Glaucoma management from a global perspective

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Renowned leaders in glaucoma management assembed Wednesday at the Alcon-sponsored session, "Ophthalmology Management Trends," preceding the 25th APAO Congress, to discuss new developments in glaucoma treatment.

Sleep and IOP significantly impact glaucoma management

Tim Roberts

IOP variation, both short and long term, impacts visual field progression and physicians must consider optimal, 24-hour IOP when selecting therapy, said Tim Roberts, MD, Consultant Ophthalmic Surgeon and head of the glaucoma unit at Royal North Shore Hospital in Australia.

"Within the classes of drugs, all studies demonstrate that prostaglandins decrease 24-hour pressure, unlike betablockers where we see daytime pressure reduction that does not protect from the sleep-induced spike," Roberts said.

Alcon's Travoprost seems to demonstrate a prolonged effect within the prostaglandin group, according to Dr. Roberts.

IOP is higher in patients with open-angle glaucoma than in normal patients over 24 hours, and most spikes in pressure were not reported during office hours, Dr. Roberts reported. In fact, approximately 67% of peak IOP occurs outside of office hours, Dr. Roberts said. Therefore, investigation of nocturnal blood pressure dips and non-office hour IOP spikes is indicated in most patients who seem to have open-angle glaucoma progression despite having a normal daytime pressure.

Fixed combination glaucoma treatment may improve adherence and efficacy compared with concomitant treatment

In a study comparing the efficacy and safety of Travatan and timolol 0.5% vs. Alcon's DuoTrav fixed combination therapy, findings showed that fixed combination therapy may improve adherence and efficacy compared with concomitant treatment, said Michael Kook, MD, Professor of Ophthalmology at the University of Ulsan, College of Medicine.

Michael Kook

"Combining multiple eye drops into one bottle and eliminating the washout effect... can result in better pressure-lowering efficacy in the glaucoma treatment process," said Dr. Kook.

In another study, Kook showed DuoTrav to be therapeutically similar to concomitant administration at the physiologic IOP peak (8 am) with a better safety profile than concomitant treatment.

"Using fixed combination medication and less eyedrops actually can render our patients less exposed to preservative-related toxicity," said Kook.

In another study, Kook showed that both Alcon's Azarga Suspension (brinzolamide 1%/timolol 0.5% ) and Merk's Cosopt (dorzolamide 2%/timolol 0.5%) produced dramatic IOP reductions compared to the baseline, but there was no clinically significant difference between the two.

However, Kook showed a difference in adverse effects between the two medications.

"If you have not experienced the use of dorzolamide 2%/timolol 0.5% fixed combination, one of the common adverse effects is such symptoms as eye irritation and pain," Kook said. "With the use of brinzolamide 1%/timolol 0.5% fixed combination, we can clearly see that the incidence of eye irritation and pain is much less compared to Cosopt."

Studies show pressure control with ExPress identical to trabeculectomy

The ExPress implant minimizes early complications, reduces postoperative care, and provides a more controlled glaucoma procedure with results similar to trabeculectomy, according to Robert Fechtner, MD, Professor and Director of the Glaucoma Division at the Institute of Ophthalmology and Visual Science, New Jersey Medical School in Newark.

In a retrospective study comparing ExPress and trabeculectomy, researchers found that in more than a year the pressure control with ExPress was identical to the pressure control with trabeculectomy, said Dr. Fechtner.

"If used correctly, I believe it [ExPress] makes postoperative care easier than the trabeculectomy," said Dr. Fechtner.

In a prospective study in which patients were randomized to undergo trabeculectomy with mitomycin C or ExPress with mitomycin C, both with mitomycin C. Over the course of more than 1 year, IOP control with ExPress was equivalent to trabeculectomy. The researchers defined complete success as pressure greater than 4 mm Hg (no hopotony) and ≤ 18 mm Hg.

"Using that criteria, 85% of ExPress eyes were successful compared to 60% of trabeculectomy," said Dr. Fechtner. "They had similar postoperative interventions and complications."

Polyquad shown to be effective and less toxic than BAK

Several studies show that Polyquad is highly effective as a preservative, but less toxic than other options, said Dr. Victor Caparas, a surgeon at the Associated Eye Specialists and the American Eye Center in Manila, Philippines.

"Clinicians, especially glaucoma specialists, have to know that they are affecting other things as well as the pressure of the eye," said Dr. Caparas. "Dry eye or other ocular surface disease has a significant presence in the glaucoma population."

Exposure to preservatives causes changes to the ocular surface and abnormal inflammatory infiltration When patients take more than one medication for more than 1 year, almost all of them experience abnormal inflammatory infiltration. When patients are on more than one medication for more than 1 year, almost all of them had abnormal inflammatory infiltration.

One study aimed at measuring the staining caused by different preservatives found that solutions contained in Polyquad did not have any significant difference from that in saline, which implies a lower toxic effect for the epithelium.

Toxic preservatives may also reduce compliance, according to Dr. Caparas.

"When you have a patient who has a burning, stinging eye, whose vision is already affected because his eye is always dry and then they even have more serious complications such as an ulcer, you are going to get patients missing eye drops, and therefore, compliance will suffer," Caparas said. "By limiting the exposure by using a less toxic preservative, we are actually doing our patients better, including compliance."

Systane Ultra shown to provide improved visual acuity

According to several studies, Systane Ultra provides improved visual acuity and increased Schirmer's test scores, said Francis Mah, MD, Assistant Professor in the Department of Ophthalmology and the Department of Pathology at the University of Pittsburgh School of Medicine in Pennsylvania.

The studies show the blurring effects and long-lasting effects of Alcon's Systane Ultra, according to Dr. Mah.

"One head to head study looking at Allergan's Optive vs. Systane Ultra showed that even 90 minutes after the dose, Systane Ultra has a longer lasting ability to keep the vision better than Optive does," Dr. Mah said.

According to a study on quality of life , patients prefer Systane Ultra to all other drops a majority of the time.

"In terms of comfort, it [Systane Ultra] is much more prefered than all other drops available for the ocular surface," Dr. Mah said.