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Clinical Pearls for Challenging Cases
Glaucoma:
Clinical Pearls for
Challenging Cases
MOA 2014
Case

34 yo, white, male

Ant Segment:
– K-Spindle, + ITD, 3+ TM pigment
Michael Chaglasian, OD, FAAO

Illinois Eye Institute
Illinois College of Optometry
[email protected]

Disclosure

GAT= 28/31 mmHg OD/OS
Pachymetry = 595 µ
Gonio and Slit Lamp Photos
Michael Chaglasian has the following disclosures:
– 1. Advisory Board: Allergan, Inc., Alcon Labs,
Carl Zeiss Meditec

The content of this presentation is in no manner influenced by
any of the aforementioned parties or companies
Agenda

Common Secondary Glaucomas

Ocular Perfusion Pressure

Ocular Hypertension

Adjunctive Therapy Options

Suspicious Optic Nerves
M. Chaglasian, OD
1
Clinical Pearls for Challenging Cases
MOA 2014
PIGMENTARY GLAUCOMA
GDx
VCC

see clinical triad of:
– Krukenberg's spindle
– Iris transillumination defects
– heavy TM pigmentation


PDS refers to those with these clinical findings
but without any glaucomatous changes to the
optic nerve
glaucoma may develop in up to 50% of patients
with PDS
– Typically only 10-15%, literature shows wide variation
RTVue 100 (Optovue)
Case

Assessment
– PDS, High IOP, thick Pach
– Normal ONH, Normal VF, Normal OCTs

Plan / Discussion
– Other Tests?
» ___________________
– Treatment Trial : ______________
– Other considerations: ________________
M. Chaglasian, OD
2
Clinical Pearls for Challenging Cases
MOA 2014
From: Primary Care of Glaucoma, Lewis & Fingeret 2000
Natural History of PDS/PG
Scheie Strip
pigment on the crystalline lens equator
Mechanism


photogrammetric and histological
studies have shown that a concave
posture (posteriorly) of the peripheral
iris allows for rubbing against the lens
zonules
Exercise-induced pigment liberation:

Pharmacologic pupillary dilation may result in
marked pigment liberation accompanied by a
rise in IOP.

The same phenomenon may occur in some
patients with PDS during strenuous exercise,
particularly exercise involving jarring
movements, such as jogging or basketball.

Pretreatment with low-dose pilocarpine prior
to exercise can limit both the pigment
liberation and the IOP spike.
Reverse Pupillary Block concept
M. Chaglasian, OD
3
Clinical Pearls for Challenging Cases
Pigmentary Glaucoma
MOA 2014
PIGMENTARY GLAUCOMA


The glaucoma part of this condition has
the same requirements as POAG, that
is ONH damage and or VF loss
MIOTICS are a theoretical drug of choice in
PG because of the mechanics:
– Lifting the peripheral iris iris off the zonules
– However their ocular side effects limit their
success:
» Low % (0.5) Pilocarpine solution

Since they are poorly tolerated in young
patients, they often cannot be used
– Only, helpful in pigment liberation stage (early)
Management
Laser Trabeculoplasty
Management of PG has two strategies:

Argon or SLT
1) control of elevated IOP and prevent
glaucomatous damage (primary)

Both work well at first,
– with up to 25% decrease in IOP,
but then quickly lose treatment
effect, often within 2-3 years
2) eliminate irido-zonular contact
- if this is possible, it can reduce pigment
liberation and over time allow the TM to get
rid of the pigment granules
PIGMENTARY GLAUCOMA

Prostaglandins

Alternatives:
– Primary, first line therapy, best overall
Laser Iridotomy

– It eliminates the “reverse pupillary block”
– By allowing direct aqueous flow into the AC,
an equilibration of pressure is obtained
which may help to move the peripheral iris
off the lens zonules.
– Brimonidine, CAI, Beta-Blocker, Fixed-Combination

Use these and look for a significant decrease
in IOP.
– Still monitor pigment liberation via slit lamp and
gonio.

