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Virginia Eye Consultants Tertiary Referral Eye Care Since 1963
• John D. Sheppard, MD, MMSc • Walter O. Whitley, OD, MBA, FAAO • Stephen V. Scoper, MD • Mark Enochs, OD Innovations in Glaucoma • David Salib, MD • Cecelia Koetting, OD, FAAO • Elizabeth Yeu, MD • Christopher Kuc, OD COPE#52116-GL • Thomas J. Joly, MD, PhD • Leanna Olennikov, OD • Dayna M. Lago, MD • Jillian Janes, OD • Constance Okeke, MD, MSCE Walter O. Whitley, OD, MBA, FAAO • Esther Chang, MD Director of Optometric Services • Jay Starling, MD Virginia Eye Consultants • Samantha Dewundara, MD Residency Program Supervisor • Surajit Saha, MD Pennsylvania College of Optometry
Disclosures Walter O. Whitley, OD, MBA, FAAO has received consulting fees, honorarium or research funding from: What is Glaucoma?? • Alcon • Diopsys • Allergan • Ocusoft • Bausch and Lomb • Science Based Health • Biotissue • Shire • Beaver-Visitec • TearLab Corporation
• Publications • Advanced Ocular Care – Co-Chief Medical Editor • Review of Optometry – Contributing Editor • Optometry Times – Editorial Advisory Board
Consider the Risk Factors Glaucoma Diagnosis
• IOP • Age • Difficult disease to detect
• CCT • Race
• C/D ratio • Family History
3 YEARS
IOP: 23 IOP: 25 CCT: 450
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The Most Valuable Glaucoma Tool Glaucoma: Diagnosis • We know it when we see it
IOP: 26 OU
Glaucoma Diagnosis Glaucoma Diagnosis
• Central corneal thickness
• Visual fields
• Scanning lasers
• Serial tonometry
• Electrodiagnositics – VEP / PERG
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GLAUCOMA SEVERITY SCALE DEFINITIONS Managing Glaucoma Patients
• Mild Stage: optic nerve changes consistent with glaucoma • Monitor IOP reduction: 1-2 week, 1 month but NO visual field abnormalities on any visual field test OR abnormalities present only on short-wavelength automated • Check IOP every 3-4 months perimetry or frequency doubling perimetry. • Repeat VF every 6-12 months
• Moderate Stage: optic nerve changes consistent with • Disc photos every 1-2 years glaucoma AND glaucomatous visual field abnormalities in one hemifield and not within 5 degrees of fixation. • Gonioscopy every year
• Severe Stage: optic nerve changes consistent with glaucoma • Optic nerve analysis every 6-12 months AND glaucomatous visual field abnormalities in both hemifields and/or loss within 5 degrees of fixation in at least • Document everything
one hemifield. http://www.aoa.org/optometrists/tools-and-resources/clinical-care-publications/clinical-practice-guidelines?sso=y http://www.americanglaucomasociety.net/professionals/glaucoma_staging_codes_teaching_module/ https://www.aao.org/guidelines-browse?filter=preferredpracticepatterns
Corneal Hysteresis How ORA Works
1st IOP
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1st IOP 1st IOP
Air-jet stops Air-jet stops
2nd IOP
ORA—Signal Plot
“In” signal peak “Out” signal peak Start Thinking Weak vs. Strong IOP 1 IOP 2
Wells AP, Garway-Heath DF, et a. Corneal hysteresis but not corneal thickness Correlates with optic nerve surface compliance in Relationship of IOP and Glaucoma patients. Invest Ophthalmol Vis Sci 2008 Corneal Hysteresis
Corneal IOP Hysteresis
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Lower CH = More Likely to Respond to Topical Medications
Higher CH = Less Likely to Respond to Topical Medication
Anand A, De Moraes CG, Teng CC, et al. Corneal hysteresis and visual field asymmetry in open angle glaucoma. Invest Ophthalmol Vis Sci 2010;51:6514
More Likely to Respond to Topical Medications Association with Progressive Low CH Field Worsening
Greater Structural Bowing of Congdon NG, Broman AT, Bandeen-Roche K, Lamina Cribrosa et al. Central corneal thickness and corneal hysteresis associated with glaucoma damage. Am J Ophthalmol 2006;141:868
Structure Function Structure Function Fundus Photograph Visual Field Optical Coherence Tomography ERG (Subjective) (Subjective) (Objective) (Objective)
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When Do I Use Electrophysiological Tests? Electrophysiology objectively measures strength and speed of the visual signal to the • Clarify Differential Diagnosis…. Is it Systemic or brain (VEP) or retina (PERG) Trauma vs. Ocular?
