Currently Available Methods to Treat Open Angle Glaucoma

Adjusting the Faucet or
Opening the Drain –
Currently Available Methods to Treat the
Plumbing Problem of Open Angle Glaucoma

Course Objective
At the end of the presentation audience participants
should be familiar with the main benefits and risks of
currently available glaucoma treatments as well as have
an awareness of the most promising potential future
glaucoma treatments.

Adjusting the Faucet
Aqueous Production

Fixing the Drain
Outflow Pathways | Non-physiologic Outflow

- Trabecular Meshwork
- Schlemm’s Canal
- Collector Channel System
- Uveal-Scleral Pathway
Fixing the Drain

- Shunting into sub-conjunctival space
- Shunting into suprachoroidal space
Fixing the Drain

Currently Available
Glaucoma Treatments
(FDA Approved)
MEDICAL • LASER • INCISIONAL

Currently Available
Medical Treatments
(FDA Approved)
EYE DROPS • ORAL MEDICATIONS

“Turns down the faucet”
– Suppresses
– Inhibits
Eye Drops
Beta-blockers

 Ocular irritation
 Bradycardia
 Arrhythmia
 Heart Block
 Systemic hypotension
 Heart failure
Eye Drops
Beta-blockers

 Central nervous system
depression
 Impotence
 May mask signs of hypoglycemia
 Exacerbation of Asthma
 Death
Eye Drops
Beta-blockers

Eye Drops
“Selective” Alpha Adrenergic

Eye Drops
“Selective” Alpha Adrenergic Agonists
– Suppresses
“Opens the Drain”
– Increases outflow

 Follicular conjunctivitis
 Eyelid retraction
 Contact dermatitis
 Headache
Eye Drops

 Dry mouth
 Systemic hypotension
 Bradycardia
 Arrythmia
 Death
Eye Drops

 infants and small children
 treat small (~1mm) ptosis
 Normal Tension Glaucoma (NTG)
Eye Drops

Eye Drops
Carbonic Anhydrase Inhibitors (CAIs)

Eye Drops
– Decreases aqueous
production

 Punctate keratopathy
 Blurred vision
 Bitter taste
Eye Drops

 90%
 ~15% reduction
 corneal endothelial
dysfunction
Eye Drops

Eye Drops
Prostaglandin Analogs

Eye Drops
“Opens the drain”
– Increases uveoscleral
outflow

 Conjunctival hyperemia
 Iris color change
 Lash growth
 Periorbitopathy
Eye Drops

 Intraocular inflammation
 Macular edema
 Herpes virus reactivation
 Headaches
Eye Drops

Eye Drops
Cholinergic Receptors

Eye Drops
Cholinergic Receptors Agonists
– Increases outflow through
trabecular meshwork

 Brow ache/Headache
 Poor night vision
(secondary to miosis)
 Induced myopia
Eye Drops

 Retinal detachment
 Cicatricial conjunctival
pemphigoid
 Corneal endothelial toxicity
 Band keratopathy
Eye Drops

• Cosopt
– Timolol + Dorzolamide
• Combigan
– Timolol + Brimonidine
• Simbrinza
– Brimonidine + Brinzolamide
Eye Drops
Fixed Combination Agents

Oral Medications

Oral Medications
– Decreases aqueous
production
– more effective

 Transient myopia
 Frequent urination
 Light-headedness
 Parasthesias (extremity
tingling)
Oral Medications

 Dehydration
 Malaise
 Weight loss
 GI symptoms
 Hypokalemia
Oral Medications

 Metabolic acidosis
 Kidney stones
 Aplastic Anemia
 Death
Oral Medications

Currently Available
Surgical Treatments
(FDA Approved)
LASER • INCISIONAL

Laser Treatments
Iridotomy | Iridoplasty | Trabeculoplasty | Cyclodestructive Procedures

• For Narrow/Closed Angle Glaucoma
• Eliminates pupillary block
Laser Treatment
Iridotomy