Many patients require multiple meds
M. Chaglasian, OD
Is another treatment option for PDS/PG.
Only for active PDS, not for older
patients.
 Medications are tried first

4
Clinical Pearls for Challenging Cases
MOA 2014
Prognosis = Caution

Some patients with PG:
– Have a severe, difficult to treat form, of
the disease and end up with severe
vision loss at an early age
– Are diagnosed at a late stage because
of low suspicion of glaucoma in younger
patients and high fluctuation in IOP
(patients seen with normal IOP)
Case

Case JB
54 yo WF
Referred in for Glaucoma Suspect
 No significant Medical History
 GAT= 24 OD and 23 OS
 Pachs= 560 and 565
 Gonio=


– Open angle with moderate pigment
Photos
Assessment
– PDS, High IOP, thick Pach
– Normal ONH, Normal VF, Normal OCTs

Plan / Discussion
– Other Tests?
» ___________________
– Treatment Trial : ______________
– Other considerations: ________________
There’s a Facebook page for
Pigmentary Dispersion Syndrome??
Visual Field
Guess how many “friends”?
M. Chaglasian, OD
5
Clinical Pearls for Challenging Cases
MOA 2014
Summary / Questions
Slit Lamp
Does this patient have glaucoma?
 If not, how high is the risk for developing
glaucoma?
 What other tests need to be done?
 When do you see this patient back?
 When/How do you start treatment?
 What is the prognosis for this patient?

RTVue
Terminology

Exfoliation Syndrome

Exfoliation Glaucoma
– XFS
– XFG
– “Psuedoexfoliation” term is still used by some
» “PEX”,
“PXS”,
“PXG”
Introduction and Background


Exfoliation syndrome (XFS) is the most common
identifiable cause of open-angle glaucoma
worldwide.
It is characterized by excess synthesis and
progressive accumulation of abnormal
extracellular fibrillar material
– The continuous accumulation of exfoliation material
(XFM) and pigment in the outflow system leads to
elevated intraocular pressure (IOP) and eventually to
the development of exfoliative glaucoma (XFG)
M. Chaglasian, OD
6
Clinical Pearls for Challenging Cases
MOA 2014
Introduction and Background

It has been estimated that the worldwide
number of individuals with XFS is between
60 and 70 million,
– or equal to the total number of people in the world
with glaucoma.

About 25% of persons with XFS have elevated
IOP, and one-third of these have glaucoma.

Taking all epidemiological studies as a whole,
XFG appears to account for about 15–20% of
open-angle glaucoma in Caucasians.
XFS in the Eye



Classic Three Zones
XFM frequently found at
the pupillary boarder
Pigment loss from pupillary
ruff and deposition in TM
– “Sandpaper” effect
– Iris transillumination at margin

Increased IOP post dilation
– Via pigment liberation
Genetics= LOXL1

Zonules, severe, coated
by XFM, replaced,
or frayed and broken
leading to phacodenesis
Lysyl oxidase-like 1 gene (LOXL1)
– genomewide association study of 16,000 Icelandic
and Swedish participants,
– two mutation of single base differences in the
sequence of the LOXL1 gene
– accounted for 99% of all cases of exfoliative
glaucoma (although not everyone with them gets glaucoma)
– Same findings found in a recent US study

lysyl oxidase family of genes is necessary for the
formation and maintenance of elastic tissue, and the
Extra Cellular Matrix (ECM)
Thorleifsson G, et al Science. 2007
Fingert JH, Am J Ophthalmol. 2007
M. Chaglasian, OD
7
Clinical Pearls for Challenging Cases
LOXL1

the effect of the genetic variants now detected in
the LOXL1 gene seems to be to lower the
production rate of the protein it specifies

slightly lower production rate of LOXL1 may be
harmless during most of a lifetime, the deficit
may accumulate through many decades,
explaining why exfoliative glaucoma is most
common among the elderly
MOA 2014
Results:
Thorleifsson G, et al Science. 2007
Genetic Testing
Our genetic health scans cover an
ever growing range of conditions.
http://www.decodeme.com
How?
How Much $$$?
http://www.decodeme.com
M. Chaglasian, OD
8
Clinical Pearls for Challenging Cases
MOA 2014
Treatment for
Hyperhomocysteinemia
XFS in the Eye


