Eyeworld

Advanced glaucoma treatment: Diagnostics, pharmaceuticals, and surgical options In this CME supplement, experts discuss: • impact of patient compliance on overall disease progression • safety and efficacy of new and current therapies • use of MIGS techniques for long-term glaucoma treatment Read it today at cmesupplements.eyeworld.org Online now! CME Supplement TM Advanced glaucoma treatment: Diagnostics, pharmaceuticals, and surgical options Supplement to EyeWorld August 2016 Supported by Aerie Pharmaceuticals, Alcon Laboratories, Allergan, and Bausch + Lomb Accreditation Statement This activity has been planned and imple- mented in accordance with the accreditation requirements and policies of the Accredi- tation Council for Continuing Medical Edu- cation through the joint providership of the American Society of Cataract & Refractive Surgery (ASCRS) and EyeWorld. ASCRS is ac- credited by the ACCME to provide continuing medical education for physicians. Designation Statement The American Society of Cataract & Refrac- tive Surgery designates this enduring materi- als educational activity for a maximum of 1.0 AMA PRA Category 1 Credits. ™ Physicians should claim only credit commensurate with the extent of their participation in the activity. Educational Objectives Ophthalmologists who participate in this activity will: • Identify the current baseline for safety, efficacy, and patient compliance with conventional therapies and discuss the impact of these levels on the manage- ment of the low-to-moderate glaucoma patient; • Assess the appropriate diagnostics for long-term glaucoma patient analysis and identify proper utilization of advanced features to identify progression; • Explain the patient compliance impact of newly available and emerging phar- maceutical regimens and the collateral changes they may have on treatment protocol efficacy; and • Describe the latest clinical data, proto- cols, appropriate patient candidates, and key surgical steps required to safely and effectively integrate MIGS technologies into practice. Claiming Credit To claim credit, participants may visit bit.ly/29GJ7YZ to review content and down- load the post-activity test and credit claim. All participants must pass the post-activity test with a score of 75% or higher to earn credit. Alternatively, the post-test form included in this supplement may be faxed to the number indicated for credit to be awarded, and a certificate will be mailed within 2 weeks. When viewing online or downloading the material, standard Internet access is required. Adobe Acrobat Reader is needed to view the materials. CME credit is valid through February 28, 2017. CME credit will not be awarded after that date. Notice of Off-Label Use Presentations This activity may include presentations on drugs or devices or uses of drugs or devices that may not have been approved by the Food and Drug Administration (FDA) or have been approved by the FDA for specific uses only. ADA/Special Accommodations ASCRS and EyeWorld fully comply with the legal requirements of the Americans with Disabilities Act (ADA) and the rules and regulations thereof. Any participant in this educational program who requires special accommodations or services should contact Laura Johnson at ljohnson@ascrs.org or 703-591-2220. Financial Interest Disclosures Ike Ahmed, MD, has received a retainer, ad hoc fees, or other consulting income from: Abbott Medical Optics, Accelerated Vision, Ace Vision Group, Ade Therapeutics, Aerie Pharmaceuticals, Alcon Laboratories, Allergan, AqueSys, Bausch + Lomb, Carl Zeiss Meditec, Clarity Medical Systems, Envisia Therapeutics, Eyelight, ForSight Labs, Glaukos Corporation, Iantech, InnFocus, Iridex, Ivantis, KeLo Tec, LayerBio, Leica Microsystems, Oculus, Omega Ophthalmics, Ono Pharma, PolyActiva, Sanoculis, Science Based Health, Transcend Medical, and TrueVision Systems. He has received research funding from AqueSys. Reay Brown, MD, has received a royalty or derives other financial gain from Glaukos and Rhein Medical. He has received research funding from Ivantis and Transcend Medical. Richard Lewis, MD, is a part-time employee of Aerie Pharmaceuticals. He has received a retainer, ad hoc fees, or other consulting income from: Alcon Laboratories, Allergan, AqueSys, AVS, Carl Zeiss Meditec, Envisia Therapeutics, Glaukos Corporation, Ivantis, Oculeve, PolyActiva, and ViSci. Nathan