3/11/2017
Disclosures
I have no financial ties or relationships to any of the companies or products (Eye)Drop It Like It’s Hot mentioned in this lecture. Although if one wants to give me money, I will listen. New & Exciting Advancements in Glaucoma
Adam T. Shupe, O.D Royo Eye Care Marysville, CA [email protected] @DrShupe
You Probably Don’t Have Glaucoma… Glaucoma As We Know It – Statistics
It is estimated that over 3 million Americans have glaucoma Approximately 50% have been diagnosed and are being treated Increased prevalence among ethnic groups African American, Hispanic, Indian, Asian American Many different types of glaucoma Primary open angle Narrow angle Angle closure Uveitic Pseudoexfoliative Pigmentary Pediatric Not all are treated the same!
Glaucoma As We Know It - Medications
There are over twenty branded medications used to treat glaucoma
Approximately half are available in an variety of generic substitutes
Even cap color is not a guaranteed identification anymore!
The last novel glaucoma medicine (tafluprost) was released in 2012 So what’s next…? All other recently released products are PF or combinations of existing medicines
But new medicines are on the horizon!
It is our responsibility to stay informed!
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New Meds #1 – Tafluprost 0.0015% New Meds #2 – Brinzolamide 1%/Brimonidine 0.2%
First preservative-free glaucoma medication First non-timolol combination medication
Prostaglandin analog Dosed one drop, three (or two) times per day Dosed one drop, every evening Combines industry-leading 2nd line treatments Carton of 30 vials, separated into three foil pouches Who is a good candidate? Unopened pouches should be refrigerated Adjunct therapy to PGAs Opened pouches may be left unrefrigerated Prostaglandin analog allergy Who is a good candidate? Beta-blocker contraindication Young glaucoma patients
Multiple medication patients
Perioperative patients
Multiple allergy patients
New Meds #3 – Dorzolamide HCl 2%/Timolol Maleate 0.5% New Meds #4 – Unoprostone Isopropyl 0.15%
Non-preserved version of existing medicine Reformulation of original medication from 2000
Dosed one drop, two (or three) times per day Concentration increased from 0.12% to 0.15%
Carton of 60 vials, separated into four foil pouches Reclassified as docosanoid, not prostaglandin
Unopened pouches should be refrigerated Increases outflow through trabecular meshwork
Opened pouches may be left unrefrigerated May affect BK and ClC-2 channels as well
Available in 180-count, three-month supply carton Effective reduction in IOP with limited side effect Who is a good candidate? Less systemic effect than most adjunct therapies Same patient profile as Zioptan Similar side effect profile to prostaglandins Pre-existing Cosopt users
New Meds #5 – Netarsudil 0.02% New Meds #6 –Latanoprostene Bunod 0.024%
Rho-kinase inhibitor Novel compound with dual-action IOP-lowering effect
First new class of glaucoma medications since 1996 Addition of nitric oxide-donating moiety to latanoprost “Triple Action” IOP-lowering capability Nitric oxide relaxes trabecular meshwork, increasing outflow Inhibits Rho-kinase (ROCK) Combines with PGA effect to produce significant IOP-lowering effect Increases trabecular meshwork outflow
Reduces episcleral venous pressure
Inhibits Norepinephrine Transporter (NET) Has completed Phase III trials, awaiting FDA approval
Decreases aqueous production However, delayed in July 2016 due to manufacturing concerns Potentially mid-to-late 2017 for FDA approval
Likely to be combined with latanoprost NicOx also working on a solo nitric-oxide donator Holds promise to be most efficacious glaucoma medication ever! Would avoid adverse effects of PGAs
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New Meds #7 – Trabodenoson New Meds #8 – Ripasudil 0.4%
Adenosine (A1) receptor agonist Rho-kinase inhibitor Receptors found in the trabecular meshwork Already in use in Japan, launched December 2014 Upregulates proteases that reduces protein accumulation in the TM Mechanism of action the same as netarsudil May also exhibit neuroprotectant properties Dosed one drop, two times per day Study showed protection against ischemia-induced ganglion cell loss Now with latanoprost! Also may be paired with latanoprost in combination drop Unknown if product will be brought to the U.S.