• When Standard Tests are Unattainable or Unreliable VEP (neuro)
• When Other Tests are Inconsistent or Borderline Result PERG (retinal) • To Monitor Subclinical Disease for Functional Changes and Alter Treatment and Efficacy
ELECTROPHYSIOLOGY DETECTS CHANGES EARLIER THAN OCT AND VISUAL FIELD1 Visual Evoked Potential (VEP)
• Main Indications • Glaucoma Asymptomatic Symptomatic • Multiple Sclerosis OCT • Ischemic Optic Neuropathy Healthy OHT Glaucoma • Traumatic Brain Injury PERG/VEP VF • Amblopyia Non structural Documented • Other Neuropathies damage documented structural damage
1. Parisi V, Miglior S, Manni G, Centofanti M, Bucci MG. Clinical ability of pattern-electroretinograms and visual evoked potentials in detecting visual dysfunction in ocular hypertension and glaucoma. Ophthalmology. 2006 Feb;113(2):216-28.
WHY USE VEP? Normal VEP
• VEP is an objective, functional test when standard tests cannot Good Signal Quality provide sufficient information for diagnosis and treatment. • Many optic nerve diseases are asymptomatic because central vision Good Waveforms is not affected until late in the disease1 • Diagnosis and management of optic nerve disorders are often based Amplitude and Latencies on structural or subjective visual field tests2 in green P100 Signal Index above 80% Data Table Shows good numerical Values and All in Green
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Abnormal VEP Pattern ERG = PERG P100 Signal Delayed
Main Indications Right eye shows delays in latency at both high and Glaucoma low Maculopathies Low contrast demonstrates changes to the magnocellular pathway -Earliest functional Can also help the clinician differentiate degradation shown in glaucoma between retinal and optic nerve disorders patients!! when used in conjunction with Visual Evoked Potential (VEP).
How Does PERG Work? Normal PERG Response 3 Quick Steps To Report Interpretation Since the PERG (in contrast to the flash ERG) is a local response from the area covered by the retinal stimulus image, Signal Quality – Look for a specifically GCC, it can be used as a sensitive indicator of green signal dysfunction within the macular region and it reflects the integrity of the optics, photoreceptors, bipolar cells and Sinusoidal Peaks – Look for 3 humps retinal ganglion cells. Magnitude, MagnitudeD and MagD/Mag Ratio are colorized.
Green indicates within normal limits Yellow indicates values are borderline Red indicates outside normal limits
*Source: http://www.iscev.org/standards/pdfs/ISCEV-PERG-Standard-2013.pdf
Abnormal PERG
AAO Basic Science Course 2015/2016: PERG is a useful tool for the early diagnosis of glaucoma
Missing 3 humps
Yellow indicates values compared to normal are borderline
Red indicates values are outside normal limits
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Visual Assessment Per NIH and Bascom-Palmer
“In patients who are glaucoma suspects, PERG signal anticipates an equivalent loss of OCT signal by several years (as many as 8 years).”