Radcliffe, MD, has received a retainer, ad hoc fees, or other consulting in- come from and is a member of the speakers bureaus of: Alcon Laboratories, Allergan, Carl Zeiss Meditec, Endo Optiks, Glaukos, Iridex, and Reichert. He has received a retainer, ad hoc fees, or other consulting income from Transcend Medical. Staff members: Laura Johnson has no ophthalmic-related financial interests. Beth Marsh has received a retainer ad hoc fees or other consulting income from Akorn and Shire. continued on page 2 This annual survey pro- vided additional information about members' clinical opinions and practice patterns regarding glaucoma management, draw- ing responses from more than 2,000 respondents. To help G laucoma is a significant problem among our pa- tient populations. The 2015 ASCRS Clinical Survey indicated that 30% of members see 50 or more patients with glaucoma each month (average: 41 patients). Panel discusses new developments in ophthalmology diagnostics and treatments by Reay Brown, MD The role of diagnostics, pharmaceuticals, and surgical choices in the pursuit of advanced glaucoma treatment Practice pearl: MIGS tech- nology is being adopted at a rapid rate. Comprehensive ophthalmologists are embrac- ing MIGS as a way to lower pressure or reduce eye drops in their glaucoma patients who need cataract surgery. This may be a paradigm shift because it shows that they are looking at MIGS as an alterna- tive to medical therapy. –Reay Brown, MD Figure 1. ASCRS members indicate their preferred therapy to add to a prostaglandin analog. Advanced glaucoma treatment: Diagnostics, pharmaceuticals, and surgical options 2 by Richard Lewis, MD Addressing patient adherence: Impact on the overall progression of glaucoma Members think 31% of pa- tients receiving 1 topical medica- tion are not compliant and 38% of those receiving more than 1 medication are not compliant. Twenty-four percent of respondents perform microinva- sive glaucoma surgery (MIGS), and 25% plan to offer this within 12 months (Figure 2). Therefore, nearly 50% of respondents are using MIGS or plan to within 12 months, which is an impressive adoption rate. Respondents indicated that 8% of their cataract patients are MIGS candidates. If 3.5 million cataract surgeries are performed in the U.S. each year and 8% are MIGS candidates, this translates into 280,000 cataract plus MIGS procedures per year. This supplement will high- light advancements in glauco- ma management. Our panel of experts will discuss the impact of patient compliance on overall disease progression, as well as the safety and efficacy of new and current therapies and the use of MIGS techniques for long-term glaucoma treatment. Dr. Brown practices with Atlan- ta Ophthalmology Associates in Atlanta. He can be contacted at reaymary@comcast.net. medications are more efficacious and tolerable than generics. Beta blockers were the preferred therapy to add to a prostaglandin analog (54%), followed by an alpha agonist, laser trabeculoplasty, topical carbonic anhydrase inhibitor, and combination aqueous suppressant (Figure 1). ophthalmologists develop more effective treatment strategies for these patients, a team of noted experts will share their insights and recommendations in this supplement. The survey reported that 75% of members prescribe a pros- taglandin analog as a first-line therapy, and 54% think brand continued from page 1 Advanced diagnostics are improving glaucoma management, but non- compliance may alter outcomes N ew diagnostic, pharma- cologic, and surgical developments continue to enhance glaucoma management. To obtain optimum treatment outcomes, however, ophthalmologists need to use them well and enhance patient compliance. Case report A 56-year-old man referred for glaucoma with progressive field loss complained of recurrent hy- peremia with his medications. His highest intraocular pressure (IOP) was 21 mm Hg. He had a long history of reference to cupping and borderline IOP. He had no history of steroid use, ocular trau- ma, diabetes, or hypertension. His vision was 20/20 in both eyes, his IOPs were 20 and 21 mm Hg, and his cornea was slightly thin. He had hyperemia in his conjunctiva but otherwise a normal anterior segment. He also had cupping. Images from our non-mydri- atic camera showed an inferior Practice pearl: Showing patients images of their optic disc (as compared to normals) is a great motivator to enhance