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Innovations in GlaucomaCOPE#52116-GL

Walter O. Whitley, OD, MBA, FAAO

Director of Optometric ServicesVirginia Eye Consultants

Residency Program SupervisorPennsylvania College of Optometry

Virginia Eye ConsultantsTertiary Referral Eye Care Since 1963

• John D. Sheppard, MD, MMSc

• Stephen V. Scoper, MD

• David Salib, MD

• Elizabeth Yeu, MD

• Thomas J. Joly, MD, PhD

• Dayna M. Lago, MD

• Constance Okeke, MD, MSCE

• Esther Chang, MD

• Jay Starling, MD

• Samantha Dewundara, MD

• Surajit Saha, MD

• Walter O. Whitley, OD, MBA, FAAO

• Mark Enochs, OD

• Cecelia Koetting, OD, FAAO

• Christopher Kuc, OD

• Leanna Olennikov, OD

• Jillian Janes, OD

Disclosures

• Alcon

• Allergan

• Bausch and Lomb

• Biotissue

• Beaver-Visitec

• Publications

• Advanced Ocular Care – Co-Chief Medical Editor• Review of Optometry – Contributing Editor• Optometry Times – Editorial Advisory Board

Walter O. Whitley, OD, MBA, FAAO has received consulting fees, honorarium or research funding from:

• Diopsys

• Ocusoft

• Science Based Health

• Shire

• TearLab Corporation

What is Glaucoma??

Consider the Risk Factors

• IOP

• CCT

• C/D ratio

• Age

• Race

• Family History

Glaucoma Diagnosis

•Difficult disease to detect

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

• Gonioscopy

• Central corneal thickness

• Visual fields

• Fundus photography

• Scanning lasers

• Serial tonometry

• Electrodiagnositics – VEP / PERG

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GLAUCOMA SEVERITY SCALE DEFINITIONS

• Mild Stage: optic nerve changes consistent with glaucoma but NO visual field abnormalities on any visual field test OR abnormalities present only on short-wavelength automated perimetry or frequency doubling perimetry.

• Moderate Stage: optic nerve changes consistent with glaucoma AND glaucomatous visual field abnormalities in one hemifield and not within 5 degrees of fixation.

• Severe Stage: optic nerve changes consistent with glaucoma AND glaucomatous visual field abnormalities in both hemifields and/or loss within 5 degrees of fixation in at least one hemifield.

http://www.americanglaucomasociety.net/professionals/glaucoma_staging_codes_teaching_module/

Managing Glaucoma Patients

• Monitor IOP reduction: 1-2 week, 1 month

• Check IOP every 3-4 months

• Repeat VF every 6-12 months

• Disc photos every 1-2 years

• Gonioscopy every year

• Optic nerve analysis every 6-12 months

• Document everything

http://www.aoa.org/optometrists/tools-and-resources/clinical-care-publications/clinical-practice-guidelines?sso=y

https://www.aao.org/guidelines-browse?filter=preferredpracticepatterns

Corneal Hysteresis How ORA Works

1st IOP

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1st IOP

Air-jet stops

1st IOP

Air-jet stops

2nd IOP

ORA—Signal Plot

“In” signal peak “Out” signal peak

IOP 1 IOP 2

Start Thinking Weak vs. Strong

IOP Corneal Hysteresis

Relationship of IOP and Corneal Hysteresis

Wells AP, Garway-Heath DF, et a.Corneal hysteresis but not corneal thickness Correlates with optic nerve surface compliance in Glaucoma patients. Invest Ophthalmol Vis Sci 2008

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Lower CH = More Likely to Respond to Topical Medications

Higher CH = Less Likely to Respond to Topical Medication

Congdon NG, Broman AT, Bandeen-Roche K, et al. Central corneal thickness andcorneal hysteresis associated with glaucoma damage. Am J Ophthalmol2006;141:868

Anand A, De Moraes CG, Teng CC, et al. Corneal hysteresis and visual fieldasymmetry in open angle glaucoma.Invest Ophthalmol Vis Sci 2010;51:6514

More Likely to Respond to Topical Medications

Association with ProgressiveField Worsening

Greater Structural Bowing of Lamina Cribrosa

Low CH

Structure Function

Fundus Photograph(Subjective)

Visual Field(Subjective)

Structure Function

Optical Coherence Tomography(Objective)

ERG(Objective)

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When Do I Use Electrophysiological Tests?

•Clarify Differential Diagnosis…. Is it Systemic or Trauma vs. Ocular?