XFG patients exhibit a greater fluctuation in the
24-hour IOP curve than patients with POAG
lens subluxation, phacodonesis
– weakened lens zonules
Potential treatment
recommendation:

– FOLTX™ tablets:
» Folacin (Folic Acid) 2.5 mg
» Pyridoxine (B6)
25 mg
» Cyanocobalamin (B12) 2 mg
– Potential complications in cataract extraction



cataract formation
poor dilation and posterior synechia
narrow angles/angle closure
Elevated Homocysteine Levels

Highly cytotoxic amino acid derived from
methionine metabolism.
– It is found in plasma, aqueous humor, and tear fluid in
XFS with and without glaucoma


Elevated HC levels are a recognized
cardiovascular risk factor, get levels!!!!!
HC levels are inversely associated with intake of
folate and vitamins B2, B6, and B12
Does FOLTX have a proven benefit?

Treatment benefits have not been
demonstrated yet.

Folic Acid Treatment on High Risk Women. JAMA 2008
So?

– Potential treatment recommendation
Does a Normal, Healthy patient with a new
diagnosis of XFS/XFG need labs and work up?
– Unclear at this time
– With Risk Factors = YES !
Diagnosis
Plasma Levels Of Homocysteine in XFG
Diagnosis made essentially as it is for
POAG.
 Understand that the patient is a higher
risk and thus treatment may be started
earlier,
but ALL patients with XFS do NOT
need treatment.

Elevated levels (>14 µg/l) in up to
43% of patients with XFS/XFG.
Graefes Arch Clin Exp Ophthalmol (2011) 249:443–448
M. Chaglasian, OD
9
Clinical Pearls for Challenging Cases
MOA 2014
Medical Therapy

Prostaglandins
– In a recent parallel diurnal study, latanoprost was slightly more
effective than timolol in lowering IOP in eyes with XFG.
– There was a trend for better diurnal IOP control with latanoprost
and a significantly lower diurnal fluctuation and mean peak IOP
with this therapy.

Beta Blockers

CAI’s

Cholinergics
– Reports are mixed on the success of this class of medications
– Dorzolamide has had mixed success in several studies
Key Points
Careful slit lamp exam pre/post dilation
Frequent IOP checks for patient with the
syndrome
 Work with PCP on Homocysteine levels
 Treat glaucoma more aggressively
 Note findings for cataract surgeon


– 1% pilocarpine at bedtime!!!, stop the pupil from moving
Laser Therapy

ALT is particularly effective, at least early on,
in eyes with XFG

The initial drop in IOP is greater in XFG
Case JB
Dx:
1. Exfoliation Syndrome/Glaucoma
High Risk but No evidence of glaucoma
damage at present
Plan:
1. IOP recheck 1-2wks, diurnal flux
2. Then start PGA qhs OU
3. Repeat testing in ~9 months
4. Patient to discuss with PCP to check
homocysteine level at next visit
– Several studies, however, have reported a gradual
reduction in success over time, with long-term success
drops to approximately 35-55% at 3-6 years.