IOP 26 mmHg IOP 18 mmHg IOP 18 mmHg Treatment initiation Invest Ophthalmol Vis Sci. 2013;54:2346–2352) DOI:10.1167/iovs.12-11026
Ganglion Cell Function Measured By Dynamic Visual Function Assessment ERG After IOP Reduction in POAG
• Researchers concluded that significant IOP-lowering therapy could improve RGC function measured by PERG in patients with preperimetric and early stages of POAG • IOP significantly decreased avg 31% • Increase in MOPP avg 14% • PERG amplitude of P50 and N95 waves increased in 75% and 79% eyes
IOP 26 mmHg IOP 18 mmHg IOP 18 mmHg Treatment initiation Karaśkiewicz J, Penkala K, Mularczyk M, et al. Evaluation of retinal ganglion cell function after intraocular pressure reduction measured by pattern electroretinogram in patients with primary open-angle glaucoma. Doc Ophthalmol. 2017; Feb 7. [Epub ahead of print].
Dynamic Visual Function Assessment Glaucoma: Treatment •Goal of treatment • Halt further visual loss • Halt further optic nerve damage
PERG •How We Treat • Reduction of IOP slows progression of glaucoma
•Treatment options • Medications • Laser therapy • Surgical intervention
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Glaucoma: Medications Overall Compliance Rates
• 10% - 25% take none of their prescribed medication
• 25% - 35% take all of their medication as prescribed
• Majority are partially compliant
1. Weintraub M. Compliance in the elderly. Clin Geriatr Med. 1990;6:445-452. 2. Lamy PP. Compliance in long term care. Geriatrika. 1985;1(8):32. 3. Coleman TJ. Non-redemption of prescriptions: linked to poor consultations. BMJ. 1994;308(6921):135.
How Do Patients Feel about their Drop Usage? Continuous Use
• 68 glaucoma pts • 54% stated their drops were expensive • 72% were suffering from side effects • 91% said medical therapy represented minimal/no inconvenience • 82% were interested in learning about procedures that could reduce or possible eliminate their need for drops
Nordstrom, Friedman, et al. Ophthalmology 2005
How Adherent are Glaucoma Patients with QD Medication?
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Glaucoma: Medications
• When COMPLIANCE with drops is low • When MEDICAL THERAPY FAILS • When the PROGRESSION continues to WORSEN
• Treatment options • Medications • Laser therapy • Surgical intervention
When Should you Refer a Glaucoma Patient? Glaucoma Surgical Options
• Do I have the right equipment to diagnose and • Laser Therapy • SLT manage the disease? • ALT • LPI • Am I comfortable managing this patient? • Surgical Options • Trabeculectomy • Trabectome • Express Shunt • Is the patient using too many medications? • Tube shunt • Canaloplasty • ECP • Is the patient progressing despite achieving target IOP?
Brujic, M. & Pohl, M. When should you refer a glaucoma patient? Review of Optometry. April 2011.
The ABC(DE)’s of Choosing a Surgery Glaucoma Clinical Trials Ronald L. Fellman, MD, Dallas • Collaborative Normal Tension Glaucoma Study (NTGS) • Advanced Glaucoma Intervention Study (AGIS) • A – Age / Angle • Collaborative Initial Glaucoma Treatment Study (CIGTS) • B – Blood aqueous barrier • Ocular Hypertensive Treatment Study (OHTS) • C – Conjunctiva • D – Disc / Discussion • Early Manifest Glaucoma Trial (EMGT) • E - Expertise • Glaucoma Laser Trial (GLT)
Accessed on September 13, 2012 from http://revophth.com/content/d/glaucoma_management/i/2088/c/36431/
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Argon Laser Trabeculoplasty Selective Laser Trabeculoplasty • Using gonioscopic views thermal burns are placed at the junction of non-pigmented and pigmented • Non-thermal treatment which uses short pulses of relatively low trabecular meshwork energy to target and irradiate only the melanin-rich cells in the TM
http://www.youtube.com/watch?v=cU1aS5_J0gE
SLT Procedure Selective Laser Trabeculoplasty Video Courtesy Nate Lighthizer, OD
• IOP decrease after SLT • Primary Therapy - 28.7% • Adjunctive therapy – 19.4% • Replacement Therapy – 4.5% • Retreatments – 12.1%
Advantages of SLT vs ALT Glaucoma: Laser Treatment
Five years post-treatment, the mean IOP decrease for the SLT group was 7.4±7.3 mmHg and 6.7±6.6 mmHg for the ALT group.
