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Currently Available Methods to Treat Open Angle Glaucoma

The document details various methods for treating open-angle glaucoma, including current medical, laser, and surgical interventions. It outlines the objectives of familiarizing participants with the benefits and risks of available glaucoma treatments while also highlighting promising future therapies. The presentation covers the mechanisms of action of different treatments, their potential side effects, and the effectiveness of various surgical techniques.

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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.
What is Glaucoma?
It’s not so simple.
Adjusting the Faucet Aqueous Production
Fixing the Drain Outflow Pathways | Non-physiologic Outflow
Outflow Pathways | Non-physiologic Outflow - Trabecular Meshwork - Schlemm’s Canal - Collector Channel System - Uveal-Scleral Pathway Fixing the Drain
Outflow Pathways | Non-physiologic Outflow - Trabecular Meshwork - Schlemm’s Canal - Collector Channel System - Uveal-Scleral Pathway Fixing the Drain
Outflow Pathways | Non-physiologic Outflow - Trabecular Meshwork - Schlemm’s Canal - Collector Channel System - Uveal-Scleral Pathway Fixing the Drain
Outflow Pathways | Non-physiologic Outflow - Trabecular Meshwork - Schlemm’s Canal - Collector Channel System - Uveal-Scleral Pathway Fixing the Drain
Outflow Pathways | Non-physiologic Outflow - Shunting into sub-conjunctival space - Shunting into suprachoroidal space Fixing the Drain
Outflow Pathways | Non-physiologic Outflow - 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
Eye Drops Beta-blockers | “Selective” Alpha Adrenergic Agonists | Carbonic Anhydrase Inhibitors (CAIs) | Prostaglandin Analogs | Cholinergic Receptors Agonists | Fixed Combination Agents
Eye Drops Beta-blockers
“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 “Turns down the faucet” – Suppresses “Opens the Drain” – Increases outflow
 Ocular irritation  Follicular conjunctivitis  Eyelid retraction  Contact dermatitis  Headache Eye Drops “Selective” Alpha Adrenergic Agonists
 Dry mouth  Systemic hypotension  Bradycardia  Arrythmia  Death Eye Drops “Selective” Alpha Adrenergic Agonists
 infants and small children  treat small (~1mm) ptosis  Normal Tension Glaucoma (NTG) Eye Drops “Selective” Alpha Adrenergic Agonists
Eye Drops Carbonic Anhydrase Inhibitors (CAIs)
Eye Drops Carbonic Anhydrase Inhibitors (CAIs) “Turns down the faucet” – Decreases aqueous production
 Ocular irritation  Punctate keratopathy  Blurred vision  Bitter taste Eye Drops Carbonic Anhydrase Inhibitors (CAIs)
 90%  ~15% reduction  corneal endothelial dysfunction Eye Drops Carbonic Anhydrase Inhibitors (CAIs)
Eye Drops Prostaglandin Analogs
Eye Drops Prostaglandin Analogs “Opens the drain” – Increases uveoscleral outflow
 Conjunctival hyperemia  Iris color change  Lash growth  Periorbitopathy Eye Drops Prostaglandin Analogs
 Intraocular inflammation  Macular edema  Herpes virus reactivation  Headaches Eye Drops Prostaglandin Analogs
Eye Drops Cholinergic Receptors
Eye Drops Cholinergic Receptors Agonists “Opens the drain” – Increases outflow through trabecular meshwork
 Brow ache/Headache  Poor night vision (secondary to miosis)  Induced myopia Eye Drops Cholinergic Receptors Agonists
 Retinal detachment  Cicatricial conjunctival pemphigoid  Corneal endothelial toxicity  Band keratopathy Eye Drops Cholinergic Receptors Agonists
• Cosopt – Timolol + Dorzolamide • Combigan – Timolol + Brimonidine • Simbrinza – Brimonidine + Brinzolamide Eye Drops Fixed Combination Agents
Oral Medications Carbonic Anhydrase Inhibitors (CAIs)
Oral Medications Carbonic Anhydrase Inhibitors (CAIs) “Turns down the faucet” – Decreases aqueous production – more effective
 Transient myopia  Frequent urination  Light-headedness  Parasthesias (extremity tingling) Oral Medications Carbonic Anhydrase Inhibitors (CAIs)
 Dehydration  Malaise  Weight loss  GI symptoms  Hypokalemia Oral Medications Carbonic Anhydrase Inhibitors (CAIs)
 Metabolic acidosis  Kidney stones  Aplastic Anemia  Death Oral Medications Carbonic Anhydrase Inhibitors (CAIs)
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 Micropulse Cyclophotocoagulation (MP3) • Uses a slow application of laser energy that is “chopped” into micropulses (or, bursts). • Does not burn or destroy eye tissue
