?
Larissa Camejo, MD:
Yes, absolutely. First, I would like to say that this is not a small occurrence. We know how many high myopes exists out there; we know that this is becoming an epidemic. The way I think about a patient in my chair who happens to be myopic is they’re automatically at a higher risk of developing glaucoma than an emmetropic patient. I keep that very much forefront.
Mario Nacinovich:
Can you unpack the why behind that? What is it about the highly myopic eye? Is it axial length, scleral thinning, lamina cribosa changes that increases vulnerability of the optic nerve?
Larissa Camejo, MD:
Absolutely. All of the above. Patients with high myopia will have longer eyes. They’re biomechanically more vulnerable to damage. They have a longer axial length to be a specific 26 mm or 26.5 mm, or longer. They will have thinner sclera, thinner cornea. They have a different laminate cribosa. They have an optic nerve that is implanted in a tilted way. They’re biomechanically more vulnerable to damage. Those axons will get damaged faster at a same intraocular pressure.
Mario Nacinovich:
Many of these patients usually have IOPs that look normal on paper. How do you reconcile a normotensive patient reading with a nerve that may be a significant risk in the high myope?
Larissa Camejo, MD:
Yes. Well, the normal intraocular pressure issue is really not just exclusive to the high myopes. It doesn’t change that much in comparison to the other glaucoma patients. We do know that intraocular pressure is just 1 piece of the puzzle. We have many other things to analyze. You have to look at it within that framework and that mindset. But once you do that, you do have to recognize that whatever you decide, when you have a myopic patient, they are more vulnerable to progress to glaucoma or to have glaucoma progression at the same intraocular pressure. The stakes are higher in terms of the risk.
Mario Nacinovich:
Let’s talk about the diagnosis here of glaucoma in these highly myopic eyes. Some colleagues, some clinicians, say, “I’m not sure if this is glaucoma or this is just a myopic nerve.” How do you frame that diagnostic challenge in your own practice?
Larissa Camejo, MD:
Well, you used the right word. It is a challenge. More often than not, we might feel that we don’t know if they have glaucoma or not. You feel that it’s a guess either way. If you decide to continue to watch or if you decide to start treatment, sometimes you may feel less confident than you would be with other patients.
The reason is because everything is a little bit off, and the tools that we have that we normally pay attention to and that makes so much sense make less sense in the patients with high myopia. The optic nerve looks a little bit funny or a little bit off. They’re larger, they’re thinner, they’re tilted, they’ll have a crescent, they’ll have PPA, all these things that are quite characteristic in glaucoma, but it could also be the myopic eye looking like that. With the OCT, the OCT, you have the retinal nerve fiber layer that we’re used to, right?
The RNFL and the GCC. You look at it and a lot of the OCTs are going to look red. They’re going to look very, very thin, but it’s not necessarily glaucoma. This is where we talk about the red disease where everything looks thin, but it doesn’t mean that they have glaucoma. They’re just longer eyes or stretched. They look thin, and therefore it’s measured that way.
You don’t want to look at the printer, you want to understand the whole picture. We want to rely more on the GCC of the macula. The OCT can be off. The visual field can also be misleading. You may have paracentral defects. You may have a little bit more fuzzy defects that don’t exactly respect the horizontal line. In general, it can be more confusing. Just like you mentioned, the intraocular pressure is or can be normal more often than not.
The key is longitudinal follow-up. The key is to obtain a good baseline and then to follow it up probably longer than what you would so you can be more convinced of the diagnosis.
Mario Nacinovich:
Let’s talk about those longitudinal changes because some of what you just said doesn’t really fit the normative databases in these types of eyes. When you’re talking about the visual field side, what’s your approach to separating these changes from true glaucomatous progression? How much time, or let’s just put a number out there, how many fields do you like to have before you feel confident calling progression?
Larissa Camejo, MD:
Right. Let’s answer the latter first. The visual fields, the more visual fields you do, especially at the beginning, especially in that first year, the better. You want to have a good baseline. This is not just for fields, this is in general. When you have a patient and you’re starting to see them and they have high myopia or even moderate myopia, you want to obtain a good amount of visual fields. Your baseline, you’re going to have your RNFL, your GCC. You want to not forget about taking pictures.
