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EW SHOW DAILY 62 Meeting Reporter Saturday, April 14, 2018 by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer She described exciting new medication, including latanopros- tene bunod 0.024%—a once-a-day dosing compound that targets the uveoscleral pathway and includes nitric oxide to relax vascular smooth muscles, resulting in more consis- tent pressure lowering compared to timolol. She also described an entirely new class of drugs for glaucoma medical therapy: the Rho kinase (ROCK) inhibitor, which relaxes trabecular meshwork tissues. Trials have shown ROCK inhib- itor to be comparable to twice daily timolol, with consistent IOP reduc- tions across the range of patients. Finally, she said studies are look- ing into the use of sustained release formulations of known effective agents, limiting the need for topical administration. All these options, Dr. Okeke said, aim to preserve vision, allowing patients to concentrate on quality of life. Turning to surgical options for glaucoma treatment, Brian Francis, MD, Arcadia, California, talked about "Navigating the MIGS Landscape." Every MIGS procedure, he said, falls into one of four catego- ries, grouped by method of action: transconjunctival filtration, aque- ous inflow, trabecular outflow, and suprachoroidal outflow. After describing the various options currently available or under investigation, he said that glaucoma surgery should be individualized based on target IOP, type of glauco- ma, health of the conjunctiva and sclera, prior glaucoma surgeries, risk of infection and hypotony, the age and life expectancy of the patient, ability to use glaucoma medications, and patient characteristics. EW Editors' note: This EyeWorld CME Educational Symposium was supported by educational grants from Aerie Phar- maceuticals (Durham, North Carolina), Alcon (Fort Worth, Texas), Allergan (Dublin, Ireland), Carl Zeiss Meditec (Jena, Germany), Glaukos (San Clem- ente, California), New World Medical (Rancho Cucamonga, California), and Santen (Osaka, Japan). Following with the talk on "What's New in Glaucoma Medical Therapy," Constance Okeke, MD, Norfolk, Virginia, began by discuss- ing the current state of medical therapy. She said that the current paradigm is to use multiple IOP lowering agents from one or more of five existing classes: prostaglan- dins, beta blockers, alpha agonists, carbonic anhydrase inhibitors, and parasympathomimetics. Often, she said, patients have to use more than one drop, adding up to as many as 6–12 drops per day. Patients have trouble with compli- ance with just one drop; add more drops and patients have trouble keeping up. Dr. Okeke summed up the checklist for eye drop success as efficacy, simplicity, and tolerability. These criteria have led to options to reduce the number of drops coming to focus at the forefront of glaucoma medical therapy. for staging and providing an idea of the probability of success. Initial workup for patients includes OCTs, more and more using ganglion cell analysis, which Dr. Noecker finds more sensitive, particularly for early cases; look- ing at the macula, for both staging and prognostication purposes; and examining the anterior segment, checking the angle—as a "tip off" for gonioscopy—and assessing the cornea. Preoperative gonioscopy, he said, is essential for planning for MIGS procedures—ab interno proce- dures in particular require an open angle. Other tests they do are aqueous angiography, ocular surface tear film testing—all patients, he said, have ocular surface problems; it's just a matter of degree—corneal hysteresis, and lens assessment. Many practices will already have these tools in the office; all they have to do is use them. T here are a lot of new things in glaucoma these days, said EyeWorld CME Educa- tional Symposium modera- tor Nathan Radcliffe, MD, New York. The session held Friday morning covered the entire spec- trum of glaucoma treatment, from diagnostics to medical and surgical treatments. Robert Noecker, MD, New Haven, Connecticut, kicked off with a talk on "Diagnostic Protocols for the Glaucoma Patients in the Age of MIGS," describing their protocol for working up patients, detailing what they do in their clinics on a daily basis. The goal for glaucoma diagno- sis, he said, has a lot to do with stag- ing the disease. In considering MIGS procedures, he said that while they are quite safe for more severe cases, they might not be as effective. The IOP target is identified based on disease severity. Dr. Noecker said that he still checks visual fields, which is helpful Optimizing glaucoma treatment Dr. Okeke discusses how new glaucoma medications are designed for efficacy, simplicity, and tolerability.

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