•When Standard Tests are Unattainable or Unreliable

•When Other Tests are Inconsistent or Borderline Result

•To Monitor Subclinical Disease for Functional Changes and Alter Treatment and Efficacy

VEP (neuro)

PERG (retinal)

Electrophysiology objectively measures strength and speed of the visual signal to the

brain (VEP) or retina (PERG)

HealthyVF

GlaucomaOCT

Documentedstructural damage

PERG/VEP

SymptomaticAsymptomatic

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.

OHT

ELECTROPHYSIOLOGY DETECTS CHANGES EARLIER THAN OCT AND VISUAL FIELD1

Non structural damage documented

Visual Evoked Potential (VEP)

• Main Indications• Glaucoma

• Multiple Sclerosis

• Ischemic Optic Neuropathy

• Traumatic Brain Injury

• Amblopyia

• Other Neuropathies

WHY USE VEP?

• VEP is an objective, functional test when standard tests cannot provide sufficient information for diagnosis and treatment.

• Many optic nerve diseases are asymptomatic because central vision is not affected until late in the disease1

• Diagnosis and management of optic nerve disorders are often based on structural or subjective visual field tests2

Normal VEP

Good Signal Quality

Good Waveforms

Amplitude and Latencies in green

Data Table Shows good numerical Values and All in Green

P100 Signal Index above 80%

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Abnormal VEP

Right eye shows delays in latency at both high and low

Low contrast demonstrates changes to the magnocellular pathway -Earliest functional degradation shown in glaucoma patients!!

P100 Signal Delayed

Pattern ERG = PERG

Main Indications

Glaucoma

Maculopathies

Can also help the clinician differentiate between retinal and optic nerve disorders when used in conjunction with Visual Evoked Potential (VEP).

How Does PERG Work?

Since the PERG (in contrast to the flash ERG) is a local response from the area covered by the retinal stimulus image, specifically GCC, it can be used as a sensitive indicator of dysfunction within the macular region and it reflects the integrity of the optics, photoreceptors, bipolar cells and retinal ganglion cells.

*Source: http://www.iscev.org/standards/pdfs/ISCEV-PERG-Standard-2013.pdf

Normal PERG Response

Magnitude, MagnitudeD and MagD/Mag Ratio are colorized.

Green indicates within normal limits Yellow indicates values are borderlineRed indicates outside normal limits

3 Quick Steps To Report Interpretation

Signal Quality – Look for a green signal

Sinusoidal Peaks – Look for 3 humps

Abnormal PERG

Missing 3 humps

Yellow indicates values compared to normal are borderline

Red indicates values are outside normal limits

AAO Basic Science Course 2015/2016:PERG is a useful tool for the early diagnosis

of glaucoma

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“In patients who are glaucoma suspects, PERG signal anticipates an equivalent loss of OCT signal by several years (as many as 8 years).”

Per NIH and Bascom-Palmer

Invest Ophthalmol Vis Sci. 2013;54:2346–2352) DOI:10.1167/iovs.12-11026

IOP 18 mmHgIOP 18 mmHgIOP 26 mmHgTreatment initiation

Visual Assessment

IOP 26 mmHgTreatment initiation

IOP 18 mmHgIOP 18 mmHg

Dynamic Visual Function AssessmentGanglion Cell Function Measured By 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

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].

PERG

Dynamic Visual Function Assessment Glaucoma: Treatment

•Goal of treatment• Halt further visual loss• Halt further optic nerve damage

•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?

• 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

Continuous Use

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?

•Do I have the right equipment to diagnose and manage the disease?

•Am I comfortable managing this patient?

• Is the patient using too many medications?

• Is the patient progressing despite achieving target IOP?

Brujic, M. & Pohl, M. When should you refer a glaucoma patient? Review of Optometry. April 2011.

Glaucoma Surgical Options

• Laser Therapy• SLT

• ALT

• LPI

• Surgical Options• Trabeculectomy

• Trabectome

• Express Shunt

• Tube shunt

• Canaloplasty

• ECP

Glaucoma Clinical Trials

•Collaborative Normal Tension Glaucoma Study (NTGS)

•Advanced Glaucoma Intervention Study (AGIS)

•Collaborative Initial Glaucoma Treatment Study (CIGTS)

•Ocular Hypertensive Treatment Study (OHTS)

•Early Manifest Glaucoma Trial (EMGT)

•Glaucoma Laser Trial (GLT)

The ABC(DE)’s of Choosing a Surgery Ronald L. Fellman, MD, Dallas

• A – Age / Angle

• B – Blood aqueous barrier

• C – Conjunctiva

• D – Disc / Discussion

• E - Expertise

Accessed on September 13, 2012 from http://revophth.com/content/d/glaucoma_management/i/2088/c/36431/