K.F. Damji, et al. Br. J. Ophthalmol. 2006;90(12):1490-1494.
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Peripheral Iridotomy (PI) Glaucoma: Laser Treatment
•Open or Narrow Angle Glaucoma •Transcleral Cyclophotocoagulation
Considerations for Optometry Advances in Glaucoma Surgery
• Laser therapy remains a viable option • Evolution of small-incision phacoemulsification techniques and small-profile IOLs • Can be used as primary or secondary treatment • Smaller wounds, less inflammation • Using antimetabolites to enhance filtration surgery • IOP lowering of 20 - 25% • MMC intra-operatively • 5-FU post-operatively with needling/injections • Glaucoma comanagement considerations • Availability of novel glaucoma procedures • Non-penetrating glaucoma surgeries (Trabectome, canaloplasty) • Endocyclophotocoagulation
Glaucoma Pre-surgical Considerations Cataract and Glaucoma
• Review health status and medications • How to position the cataract operation in the management scheme of the patient’s glaucoma • Anticoagulants condition?
• Coughing • Is it better to choose one sequence and type of surgery before the other, or to combine two procedures?
• STRESS the IMPORTANCE of visual fields PRIOR to cataract surgery
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Selecting the Appropriate IOL Choices in Glaucoma Surgical Approach
• For vast majority there are 3 choices: “Yes – I would like to be free from glasses!”
1. Undergo cataract extraction alone, pay no surgical attention to STANDARD glaucoma condition
MULTIFOCAL 2. Undergo glaucoma filtering surgery first and allow full healing TORIC before a second operation for cataract removal
3. Undergo a single combined cataract and IOL implantation operation at the time of the glaucoma filtering surgery
Trabeculectomy
• Traditionally done when meds and/or lasers fail to adequately control the pressure
• In advanced cases can be first line mode of treatment Traditional glaucoma surgery • Gold Standard Surgical technique • Long history • Low eye pressures • Reduce or eliminate medications and costs
Candidates for Trabeculectomy Trabeculectomy Procedure • Optic nerve progression despite MMT and/or LT • Surgical exposure • Conjunctival flap • Visual field progression despite MMT and/or LT • Scleral flap - +/- antifibrosis agent • Sclerostomy • Inability to take drops adequately • Iridectomy – needed to prevent the iris from incarcerating into the • Target pressure is LOW internal ostium • Scleral flap closure • Moderate/advanced disease • Conjunctival closure
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Trabeculectomy Complications Tube Shunt and Cataract Surgery
• Scar formation-failure • Bleb leak • Blurring of vision • Hypotony • Choroidal hemorrhage • Infections • Cataract formation
Standard Surgical Treatments Tube Shunt Advantages Tube Shunt- Advantages • Safer for contact lens wearers • Safer for contact lens wearers • More standardized post operative care • More standardized post operative care • Used when previous trabeculectomy failed • Used when previous trabeculectomy failed • Results comparable to trabeculectomy • Results comparable to trabeculectomy
Filtering Surgery Alternatives: Express Shunt
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Why Express Shunt over Simple Endocyclophotocoagulation (ECP) Trabeculectomy? and Cataract Surgery • ECP uses laser probe with a camera • Trabeculectomy • Ex-PRESS implantation: procedure: • The above steps skipped • Laser energy applied to ciliary body; shrinks the tissue • A sclerostomy under the • Instead, implant inserted through a 27g needle tract • Reduction of aqueous humor production and overall scleral flap with two to • three punches with a Less inflammation decreases the intraocular pressure Kelly Descemet’s punch • More standardization • Surgical peripheral • Less time iridectomy • Less early hypotony • Fewer complications • Similar IOP results
Maris PJG Jr, Ishida K, Netland PA. Comparison of trabeculectomy with Ex-PRESS miniature glaucoma device implanted under scleral flap. J Glaucoma. 2006;16:14-19.