understanding of the disease and compliance. –Richard Lewis, MD " The non-mydriatic camera has been a huge boost to our practice, providing an image within 30 to 60 seconds. " –Richard Lewis, MD continued on page 3 Figure 2. The survey asked: "Which of the following best describes your use of/interest in MIGS?" Supported by Aerie Pharmaceuticals, Alcon Laboratories, Allergan, and Bausch + Lomb 6 7 Panel discussion Reay Brown, MD: Dr. Ahmed, in an average cataract case, when a patient is using 2 drops for glaucoma but the intraocular pressure (IOP) is not very high, what is your typical microinvasive glaucoma surgery (MIGS) combi- nation? Ike Ahmed, MD: When we combine glaucoma surgery with cataract surgery, safety is para- mount because refractive out- comes and recovery are critical to patient satisfaction and outcomes. I think the canal space is the ideal place for safety and for a modest IOP reduction. Dr. Brown: Dr. Radcliffe, what types of combinations do you use? Nathan Radcliffe, MD: I com- bine endocyclophotocoagulation with a variety of outflow proce- dures, such as the micro-stent (iStent) or a goniotomy. Dr. Brown: Do any of you recommend cataract surgery a bit earlier to take advantage of IOP reduction? Richard Lewis, MD: Cataract surgery is probably our single best glaucoma therapy. It's valuable in angle closure. It tends to be cu- rative and changes the dynamic. Even in open-angle glaucoma, it reduces pressure but it also presents other opportunities, such as a MIGS procedure or other options. Dr. Radcliffe: I do but I also try to avoid the temptation. If it is urgent to remove the cataract because we need to reduce IOP, that does not sound like a MIGS patient to me, so I am very careful about that. If I'm counting on significant pressure reduction, I use a trabeculectomy or tube. Dr. Brown: Regarding medica- tions, if you're adding a second Dr. Ahmed: I teach my residents and fellows that 13 is the new 21. If patients truly have glaucoma, with damage to their optic nerve, I think they need to significantly reduce IOP. The longer we follow our patients, we often wish we were more aggressive because we see visual field progression. Patients who have lower targets tend to be stable for a longer period of time, even if they have moderate disease. Therefore, the problem is how to achieve that safely. That is why I think combinations—medications, MIGS, drug delivery—allow us to get there. Therefore, I tend to be more aggressive than I may have been early in my career. Dr. Lewis: As a point-counter- point, I received a phone call from a patient in whom I per- formed trabeculectomy in both eyes 18 years previously because of very high IOPs. He had been in his 30s. He complained that his eye was "not feeling right." We found that he had endophthal- mitis. Therefore, as aggressively as we want to reduce pressure, we have to balance it against the long-term risk of complications from our procedures. Dr. Ahmed: You're absolutely right. That's why I think we were not eager to get there with our OLD therapies, but I think our new therapies will allow us to get there and stay there. Dr. Brown: As I have practiced longer, I am much less aggressive with trabs and tubes, but we need aggression in innovation because we need to try things and find out what works. MIGS is so excit- ing because it is safe, and new longer-acting medications are also exciting. eye drop, when do you consider a combination eye drop as your second choice as opposed to a single medication? Dr. Lewis: The second med- ication once again raises the question of compliance and whether we will have enough additivity. None of the secondary medications, at least timolol and a prostaglandin, were sufficiently additive to achieve approval by the Food and Drug Administra- tion, but 50% of ophthalmolo- gists use timolol as their second medication. It's inconsistent. Dr. Brown: Yes, we all want to help the patient, but we don't want to cause problems that they did not have before. There is so much in the pipeline. What are you most excited about as we enter the golden age of glaucoma treatment? " As I have practiced longer, I am much less aggressive with trabs and tubes, but we need aggression in innovation because we need to try things and find out what works. MIGS is so exciting because it is safe, and new longer-acting medications are also exciting. " –Reay Brown, MD

• Cover