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Argon Laser Trabeculoplasty

•Using gonioscopic views thermal burns are placed at the junction of non-pigmented and pigmented trabecular meshwork

Selective Laser Trabeculoplasty

• Non-thermal treatment which uses short pulses of relatively low energy to target and irradiate only the melanin-rich cells in the TM

http://www.youtube.com/watch?v=cU1aS5_J0gE

Selective Laser Trabeculoplasty

• IOP decrease after SLT• Primary Therapy - 28.7%• Adjunctive therapy – 19.4%• Replacement Therapy – 4.5%• Retreatments – 12.1%

SLT ProcedureVideo Courtesy Nate Lighthizer, OD

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

• Laser therapy remains a viable option

• Can be used as primary or secondary treatment

• IOP lowering of 20 - 25%

• Glaucoma comanagement considerations

Advances in Glaucoma Surgery

•Evolution of small-incision phacoemulsification techniques and small-profile IOLs• Smaller wounds, less inflammation

•Using antimetabolites to enhance filtration surgery• MMC intra-operatively• 5-FU post-operatively with needling/injections

•Availability of novel glaucoma procedures• Non-penetrating glaucoma surgeries (Trabectome,

canaloplasty)• Endocyclophotocoagulation

Glaucoma Pre-surgical Considerations

• Review health status and medications

• Anticoagulants

• Coughing

Cataract and Glaucoma

•How to position the cataract operation in the management scheme of the patient’s glaucoma condition?

• 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 Surgical Approach

• For vast majority there are 3 choices:

1. Undergo cataract extraction alone, pay no surgical attention to glaucoma condition

2. Undergo glaucoma filtering surgery first and allow full healing 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

IOL Choices in Glaucoma

“Yes – I would like to be free from glasses!”

STANDARD

MULTIFOCALTORIC

Traditional glaucoma 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

•Gold Standard Surgical technique• Long history

• Low eye pressures

• Reduce or eliminate medications and costs

Candidates for Trabeculectomy

•Optic nerve progression despite MMT and/or LT

•Visual field progression despite MMT and/or LT

• Inability to take drops adequately

•Target pressure is LOW

•Moderate/advanced disease

Trabeculectomy Procedure

•Surgical exposure

•Conjunctival flap

•Scleral flap - +/- antifibrosis agent

•Sclerostomy

• Iridectomy – needed to prevent the iris from incarcerating into the internal ostium

•Scleral flap closure

•Conjunctival closure

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Trabeculectomy Complications

•Scar formation-failure

•Bleb leak

•Blurring of vision

•Hypotony

•Choroidal hemorrhage

• Infections

•Cataract formation

Tube Shunt and Cataract Surgery

Standard Surgical Treatments

Tube Shunt- Advantages

• Safer for contact lens wearers

• More standardized post operative care

• Used when previous trabeculectomy failed

• Results comparable to trabeculectomy

Tube Shunt Advantages

•Safer for contact lens wearers

•More standardized post operative care

•Used when previous trabeculectomy failed

•Results comparable to trabeculectomy

Filtering Surgery Alternatives:Express Shunt

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Why Express Shunt over Simple Trabeculectomy?

• Trabeculectomyprocedure: • A sclerostomy under the

scleral flap with two to three punches with a Kelly Descemet’s punch

• Surgical peripheral iridectomy

• Ex-PRESS implantation:• The above steps skipped • Instead, implant inserted through a

27g needle tract• Less inflammation• More standardization• Less time• Less early hypotony• Fewer complications• Similar IOP results

Maris PJG Jr, Ishida K, Netland PA. Comparison of trabeculectomy with Ex-PRESS miniature glaucoma device implantedunder scleral flap. J Glaucoma. 2006;16:14-19.

Endocyclophotocoagulation (ECP)and Cataract Surgery

•ECP uses laser probe with a camera

• Laser energy applied to ciliary body; shrinks the tissue

•Reduction of aqueous humor production and overall decreases the intraocular pressure

What Do You Get When You Add?

+

Great Candidate for MIGS/PHACO

What is MIGS?

Less is More

“The new MIGS procedures are to trabeculectomy what phacoemulsification was to intracapsular cataract extraction or LASIK was to RK.”

REMEMBER THE TRABECULECTOMY?