• For Plauteau Iris Glaucoma
Laser Treatment
Iridoplasty

Glaucoma Surgery
Categories
Non-Invasive Minimally Invasive Penetrating

Glaucoma Surgery
Categories
Shunt Enhance Ablate

Laser Trabeculoplasty
Argon | Selective | Micropulse

 For open angle glaucoma
 Performed in 1 or 2 sessions
 May result in microscopic scars
 May limit future surgeries
Laser Treatment
Argon Laser Trabeculoplasty (ALT)

 Uses a “Q-switched, frequency-doubled Nd:YAG laser”
 Can be performed after ALT
 Less traumatic compared to ALT
 Less damage to the eye tissue
 Quick, usually painless
 Performed in 2 ways: Gonioscopic or Transscleral
Laser Treatment
Selective Laser Trabeculoplasty (SLT)

Laser Treatment
Selective Laser Trabeculoplasty (SLT)
Video Credit: Prof. Philippe Denis,University Hospitals of Lyon

 Micro-pulses
 Less damage and scarring
 Minimal inflammation
and post-operative IOP
elevation
Laser Treatment
Micropulse Laser Trabeculoplasty (MLT)

• Continuous Wave Cyclophotocoagulation
– Ab-Externo (i.e. IRIDEX G6 laser)
– Ab-Interno (EndoCycloPhotocoagulation (ECP)
• Micropulse Cyclophotocoagulation (MP3)
Laser Treatment
“Cyclodestructive” Procedures

Laser Treatment
Ab-Externo CW Cyclophotocoagulation
• Destruction of the ciliary body to to reduce
aqueous humor secretion and lower IOP
• Anesthesia is needed, as the procedure is painful.
× Inflammation and hyptotony

 For mild to moderate glaucoma
 Done with cataract surgery
 Relatively low risk glaucoma treatment
× Uveitis - quite severe after ECP
Laser Treatment
Ab-Interno CW Cyclophotocoagulation
EndoCycloPhotocoagulation (ECP)

Laser Treatment
EndoCycloPhotocoagulation (ECP)

Laser Treatment
Micropulse Cyclophotocoagulation (MP3)
• A “gentler” form of
cyclophotocoagulation
• Appears to work very much
like the eye drop Pilocarpine
• No restrictions on one’s
activities after
• Low risk profile

Laser Treatment
• Uses a slow application of laser energy that is
“chopped” into micropulses (or, bursts).
• Does not burn or destroy eye tissue

Laser Treatment
NUHS Prospective Clinical Study1
• 33% IOP reduction at 18 months, (N = 38 patients)
• 61% med reduction (2.1±1.1 to 1.3±1.0)

Laser Treatment
Video Credit: Robert Noecker, MD

Laser Treatment
• Common complications:
– pupil dilation (11%),
– corneal surface drying (7%),
– significant inflammation (3%),
– swelling of the macula (2%), and
– decreased near vision (2%).

Incisional Surgery
Traditional “Penetrating” Surgical Methods | Lower Risk Surgeries

Traditional “Penetrating”
Surgical Methods
Trabeculectomy | Glaucoma drainage devices

Trabeculectomy
 Fistula
 Bleb dependent
 Bleb failure
 Lifetime risk of infection
 Lifestyle Limitation

Trabeculectomy
Photo Sources:
Cystic Bleb: Research paper: Safe Excision of a Large Overhanging Cystic Bleb Following Autologous Blood Injection and
Compression Suture. Available from:
https://www.researchgate.net/publication/236095083_Safe_Excision_of_a_Large_Overhanging_Cystic_Bleb_Following_A
utologous_Blood_Injection_and_Compression_Suture [accessed Apr 12, 2017]
Scarred Bleb: Ian Murdoch

Glaucoma Drainage Devices
 Non-Valved vs. Valved
 Movement of the implant
 Infection
 Scarring
 Double Vision

Glaucoma Drainage Devices

Lower Risk Surgeries
Ab-Externo (Canaloplasty) | Ab-Interno aka MIGS

 “Non-Penetrating”
 No Hole. No Bleb
 Lower IOP. Fewer Drops
 Safer than traditional surgeries
 Pro-Active Lifestyle
Photo credit: ellex.com
Ab-Externo Canaloplasty

Video Credit: Ellex.com

Ab-Interno aka
Minimally Invasive Glaucoma Surgery (MIGS)
• Ab-Interno Canaloplasty (ABiC)
• Trabeculotomy
• iStent
• CyPass
• Xen Gel Stent
• Cataract Surgery