Currently in Phase III trials
Other companies also investigating drugs in this new class
New Meds #9 – Alphabet Soup New Meds #10 – Lomerizine
AMA0076: ROCK-inhibitor, in Phase II trials since 2012 Oral calcium channel blocker
Alleged to produce significantly less hyperemia Targeted vasodilating effect with affinity for cerebral and neural tissues
OPC-1085EL: latanoprost/carteolol, Phase III ongoing Increases blood flow without significantly lowering blood pressure Currently marketed in Japan as a treatment for migraines Registered in Japan in September 2016 Increased blood flow may provide neuroprotectant effect against ischemia DE-117: omidenapag isopropyl, Phase III upcoming
Non-prostanoid selective EP2 receptor agonist Phase II trials ongoing in Japan
Endoscopic Cyclophotocoagulation (ECP) New Drug Delivery Systems
Sustained-release drug therapies are on the horizon Minimally invasive glaucoma surgery (MIGS)
Avoids patient adherence issues Ciliary processes photocoagulated
Intracameral depots Often performed intraoperatively
ENV515 is in phase II trials Fiber optic camera probe with laser
Utilizes extended-release travoprost Reduces aqueous production
Bimatoprost SR is in phase III trials Generally 270 degree arc treated
External devices Potentially opens narrow angles
Helios is a bimatoprost-laden polymer ring Advantages:
Sustained delivery for six months of wear Very low risk profile
Drug-eluting punctal plugs also under development Easy to perform (approx. five min)
OTX-TP is biodegradable intracanilicular travoprost (Phase III) Disadvantages: Evolute is latanoprost-eluting parasol plug (Phase II) Slight IOP drop
CI: PXE and uveitic glaucoma
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More MIGS Glaucoma As We Know It - Technology
Glaucoma shunt devices proliferating
Physically inserted intraoperatively Managing glaucoma is more than just checking IOP! Location, location, location Visual Field testing iStent: trabecular meshwork
Hydrus: Schlemm’s canal Gonioscopy
CyPass: suprachoroidal space Fundus photography
XEN: subconjunctival space Pachymetry iStent Inject: trabecular meshwork And… iStent Supra: suprachoroidal space Ocular Coherence Tomography (OCT)
Advancements in OCT Technology All The Pretty Pictures
Significant improvement in quality
Faster, less blink artifact
Clear image without dilation
Less technician-dependent
No targeting, cube of information
More versatility in testing
Pachymetry
Angle imagery
Progression modules available
RNFL trend analysis
Going Where No OCT Has Gone Before New IOP-Monitoring Technology
Triggerfish approved by FDA in March 2016
Microsensor-embedded high-dK silicone SCL
Time Domain OCT -> Spectral Domain OCT -> Swept-Source OCT Gauges fluctuations in corneal circumference secondary to ocular intraocular pressure ~1,000 nm wavelength allows deeper penetration into tissues Mathematical relationship to IOP – not actual mmHg Deeper scan captures more information (i.e. choroid, sclera, lamina cribosa)
Better signal strength through media opacity (i.e. cataract, hemorrhage) Takes ~300 measurements (once every 5 minutes)
Also invisible to the eye -> no distracting laser sweeps Data transmitted to periocular antenna
Capable of ~100,000 A-scans per second connected to wearable recorder
Compared to SD (~20,000-70,000 scans) and TD (100-400 scans) Data downloaded from recorder after 24 hours
Gathers more information over a larger scan window Lens is single-use only, must be discarded
Important for scanning patients with difficult fundi Available in BC 8.4 mm, 8.7 mm, 9.0 mm
Not yet commercially available in U.S.* Cost: $9,000 for system, $1,000 for one setup
CPT 0329T “Monitoring of IOP >24 hours”
May change our profession’s approach to IOP
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Now What? How Do I Manage? Repeat Test Example
24-2, April 2013 24-2, May 2013
After initial diagnosis, every three months…
Office visit with visual field testing
Dilated exam with fundus photos
Office visit with gonioscopy
Annual exam with OCT
Rinse and repeat
Don’t be afraid to test!
Don’t be afraid to repeat test!
So, How Do I Get Paid? Show Me The Money! 2016 Medicare Reimbursement, Los Angeles Area
Step #1: Get on medical insurance panels CPT 92133, OCT Optic Nerve: $49.32
Always get updated medical insurance information CPT 92083, Visual Field, Extended: $73.02
Step #2: Never “just run a test” CPT 92020, Gonioscopy: $29.58
Your patients (and your wallet) will appreciate it! CPT 92250, Fundus Photos: $90.31
Step #3: Don’t be afraid to binge test CPT 76514, Pachymetry: $17.00 Do not let glaucoma walk out the door
Step #4: Repeat tests as necessary One full glaucoma work-up: $259.23 Do not make decisions based on unreliable data
Typical Glaucoma Management Cycle Who To Refer To? 2016 Medicare Reimbursement, Los Angeles Area
Schedule every three months! What is the reimbursement? Your friendly local glaucoma-certified optometrist!
Many of us are well-qualified and eager to manage glaucoma
January: Full exam + OCT 92014 + 92133 = $187.64 Referring solely to ophthalmology damages our efforts to expand scope
April: Office visit + Visual Field 92012 + 92083 = $168.67
July: Dilated exam + Disc Photos 92014 + 92250 = $228.63
October: Office visit + Gonioscopy 92012 + 92020 = $125.23
Rinse and Repeat! Total: $710.17/year
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When To Refer To OMD Questions? (Softballs Only)
Angle closure (after IOP is controlled)
Narrow angles (LPI)
Surgical candidate
Poor compliance with medication
Progression despite maximum medication
Cannot afford medications
SLT, MIGS, trabeculectomy all possible
Thank You!
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