Scar formation – failureHypotonyBurring of visionBlebitis

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MIGS PROCEDURES

Ab externo (outside in)

• Express Shunt, Alcon

• Canaloplasty, iScience

• Endocyclophotocoagulation, Endo Optiks

Ab interno (inside out)

• Trabectome, Neomedix

• iStent, Glaukos –recently FDA Approved

• *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

Trabectome

Photo accessed from http://www.downstate.edu/ophthalmology/patient-info/patient-info-glaucoma.html on 11/4/16

Anatomical Considerations

MIGS ADVANTAGESSafer

Faster recoveryGentler

Combined with cataract sx

Less glaucoma meds

Less OR time

Avoids serious complications

Spares the conjunctiva

Decreased IOP fluctuations

No Bleb

Good for contact lens wearers

Fewer follow-up appointments

Baby Boomer Cataract Patients

QUALITY-OF-LIFE ISSUES

• Improved quality of vision

• Less dependence on glasses / contact lenses

• Patients now• More demanding

• More knowledgeable

• More sophisticated

• More informed

Patients looking for better outcomes

and quality of life - your practice can offer this!

79.5%Cataract Only

20.5%Cataract +

Minimum of

1 OHT Med

3.5M US Cataract Procedures

718K

96

Centers for Medicare and Medicaid Services. 2002 – 2007. Medicare Standard Analytical File. Baltimore, MD. 2007.

Concomitant Cataract & Glaucoma Patients - US

Significant Treatment Opportunity

One in five Cataracts Eyes on OHT Medication

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MIGS APPROACH IS SIMILAR

• Less dependence on their glaucoma medications

• Reducing or perhaps eliminating the need for drops

– Compliance issues

– Cost issues

• May permit better IOP control on/off drops

• JUST LIKE CATARACT SURGERY• Outpatient surgery in an ASC

• Topical anesthesia

• Internal approach.... no astigmatism

• No patch

• Minimal restrictions on physical activity

• Intraocular lens technology

Are Patients Interested in MIGS?

• 28pts

• 79% did not mind instilling drops

• 64% did not mind wearing glasses

• 86% were interested in reducing their need for topical medications

Trabectome Trabectome

Candidates for Trabectome

•Progression despite MMT/Laser

•On 1-2 glaucoma medications

•Target pressure in mid teens

•Combined visually significant cataract and glaucoma

•Glaucoma in its early-to-moderate-stage

Advantages of Trabectome

• Non-penetrating/no disturbance of conjunctiva

• Requires no bleb

• Low patient risk

• Restores the eye’s natural fluid balance

• Simpler than traditional therapies

• Low complication rate

• Easily combines with cataract extraction

• Safe, economical and effective

• Reduction of glaucoma medications

• Good for contact lens wearers

• Fewer follow-up appointments

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Trabectome – Disadvantages

•20% had a post op iop spike

•Post op hyphema is typical

•Synechia formation around cleft

•Descemet’s injury

•Cost of equipment

TrabectomeIOP & Glaucoma Medication Use Outcome

Mean pre-op IOP

Mean IOPs with standard deviations at various intervals after surgery over 72 months

Mean pre-op medication use

Mean medication use after surgery over 72 months

IOP (mmHg)

Glaucoma Medication Use

Trabecular Bypass Devices

• These procedures facilitate the flow of aqueous into Schlemm’s canal by:• Stenting the canal

• iStent (Glaukos Corp)

• Excimer laser trabeculostomy

• Shunting the canal• Eyepass Glaucoma Implant (GMP Companies)

• Divert aqueous into the suprachoroidal space• Solx Gold Micro-Shunt (OccuLogix, Inc)

Istent

•Titanium, L-shaped, trabecular microbypass stent

•Snorkle through TM

•Use Gonio to place it

US IDE Trial - Primary Endpoint

At 12 months, 72% of iStent® subjects with IOP ≤ 21 mm Hg without medication vs. 50% with cataract surgery alone (P<0.001)

0

20

40

60

80

100

Cataract Surgery iStent

Percent of Patients With IOP ≤21 mm Hg Without Medication Use

50%

72%

®

US IDE Trial - Secondary Endpoint

108

At 12 months, 66% of iStent® subjects with ≥ 20% IOP reduction without medication vs. 48% with cataract surgery alone (P=0.003)

0

20

40

60

80

100

Cataract Surgery iStent

Percent of Patients With a ≤20% Reduction in IOP Without Medication Use

66%48%

®

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And There’s More

Ab internocanaloplasty

Xen45

CyPass Solx Gold Shunt

Excimer Laser Trabeculostomy

• Very similar to trabectome

• Punching out holes in the TM

Canaloplasty – Non-Penetrating

Canaloplasty is a 360 degree viscodilation of Schlemm’s canal with the microcatheter. iTrack ophthalmic microcatheter with illuminated beacon tip.