Selective laser trabeculoplasty (SLT) may be an
effective and safe alternative to ALT in the
treatment of XFG
Surgical Therapy


The results of trabeculectomy in XFG are
comparable to those with POAG.
However, surgical complications are more
common in patients with XFS.
– Weakened zonular support may allow intraoperative
lens movement or, in extreme cases, subluxation

The most important and the most difficult choice
for treating XFG is still the decision for timely
surgery.
M. Chaglasian, OD
Case WS

75 yo male

+ HTN w/ multiple BP meds x 20+ yrs
– 105/68 in office
– 5’ 5”, 142 lbs

CCT= 532µ

Initial IOP 23 mmHg

Current Medication:

Good compliance and follow up
– Now repeatedly 11-13 mmHg over 5+ years
– PGA
10
Clinical Pearls for Challenging Cases
MOA 2014
Photos
Guided Progression Analysis™ (GPA™)
9 Years Later.
Can you see the change?
Stereo Photos

Obtain Baseline
Photographs
– Stereo is preferred
» Screen-Vu Stereo Viewer™

www.berezin.com
– Read, Review, and
Document in record
– Repeat periodically, or
when change is suspected
M. Chaglasian, OD
11
Clinical Pearls for Challenging Cases
MOA 2014
OPP and Glaucoma:
Hemodynamics
Case WS

Q= What is the Explanation?

Compliance?
– Progression with IOP in low teens.
Other Potential Risk Factors:
 24 Hour IOP
– Highest IOP in Nocturnal Period (midnight-5AM)

DOPP
– Diastolic Ocular Perfusion Pressure
•
SPP = SBP – IOP
•
DPP = DBP – IOP
Diastolic Measure
• easiest to use, best current evidence
•
MPP = 2/3 mean arterial pressure – IOP
• Arterial Pressure = DBP + 1/3 (SBP – DBP)
• May best reflect perfusion physiology
Higher
IOP
Negatively Impacts
Perfusion Pressure
Ocular Perfusion Pressure
and Glaucoma
Ocular Perfusion Pressure
Lower Diastolic,
Systolic, or
Mean Pressure
Reduces Perfusion
Pressure
risk factor for glaucoma
New Evidence
Ocular Perfusion Pressure (OPP) = BP – IOP
(BP is mean arterial pressure, diastolic BP, or systolic BP)
Ocular Perfusion Pressure

Lower
Perfusion Pressure
Is Associated with
Increased Risk for
Open Angle Glaucoma
Higher
IOP
Negatively Impacts
Perfusion Pressure
Perfusion Pressure
Is a Result of
A Delicate Balance
Between IOP
and Blood Pressure
Leske MC, et al. Ophthalmology 2007; 114,: 1965-72
Leske MC, et al. Ophthalmology 2008;115, 65-93.
Hayreh SS. Trans Am Acad Ophthalmol 1974;78:240-54
Ocular Perfusion Pressure
and Glaucoma
The differential between arterial BP and IOP
– Ocular perfusion is regulated to maintain
constant blood flow to the optic nerve despite
fluctuating blood pressure and IOP
– The major cause of reduced blood flow is
thought to be secondary to vascular
dysregulation in susceptible patients,
resulting from abnormal/insufficient autoregulation.
M. Chaglasian, OD
Lower Diastolic,
Systolic, or
Mean Pressure
Reduces Perfusion
Pressure
Lower
Perfusion Pressure
Is Associated with
Increased Risk for
Open Angle Glaucoma
Perfusion Pressure
Is a Result of
A Delicate Balance
Between IOP
and Blood Pressure
Leske MC, et al. Ophthalmology 2007; 114,: 1965-72
Leske MC, et al. Ophthalmology 2008;115, 65-93.
Hayreh SS. Trans Am Acad Ophthalmol 1974;78:240-54
12
Clinical Pearls for Challenging Cases
MOA 2014
Ocular Perfusion Pressure
and Glaucoma Progression
POAG Risk Factors at year 9
Barbados Eye Study
Ocular Perfusion Pressure (OPP) = BP – IOP
(BP is mean arterial pressure, diastolic BP, or systolic BP)
Highest
Risk
Low ocular perfusion pressure has been
shown to be strongly associated with the
prevalence of glaucoma progression in
multiple population-based surveys
Tielsch JM, et al. Arch Ophthalmol. 1995.
Leske MC, et al. Arch Ophthalmol. 1995.
Leske MC, et al. Arch Ophthalmol. 2002.
Quigley HA, et al. Arch Ophthalmol. 2001.
Bonomi L, et al. Ophthalmol. 2000.
Leske et al.Ophthalmology 114 (11), November 2007
Leske MC, Wu S-Y, Nemesure B, et al. Ophthalmol 2008;115:85-93.
OPP and Glaucoma Progression:
Population Studies

