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4 | EYEWORLD DAILY NEWS | JULY 25, 2021 ASCRS ANNUAL MEETING DAILY NEWS Neuroprotection has been talked about for years, Dr. Lew- is said, noting three categories: non IOP-lowering medications, IOP-lowering medications, and devices. He also highlighted vita- mins, diet, and exercise. Devices are an option, but there needs to be something connecting the optic nerve to the brain to be function- al. Genetic targets have exciting potential, Dr. Lewis said, adding that there are a lot of interesting studies in both retina and cornea relating to genetic and regener- ative therapy. It's going to be a multifactorial approach to neuro- protection. In summary, Dr. Lewis said that preventing visual loss from glaucoma in the 21st century will require earlier detection of at-risk patients, more effective IOP-low- ering strategies, and enhanced prescription options. Editors' note: Dr. Lewis has fi- nancial interests with various ophthalmic companies. In terms of greater IOP lowering, Dr. Lewis mentioned prostaglandins and ROCK in- hibitors, which he described as outflow drugs, that can have great efficacy. The limitations, however, are ocular side effects (especially hyperemia) and adherence. Dr. Lewis went on to discuss less complicated surgeries, first mentioning SLT. Pros of this in- clude that SLT has been found to be more cost effective than drops and may be repeated, but it has limited IOP lowering and limited long-term efficacy. "The most exciting thing that came out of glaucoma in my career was MIGS," he said. He said these were utilized to make glaucoma surgery safer, and they allowed comprehensive ophthal- mologists access to the glaucoma space. So why do some patients go blind from glaucoma? It's still under diagnosed, Dr. Lewis said. Additionally, there is still some- thing lacking in compliance and inadequate treatment. Patients have problems applying daily drops. There are problems with adherence, admin- istration, and the amount (limited to drops that penetrate the cornea or sclera). There are also problems with current glaucoma surgery. MIGS devices are not getting the IOP low enough. There is a 50% failure rate at 5 years for trabs and tubes. Despite mitomycin use, wound healing is poorly understood. The bottom line is glaucoma often progresses despite therapy, he said. The unmet needs in pre- venting visual loss in glaucoma are earlier detection of at-risk patients, more effective therapy, and broader treatment options (beyond lowering of IOP). In terms of the need for ear- lier specific detection, Dr. Lewis mentioned diagnostics, screen- ing, and genetics. The number of glaucoma patients is going to double. Physicians have to figure out better ways of detecting the disease and treating it. We make the diagnosis primarily by check- ing pressure and optic nerve and visual field, he said, noting new tests in development that can check and monitor pressure. It's also necessary to get more effective IOP-lowering therapy, he said. IOP is poorly controlled during sleep. Physicians know from studies that pressures are elevated at nighttime. "That gets us back to the way we conventionally treat glaucoma, which is medications," Dr. Lewis said. Some would argue IOP low- ering with drops has been maxed out, while others would say it hasn't been. Intraocular injections have been available for many years to treat infection and inflammatory disease, Dr. Lewis said, including pars plana injections. Advantages of interventional glaucoma are that it avoids systemic side effects, it's a localized therapy, overcomes issues of compliance, and there is a wider range of potential medi- cations. The current challenges for glaucoma, Dr. Lewis said, are ap- propriate medications, an optimal delivery system, and safety. Visual loss in glaucoma arises from damage in the retinal ganglion cells interfering with transmission of visual information to the brain. continued from page 1 Dr. Lewis discusses glaucoma blindness in the Binkhorst Lecture. Source: ASCRS

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