Laser Treatment Micropulse Cyclophotocoagulation (MP3) 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 Micropulse Cyclophotocoagulation (MP3) Video Credit: Robert Noecker, MD
Laser Treatment Micropulse Cyclophotocoagulation (MP3) • 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
Traditional “Penetrating” Trabeculectomy  Fistula  Bleb dependent  Bleb failure  Lifetime risk of infection  Lifestyle Limitation
Traditional “Penetrating” 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
Traditional “Penetrating” Glaucoma Drainage Devices  Non-Valved vs. Valved  Movement of the implant  Infection  Scarring  Double Vision
Traditional “Penetrating” 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 Lower Risk Surgeries Ab-Externo Canaloplasty
Lower Risk Surgeries Ab-Externo Canaloplasty Video Credit: Ellex.com
Lower Risk Surgeries Ab-Externo Canaloplasty
Lower Risk Surgeries Ab-Externo Canaloplasty
Lower Risk Surgeries Ab-Externo Canaloplasty
Lower Risk Surgeries 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 Lower Risk Surgeries Ab-Externo Canaloplasty
Lower Risk Surgeries Ab-Interno Canaloplasty  Comprehensive: treats trabecular meshwork, Schlemm’s canal and collector channels  Better aqueous outflow  No permanent implant or stent
Lower Risk Surgeries Ab-Interno Canaloplasty Video Credit: Ellex.com
Exam n Mean IOP (mm Hg) ± 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 Lower Risk Surgeries Ab-Interno Canaloplasty
Exam n Mean IOP (mm Hg) ± SD Mean Medications (n) ± 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 Reduction in IOP and medication use for all enrolled patients Lower Risk Surgeries Ab-Interno Canaloplasty
Exam n Mean IOP (mm Hg) ± SD Mean Medications (n) ± 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 Reduction in IOP and medication use for all enrolled patients Lower Risk Surgeries Ab-Interno Canaloplasty
Trabeculotomy MIST • GATT • Trabectome • Kahook Dual Blade Trabeculotomy
• 45% Average IOP reduction (2 Years Study)  Low risk procedure  After canaloplasty (with stent) Lower Risk Surgeries 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 Lower Risk Surgeries
 For ocular hypertension or mild open angle glaucoma  Done with cataract surgery  Limits future surgeries  Expensive Ab-Interno Trabeculotomy: Trabectome™ Lower Risk Surgeries
Lower Risk Surgeries 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 Lower Risk Surgeries
Trabeculotomy – Kahook Dual Blade Lower Risk Surgeries Video Credit: Leonard Seibold, MD
 For ocular hypertension or mild open angle glaucoma  Done with cataract surgery  Limits future surgeries  Expensive iStent Lower Risk Surgeries
iStent Lower Risk Surgeries Video Credit: Ike Ahmed, MD
• One Year Results (IOP < 22mmHg): – Cataract surgery alone: 50% – iStent plus CE/IOL: 72% iStent Lower Risk Surgeries
• Two Year Results (IOP < 22mmHg): – Cataract surgery alone: 61% – iStent plus CE/IOL: 71% – NOT statistically significant! iStent Lower Risk Surgeries
• 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® Lower Risk Surgeries
CyPass Micro-Stent® Lower Risk Surgeries
• 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) CyPass Micro-Stent® Lower Risk Surgeries
• Two Years Results – 72.5% of patient with CyPass achieved this reduction vs. 58% with cataract surgery alone. CyPass Micro-Stent® Lower Risk Surgeries
CyPass Micro-Stent® Lower Risk Surgeries 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 Lower Risk Surgeries
Xen 45 Gel Stent Lower Risk Surgeries
• 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 Lower Risk Surgeries
• 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 Lower Risk Surgeries
 Hyphema  Short- or long-term hypotony (IOP that is too low)  loss of vision (6.2% long-term loss) Xen 45 Gel Stent Lower Risk Surgeries
Cataract Surgery Lower Risk Surgeries • 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 “Opens the drain” – ‘Relaxes’ the Trabecular Meshwork
Medications Norepinephrine Transporter (“NET”) Inhibitors “Turns down the faucet” – 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 Stegmann Canal Expander Video Credit: Matthias C. Grieshaber, MD
• Success Rate Surgery Stegmann Canal Expander
Surgery Stegmann Canal Expander
THANK YOU (626) 289 7856 david@new-glaucoma-treatments.com

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Currently Available Methods to Treat Open Angle Glaucoma

  • 1.
