Glaucoma Update PDF

**Glaucoma is Coming to Your Practice!\ \ 2x Increase by 2050** How are we approaching glaucoma patients in 2025 and beyond? Changing paradigm: Diagnosis In The Glaucoma Suspect\ ---When To Treat? Glaucoma suspects can be (broadly) categorized into [two] groups: - - - - **CASE** 64 y...

**Glaucoma is Coming to Your Practice!\ \ 2x Increase by 2050** How are we approaching glaucoma patients in 2025 and beyond? Changing paradigm: Diagnosis In The Glaucoma Suspect\ ---When To Treat? Glaucoma suspects can be (broadly) categorized into [two] groups: - - - - **CASE** 64 yo, white male, low myope History of **ocular hypertension** w/ IOP in mid/high **20's**. Excellent health. Question of family History of IOP. Last seen 5-6 years ago. Was aware of OHTN but felt everything was normal. **Results from earlier examination:\ **(other findings were normal/unremarkable) Baseline Photos. Important for all Suspects First Red Flag: IOP= 25/23 OD/OS Patient education is key,\ Explain risk of future glaucoma\ There are tools to help with this: Ocular hypertension type of Glaucoma Suspect How to Manage OHTN? **Percent of subjects that Developed POAG,\ by Central Corneal Thickness and Baseline IOP** **Percent POAG Endpoints**\ (patients that developed glaucoma) **When is Therapy Indicated?** **When there are other (multiple) significant Risk Factors:** When Risk Calculation is over \~ 15% **Free Online OHTS Risk Calculator (or verified phone App)** **What does OHTS Risk Calculator Mean?** Expert Panel Recommendations These are suggested guidelines only, treat every case individually **Without Risk Calculator, just use\ Pachymetry Alone: 3 Outcomes** **[Thin]: \588 µ Low Risk** **OHTS: 20 Year Data. The difference is Risk Factors:** **OHTS Risk Calculator (patient data entered)** **Back to Previous Case:** **OHTS Risk Calculator** **5 years later: CC = "blurry spot in right eye"** Left Eye: Right Eye: FDT Five Years Later (now 64 ys old): IOP (GAT) Central Corneal Thickness CCT Corneal Hysteresis Family History Gonioscopy Photo, VF and OCT Tonometry:\ Many Good options The difficulty in using IOP as a marker of disease is how much it varies and how difficult it is to detect elevated IOP. Tonometry: **[Fiction]** IOP is highest in morning IOP is always a single, exact number One or two IOP readings is sufficient The only IOP method that counts is Goldmann **Tonometry and IOP: Facts!** Multiple IOP readings, different days and different times, are essential for glaucoma suspects and patients being treated. IOP spikes are a significant risk factor for disease progression. While Goldmann tonometry remains the default standard, other forms can be utilized as a primary or adjunctive measure In the future implantable, intraocular sensors may be utilized to monitor IOP over 24hrs and 365 days IOP spikes often occur outside of office hours IOP peaks outside of office hours have been reported in 66%, 69% and 52% of glaucoma patients in different studies Querat et al. reported that 63% of study eyes had different daily IOP patterns on different days Studies indicate when performing only sporadic IOP measurements during office hours a few times a year there is a high probability of missing important IOP Self Tonometry Patients would monitor their IOP over time with easy-to-use devices Easiest approach regarding continuous monitoring Adapt current device such as Noncontact tonometer or Rebound tonometer May be difficult for some patients to perform Not easy to obtain 24-hour IOP 24-Hour IOP Monitoring How do we evaluate IOP if we are only measuring it briefly in office? Home Self Tonometry Home tonometery Patient is self-taught or has minimal assistance from technician on proper use of device A successful measurement is indicated with a check mark, shown on the display screen and single long beep A measurement sequence consists of six measurements **Home Tonometry:** Home IOP Monitoring\ - personal case examples Home IOP Monitoring\ - personal case examples Low In-Office IOP Young Ocular Hypertensive, neg Fam Hx\ - first HOME week \- Second HOME week Home Self Tonometry Self-tonometry provides IOP data that supplements in-clinic tonometry and would not be detectable over daytime in-clinic