Exam n Mean IOP (mm Hg) ±
SD
Mean Medications (n) ± SD
Baseline 18 25.2 ± 6.4 2.1 ± 1.0
12 Months 16 16.8± 4.9 0.5 ± 0.6
18 Months 16 15.5 ± 4.2 0.8 ± 0.8
24 Months 14 18.1 ± 5.4 1.0 ± 1.0
30 Months 11 15.5 ± 3.5 0.8 ± 0.9
36 Months 13 16.2 ± 3.3 1.1 ± 0.8
Source: R.A. Lewis, K. von Wolff, M. Tetz, N. Koerber, J.R. Kearney, B.J. Shingleton, T.W. Samuelson. Canaloplasty: three-year results of circumferential viscodilation and
tensioning of Schlemm’s canal using a microcatheter to treat open-angle glaucoma. J. Cataract Refract. Surg., 37 (2011), pp. 682-690.
Three-Year Treatment Outcomes – Ab-Externo Canaloplasty w/o Suture

Ab-Interno Canaloplasty
 Comprehensive: treats trabecular meshwork,
Schlemm’s canal and collector channels
 Better aqueous outflow
 No permanent implant or stent

Video Credit: Ellex.com

SD
Mean Medications (n) ±
SD
Baseline 106 19.5 ± 6.6 2.0 ± 1.0
3 Month 69 15.7 ± 4.4 0.0 ± 1.0
6 Months 69 15.0 ± 3.8 0.0 ± 1.0
12 Months 20 13.9 ± 1.9 0.0 ± 1.0
Source: MAHMOUD A. KHAIMI, MD
Reduction in IOP and medication use for all enrolled patients

SD
SD
Baseline 122 18.6 ± 6.4 2.0 ± 1.0
3 Month 88 14.0 ± 3.4 1.0 ± 1.0
6 Months 65 14.1 ± 3.7 1.0 ± 1.0
12 Months 38 12.9 ± 2.0 1.0 ± 1.0
Source: MARK J. GALLARDO, MD

SD
SD
Baseline 228 19.0 ± 6.5 2.0 ± 1.0
3 Month 157 14.7 ± 3.9 0.0 ± 1.0
6 Months 134 14.5 ± 3.8 1.0 ± 1.0
12 Months 48 13.3 ± 2.0 1.0 ± 1.0
Sources: MAHMOUD A. KHAIMI, MD and MARK J. GALLARDO, MD

Trabeculotomy
MIST • GATT • Trabectome • Kahook Dual Blade Trabeculotomy

• 45% Average IOP reduction (2 Years Study)
 Low risk procedure
 After canaloplasty (with stent)
Micro-invasive Suture Trabeculotomy (MIST)

Gonioscopy-Assisted Transluminal
Trabeculotomy (GATT)
• 37.3% mean IOP reduction (2 Yrs Study)
 conjunctival-preserving
 after failed trabeculectomy or GDD implants
 hyphema complication
 IOP Spike

 For ocular hypertension or mild open angle
glaucoma
 Limits future surgeries
 Expensive
Ab-Interno Trabeculotomy: Trabectome™

Ab-Interno Trabeculotomy: Trabectome™

Trabeculotomy – Kahook Dual Blade
• Incises TM via clear corneal micro incision
• Paired with cataract surgery or alone
• No bleb and no implant left behind

Trabeculotomy – Kahook Dual Blade
Video Credit: Leonard Seibold, MD

 For ocular hypertension or mild open angle
glaucoma
 Limits future surgeries
 Expensive
iStent

iStent
Video Credit: Ike Ahmed, MD

• One Year Results (IOP < 22mmHg):
– Cataract surgery alone: 50%
– iStent plus CE/IOL: 72%
iStent

• Two Year Results (IOP < 22mmHg):
– Cataract surgery alone: 61%
– iStent plus CE/IOL: 71%
– NOT statistically significant!
iStent

• For cataract patients with mild to moderate POAG
• Implanted during cataract surgery
• Placed in the supraciliary space
• Can be placed prior to or after most other
glaucoma surgeries
CyPass Micro-Stent®

• Two Years Results
– 61.2% of patients with CyPass maintained this (vs.
43.5% with cataract surgery alone)
– 32% more effective than cataract surgery alone
(7.0 mmHg vs 5.3 mmHg)

• Two Years Results
– 72.5% of patient with CyPass achieved this
reduction vs. 58% with cataract surgery alone.