What Do You Get When You Add? What is MIGS? +
Less is More
Great Candidate for MIGS/PHACO
REMEMBER THE TRABECULECTOMY?
“The new MIGS procedures are to trabeculectomy what phacoemulsification was to intracapsular cataract extraction or LASIK was to RK.”
Scar formation – failure Hypotony Burring of vision Blebitis
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MIGS PROCEDURES Anatomical Considerations
Ab externo (outside in) • Express Shunt, Alcon • Canaloplasty, iScience • Endocyclophotocoagulation, Endo Optiks Ab interno (inside out) • Trabectome, Neomedix • iStent, Glaukos –recently FDA Approved Trabectome • *CyPass, Transcend Medical • *Hydrus, Ivantis • *Gold micro-shunt, SOLX • *supraciliary microstent increases uveoscleral outflow
PN: 400-0135-2013-US Rev. 0 Release Date: 08/27/2013 Photo accessed from http://www.downstate.edu/ophthalmology/patient-info/patient-info-glaucoma.html on 11/4/16
MIGS ADVANTAGES Baby Boomer Cataract Patients Safer Avoids serious complications Less OR time Faster recovery Gentler Less glaucoma meds Decreased IOP fluctuations
Combined with cataract sx No Bleb Good for contact lens wearers Spares the conjunctiva Fewer follow-up appointments
Concomitant Cataract & Glaucoma Patients - US QUALITY-OF-LIFE ISSUES Significant Treatment Opportunity One in five Cataracts Eyes on OHT Medication • Improved quality of 20.5% 3.5M US Cataract Procedures vision Cataract + • Less dependence on Minimum of glasses / contact lenses 1 OHT Med 718K • Patients now • More demanding • More knowledgeable • More sophisticated • More informed 79.5% Cataract Only
Patients looking for better outcomes 96 and quality of life - your practice can offer this! Centers for Medicare and Medicaid Services. 2002 – 2007. Medicare Standard Analytical File. Baltimore, MD. 2007 .
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MIGS APPROACH IS SIMILAR Are Patients Interested in MIGS?
• Less dependence on their • JUST LIKE CATARACT SURGERY glaucoma medications • Outpatient surgery in an ASC • 28pts • • • Reducing or perhaps Topical anesthesia 79% did not mind instilling drops • Internal approach.... no • 64% did not mind wearing glasses eliminating the need for astigmatism drops • No patch • 86% were interested in reducing their need for topical medications – Compliance issues • Minimal restrictions on physical activity – Cost issues • Intraocular lens technology • May permit better IOP control on/off drops
Trabectome Trabectome
Candidates for Trabectome Advantages of Trabectome • Non-penetrating/no disturbance of conjunctiva • Progression despite MMT/Laser • Requires no bleb • Low patient risk • On 1-2 glaucoma medications • Restores the eye’s natural fluid balance • Simpler than traditional therapies • Low complication rate • Target pressure in mid teens • Easily combines with cataract extraction • Safe, economical and effective • Combined visually significant cataract and glaucoma • Reduction of glaucoma medications • Good for contact lens wearers • Glaucoma in its early-to-moderate-stage • Fewer follow-up appointments
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Trabectome IOP & Glaucoma Medication Use Outcome Trabectome – Disadvantages IOP (mmHg)
• 20% had a post op iop spike Mean pre-op IOP
Mean IOPs with standard • Post op hyphema is typical deviations at various intervals after surgery over 72 months • Synechia formation around cleft • Descemet’s injury • Cost of equipment Glaucoma Medication Use
Mean pre-op medication use
Mean medication use after surgery over 72 months
Trabecular Bypass Devices Istent • These procedures facilitate the flow of aqueous into Schlemm’s canal by: • Stenting the canal • iStent (Glaukos Corp) • Titanium, L-shaped, trabecular microbypass stent • Excimer laser trabeculostomy • Snorkle through TM • Shunting the canal • Eyepass Glaucoma Implant (GMP Companies) • Use Gonio to place it • Divert aqueous into the suprachoroidal space • Solx Gold Micro-Shunt (OccuLogix, Inc)
US IDE Trial - Primary Endpoint US IDE Trial - Secondary Endpoint Percent of Patients With a ≤20% Reduction in IOP Without Medication Use Percent of Patients With IOP ≤21 mm Hg Without Medication Use
100 100 80 80 72% 66% 60 60 48% 50% 40 40 ® ® 20 20 0 0 Cataract Surgery iStent Cataract Surgery iStent
At 12 months, 72% of iStent® subjects with IOP ≤ 21 mm Hg At 12 months, 66% of iStent® subjects with ≥ 20% IOP reduction without medication vs. 48% with cataract surgery alone (P=0.003) without medication vs. 50% with cataract surgery alone (P<0.001) 108
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And There’s More
Xen45
Ab interno canaloplasty
CyPass Solx Gold Shunt
Excimer Laser Trabeculostomy Canaloplasty – Non-Penetrating
• Very similar to trabectome • Punching out holes in the TM
Canaloplasty is a 360 degree viscodilation of Schlemm’s canal with the microcatheter. iTrack ophthalmic microcatheter with illuminated beacon tip.
