Article

CLINICAL: Glaucoma

New Tools for Patient Care

Glaucoma is a sight-stealing disease. Therefore, O.D.s are consistently trying to stay current on ever-evolving technology.

Here’s a look at such technology within the past five years.

DIAGNOSTIC TECHNOLOGY

FDA-approved in 2015, OCT-A provides 3D, high-resolution images of segmented retinal tissue layers, based on the motion contrast of red blood cell movement across time, sans injection or dye. Specifically, the technology measures optic disc, peripapillary and retinal perfusion, as well as peripapillary vessel density. Optic disc flow is shown to decrease 25% in glaucoma patients vs. normal eyes, and glaucoma-tous eyes have had a smaller percentage of peripapillary vessel density vs. normal eyes.

THERAPEUTIC TECHNOLOGY

  • Latanoprostene Bunod 0.024% (Vyzulta, Bausch + Lomb). FDA-approved in 2017 for the reduction of IOP in ocular hypertension or open-angle glaucoma, the nitric oxide-donating prostanoid FP receptor agonist has a dual mechanism of action, increasing uveoscleral outflow and relaxing the trabecular meshwork to improve conventional outflow. It is dosed once daily.
  • Latanoprost Ophthalmic Emulsion 0.005% (Xelpros, Sun Pharma). FDA-approved in 2018, this drug was developed with SPARC’s Swollen Micelle Microemulsion technology for decreasing IOP in open-angle glaucoma or ocular hypertension. It is dosed once daily, at night, and is BAK-free.
  • Netarsudil 0.02% (Rhopressa, Aerie Pharmaceuticals). Also FDA-approved in 2017 to reduce IOP in ocular hypertension or open-angle glaucoma, it accomplishes this by blocking rho kinase (ROCK) and the norepinephrine transporter, leading to enhanced outflow through the trabecular meshwork and a decrease in aqueous production. Studies confirm its pharmacology enables lower IOP via direct decrease in trabecular outflow resistance, as well as a reduction in episcleral venous pressure and aqueous humor production. The drug may be a useful option for both initial and adjunctive therapy and is dosed once daily.
  • Netarsudil and Latanoprost ophthalmic solution 0.02%/0.005% (Rocklatan, Aerie Pharmaceuticals). At press time, Aerie announced the FDA had approved Rocklatan to reduce elevated IOP in patients with open-angle glaucoma or ocular hypertension. In the once-daily fixed-dose combination drop, netarsudil targets outflow through the trabecular meshwork (see Rhopressa, above) while latanoprost increases fluid outflow through the uveoscleral pathway. Aerie plans to launch the drug in the second quarter of 2019.

SURGICAL TECHNOLOGY

  • Hydrus Microstent (Ivantis Inc.). FDA approved in 2018 and designed to treat mild to moderate primary open-angle glaucoma in conjunction with cataract surgery, this is an 8 mm stent that has a 1 mm inlet segment in the anterior chamber and a 7 mm scaffold segment located in Schlemm’s canal. In a trial (HORIZON) comparing the stent in combination with cataract surgery and cataract surgery alone, the combination group experienced a decrease in IOP by 29.4% from baseline; 86.8% of patients using one preoperative medication were medication free at 24 months. In the cataract surgery-only group, IOP decreased by 20.5% from baseline, and 47.1% of patients using one preoperative medication were medication free at 24 months.
  • iStent Inject (Glaukos). Also FDA approved in 2018 for primary open-angle glaucoma to be used in conjunction with cataract surgery, its injector is preloaded with two stents, resembling punctal plugs, inserted into Schlemm’s canal with the heads located in the anterior chamber. Stents are placed roughly three clock hours apart and allow aqueous to flow through the lumen and into Schlemm’s canal. In the FDA pivotal clinical trial, the iStent inject lowered IOP by 31% from baseline at 24 months, and 84% of patients were drug-free at 23 months. OM