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(Inotek) works by enhancing the extracellular matrix turnover in the trabecular meshwork. Latanoprostene bunod (Vesneo, Bausch + Lomb) chemically combines nitric oxide with latanoprost to create the new molecule, a nitric oxide-donating prostaglandin F2-alpha analogue. Sustained release devices will allow us to use proven prosta- glandin analogues, but reduce our reliance upon patient compli- ance. There are several develop- ment programs under way that will (hopefully) demonstrate long-lasting efficacy. Among them: sustained-release travo- prost delivered via punctal plug (OTX-TP, Ocular Therapeutix) and a long-lasting bimatoprost implant (bimatoprost SR, Aller- gan). There are two latanoprost programs in development: one that uses a punctal plug delivery system (Mati Therapeutics) and one that uses a sustained release insert and Durasert technology (pSivida/Pfizer). With numerous medical therapies and various surgical techniques in our armamen- tarium, we have little reason not to begin customizing our treatment strategies to best meet our patients' visual goals. The subsequent monograph has been designed to show clinicians how the latest diagnostic tools can make diagnosing disease pro- gression easier, why attention to compliance cannot be underrated, and how to customize surgical approaches by incorporating the latest in microinvasive glaucoma surgery (MIGS) techniques. References 1. ASCRS Clinical Survey 2014. Global Trends in Ophthalmology. Fairfax, VA: Amer- ican Society of Cataract and Refractive Surgery, 2014. 2. Lavik E, Kuehn MH, Kwon YH. Novel drug delivery systems for glaucoma. Eye (Lond). 2011;25(5):578–86. 3. Heijl A, Leske MC, Bengtsson B, et al. Reduction of intraocular pressure and glau- coma progression: results from the Early Manifest Glaucoma Trial. Arch Ophthalmol. 2002;120(10):1268–79. Dr. Lewis is the former director of glaucoma, University of California, Davis, and in practice at Sacramento Eye Consultants. He can be contact- ed at rlewiseyemd@yahoo.com. continued from page 1 Figure 1. Number of glaucoma patient visits yearly Source: 2014 ASCRS Clinical Survey Approximately how many patients do you see per year that you would consider as having glaucoma? Overall U.S. Non-U.S. <200 200– 399 400– 599 600–799 800–999 >1000 Don't see Patients/year Glaucoma patients 40 30 20 10 0 Nearly 60% of U.S. respondents see 400 or more glaucoma patients a year, almost twice the rate of non-U.S. respondents Dr. Francis: The newer electro- physiology tests and microper- imetry are easier to perform in patients, and they may give us information that is psychophysi- cal but not as prone to error as a visual field. Patient assessment and treatment plans Dr. Radcliffe: If you're switching from a QD dosing to a BID sched- ule, make sure the patient's care- taker is a BID caretaker. Otherwise, you're likely to get QD dosing for the BID product. Dr. Rhee: I use a 24-2 SITA stan- dard. Nathan Radcliffe, MD: SITA stan- dard rather than the SITA Fast. Dr. Lewis: What do you think of the newer diagnostics? Dr. Rhee: Pattern ERG intrigues me, but I don't think it's main- stream quite yet. Dr. Radcliffe: Spectral-domain OCT with a good software pack- age is still your best tool; I don't think we're at a point of advocat- ing swept-source OCT. The optic nerve head analysis, in terms of tracking longitudinal changes, is less sensitive than the retinal nerve fiber layer analysis. Dr. Lewis: Do you use SITA swap? Dr. Rhee: If the nerve looks ver y suspicious and I'm quite nervous about it, SITA swap ends up being very reassuring for me. I'm much more dependent on psychophysi- cal testing. Dr. Lewis: The disadvantage is it takes a little longer to do. So what is your routine visual field test? Panel discussion Imaging and diagnostics Rick Lewis, MD: During early diagnosis, where do you put the emphasis? Douglas J. Rhee, MD: On both optical coherence tomography (OCT) and visual field equally. I diagnose 50% of new onset cases by visual field, the other half by OCT. We look for structural change with OCT—what does everyone else do? Brian Francis, MD: I use OCT mostly to assess the nerve fiber layer, but also to look at the ganglion cells and the macula. Innovating advanced treatments to increase compliance and improve outcomes for glaucoma patients 2

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