Adverse Event
Cataract Surgery
with CyPass (N = 374)
n (%)
Cataract Surgery Only
(N = 131) n (%)
Subjects with Any Adverse Event 147 (39.3%) 47 (35.9%)
BCVA loss => 10 letters read at/after 3
month postoperative visit 33 (8.8% 20 (15.3%)
AC cell and flare requiring steroid treatment
at/after 30 days postoperative3 32 (8.6%) 5 (3.8%)
Worsening in visual field MD by => 2.5 dB
as compared with preoperative 25 (6.7%) 13 (9.9%)
IOP => 10 mmHg over baseline
at/after 30 days postoperative^ 16 (4.3%) 3 (2.3%)
Corneal edema at/after 30 days
postoperative, or severe in nature 13 (3.5% 2 (1.5%)

 6.0 millimeter long flexible tube made of chemically
treated gelatin
 A subconjunctival implant
 Essentially an ab-interno trabeculectomy
 Still requires a bleb to achieve
IOP lowering
Xen 45 Gel Stent

Xen 45 Gel Stent

• One Year Results (with Cataract Surgery)
– ~ 30% IOP reduction
(average drop from 20.8mmHg to 14.4mmHg)
– ~60% Medication reduction
(average decrease from 2.7 to 1.1)
Xen 45 Gel Stent

• Three Year Results (w & w/o Cataract Surgery)
– ~ 40% IOP reduction
– ~ 75% Medication reduction
– 5% of participants required additional
glaucoma surgery to
achieve IOP control.
Xen 45 Gel Stent

 Hyphema
 Short- or long-term hypotony
(IOP that is too low)
 loss of vision (6.2% long-term
loss)
Xen 45 Gel Stent

Cataract Surgery
• Cataract surgery alone on an eye with glaucoma will
sometimes lower the pressure in the eye.

Next Generation
Plumbing
What’s “In the Pipeline”?
MEDICATIONS | SURGERY

Next Generation Plumbing
ROCK & NET Inhibitors | Adenosine Receptor
Agonists | Modified Prostaglandin Analogs
MEDICATIONS

Medications
Rho-Kinase “ROCK” Inhibitors
– ‘Relaxes’ the Trabecular
Meshwork

Medications
Norepinephrine Transporter (“NET”)
Inhibitors
– Reduces aqueous fluid

Medications
Adenosine Receptor Agonists
• Work by increasing outflow
through Trabecular
Meshwork (TM)

Medications
Modified Prostaglandin Analogs
• PG plus Nitric Oxide
– Nitric Oxide relaxes the TM
and Schlemm’s Canal

Next Generation Plumbing
iStent Supra | Hydrus™ Microstent | InnFocus
MicroShunt | Stegmann Canal Expander
SURGERY

• Implanted alone or at the
time of cataract surgery
• IOP reduction of at least
– 20% (12 mos.)
Surgery
iStent Supra

Video Credit: Dr. Jose I. Belda
Surgery
iStent Supra

• For mild, controlled glaucoma
undergoing cataract surgery
• As long as an eyelash,
“scaffolding device”
• Done with cataract surgery
• Promising
Surgery
Hydrus™ Microstent

Surgery
Hydrus™ Microstent
Video Credit: Dr. Ike Ahmed

 Shunt restricts flow reducing risk of
hypotony
 “a modified trabeculectomy”
 Requires bleb to work
Surgery
InnFocus MicroShunt

• Tube-shaped “scaffolding device”
• Placed into Schlemm’s canal
• Keeps up to half of the canal open –
permanently.
Surgery
Stegmann Canal Expander

Surgery
Video Credit: Matthias C. Grieshaber, MD

• Success Rate
Surgery

Surgery

THANK YOU
(626) 289 7856
david@new-glaucoma-treatments.com

Currently Available Methods to Treat Open Angle Glaucoma

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