    Adjusting the Faucetor Opening the Drain – Currently Available Methods to Treat the Plumbing Problem of Open Angle Glaucoma
  • 2.
    Course Objective At theend 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.
  • 3.
  • 4.
  • 7.
  • 8.
    Fixing the Drain OutflowPathways | Non-physiologic Outflow
  • 9.
    Outflow Pathways |Non-physiologic Outflow - Trabecular Meshwork - Schlemm’s Canal - Collector Channel System - Uveal-Scleral Pathway Fixing the Drain
  • 10.
    Outflow Pathways |Non-physiologic Outflow - Trabecular Meshwork - Schlemm’s Canal - Collector Channel System - Uveal-Scleral Pathway Fixing the Drain
  • 11.
    Outflow Pathways |Non-physiologic Outflow - Trabecular Meshwork - Schlemm’s Canal - Collector Channel System - Uveal-Scleral Pathway Fixing the Drain
  • 12.
    Outflow Pathways |Non-physiologic Outflow - Trabecular Meshwork - Schlemm’s Canal - Collector Channel System - Uveal-Scleral Pathway Fixing the Drain
  • 13.
    Outflow Pathways |Non-physiologic Outflow - Shunting into sub-conjunctival space - Shunting into suprachoroidal space Fixing the Drain
  • 14.
    Outflow Pathways |Non-physiologic Outflow - Shunting into sub-conjunctival space - Shunting into suprachoroidal space Fixing the Drain
  • 15.
    Currently Available Glaucoma Treatments (FDAApproved) MEDICAL • LASER • INCISIONAL
  • 16.
    Currently Available Medical Treatments (FDAApproved) EYE DROPS • ORAL MEDICATIONS
  • 17.
    Eye Drops Beta-blockers |“Selective” Alpha Adrenergic Agonists | Carbonic Anhydrase Inhibitors (CAIs) | Prostaglandin Analogs | Cholinergic Receptors Agonists | Fixed Combination Agents
  • 18.
  • 19.
    “Turns down thefaucet” – Suppresses – Inhibits Eye Drops Beta-blockers
  • 20.
     Ocular irritation Bradycardia  Arrhythmia  Heart Block  Systemic hypotension  Heart failure Eye Drops Beta-blockers
  • 21.
     Central nervoussystem depression  Impotence  May mask signs of hypoglycemia  Exacerbation of Asthma  Death Eye Drops Beta-blockers
  • 22.
  • 23.
    Eye Drops “Selective” AlphaAdrenergic Agonists “Turns down the faucet” – Suppresses “Opens the Drain” – Increases outflow
  • 24.
     Ocular irritation Follicular conjunctivitis  Eyelid retraction  Contact dermatitis  Headache Eye Drops “Selective” Alpha Adrenergic Agonists
  • 25.