diurnal curves. A subset of patients in whom home tonometry was ordered by their glaucoma clinician because of suspicion of occult IOP elevation demonstrated reproducible IOP elevation outside of the clinic setting. Such patients tended to be younger and male and not to have undergone previous filtering surgery. The Future? A better IOP Measure? AI-based, truly contact-free Fast, safe and painless: under 3 mins User-friendly: affordable and simple Any time of day: either sitting or supine Clinically reliable method Alarm raised at certain point Long-term stability is unknown Implantable Device for IOP Measure Diagnostic Genetics in Glaucoma Genetics in Glaucoma **2020+** What is a polygenic risk score? Humans share the same genetic code apart from some differences These are called genetic variants, and make each of us unique Some of these variants increase the risk of developing certain diseases One can combine the risks from hundreds or thousands of these genetic variants to estimate disease risk This overall risk is known as a polygenic risk score It compares a person's risk to other people in the population Diagnostic, Genetic Testing for Glaucoma\ Still in Development [Questions:] **OCT Interpretation: A New and Easy Method for all Users** For today what can we take back to our practices?\ \ Make OCT Interpretation Easier: Four Steps It starts with retinal/ONH anatomy: OCT Imaging: What are we looking for? Classic Structure/Function in Glaucoma **Case example of glaucoma with focal damage** **The optic nerve photograph shows thinning of the inferior optic nerve neuroretinal rim (A) with a superior paracentral visual field defect (B).** **SD-OCT imaging confirms corresponding inferior RNFL thinning seen both on the thickness map and quadrant thickness (C) and inferotemporal macular thinning of the ganglion cell and inner plexiform layers (D)** 1\. **OCT Scan Reports** can be tricky**. Key Highlights.** Start by looking at scan quality and a few other things. Before Interpreting your OCT Report\ Assure a Good Quality Scan **[First Steps Evaluate:]** OCT Scan Reports can be tricky. Key Highlights. Starting points for reading a scan report. Is there segmentation failure or other image artifact present? Identify these things first and don't waste your time. How can you confidently identify glaucomatous loss to the RNFL and GCA? Three Questions: The CU Method by Don Hood (abbreviated) Is there some correlation to the Visual Field? To the fellow eye? Masqueraders and Mimickers (of glaucoma) Don't make the wrong diagnosis, Examples and Cases Signal Strength Image centration Optic disc in center of frame No evidence of eye movement. Look for jagged vessels on IR image Low signal strength leads to faint retinal image More likely segmentation algorithm will fail or be inaccurate Low signal underestimates RNFL thickness Tips -- **artificial tears and dilating can** allow for improved signal strength OCT Signal Strength Guidelines\* What Do You Look For When You Evaluate a Scan? **RNFL Thickness Map** **RNFL Deviation Map** PanoMap Version: RNFL and GCA together What Do You Look For When You Evaluate a Scan? Quality score Illumination Focus OK Image centered Any signs of eye movement Segmentation accuracy B Scan Centration **No Deviation Map on this report version** "Hood" Report version of the same eye: **Newer Report: "Hood Report" (no Deviation/Probability Map)** RNFL and GCC (Ganglion Cell Complex)\ Thickness Maps Only Is there a segmentation failure or image artifact present? **Red Disease!** **Common Forms of OCT B-Scan Segmentation Failure and Image Artifact** - **De-centration (28% of scans)** - **Error associated with posterior vitreous detachment (14%)** - **Posterior RNFL misidentification (8%)** - **Poor signal (5%)** - **High Myopia (2%)** - **Peripapillary atrophy associated error (1%)** - **Incomplete segmentation (1%)** - **Motion artifact (\+8 D and -12 D OCT for over -12D is NOT useful and should not be ordered Temporal shift of the ST and IT RNFL bundles Focus on changes in Ganglion Cell Maps, sometimes they are more reliable SUMMARY:\ Make OCT Interpretation Easier: Four Steps OCT Scan Reports can be tricky. Key Highlights. Starting points for reading a scan report. 