Canaloplasty – Advantages Solx Gold Shunt • Non-penetrating • Holds open Schlemm’s canal • Candidates: failed trabeculoplasty to refractory • Requires no bleb disease • Requires no device • Safety: No bleb-related complications, highly • Safely lowers pressure by an average of nearly 40% biocompatible material • Reduces or eliminates medications and costs • Efficacy: Novel mechanism of action, advanced • Provides less risk of complications after surgery engineering to optimize performance • Fewer follow-up appointments • Reduced scarring
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Transcend CyPass System XEN gel stent
• 300um lumen stent that is 6mm • Sustained-release implant capable of delivering bimatoprost long • Intracameral injection • Mean pre-operative IOP was 22.9 mm Hg on 2.6 meds • Fenestrations in tube allow • Mean postoperative IOP at 36 months was 13.2 mm Hg on 0.7 meds aqueous to egress through its length • AE - 3% chance of hypotony, shallow anterior chamber and choroidal effusion
• Place into through the angle into supraciliary space
ICE, ICE Baby Kahook Video by Constance Okeke, MD Video Courtesy of John Berdahl, MD and Justin Schweitzer, OD
Post-operative Cataract IOP Spikes How To Choose Which Procedure? • Based on Stage and Severity in Glaucoma Patients • Moderate to advanced cases – Trabectome • Adequate control prior to surgery • Early to Moderate – iStent or Trabectome • Additional drops • ? multiple iStents off label • • iStent inject shows promise SLT prior • Consideration of combined glaucoma and cataract procedures • Aggressive treatment peri-operatively • Diamox at the end of the case, early post-op • Closer follow-up post-operatively
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Glaucoma Surgical Pearls Glaucoma Pipeline
• Advances in technology have allowed for many good options for our cataract and glaucoma patients
• When considering cataract surgery in patient with glaucoma, a thorough assessment first of the stage and status of glaucoma is imperative
• Visual fields should be obtained PRIOR to cataract surgery
• Establish glaucoma comanagement protocols so everyone is on the same page.
http://eyetubeod.com/2015/09/glaucoma-drugs-in-the-pipeline
Latanoprostene bunod Vesneo; Bausch + Lomb
• Nitric oxide-donating prostaglandin F2-alpha analogue • QD dosing • Reduced mean IOP by 7.5 to 9.1 mm Hg from baseline between 2 and 12 weeks of treatment. • Statistically superior (P < .05) to that of timolol in both studies
http://www.touchophthalmology.com/articles/latanoprostene-bunod-dual-acting-nitric-oxide-donating-prostaglandin-analog-lowering/page/1/0
Sustained-release travoprost Rhopressa - Aerie OTX-TP; Ocular Therapeutix
• An intracanalicular depot composed of polyethylene glycol hydrogel • Rho kinase and norepinephrine transporter inhibitor and drug-containing microparticles • Lowers IOP by the “triple action” of reducing aqueous production, • Works up to 90 days increasing trabecular outflow, and decreasing episcleral venous pressure • In a phase 2 trial, once-daily AR-13324 0.02% lowered IOP by 5.7 mm Hg from the unmedicated baseline.