When you follow up, you want to obtain several visual fields, like at least 3 to 4 would be what I would share with you. But sometimes it takes more. You want to be convinced of that baseline and repeatability.
Mario Nacinovich:
That would take course of over how much time are we talking? Are we talking months? Are we talking a year? What’s your norm in terms of the amount of time that’s involved in that?
Larissa Camejo, MD:
Yes. For the visual field, I think we have a lot of more recent data that the more we get early on, the better. A lot of us are used to seeing a patient when they have glaucoma every 4 months; if they’re more suspect every 6 months. These patients that do it a little bit differently, I would bring them back maybe a month after their initial visit and repeat a visual field.
Mario Nacinovich:
Excellent.
Larissa Camejo, MD:
A little bit more frequent.
Mario Nacinovich:
We’re going to switch gears to talk a little bit of when to treat, and then certainly in terms of how aggressively that treatment is recommended. Before we jump into the surgical aspects, I want to talk about your thresholds and perhaps the recommended thresholds that are out there. In a highly myopic patient with suspicious nerves and maybe very early functional changes, does their myopia push you to treat earlier than you might in a non-myopic patient?
Larissa Camejo, MD:
Yes. There’s a higher risk of developing glaucoma. We have plenty of studies saying this and stating this, like a Beijing eye study and the Blue Eyes Mountain Study from Australia. My inclination to treat is going to be earlier once I know I’m convinced. In other words, my threshold to diagnosis is much higher when we have a myopic patient in front of us, but once I’m convinced, yes, decisiveness in treating.
Mario Nacinovich:
Then how do you think about target IOP in these eyes? Do you mentally lower the bar for what you’re considering safe?
Larissa Camejo, MD:
I mentally do lower the bar for these patients, because again, they’re biomechanically more vulnerable to develop the disease, but I also don’t lose track of the big picture. I think in the treatment of glaucoma, in the treatment of any eye disease that we do as ophthalmologists, the big picture is keep the vision going. You have to look at all the variables. Just like these eyes are more vulnerable for glaucoma disease, they’re also more vulnerable for consequences from surgical treatment of glaucoma disease, like hypotony that could affect your vision.
Yes, treat when you have to treat, and we’ll talk probably more about it, about the step approach of the treatment.
Mario Nacinovich:
Absolutely. Let’s talk about that next step. Where does laser trabeculoplasty fit in your algorithm for these high myopes with early to moderate open-angle glaucoma?
Larissa Camejo, MD:
Definitely early, but I will say that that’s how I treat every glaucoma patient that I have in front of me. I do believe in SLT as first-line since the beginning of my career 20 years ago, I think it makes a lot of sense. Here we have yet another reason to do it, actually 2.
In my mind, in addition to the multiple reasons of why it should be first-line and avoid the patient to start to being exposed to medications and the consequences that it could have in the ocular surface, etc. Patients with myopia are younger. They have a longer way to go, and the more we can delay medications, the better.
That’s one reason. Another reason is, we mentioned how the intraocular pressures may be lower and you may think, “Oh, well, are we going to lower the pressure?” Sometimes we do SLT also to decrease the fluctuations in the intraocular pressure, which we also know is quite relevant in decreasing the progression of glaucoma.
Mario Nacinovich:
Yeah, that variability to get that under control is critical as well. All right. Switching gears to surgical management, we’ve certainly teased it out enough. Let’s talk about it. MIGS, tubes, trabs, big picture here. When you’re choosing between MIGS and trabeculectomy and tube shunts and cyclo-destructive procedures in highly myopic eyes, what’s the overarching principle guiding your decision-making?
Larissa Camejo, MD:
The overall guiding principle is there’s a higher risk of problems with glaucoma surgery in myopic patients. We have to think, again, big picture, preserve this on the longest. These sometimes can be younger patients. We have the technology nowadays. I think that the way that we approach myopes now should be different than the way that we approached them even 15 years ago, because we have different things at our disposition, different tools.
I like to think about this from less to more. Of course, we have to think, like in any other glaucoma patient, what is the damage that we have in front of us? What is the target intraocular pressure? But we also have to take into account the risk of hypotony. Perhaps there’s a little bit of more of a balance here where you don’t have to be as aggressive. I wouldn’t necessarily pursue single digits, like maybe we have in the past, but I would certainly like low teens if it’s necessary.