     Dry mouth Systemic hypotension  Bradycardia  Arrythmia  Death Eye Drops “Selective” Alpha Adrenergic Agonists
  • 26.
     infants andsmall children  treat small (~1mm) ptosis  Normal Tension Glaucoma (NTG) Eye Drops “Selective” Alpha Adrenergic Agonists
  • 27.
  • 28.
    Eye Drops Carbonic AnhydraseInhibitors (CAIs) “Turns down the faucet” – Decreases aqueous production
  • 29.
     Ocular irritation Punctate keratopathy  Blurred vision  Bitter taste Eye Drops Carbonic Anhydrase Inhibitors (CAIs)
  • 30.
     90%  ~15%reduction  corneal endothelial dysfunction Eye Drops Carbonic Anhydrase Inhibitors (CAIs)
  • 31.
  • 32.
    Eye Drops Prostaglandin Analogs “Opensthe drain” – Increases uveoscleral outflow
  • 33.
     Conjunctival hyperemia Iris color change  Lash growth  Periorbitopathy Eye Drops Prostaglandin Analogs
  • 34.
     Intraocular inflammation Macular edema  Herpes virus reactivation  Headaches Eye Drops Prostaglandin Analogs
  • 35.
  • 36.
    Eye Drops Cholinergic ReceptorsAgonists “Opens the drain” – Increases outflow through trabecular meshwork
  • 37.
     Brow ache/Headache Poor night vision (secondary to miosis)  Induced myopia Eye Drops Cholinergic Receptors Agonists
  • 38.
     Retinal detachment Cicatricial conjunctival pemphigoid  Corneal endothelial toxicity  Band keratopathy Eye Drops Cholinergic Receptors Agonists
  • 39.
    • Cosopt – Timolol+ Dorzolamide • Combigan – Timolol + Brimonidine • Simbrinza – Brimonidine + Brinzolamide Eye Drops Fixed Combination Agents
  • 40.
  • 41.
    Oral Medications Carbonic AnhydraseInhibitors (CAIs) “Turns down the faucet” – Decreases aqueous production – more effective
  • 42.
     Transient myopia Frequent urination  Light-headedness  Parasthesias (extremity tingling) Oral Medications Carbonic Anhydrase Inhibitors (CAIs)
  • 43.
     Dehydration  Malaise Weight loss  GI symptoms  Hypokalemia Oral Medications Carbonic Anhydrase Inhibitors (CAIs)
  • 44.
     Metabolic acidosis Kidney stones  Aplastic Anemia  Death Oral Medications Carbonic Anhydrase Inhibitors (CAIs)
  • 45.
    Currently Available Surgical Treatments (FDAApproved) LASER • INCISIONAL
  • 46.
    Laser Treatments Iridotomy |Iridoplasty | Trabeculoplasty | Cyclodestructive Procedures
  • 47.
    • For Narrow/ClosedAngle Glaucoma • Eliminates pupillary block Laser Treatment Iridotomy
  • 48.
    • For PlauteauIris Glaucoma Laser Treatment Iridoplasty
  • 49.
  • 50.
  • 51.
    Laser Trabeculoplasty Argon |Selective | Micropulse
  • 52.
     For openangle glaucoma  Performed in 1 or 2 sessions  May result in microscopic scars  May limit future surgeries Laser Treatment Argon Laser Trabeculoplasty (ALT)
  • 53.
     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)
  • 54.
    Laser Treatment Selective LaserTrabeculoplasty (SLT) Video Credit: Prof. Philippe Denis,University Hospitals of Lyon
  • 55.
     Micro-pulses  Lessdamage and scarring  Minimal inflammation and post-operative IOP elevation Laser Treatment Micropulse Laser Trabeculoplasty (MLT)
  • 56.
    • Continuous WaveCyclophotocoagulation – Ab-Externo (i.e. IRIDEX G6 laser) – Ab-Interno (EndoCycloPhotocoagulation (ECP) • Micropulse Cyclophotocoagulation (MP3) Laser Treatment “Cyclodestructive” Procedures
  • 57.
    Laser Treatment Ab-Externo CWCyclophotocoagulation • 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
  • 58.