1. Is there segmentation failure or other image artifact present? Identify these things first and don't waste your time. 2. How can you confidently identify glaucomatous loss to the RNFL and GCA? 3. Is there some correlation to the Visual Field? To the fellow eye? Masqueraders and Mimickers (of glaucoma) **Topical Medications are a Problem and a Pain (literally), for our patients.** Targeted Delivery to Diseased Tissues Bitmatoprost SR 24/7 Drug Release for \~4 Months Implant Biodegradation: Patient Variability Over Time Consistent IOP Control Over Time: Study 1 Effective for up to 2 yrs in 28% **Travoprost Intraocular Drug-Eluting Delivery Device** Travoprost Implant Clinical Trial Microdose latanoprost: Piezoelectric microdosing technology Reduced volume: Typical Eye Drop: [Microdosing:] DLST Direct selective laser trabeculoplasty DLST VIDEO MIGS Minimally invasive glaucoma surgery Let's Make this Simple MIGS Device Options. Where do they go? TM Bypass Canaloplasty (TM Cleaning), Goniotomy (TM Removal) Options **Why MIGS?** **Cataract surgery (CE) is an opportunistic time to help a glaucoma patient** Patient is already undergoing intra-ocular surgery At the same time as CE, implant a trabecular bypass stent **MIGS and Disease Severity** Mild to Moderate glaucoma Moderate to severe (refractory) glaucoma **Angle Anatomy:** Diseased TM is part of the problem in Open Angle Glaucoma **Eye Plumbing 101** MIGS: different target locations Trabecular By-Pass: Restore the Pathway for Natural Outflow Real World Data 273 Eyes, 36m Study Period **[Mean] Decrease IOP = 15.6%** **68% decrease in medications** **How and why to improve on a stent?** Single iStent: Why variability? Anatomy. **Collector Channels: Anatomically Variable** **Two are Better than One** **Second iStent inject** **Would a 3^rd^ stent be even better?** Surgical Procedure **New Innovations:**\ First-ever micro-invasive implantable device for ***[standalone]*** glaucoma treatment. Received FDA 510(k) Clearance in August 2022, Available to patients in 2023 Multi-Stent, Implantable Trabecular By-Pass **Other Cool Stuff on the Plumbing Side of Glaucoma** AQUEOUS OUTFLOW AS A MECHANICAL PUMP PULSE-DEPENDENT COLLECTOR CHANNEL MOTION VIDEO TRABECULAR MESHWORK PULSE-INDUCED MOTION VIDEO **Other MIGS\ Surgical Options** **All FDA Approved** **Ab-interno Canal-based MIGS stent** The "stent" is a tiny scaffold inserted about the size of an eyelash that is inserted into the main drainage channel of the eye to help lower eye pressure and reduce the need for medications **Tri-Modal MOA:** Nickel/titanium stent scaffolds 90 degrees of trabecular meshwork, holding the canal open Indication: Microstent: Ab-interno Canal-based MIGS **Microstent HORIZON Trial 5-Year Data** Real-time Confirmation of Accurate Delivery **Additional MIGS Options:**\ **Canaloplasty, Goniotomy, Trabeculotomy** Kahook Dual Blade (KDB) - [Goniotomy] The Kahook Dual Blade (KDB) is a disposable ophthalmic knife, used to manually cut and remove TM in OAG patients - Providing better aqueous access to the canal - Numerous types and severity levels of glaucoma - In conjunction with cataract surgery or standalone - 15-26% reduction of IOP at 12 months - "inexpensive, easily approved MIGS **Canaloplasty:** "Cleaning" and TM Removal Option. **Canaloplasty (video)** Canaloplasty is a relatively new non-penetrating surgery for the reduction of intraocular pressure in patients affected by glaucoma. The technique uses a microcatheter to perform a 360 º cannulation of Schlemm\'s canal and is engineered with an internal reservoir delivering a controlled amount of viscoelastic fluid. Goal is to remove herniations and adhesions that develop in the tube like canal and lead reduced outflow. **Canaloplasty: Clinical Trial Results** This opens up access to the TM **MIGS: Many Questions remain** There is so much we need to learn to improve the MIGS procedures we have. For example, why, 2 to 3 years after some MIGS procedures are performed, does efficacy start to dwindle? What happens with healing in the angle? What can we do better about outflow? Why does the suprachoroidal space shut down? If we can answer some of these questions, then perhaps more people will accept and embrace MIGS.