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80 EW MEETING REPORTER September 2013 continued from page 79 Live reports from the World Glaucoma Congress, July 17-20, Vancouver coma" symposium, glaucoma specialists presented clinical data on the subject. These ranged from glaucoma patients' fear of falling and how that can impact their lives, to having less physical activity because of visual loss, and being unable to recognize faces or defensively drive a car. Simon J. Warner, MD, Canada, gave the "Rehabilitation in patients with glaucoma-related lowvision" presentation, wrapping up the symposium. He said that many patients are unaware of their visual loss. He echoed Mr. Lovett's request that glaucoma specialists not wait until patients have significant visual loss to refer them for vision loss assistance, but refer them for low vision therapy when they have the beginnings of visual loss so they can better navigate their environment. "Any amount of visual loss can result in frustration, fear, and anxiety," Dr. Warner said. "And even a small loss can lead to disability and anxiety. This is why you need to refer early … please don't wait until patients are legally blind before referring for visual rehabilitation." "The more residual vision that patients have, the better we can do, and the better we can prepare them for future changes and future loss," Dr. Warner said. Hot topics in glaucoma discussed Image sources: Tourism Vancouver/Canadian Tourism Commission (CTC) Key developments in hot topics in glaucoma were discussed at the "What's hot in glaucoma – important contributions in the past year" symposium, ranging from glaucoma genetics to the future of neuroprotection to the current status of minimally invasive glaucoma surgery. Jamie Craig, MD, Australia, presented "The hunt for glaucoma genes – a status report"; Ronnie George, MD, India, presented "Angle closure in the developing world: What does the future hold?"; M. Francesca Cordeiro, MD, U.K., presented "Is neuroprotection feasible?"; Iqbal (Ike) K. Ahmed, MD, Canada, presented "Minimally invasive glaucoma surgery (MIGS) – where we are, where we're going to"; Neeru Gupta, MD, Canada, presented "Glaucoma as a disease of the central nervous system"; and Michael V. Boland, MD, U.S., presented "Glaucoma meets clinical informatics – what the future holds." In all areas of development, physicians discussed new possibilities, including using genetic testing to treat patients with a higher risk percentile for developing glaucoma earlier, how economics might impact angle closure glaucoma in developing nations, and how future glaucoma neuroprotection researchers might take notice of the persistence of researchers in other neurological fields, including Parkinson's, Alzheimer's, and strokes. Dr. Ahmed outlined clinical evidence of the effectiveness and good safety profile of MIGS procedures. He said he is looking forward to how MIGS will fill the gap between medical treatment and filtration surgery. "I think the era is exciting for MIGS, and we have a lot of opportunity to study this further," he said. Physicians: Generics vs. brand name debate complicated The same brand name and generic glaucoma drug are not always the same in potency and particulates, experts say. Generic drugs are not held under the same strict requirements that brand name drugs are and can have different bottles that confuse patients; in addition, the cost differential might not be as significant as many think. These are only a few of the issues that complicate the brand name vs. generic debate. At "Generic drugs in glaucoma," two of the three authors who have published on the topic—Malik Y. Kahook, MD, U.S., and Zaid Mammo, MD, Canada (the third, a physician from India, was not present)—presented their results as well as tips for physicians. Two other physicians, E.F. Meier-Gibbons, MD, Switzerland, and Cindy Hutnik, MD, Canada, gave their views on the economic implications and IOP-lowering efficacy, respec- tively. Dr. Kahook and colleagues studied the concentration of the active substance in different temperatures of prostaglandins and carbonic anhydrase inhibitors and found that the generic had a lower mean concentration when the temperature was higher than the brand name drug. They also used microflow imaging and found more particulates in the generic, which was a drug from India that they ordered from a Canadian pharmacy, as many patients do. Dr. Kahook showed a slide of one of the particulates, which drew gasps from the packed crowd. The particulate was a worm-shaped object, which no longer appeared alive, he said, but was not something he would want patients putting into their eyes. He explained that when a drug goes "off-patent" and can then be made into a generic, the brand name company only has to provide the content ingredients, not the "recipe" or "know-how" for creating the same drug. And in ophthalmology, because it is difficult to test bioequivalence—the target a generic has to meet—generic ophthalmic drugs only have to follow the basic ingredients of the brand name drug. Clinical trials are often not needed for generics. In addition, "prostaglandin analogues are notorious for being very difficult to work with and package," he said. The cost difference is not always less with generics, either. "When we think generic, we think inexpensive, but that's not always the case," Dr. Kahook said. "You can make a lot of money as a company on some of these generics, and the pharmacist can also make a big mark-up on the generics as well." Still, when he can, he prescribes generics to his patients so they can save costs. He suggested that ophthalmologists ask patients to bring in their glaucoma medication bottles and check the generic formulations for the manufacturer name. "Stay alert for an increase in side effects or a decrease in efficacy," Dr. Kahook said. "Consider switching back to brand name if needed." EW