     For mildto moderate glaucoma  Done with cataract surgery  Relatively low risk glaucoma treatment × Uveitis - quite severe after ECP Laser Treatment Ab-Interno CW Cyclophotocoagulation EndoCycloPhotocoagulation (ECP)
  • 59.
  • 60.
    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
  • 61.
    Laser Treatment Micropulse Cyclophotocoagulation(MP3) • Uses a slow application of laser energy that is “chopped” into micropulses (or, bursts). • Does not burn or destroy eye tissue
  • 62.
    Laser Treatment Micropulse Cyclophotocoagulation(MP3) 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)
  • 63.
    Laser Treatment Micropulse Cyclophotocoagulation(MP3) Video Credit: Robert Noecker, MD
  • 64.
    Laser Treatment Micropulse Cyclophotocoagulation(MP3) • Common complications: – pupil dilation (11%), – corneal surface drying (7%), – significant inflammation (3%), – swelling of the macula (2%), and – decreased near vision (2%).
  • 65.
    Incisional Surgery Traditional “Penetrating”Surgical Methods | Lower Risk Surgeries
  • 66.
  • 67.
    Traditional “Penetrating” Trabeculectomy  Fistula Bleb dependent  Bleb failure  Lifetime risk of infection  Lifestyle Limitation
  • 68.
    Traditional “Penetrating” Trabeculectomy Photo Sources: CysticBleb: 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
  • 69.
    Traditional “Penetrating” Glaucoma DrainageDevices  Non-Valved vs. Valved  Movement of the implant  Infection  Scarring  Double Vision
  • 70.
  • 71.
    Lower Risk Surgeries Ab-Externo(Canaloplasty) | Ab-Interno aka MIGS
  • 72.
     “Non-Penetrating”  NoHole. No Bleb  Lower IOP. Fewer Drops  Safer than traditional surgeries  Pro-Active Lifestyle Photo credit: ellex.com Lower Risk Surgeries Ab-Externo Canaloplasty
  • 73.
    Lower Risk Surgeries Ab-ExternoCanaloplasty Video Credit: Ellex.com
  • 74.
  • 75.
  • 76.
  • 77.
    Lower Risk Surgeries Ab-Internoaka Minimally Invasive Glaucoma Surgery (MIGS) • Ab-Interno Canaloplasty (ABiC) • Trabeculotomy • iStent • CyPass • Xen Gel Stent • Cataract Surgery
  • 78.
    Exam n MeanIOP (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 Lower Risk Surgeries Ab-Externo Canaloplasty
  • 79.
    Lower Risk Surgeries Ab-InternoCanaloplasty  Comprehensive: treats trabecular meshwork, Schlemm’s canal and collector channels  Better aqueous outflow  No permanent implant or stent
  • 80.
    Lower Risk Surgeries Ab-InternoCanaloplasty Video Credit: Ellex.com
  • 81.
    Exam n MeanIOP (mm Hg) ± 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 Lower Risk Surgeries Ab-Interno Canaloplasty
  • 82.
    Exam n MeanIOP (mm Hg) ± SD Mean Medications (n) ± 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 Reduction in IOP and medication use for all enrolled patients Lower Risk Surgeries Ab-Interno Canaloplasty
  • 83.
    Exam n MeanIOP (mm Hg) ± SD Mean Medications (n) ± 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 Reduction in IOP and medication use for all enrolled patients Lower Risk Surgeries Ab-Interno Canaloplasty
  • 84.
    Trabeculotomy MIST • GATT• Trabectome • Kahook Dual Blade Trabeculotomy
  • 85.
    • 45% AverageIOP reduction (2 Years Study)  Low risk procedure  After canaloplasty (with stent) Lower Risk Surgeries Micro-invasive Suture Trabeculotomy (MIST)
  • 86.
    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 Lower Risk Surgeries
  • 87.
     For ocularhypertension or mild open angle glaucoma  Done with cataract surgery  Limits future surgeries  Expensive Ab-Interno Trabeculotomy: Trabectome™ Lower Risk Surgeries
  • 88.
    Lower Risk Surgeries Ab-InternoTrabeculotomy: Trabectome™
  • 89.