Studies Summary
Baltimore Eye Survey (AA and Caucasian)1
– 6x excess of POAG in subjects with lowest category of
Ocular Perfusion Pressure (OPP)

Egna-Numarkt Study

These large studies provide strong
evidence among different populations
for the relationship between vascular
deficits and the prevalence, incidence
and progression of glaucoma

Some Limitations,
(Caucasian)2
– Lower Diastolic Ocular Perfusion Pressure (DOPP)
associated with marked, progressive increase in frequency
of POAG

Barbados 4 yr Eye Study (African-Caribbean)3
– 4-year risk of developing glaucoma increased dramatically at
lower perfusion pressure

Proyecto Ver (Hispanic)4
– Found lower Diastolic Perfusion Pressure (DPP) associated
with increased risk of POAG
1.
2.
3.
4.
– no direct measure of ocular blood flow
– Varied definitions of hypertension
Tielsch JM, Katz J, Sommer A, Quigley HA, Javitt J. Arch Ophthalmol 1995;113:216-21
Bonomi L, Marchini G, Marraffa M et al. Ophthalmology 2000;107:1287-93
Leske MC, Wu S-Y, Nemesure B, et al. Arch Ophthalmol 2002;120:954-9.
Quigley HA, West SK, Rodriguez J, et al. Arch Ophthalmol. 2001;119:1819-26.
Los Angeles Latino Eye Study
Clinical Control of OPP
Lower IOP improves OPP
Cross-sectional study of
6,357 Latinos, >40 years
in Los Angeles, CA.
•
•
Persons with low diastolic
and systolic perfusion
pressures had a higher
risk of POAG.
•
Measure blood pressure on your patients
•
•
DOPP <50 mmHg, the
prevalence of glaucoma
rapidly increases linearly.
Higher systemic BP improves OPP, but you do
not necessarily want to raise BP:
•
• Remains number 1 goal !!
• Stroke #3 cause of death in US behind CVD & CA!
• Avoid drugs that lower systemic BP beyond patient’s desired
systemic control.
• Communicate with PCP
Varma R, et al. Ophthalmology. 2004;111:1439-1448.
M. Chaglasian, OD
• Look for nocturnal hypotension.
13
Clinical Pearls for Challenging Cases
MOA 2014
Nocturnal Hypotension and OPP
•
24 hr IOP Measure via SCL
SENSIMED Triggerfish® - Continuous IOP Monitoring
Low blood pressure (BP) at night, coupled with
high IOP in supine position, compromise OPP.
Not approved in USA
• ? Up to 50% of patients with HTN
• Using systemic BP meds in the AM to minimize
nocturnal hypotension makes sense.
•
Using IOP lowering drugs that lower IOP while
sleeping makes sense.
• Avoiding IOP meds that LOWER systemic BP at night
(beta blockers, alpha agonists) makes sense.
Graham SL, Drance S. Surv Ophthalmol. 1999;43(suppl 1):S10-16.
Hayreh SS, et al. Am J Ophthalmol. 1994;117:603-624.
Colligan JC, et al. Int Ophthalmol 1998;22:19-25.
Br J Ophthalmol 2011;95:627e629/
Back to Case
24 Hour Blood Pressure

Holter Monitor
Case WS
Supine

DOPP=
– DBP of 68 mmHg @ 2PM and IOP of 12 mmHg
– Gives 56 mmHg

Nocturnal BP with Holter Monitor

Nocturnal IOP (estimate)
– DBP @ 2AM = 58
Sitting
Blood
Pressure
– IOP of 12 mmHg @ 2PM = ?? @ 2AM ~ 18 mmHg