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Roclatan -Aerie Trabodenoson - Inotek
• Combination of Rhopressa and latanoprost • Selective adenosine mimetic • Lowered IOP by 34% • Mechanism for IOP control designed to directly protect retinal • SE - Hyperemia ganglion cells through a neuroprotective effect
OSD and Glaucoma Who Should We Evaluate?
• Leung EW, Medeiros FA, Weinreb RN. Prevalence of ocular surface •Everyone! disease in glaucoma patients. J Glaucoma 2008;17:5:350-355. •Symptomatic patients •CL patients •Surgical candidate •Conditions associated with OSD • Medication • Ocular disease • Systemic disease
Focus on Dry Eye Prevalence Case Example – POAG / MGD
•Cataract Surgery 77% •76YOWF – Present for follow up for •Penetrating Keratoplasty 60% Glaucoma and dry eye disease. Compliant with drops OU. Vision has been blurry and •Lasik 27% eyes irritated more in the past few months •Glaucoma Surgery 78% • Previous treated with topical azithromycin •Blepharoplasty 26% • Current Ocular Meds: Restasis BID OU, latanoprost qhs OU • Numerous systemic meds including singulair, Trattler, ASCRS CME Supplement, 2013 synthroid Sheppard, WCC, 2015 Azuma, BMC Research Notes, 2014 Leung, Journal of Glaucoma, 2008 Prischmann, JAMA Facial Plastic Surgery, 2013
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•SPEED Score: 33 •Tear Osmolarity 308 / 315 •SLE: 2+ MGD OD / 3+ MGD OS / 1+ SPK OU •Cloud secretions OU •MG Structure: See images •IOP: 14/13 •HVF: Stable OU Early to Moderate Structural Advanced Gland Atrophy / Dropout Changes to Meibomian Glands
Post Treatment Restasis Works on All Three Layers • 6 Weeks Post Treatment and Underlying Inflammation • Post Tx Osmolarity • 300/299 • Post Lipiflow Management • Heat masks qhs OU • Hydroeye as directed • Restasis BID OU • Lipid based tear BID OU • Latanoprost qhs OU • F/u 3 months dry eye • Order tear osmolarity • Order inflammadry • SPEED Questionnaire
The Asclepius Panel Recommended Treatment TM Model for Dry Eye Inflammation Xiidra
Cornea/External Disease Advisory • Lifitegrast is a small molecule integrin antagonist that Group interferes with binding of ICAM-1 to the integrin LFA-1 on Treatment Consensus Thereafter the T cell surface, inhibiting T cell recruitment and activation associated with dry eye disease (DED)
® Lotemax® QID Lotemax® BID Lotemax …up to QID for flare-ups • Lifitegrast ophthalmic solution 5.0% has been investigated in (loteprednol etabonate ophthalmic (loteprednol etabonate ophthalmic (loteprednol etabonate ophthalmic suspension 0.5%) suspension 0.5%) suspension 0.5%) 4 (one Phase 2 and three Phase 3) randomized controlled trials for treatment of DED1–3 Restasis® BID (cyclosporine ophthalmic emulsion) 0.05%) • FDA Approved to treat both the signs and symptoms of dry eye disease
Artificial Tears
Adapted from Holland EJ. Ophthalmol Times. 2007;32:3-11.
1. Semba CP, et al. Am J Ophthalmol. 2012;153(6):1050-60. 2. Sheppard JD, et al. Ophthalmology. 2014;121(2):475–83. 3. Tauber J, et al. Ophthalmology. 2015;122(12):2423-31.
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Conclusions
• Glaucoma Dx / Tx is constantly advancing
• Consider benefits of MIGS
• Address the ocular surface Thank you
• Anticipate continuous innovation [email protected]
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