Eyeworld Daily News

24 | EYEWORLD DAILY NEWS | APRIL 24, 2022 ASCRS ANNUAL MEETING DAILY NEWS Netarsudil works at a cellular level within the trabecular meshwork. It helps improve the trabecular mesh- work outflow facility, with decreased actin-myosin contraction and reduced actin stress fibers and focal adhe- sions in the trabecular meshwork. It also decreases distal resistance with increased diameter of the episcleral veins and decreasing EVP. It's the first class of medication where we're seeing decreased EVP, Dr. Ristvedt added. Dr. Ristvedt also mentioned using SLT as first-line therapy, noting that it can also be used to decrease medica- tion use. The LiGHT trial indicated that 95% in the SLT group achieved their target pressure at 36 months. Dr. Ristvedt then spoke about the drug delivery pipeline, noting that there a lot of new ways to deliver medications. She mentioned options in surface implants, gel-forming drops, intrascleral implants, punctal plugs, subconjunctival implants, injectable drugs, and intracameral implants. Editors' note: Dr. Rhee has financial interests with Allergan, Glaukos, Ivantis, Ocular Therapeutix, Aerie, and Alcon. Dr. Ristvedt has financial interests with Allergan, Glaukos, Sight Sciences, and RxSight. He later discussed staging of the disease and clinical trials. Stages of glaucoma are early/mild, mod- erate, and advanced/severe. Early to moderate may show optic nerve abnormalities consistent with glauco- ma, RNFL changes, but no visual field abnormalities, or abnormalities only present on SWAP or FDT visual field testing. A moderate stage may have signs such as optic nerve abnormalities consistent with glaucoma, RNFL chang- es and visual field abnormalities in one hemifield and not within 5 degrees of fixation. An advanced stage of glauco- ma may be categorized as optic nerve abnormalities consistent with glau- coma, RNFL changes, glaucomatous visual field abnormalities in both hemi- fields, and/or loss within 5 degrees of fixation in at least one hemifield. Dr. Rhee wrapped up his presenta- tion by discussing clinical trials, noting the numerous randomized controlled trials looking at a variety of disease stages. The way to organize them is where the studies fit into the spectrum of disease, he said. Also during the session, Deborah Ristvedt, DO, gave an overview of medications and laser. Some of the challenges in managing glaucoma include frequent dosing, the side effect profile, ocular surface disease, com- pliance, economic burden, decreased quality of life, and glaucoma fatigue. Physicians have begun to think of glau- coma treatment differently, she said. She would like to see options that offer improved efficacy, less side effects, safer therapy, less burden to the patient, with a focus on the ocular sur- face and quality of life. There are now preservative-free, combination options, and new ways of delivering drugs and different mechanisms of action. Dr. Ristvedt detailed some of the newer glaucoma treatments, like nitric oxide-donating prostaglandin ana- logs, rho-kinase inhibitors, netarsudil/ latanoprost ophthalmic solution, intra- cameral implants, and potential future options with sustained drug delivery. D uring the Glaucoma Essen- tials symposium on Saturday morning, Douglas Rhee, MD, presented "Stratifying Stage and Risk for Glaucoma: Using Pivot- al Studies in Glaucoma to Manage Patients." He highlighted risk factors for developing glaucoma, as well as risk factors for blindness from glaucoma. Risk factors for the development of glaucoma include epidemiologic risk factors, clinical risk factors, and genetic risk factors. For ocular hypertensive patients, there is a specific risk factor calculator. In terms of epidemiologic risk fac- tors for developing primary open-angle glaucoma (POAG), Dr. Rhee said that older age, family history (especially first-degree relatives), ancestry, and systemic hypertension may all play a role. Those of African or Asian ancestry may be more likely to develop POAG than those of European ancestry. Dia- betes is not a risk factor, though it used to be considered one. Clinical risk factors may include elevated IOP, suspicious optic nerve findings, and thin central corneal thickness. Dr. Rhee highlighted some specific optic nerve findings that may be suspicious. There may also be optic nerve changes over time, so it's helpful to have photographs. He mentioned some of the many genetic risk factors that may make someone more likely to develop POAG, adding that genetic testing is not commonly used, and there is no com- mercially available testing. As far as risk factors for blindness, predictive risk factors to look at for progression include advanced disease at the time of presentation, elevated IOP, diurnal IOP fluctuations, older age, central corneal thickness, disc hemorrhage, and genetic factors. In the multitude of studies, it's advanced disease at the time of presentation, elevated IOP, and diurnal IOP fluctua- tions that have the most support in the literature, he said. Glaucoma essentials covered in symposium Dr. Ristvedt gives a medication and laser overview, noting how newer options are helping to reshape medical therapy.

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