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EW FEATURE 36 may be missing a slow but real pro- gression." Be vigilant about resetting those baselines, too. If a patient has under- gone cataract surgery, the VF may improve slightly so that may be- come the "new" baseline. Similarly, a patient who had been lost to fol- low-up and without drops for any length of time will likely have pro- gression and need a new baseline. Dr. Noecker added the more advanced a patient's glaucoma, the more likely he is to rely upon VF assessment. "I rely heavily on what the end-stage patients tell me," he said. "They're usually very sensitive to visual changes. At that point, they've lost so many ganglion cells already, you won't be able to detect a change as easily." In the future, however, the goal of functional assessment has been to move to something more objective than VF, Dr. Cantor said. "The goal is to take the patient's thumb out of the process." Electrophysiology may offer objectivity, but has been limited by reproducibility and signal-to-noise ratio. "There's still work to be done," Dr. Cantor said, but "hopefully, we're going to be able to isolate the signal from the eye in order to assess retinal ganglion cell function." Ongoing work is attempting to correlate what is being seen with electrophysiology with structural changes to determine the status of glaucoma suspects, he said. If successful, electrophysiology "may be less prone to artifacts than regular VFs," Dr. Noecker said. Diagnosing structural damage Evaluating the optic nerve structure at the time of the initial examina- tion coupled with stereo disc pho- tography "will always be useful," Dr. Liebmann said, and referring back to that original photo will help assess damage as well. These days, most specialists use spectral-domain (SD) OCT technolo- gies, but Dr. Cantor said the "funda- mental" problem with OCT is "the technology keeps progressing so rap- idly that our ability to understand what it presents and the develop- ment of analysis packages of soft- ware to analyze it and understand it can never catch up." Once valida- tion studies have been completed, researchers are using the next generation machines, he said. While swept-source and even SD-OCT is "quite promising, it still needs further validation in longitu- dinal trials to help us determine what changes constitute glaucoma- tous changes vs. natural aging," Dr. Samuels said. "A completely objec- tive test that could identify damage prior to having functional field loss would be ideal." Once damage gets too ad- vanced, "sometimes the SD-OCT doesn't help you," Dr. Liebmann said. "You're more dependent on the functional aspect." For glaucoma specialists, deter- mining whether progression is re- lated to glaucoma or another eye disease is not trivial, Dr. Samuels said, "especially when the disease often progresses quite slowly." "You have to use everything available to you because there is no one magic thing that works on every patient to diagnose progression," Dr. Noecker said. Bottom line? "The yardsticks that we have to measure progression are still crude and we need better," Dr. Cantor said. EW Editors' note: Drs. Noecker and Samuels have no financial interests related to their comments. Dr. Cantor has financial interests with Allergan (Irvine, Calif.), Bausch + Lomb (Bridgewater, N.J.), Liquidia Technologies (Research Triangle Park, N.C.), Mati Therapeutics (Austin, Texas), Mobius Therapeutics (St. Louis, Mo.), and Aerie Pharmaceu- ticals (Bedminster, N.J.). Dr. Liebmann has financial interests with Alcon (Fort Worth, Texas), Allergan, Diopsys (Pine Brook, N.J.), Merz (Frankfurt, Germany), Optovue (Fremont, Calif.), and Quark Pharmaceuticals (Fremont, Calif.). Contact information Cantor: lcantor@iupui.edu Liebmann: jml18@earthlink.net Noecker: noeckerrj@gmail.com Samuels: bcsamuel@uab.edu Glaucoma May 2014 POAG continued from page 35 by Maxine Lipner New glaucoma treatments in the pipeline AT A GLANCE • The new class of Rho-kinase inhibitors works for 24 hours a day and appears to lower pressure. • New spins on latanoprost are being developed including a preservative- free and long-lasting option. • One latanoprost possibility includes a version with a nitric oxide- donating side chain that appears to boost efficacy. • Unique long-lasting approaches from new agents to pellets and contact lenses could replace drops. N ew glaucoma medical treatments are likely to be in the offering soon and will be a welcome addition for practition- ers, believes Steven T. Simmons, MD, associate clinical professor, Al- bany Medical College, Albany, N.Y. "I think there is a tremendous need," Dr. Simmons said. "We haven't had a new class of medicine in our field for the last 15 to 17 years." Because so much time has passed since something new was offered, problems with current medicines are beginning to arise. "Because we're in the second decade of using these medicines, a lot of patients, especially in a tertiary care office like mine, are starting to [be- come] intolerant to classes of medi- cine," Dr. Simmons said. "Patients may be allergic to sulfonamides so it eliminates the topical carbonic an- hydrase inhibitors; they've devel- oped an allergy to brimonidine, or they're starting to develop some orbital issues related to the prostaglandin analogues—so the more classes available, the better off we are." New emerging agents A new class that Dr. Simmons sees as bringing fresh hope is the Rho- kinase inhibitors. "This is an out- flow drug that we believe works 24 hours a day, 7 days a week," he said. "That's important because of the 4 major classes, only 2 work 24 hours a day, 7 days a week—the other 2 classes only work while we're awake." In phase 2 testing, the Rho-kinases appear to be lowering pressure approximately 25% from the untreated baseline, he noted. "This may be on the low end of the various phase 3 studies that brought the prostaglandin ana- logues to market, but may be equal to or better than the beta blockers and alpha agonists," Dr. Simmons said. Dr. Samuels speaks with a patient about the diagnosis of glaucoma and the tests that will be completed during the clinic visit. Source: Nik Layman continued on page 38

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