Whats new in Glaucoma

1. Andrew White
BMedSc(Hons), MBBS, PhD, FRANZCO
Glaucoma consultant, Westmead Hospital
Clinical Senior Lecturer, University of Sydney
Chair, Expert Advisory Panel, Glaucoma Australia
Chair, Project Steering Committee: Community Eye Care ACI
Associate Board Member, World Glaucoma Association
WHAT’S NEW IN GLAUCOMA

2. THERE'S MORE TO GLAUCOMA THAN
PRESSURE
• Increasing thought of as the
most common optic
neuropathy and a form of
accelerated aging
• Increasingly important factors
to consider
• Ocular Perfusion
• Metabolic/mitochondrial
dysfunction
• Oxidative status
• Scleral
compliance/capacitance
• Genetic sensitivity

3. CAN WE DO ANYTHING CLINICALLY
OTHER THAN REDUCE IOP?
• In a word: No
• Some way from neuroregeneration
• Approximately 50 potential neuroprotective agents validated in in vitro/ex
vitro and glaucoma models1
• No significant clinical trial findings to back this up and many notable failures
• There may be flaws in current trial design
Baltmr A et al Exp Eye Res 2010;91(5):554 –566.

4. WHAT’S NEW IN GUIDELINES

5. NEW GUIDELINES ARE OUT (MORE ON
THE WAY)

6. • Collaborative care is the way of
the future
• Generally positive response
from optometry
• In the process of building
better collaborative care model
COLLABORATIVE CARE GUIDELINES

7. WHAT IS REFERRAL-REFINEMENT?
• Referral Refinement is external
validation of initial assessment
which improves over time as
feedback is given.
• Very big in the UK
• A component of nearly all
community and commercial
glaucoma screening schemes
0
10
20
30
40
50
60
70
80
90
100
0 3 6 9 12 15 18 21 24 27 30 33 36
Percentage
Time (Months)
False +ve
False -ve

8. WHAT’S NEW IN DROPS?

9. RECENT CHANGES
• Latanoprost 1st generic PGA 2012
• Azarga (Brinzolamide/Timolol)
increasingly used – nicer pH than
Cosopt
• Increasing move away from BAK
formulations
• Saflutan and Lumigan PF: preservative
free PGAs. PF Ganfort on the way
(August)
• Travatan and DuoTrav now Polyquad
rather than BAK
• Brimonidine has recently been shown to
be neuroprotective (again) in clinical
trial1
• A variety of depot preparations in
development
1

10. ALL GLAUCOMA MEDICATIONS HAVE AN
IMPACT
Broadway et al. Arch Ophthalmol. 1994;112:1437-1445

11. PEOPLE DON’T TAKE THEM ANYWAY……
• Healey et al.
2014

12. ADVANCES IN LASER SURGERY

13. SELECTIVE LASER TRABECULOPLASTY
• Increasing use typically primary or adjunctive
therapy
• Cost effective vs drops1
• GITS Trial (Aus): Head to head initial treatment
trial SLT vs Latanoprost
• LIGHT Study (UK): Quality of life in patients
with SLT as initial treamtment vs drops
• Transcleral application may work as well as
using a lens to treat the meshwork2,3
• 1Stein JD et al. Arch Ophthalmol. 2012; 130(4):
497–505.
• 2Belkin M, Invest Ophthalmol Vis Sci.
2013;54:e-abstract 1863.
• 3Belkin M, Invest Ophthalmol Vis Sci.
2014;55:e-abstract 819.

14. 0
5
10
15
20
25
30
PreSLT 6 weeks 6 months 9 months 12 months
IOP (mmHg)

15. Zhekov I et al BMJ Open. 2013 Jul 6;3(7).

16. ENDOSCOPIC
CYCLOPHOTOCOAGULATION
• Usually combined with Phaco
• Up to 300 deg treated at a time
Lindfield D, Ritchie RW, Griffiths MF.
Phaco-ECP': combined endoscopic cyclophotocoagulation and
cataract surgery to augment medical control of glaucoma. BMJ
Open. 2012 May 30;2(3).

17. WHERE ARE WE UP TO WITH TUBES
AND TRABS?

18. Trabeculectomy
• Described by Watson and Cairns in 1968
• Still the gold standard for reduction in
IOP
• Channels aqueous outflow into episcleral
venous network through a sclerostomy
under a partial thickness scleral flap
• Rate of flow controlled by
adjustable/releasable sutures
• Antimetabolites like Mitomycin C used
introperatively to reduce conjunctival
scarring and risk of failure
• Less likely to be combined with cataract
surgery than previously
18

19. AVERAGE IOP: MY DATA
0
5
10
15
20
25
30
35
pre op 1 7 30 60 90
AverageIOP(mmHg)
Days Post Op

20. TUBES

21. WILL TUBE OR TRABECULECTOMY GIVE
BETTER IOP CONTROL?
• Basically, we don’t know for sure
• Taken as an article of faith by many
that a trabeculectomy will give a lower
IOP than a tube and is more likely to be
drop free
However,
• PTVT not done as yet
• TVT 5 yr outcome showed similar IOP
control with same number of
medications but higher rate of
trabeculectomy failure 1
• 1:Gedde et al Am J Ophthalmol. 2012
May;153(5):789-803
21

22. MINIMALLY INVASIVE DRAINAGE
SURGERY

23. DEEP SCLERECTOMY
• Relies on percolation of fluid rather
than direct filtration
• Selling point is perceived safety,
lower risk hypotony
• Some (40-50%) need YAG
goniopuncture to reduce IOP
making it a staged penetrating
surgery
Sarodia U, Shaarawy T, Barton K.
Nonpenetrating glaucoma
surgery: a critical evaluation. Curr
Opin Ophthalmol. 2007
Mar;18(2):152-8

24. CANALOPLASTY
• Suture in Canal of Schlemm
opening it up
• Significant learning curve (21%
did not achieve full
canalisation, 12% developed a
bleb)1
• After 3 yrs: (12.7%), transient
IOP elevation (6.4%), and
partial suture extrusion through
the trabecular meshwork
(0.6%)2
1 Lewis et al. Canaloplasty: circumferential viscodilation
and tensioning of Schlemm's canal using a flexible
microcatheter for the treatment of open-angle glaucoma in
adults: interim clinical study analysis. J Cataract Refract
Surg. 2007;33:1217–1226
2Lewis et al. Canaloplasty: Three-year results of
circumferential viscodilation and tensioning of
Schlemm canal using a microcatheter to treat
open-angle glaucoma.J Cataract Refract Surg. 2011;
37:682-90.

25. ISTENT
• Sixty-six percent of treatment eyes versus
48% of control eyes achieved ≥20% IOP
reduction without medication (P = 0.003)
Samuelson TW, Katz LJ, Wells JM, Duh YJ,
Giamporcaro JE; US iStent Study Group.
Randomized evaluation of the trabecular
micro-bypass stent with phacoemulsification
in patients with glaucoma and cataract.
Ophthalmology. 2011 Mar;118(3):459-67.
Epub 2010 Sep 15.

26. HYDRUS MICROSTENT

27. STARFLO IMPLANT
CYPASS
Shunt into choroidal space
Multiple attempts to use this pathway
previously without success
Undergoing trials at present (COMPAS)