    Trabeculotomy – KahookDual Blade • Incises TM via clear corneal micro incision • Paired with cataract surgery or alone • No bleb and no implant left behind Lower Risk Surgeries
  • 90.
    Trabeculotomy – KahookDual Blade Lower Risk Surgeries Video Credit: Leonard Seibold, MD
  • 91.
     For ocularhypertension or mild open angle glaucoma  Done with cataract surgery  Limits future surgeries  Expensive iStent Lower Risk Surgeries
  • 92.
    iStent Lower Risk Surgeries VideoCredit: Ike Ahmed, MD
  • 93.
    • One YearResults (IOP < 22mmHg): – Cataract surgery alone: 50% – iStent plus CE/IOL: 72% iStent Lower Risk Surgeries
  • 94.
    • Two YearResults (IOP < 22mmHg): – Cataract surgery alone: 61% – iStent plus CE/IOL: 71% – NOT statistically significant! iStent Lower Risk Surgeries
  • 95.
    • For cataractpatients 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® Lower Risk Surgeries
  • 96.
  • 97.
    • Two YearsResults – 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) CyPass Micro-Stent® Lower Risk Surgeries
  • 98.
    • Two YearsResults – 72.5% of patient with CyPass achieved this reduction vs. 58% with cataract surgery alone. CyPass Micro-Stent® Lower Risk Surgeries
  • 99.
    CyPass Micro-Stent® Lower RiskSurgeries 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%)
  • 100.
     6.0 millimeterlong 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 Lower Risk Surgeries
  • 101.
    Xen 45 GelStent Lower Risk Surgeries
  • 102.
    • One YearResults (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 Lower Risk Surgeries
  • 103.
    • Three YearResults (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 Lower Risk Surgeries
  • 104.
     Hyphema  Short-or long-term hypotony (IOP that is too low)  loss of vision (6.2% long-term loss) Xen 45 Gel Stent Lower Risk Surgeries
  • 105.
    Cataract Surgery Lower RiskSurgeries • Cataract surgery alone on an eye with glaucoma will sometimes lower the pressure in the eye.
  • 106.
    Next Generation Plumbing What’s “Inthe Pipeline”? MEDICATIONS | SURGERY
  • 107.
    Next Generation Plumbing ROCK& NET Inhibitors | Adenosine Receptor Agonists | Modified Prostaglandin Analogs MEDICATIONS
  • 108.
    Medications Rho-Kinase “ROCK” Inhibitors “Opensthe drain” – ‘Relaxes’ the Trabecular Meshwork
  • 109.
  • 110.
    Medications Adenosine Receptor Agonists •Work by increasing outflow through Trabecular Meshwork (TM)
  • 111.
    Medications Modified Prostaglandin Analogs •PG plus Nitric Oxide – Nitric Oxide relaxes the TM and Schlemm’s Canal
  • 112.
    Next Generation Plumbing iStentSupra | Hydrus™ Microstent | InnFocus MicroShunt | Stegmann Canal Expander SURGERY
  • 113.
    • Implanted aloneor at the time of cataract surgery • IOP reduction of at least – 20% (12 mos.) Surgery iStent Supra
  • 114.
    Video Credit: Dr.Jose I. Belda Surgery iStent Supra
  • 115.
    • For mild,controlled glaucoma undergoing cataract surgery • As long as an eyelash, “scaffolding device” • Done with cataract surgery • Promising Surgery Hydrus™ Microstent
  • 116.
  • 117.
     Shunt restrictsflow reducing risk of hypotony  “a modified trabeculectomy”  Requires bleb to work Surgery InnFocus MicroShunt
  • 118.
    • Tube-shaped “scaffoldingdevice” • Placed into Schlemm’s canal • Keeps up to half of the canal open – permanently. Surgery Stegmann Canal Expander
  • 119.
    Surgery Stegmann Canal Expander VideoCredit: Matthias C. Grieshaber, MD
  • 120.
  • 121.
  • 123.
    THANK YOU (626) 2897856 david@new-glaucoma-treatments.com