Get whatever is necessary. But within that boundary, we want to go step approach. The way that I do it, I look at the patient and I try to do… I start with minimally invasive glaucoma surgery, usually stay in the eye, usually angle, MIGs. If I consider that that’s not going to be enough, either as a secondary approach or from the beginning, I consider that’s not going to be enough, then I start to think, okay, how much do I need to lower the pressure? How many medications can this patient tolerate? There are patients out there that cannot tolerate medications or do not want to use medications. We have to take all these variables into account, and then I may decide between a blep forming surgery or a tube. Then I have my preferences within those two categories as well.
Mario Nacinovich:
I appreciate what you said there about the safety and efficacy trade-offs, the age of the patient. Let’s talk about that conversation with the patient. How do you set expectations around how much pressure reduction MIGS can realistically deliver if you’re aiming for a pretty low target IOP, trying to avoid those single digits, like you mentioned?
Larissa Camejo, MD:
Absolutely. Like in any other case, I think that when we treat patients is really a team approach. If the patient doesn’t understand what is happening, and I think we owe it to a patient to educate them, to explain what we know about their eyes, because it’s their eyes and not ours, so they deserve to know.
Then they also are better and they’re more compliant in my experience when they are involved in the whole planning. I prefer to do MIGS as much as possible, angle MIGS. But again, it depends on where you want to be and if they can tolerate drops. With the MIG, you’re not going to get to those low teens usually, but perhaps if you have somebody who’s very, very myopic, who is young, in my experience, I prefer to go to the angle MIGS if I can complement with medications. I will do that. But if you have a patient where that’s not an option, then I go to, depends on if you want really the low teens, I go to a bleb forming. For me, that’s a XEN Gel Stent in these patients over a trabeculectomy. I do reach those low teens, not unusually. That is my preference there.
Mario Nacinovich:
Where, if at all, does the cyclophotocoagulation (CPC) fit into your strategy for some of these patients?
Larissa Camejo, MD:
I think that right now, the way that we do CPC does fit in. I mean, we have both the MicroPulse and even the G-Probe traditional CPC with the slow coagulation settings, I think it can be very useful. I do think that we have to be very careful with any procedure that can cause hypotony. In the case of the CPC, I would be very light-handed. I find it, in my patients, I use it the most after a tube. Say that I use a tube and they still need lowering, that would be my go-to. I would do a CPC.
Mario Nacinovich:
Most excellent. Let’s talk about cataract refractive goals in glaucoma. You’re dual-certified, you’ve had fellowships in both, and many of these patients are also your cataract patients, and certainly they’ve got some outspoken, strong, refractive goals. I’m sure they communicate to you about what they want to do and how they want to see. How do you balance refractive targets with glaucoma control when you’re planning cataract plus glaucoma surgery in a highly myopic patient?
Larissa Camejo, MD:
Absolutely. I love this because this is my daily…It’s what we do on the daily, is patient always tell when I’m giving talks, every single patient has dry eye, cataract, and glaucoma, and we have to talk about all 3. You are right. These patients tend to be younger. They’re going to have high myopia. You can’t just be, “Oh, I must lower the pressure in this eye.” Then forget about the big picture. You want to make sure that they can see well; they’re going to expect to see well.
You also need to understand that you have the other eye to plan for. You can’t correct the -13 to an emmetropic eye and then the other eye, leave it as it is. You’re going to have to plan, even if the glaucoma is not as bad, it’s a bird’s eye view.
You want a bilateral planning. Dry eye becomes, of course, as always is at the center, both as a pre-operative planning for cataract and for glaucoma.
Mario Nacinovich:
I was going to say this before, during, and after, you’ve got to worry about that. Yeah.
Larissa Camejo, MD:
100%. 100%. There’s been so much talk about dry eye disease and how you have to correct it before you get the biometric measurements for IOL calculations and to prevent discomfort for cataract surgery. But really, for the longest time, I’ve also applied the same principle to glaucoma surgery.
I do believe I see it clinically that glaucoma surgery does better when you treat dry eye. I think it’s one of the reasons why surgeries with XEN Gel Stent, for example, may do better in some patients than others, is when they have a better baseline. I have that conversation. I explain everything, that first, it’s like an investment. The amount of time that I dedicate on that first pre-planning visit to talking about these things, and then it gets so much easier. I start to treat the dry eye. I make sure that we have good measurements.