Canaloplasty – Advantages

•Non-penetrating

•Holds open Schlemm’s canal

•Requires no bleb

•Requires no device

•Safely lowers pressure by an average of nearly 40%

•Reduces or eliminates medications and costs•Provides less risk of complications after surgery

•Fewer follow-up appointments

•Reduced scarring

Solx Gold Shunt

•Candidates: failed trabeculoplasty to refractory disease

•Safety: No bleb-related complications, highly biocompatible material

•Efficacy: Novel mechanism of action, advanced engineering to optimize performance

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Transcend CyPass System

• 300um lumen stent that is 6mm long

• Fenestrations in tube allow aqueous to egress through its length

• Place into through the angle into supraciliary space

XEN gel stent

• Sustained-release implant capable of delivering bimatoprost

• Intracameral injection

• Mean pre-operative IOP was 22.9 mm Hg on 2.6 meds

• Mean postoperative IOP at 36 months was 13.2 mm Hg on 0.7 meds

• AE - 3% chance of hypotony, shallow anterior chamber and choroidal effusion

ICE, ICE Baby Video Courtesy of John Berdahl, MD and Justin Schweitzer, OD

Kahook Video by Constance Okeke, MD

How To Choose Which Procedure?

• Based on Stage and Severity• Moderate to advanced cases – Trabectome

• Early to Moderate – iStent or Trabectome

• ? multiple iStents off label

• iStent inject shows promise

Post-operative Cataract IOP Spikes in Glaucoma Patients

•Adequate control prior to surgery• Additional drops• 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

•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

Glaucoma Pipeline

Latanoprostene bunodVesneo; 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 travoprostOTX-TP; Ocular Therapeutix

• An intracanalicular depot composed of polyethylene glycol hydrogel and drug-containing microparticles

• Works up to 90 days

Rhopressa - Aerie

• Rho kinase and norepinephrine transporter inhibitor

• Lowers IOP by the “triple action” of reducing aqueous production, 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

• Combination of Rhopressa and latanoprost

• Lowered IOP by 34%

• SE - Hyperemia

Trabodenoson - Inotek

• Selective adenosine mimetic

• Mechanism for IOP control designed to directly protect retinal ganglion cells through a neuroprotective effect

OSD and Glaucoma

• Leung EW, Medeiros FA, Weinreb RN. Prevalence of ocular surface disease in glaucoma patients. J Glaucoma 2008;17:5:350-355.

Who Should We Evaluate?

•Everyone!

•Symptomatic patients

•CL patients

•Surgical candidate

•Conditions associated with OSD•Medication•Ocular disease•Systemic disease

Focus on Dry Eye Prevalence

•Cataract Surgery 77%

•Penetrating Keratoplasty 60%

•Lasik 27%

•Glaucoma Surgery 78%

•Blepharoplasty 26%

Trattler, ASCRS CME Supplement, 2013Sheppard, WCC, 2015Azuma, BMC Research Notes, 2014Leung, Journal of Glaucoma, 2008Prischmann, JAMA Facial Plastic Surgery, 2013

Case Example – POAG / MGD

•76YOWF – Present for follow up for Glaucoma and dry eye disease. Compliant with drops OU. Vision has been blurry and eyes irritated more in the past few months•Previous treated with topical azithromycin •Current Ocular Meds: Restasis BID OU,

latanoprost qhs OU•Numerous systemic meds including singulair,

synthroid

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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 Changes to Meibomian Glands

Advanced Gland Atrophy / Dropout

Post Treatment

• 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

•6 Weeks Post Treatment

Restasis Works on All Three Layers and Underlying Inflammation

The Asclepius Panel Recommended Treatment Model for Dry Eye Inflammation

Adapted from Holland EJ. Ophthalmol Times. 2007;32:3-11.

Lotemax® QID(loteprednol etabonate ophthalmicsuspension 0.5%)

Artificial Tears

Lotemax® BID(loteprednol etabonate ophthalmicsuspension 0.5%)

Lotemax®…up to QID for flare-ups(loteprednol etabonate ophthalmicsuspension 0.5%)

Restasis® BID(cyclosporine ophthalmic emulsion) 0.05%)

Thereafter

Cornea/External Disease Advisory GroupTreatment Consensus

XiidraTM

• Lifitegrast is a small molecule integrin antagonist that interferes with binding of ICAM-1 to the integrin LFA-1 on the T cell surface, inhibiting T cell recruitment and activation associated with dry eye disease (DED)

• Lifitegrast ophthalmic solution 5.0% has been investigated in 4 (one Phase 2 and three Phase 3) randomized controlled trials for treatment of DED1–3

• FDA Approved to treat both the signs and symptoms of dry eye disease

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

• Anticipate continuous innovation

Thank youwwhitley@vec2020.com