After a 20-year drought in glaucoma drug development, we recently got two new ones—and a third is on the way. Late 2017 gave us Vyzulta (latanoprostene bunod, Bausch + Lomb) and Rhopressa (netarsudil, Aerie), and soon we expect to see Roclatan (Aerie). These agents go where no drug has gone before: the trabecular meshwork (TM). Vyzulta, dosed QHS, combines a prostaglandin analog with butanediol mononitrate, which releases nitric oxide (NO) to relax the TM and increase outflow.1 Patients with glaucoma often have a lower concentration of NO.2
Rhopressa is an entirely new class of drug, a rho-kinase inhibitor, that targets the TM and is said to alter the cytoskeleton. Research shows it can lower IOP up to 5mm Hg, regardless of entering IOP. It would make an ideal second medication but may also be a great option as a primary treatment in normal tension glaucoma or early primary open-angle glaucoma.
Later this year or in early 2019, Roclatan, a combination of latanoprost and Rhopressa, may hit the market. Recent clinical FDA trial results look remarkable.
Good Things, Small Packages
Minimally invasive glaucoma surgery (MIGS) has caused a significant shift in care. Studies show these procedures have a far lower risk profile than conventional surgery and can get most patients down to one or no medications after implantation.3,4 With four million cataract procedures performed each year and a 20% rate of concurrent glaucoma in that population, we should be seeing 800,000 MIGS procedures a year. But we have yet to get close to this number, in part because optometry is not up to speed. A recent patient referred to us for cataract surgery said her OD recommend she get a “stent for glaucoma,” without elaboration. Though she has done quite well, I could have missed that brief suggestion in my pre-op assessment; ODs can and should provide more robust recommendations.
Our word goes far with patients, and it’s a pivotal opportunity to save their vision on fewer medications.
I recently had a family friend’s grandfather present with 0.9 cup-to-disc ratios, visual field loss and pressures of 27mm Hg and 28mm Hg—while on three different drops. He was on track for complete vision loss. Practicing in Kentucky, I performed a selective laser trabeculoplasty, which initially lowered his pressures to 19mm Hg OU. While I was pleased with this outcome, his pressures were 22mm Hg and 23mm Hg just one month later. He also needed cataract surgery, so I recommended MIGS at the same time, which lowered his pressures to 18mm Hg in each eye.
Given his fixation loss potential and his difficulty with various drops, I opted for a compounded quad drop QHS (timolol, brimonidine, dorzolamide and latanoprost) and a triple drop (timolol, brimonidine and dorzolamide) in the morning. It’s been over a year now and his most recent visit is showing great stability with consistent pressures of 13mm Hg and 14mm Hg. Compounded drops give us even more flexibility to customize the regimen to the patient’s needs. They should be considered sooner in patients who are having difficulty with multiple drops or who need a preservative-free formulation.
The Triggerfish contact lens, placed by an eye doctor and left in for 24 hours, records shape changes that correlate with IOP and visual field progression.5 This technology can tell us the overnight IOP level and may help assess risk of future functional loss, even in situations when insufficient historical visual field information is available.5 And as a contact lens, it’s bread-and-butter optometry.
The incidence of glaucoma is increasing, and optometry must play a proactive role to manage it effectively. Knowing about new drop options, surgical advances and new diagnostics is key to elevating your care and improving patients’ lives.
1. Kaufman PL. Latanoprostene bunod ophthalmic solution 0.024% for IOP lowering in glau-coma and ocular hypertension. Expert Opin Pharmacother. 2017;18(4):433-44.
2. Neufeld AH, Hernandez RM, Gonzalez M. Nitric oxide synthase in the human glaucomatous optic nerve head. Arch Ophthalmol. 1997;115(4):497-503.
3. Lee JH, Amoozgar B, Han Y. Minimally invasive modalities for treatment of glaucoma: an update. J Clin Exper Ophthalmol. 2017;8:4.
4. Lavia C, Dallorto L, Maule M, et al. Minimally-invasive glaucoma surgeries (MIGS) for open angle glaucoma: A systematic review and meta-analysis. PLoS One. 2017;12(8):e0183142.
5. De Moraes CG, Mansouri K, Liebmann JM, et al. Association between 24-hour intraocular pressure monitored with contact lens sensor and visual field progression in older adults with glaucoma. JAMA Ophthalmol. May 24, 2018. [Epub ahead of print].