We have the beautiful thing of having now glaucoma surgeries that don’t destroy your refractive plants. They’re quite neutral, both the angle MIGS and quite honestly, also the XEN, because we’re not cutting into the sclera and even the tubes. These are way less refractive altering than a trabeculectomy. You can do a lot more in your planning, and as long as the damage is not terrible, you can really improve quality of life in these patients quite importantly.
Mario Nacinovich:
Let’s talk about 1 of those patients. Can you briefly walk us through a representative case? A highly myopic patient, let’s call them young, with some moderate glaucoma and perhaps a visually significant cataract. I say young by the Palm Beach Gardens standards. How do you counsel and plan that…
Larissa Camejo, MD:
So about 80.
Mario Nacinovich:
Yes. How do you counsel and plan for surgery in these patients?
Larissa Camejo, MD:
Absolutely. Basically, like I said, you start treating, you make sure you have a good base on the good ocular surface, you’re past the point where you’re sure you need to treat, so then you’re deciding to treat. Your target you said would be about the mid-teens?
Mario Nacinovich:
Yeah, absolutely.
Larissa Camejo, MD:
Yep. Okay. You basically look at how much damage you have. If you have a target of mid-teens, you may have an arcuate defect or so, and you can have that conversation. For me, it’s very crucial to understand, all right, how do they feel about using drops, theoretically, at least for now, the rest of their lives, or can they tolerate it? Are there any allergies? If I have a wiggle room, meaning they can tolerate a drop or 2 and they are okay understanding that this is a marathon and we may have to go back to the OR at some point in the future, I will start with angle MIGS and do the lens that I feel is best for that patient in our conversation and meeting their goals. That’s where I start.
Mario Nacinovich:
Excellent. Excellent. For the busy comprehensive ophthalmologist who doesn’t live in your world, they don’t live in the glaucoma day to day, what are your practice pearls for them for managing glaucoma risk in highly myopic patients?
Larissa Camejo, MD:
Yeah, I think we just have to have those antennas up all the time. When you have a high myopic patient, just to have a couple of things in mind, extra in our repertoire of things that we need to do for glaucoma diagnosis. Two big mistakes that can happen are: 1) over-diagnosing glaucoma, very easy to do. Don’t treat the OCT, treat the patient, and everything that we discussed in terms of all the tools that we have for diagnosis. Don’t overdiagnose glaucoma, easier said than done. Give yourself time for that longitudinal follow-up.
The second mistake would be, of course, on the other end, missing progression. Not difficult to do. Definitely give yourself again time, longitudinal follow-up, but once you feel progression is real, don’t shy away from treatment, act decisively. On a very practical point, because more often than not, you’re not going to be on one side or the other.
We’re going to be on the, “I have no clue. I am not sure, but I have a very high suspicion.” Then offer a safe treatment, and again, follow longitudinally, safe treatment like SLT or even angle MIGS.
Mario Nacinovich:
Larissa, this has been incredibly helpful. I hope our listening audience, which ranges from comprehensive ophthalmologists to glaucoma specialists, cataract surgeons, optometrists, and certainly a world of technicians that may be listening, where can listeners go to learn more about your work and connect with you?
Larissa Camejo, MD:
Thank you for asking. Well, I’m in private practice and it’s a solo private practice. We are looking for associates if anybody’s interested. Thank you again, Mario, for asking. We have our website, http://pbglaucomaexpert.com/, and they can contact me that way. I’m also usually, I love to go to our national meetings. I tend to go to EnVision every year and our big meetings at AAO and AGS and ASCRS, and love to connect with colleagues and learn from my colleagues as well. Yes, look forward to meeting more people.
Mario Nacinovich:
Excellent. Ladies and gentlemen, Dr. Larissa Camejo, a very good friend of mine. We’ve become very close over the years and certainly has her patient’s best of mind. Sometimes it takes a little bit longer and watchful waiting to ensure that we are treating what we are treating in this case of high myopes in glaucoma and that we’re not missing a real progression along the way.
Larissa, thank you for joining us on The Spotlight Series. Thanks to all of you for listening. If you’ve enjoyed this episode, please share it with a colleague and be sure not to miss what’s coming up next in our spotlight.
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