Eyeworld

130 | EYEWORLD | APRIL 2019 G UCOMA by Maxine Lipner EyeWorld Senior Contributing Writer RESEARCH HIGHLIGHT laser for cataract surgery as well as refractive sur- gery, there have been documented acute IOP rises during and immediately after docking with the femtosecond laser system." Investigators wanted to see if that IOP rise continued into the next day and beyond, if there was persistent elevation in IOP, and whether there were any safety concerns about this beyond the procedure itself. The study included patients undergoing fem- tosecond laser-assisted cataract surgery at either the University of Colorado Eye Center or Van- derbilt University who were between the ages of 18 and 89. Patients were divided into two groups: (1) healthy control eyes with no prior history of glaucoma, ocular hypertension, or suspicion of glaucoma, and (2) a glaucoma group that included eyes with documented glaucoma, suspicion of glaucoma, or ocular hypertension. F emtosecond laser-assisted cataract surgery (FLACS) is a potentially safer way for conducting cataract removal, according to some physicians. But what about in those with glaucoma? Results of a study 1 pub- lished in the Journal of Cataract & Refractive Surgery showed that while both glaucoma patients and control eyes had a short-term rise in pressure following the FLACS procedure, this was significantly greater in those with glaucoma, said Leonard Seibold, MD. Investigators wanted to look into this for sev- eral reasons. "The first was that we wanted to see if there was a long-term IOP reduction in patients undergoing FLACS similar to what we know oc- curs after conventional phacoemulsification," Dr. Seibold said. "The second driver was that in prior studies looking at the use of the femtosecond Studying IOP changes in glaucomatous eyes undergoing FLACS There are also now agents capable of en- hancing trabecular outflow as well as influencing episcleral venous pressure (EVP). Dr. Serle noted that netarsudil has been confirmed to reduce episcleral venous pressures, due to the dilation of the episcleral vessels. 2 There's some thought that in cases where the trabecular meshwork has been bypassed with MIGS or trabecular function has been improved with SLT, pressure reduction may be enhanced with an agent that reduces EVP such as netar- sudil, either alone or in combination, she noted. "Netarsudil improves outflow through the entire trabecular outflow pathway," Dr. Serle said. Since damage to the trabecular outflow pathways occurs over a lifetime for glaucoma patients, beginning them early on medications that directly affect trabecular tissues such as Rhopressa (netarsudil, Aerie Pharmaceuticals), Roclatan, and Vyzulta (latanoprostene bunod, Bausch + Lomb) may prevent, slow, or reverse trabecular pathway damage, she said. For those who are on many medications, obtaining compounded drops in which these are mixed together can make the patient's regimen easier. Dr. Brubaker has begun using this ap- proach with a patient who was initially on four medications plus Rhopressa. "She told me she had to put one eye drop in and wait 5 minutes," he said. "It would take about half an hour to get through her eye drop routine." Now, she's able to take just one compounded drop from Imprimis, as well as the Rhopressa, which is not available for compounding. The big question is whether the compounded product will be as effective as the individual ones, he noted, adding that use is still early. Going forward, there is a new class of IOP-reducing compounds beginning Phase 3 trials in 2019, omidenepag isopropyl (EYBELIS, Santen), a selective prostaglandin EP2 receptor agonist, Dr. Serle noted, adding that devices im- planted in the periocular or intraocular space with reservoirs for slow drug release will probably be the next major change, taking patient compliance out of the equation. continued from page 128 About the doctor Leonard K. Seibold, MD Associate professor Director of glaucoma fellowship University of Colorado Eye Center Aurora, Colorado continued on page 131

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