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EW SHOW DAILY 68 Meeting Reporter Saturday, May 6, 2017 by Liz Hillman EyeWorld Staff Writer tene bunod 0.024%, Bausch + Lomb, Bridgewater, New Jersey) metabolizes into BAK-free latanoprost and nitric oxide to increase aqueous outflow by acting on the uveoscleral path- way as well as the trabecular mesh- work and Schlemm's canal. Vesneo is under FDA review. There are also several programs developing sus- tained release drug delivery systems. "It's an exciting time in glauco- ma," Dr. Noecker said, acknowledg- ing that the field has received a lot of attention for advances in MIGS, but, he added, medical therapy has seen recent advancements as well. "Medical therapy is still the main- stay of what we do." Finally, Nathan Radcliffe, MD, New York, spoke about the various MIGS options that are available, targeting the different areas that could improve IOP: ab interno tra- beculectomy (Trabectome [NeoMe- dix, Tustin, California] and Kahook Dual Blade [New World Medical, Rancho Cucamonga, California]), ab interno viscocanalostomy (Visco360 [Sight Sciences, Menlo Park, Califor- nia]), trabecular microbypass stent (iStent [Glaukos, San Clemente, California]), supraciliary microstent (CyPass [Alcon, Fort Worth, Texas]), and subconjunctival stent (Xen [Al- lergan]). In the pipeline, there's the MicroShunt (Santen, Osaka, Japan), Hydrus (Ivantis, Irvine, California), and the iStent inject and iStent Su- pra (Glaukos). Dr. Radcliffe said with all the different MIGS options, treatment can be tailored to the patient's needs and, in some cases, MIGS can even be combined. "The benefit of combining MIGS is trying to get a little more efficacy out of these procedures, and we need to learn more and, of course, the cost is something that needs to be addressed," he said. In general, Dr. Radcliffe said MIGS have revolutionized glauco- ma treatment. Though algorithms continue to evolve, Dr. Radcliffe encouraged physicians to start somewhere in this space and advised them to not miss the opportunity to include a MIGS procedure with cataract surgery for the appropriate glaucoma patient. EW Editors' note: This event was supported by educational grants from Alcon, Al- lergan, Bausch + Lomb, and Glaukos. A n EyeWorld CME event on Friday morning focused on diagnostics, medical therapies, and microinvasive glauco- ma surgery (MIGS) for glaucoma patients. According to polling from the audience, 66% of those in atten- dance did not consider themselves glaucoma specialists, but they still saw many glaucoma patients each month (the highest percentage reported seeing between 50 and 100 glaucoma or ocular hypertension pa- tients each month). As such, Doug- las Rhee, MD, Cleveland, moderator of the session, said learning about the different diagnostic, medical, and surgical options for glaucoma patients is important. Thomas Patrianakos, MD, Chicago, discussed diagnostic protocols that can help guide the management of glaucoma. We know glaucoma is a multifactorial disease with pathology in the trabecular meshwork, Schlemm's canal, or in collector channels, he said. "Ideally, you want to target the area of where that pathology is, however, currently, there is no way to determine where the site of pathology is," Dr. Patrianakos add- ed, noting that OCT and aqueous angiography could be the way of the future. What's currently done in terms of diagnostics to guide management is looking at disease severity, extent of visual field damage, imaging stud- ies, and target IOP. "You want to balance safety and efficacy," Dr. Patrianakos said. "The risk of the procedure should not outweigh the risk of the disease." Other factors Dr. Patrianakos mentioned that can help deter- mine the best surgical intervention include the status of the angle with preoperative gonioscopy, status of the conjunctiva and presence of prior surgeries, type of glaucoma (secondary open angle glaucoma, for example, may respond better to trabecular meshwork ablation), sta- tus of the lens (studies suggest tubes might be better for pseudophakic patients, while trabs are better for phakic patients), patient expecta- tions, and financial considerations. Robert Noecker, MD, Fairfield, Connecticut, discussed combination therapies, which he noted are widely available outside the U.S., but not yet approved in the U.S. Dr. Noecker said "getting to the point," or reach- ing the desired target IOP, "is what we really want to do," and combina- tion therapies could get a patient to the target pressure quicker. Combination therapies, Dr. Noecker said, can be more effective than component medications; they can simplify the patient regimen, increasing convenience and com- pliance; they can reduce issues with drop washout/spacing, exposure to preservatives, and may reduce cost. Disadvantages include that the dos- age frequency could be the same for both drugs, exposure to risks or side effects could be the same for both drugs, and there could be formulary rejections. Established combination ther- apies include the timolol 0.5%/bri- monidine 0.2% combination Com- bigan (Allergan, Dublin, Ireland), the timolol 0.5%/dorzolamide 2.0% combination Cosopt (Akorn Phar- maceuticals, Lake Forest, Illinois), and the brinzolamide 1%/brimoni- dine 0.2% combination Simbrinza (Alcon, Fort Worth, Texas). There are several combination drugs in the pipeline, Dr. Noecker said. Roclatan (Aerie Pharmaceu- ticals, Irvine, California) is a rho kinase inhibitor netarsudil and latanoprost that increases aqueous outflow through the trabecular meshwork and lowers episcleral venous pressure. This is currently in Phase 3 clinical trials. Trabodenoson (Inotek Pharmaceuticals, Lexington, Massachusetts) serves to increase outflow with the proven prosta- glandin analogue latanoprost; as a combination therapy, it's in Phase 2 clinical trials. Vesneo (latanopros- Diagnostics, therapies, and MIGS: What's available and what's in the pipeline for glaucoma Dr. Radcliffe spoke about MIGS options available as well as those coming down the pipeline. CME event covers diverse landscape from glaucoma diagnostics to surgical procedures

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