Nocturnal DOPP
– 58 -18 = 40 mmHg, potentially a high risk
PCON October 1, 2005
M. Chaglasian, OD
14
Clinical Pearls for Challenging Cases
MOA 2014
CASE AC
Case WS


Is there anything else that can be done?
Possibly:
– Offer Nocturnal IOP control
– Offer Improved DOPP
Add a CAI BID
 45
yo, woman
 Myopia, no sig. medical history
 + family history glaucoma
 GAT= 27 OD 25 OS
 Pachs = 565 µ
Letter to PCP, explain OPP and
Low BP related Risk
? Adjust BP Meds
24-hour habitual IOP
Azopt vs. timolol add-on efficacy
DIURNAL/WAKE
IOP (mm Hg)
22
NOCTURNAL/SLEEP
CASE AC
DIURNAL/WAKE
latanoprost only (N=26)
Azopt add-on (N=26)
timolol add-on (N=26)
20
18
16
11:30 AM
1:30 PM
7:30 AM
9:30 AM
3:30 AM
1:30 AM
11:30 PM
9:30 PM
5:30 PM
7:30 PM
3:30 PM
5:30 AM
14
Clock Time
Liu JHK, et al.. Ophthalmology 2008. I
Summary
VFs
IOP Fluctuation
plus
 Increased Nocturnal IOP
plus
 Low Nocturnal Blood Pressure
equals
 Low Diastolic Perfusion Pressure
equals

M. Chaglasian, OD
15
Clinical Pearls for Challenging Cases
MOA 2014
Pachymetry
Correction Values
Corneal Thickness (µm)
Correction Value
405
7
425
6
445
5
465
4
485
3
505
2
525
1
Conversion Charts: don’t really work
NOT VALID!
545
0
565
-1
585
-2
605
-3
625
-4
645
-5
665
-6
685
-7
705
-8
Correction values according to corneal
thickness of 545 µm
What do you do now?
M. Chaglasian, OD
16
Clinical Pearls for Challenging Cases
MOA 2014
IOP and CCT

Risk Calculator
“Assuming that CCT can be used as a correction
factor for GAT is a misinterpretation of the results
of OHTS… that couldn’t be further from the truth.
Adjusting IOP based on CCT is attempting to
instill a degree of precision into a flawed
measurement. You may actually correct in the
wrong direction. The issues related to the most
accurate tonometry need to include the material
properties of the cornea”
» James Brandt, MD, Director, Glaucoma Services, UC Davis
http://ohts.wustl.edu/risk/calculator.html
Risk Calculator Outcomes:
Recommendation Guide to Patient
Management (by expert panel)
Pachymetry: 3 Outcomes
<555 µ
5-Year Risk for Progression of OHTN  Glaucoma

Thin:
High Risk

Average: 555-588 µ
No change in Risk
Low

Thick:
Low Risk
Moderate
Risk Level
>588 µ
High
Applied to patients with ocular hypertension
5%
Monitor
5%-15%
Consider treatment
15%
Treatment
OHTS – RC Limitations?

http://ohts.wustl.edu/risk/calculator.html
Recommendations
The predictions derived using these methods are designed
to aid but not to replace clinical judgment.
Risk Calculator
No Longer
Available
Range
A number of factors described as predictive in
previous studies either did not add to the
explanatory power of the OHTS–EGPS pooled
model or were not assessed in this study.
These include:
1.
2.
3.
4.
Family History
Life Expectancy
Diabetes (?)
Race (?)
Also iPhone App
M. Chaglasian, OD
17
Clinical Pearls for Challenging Cases
MOA 2014
SAP
Case EG
VFs
GDx
67 yo, AA male, Retired school teacher
Good health, no medications
 + Family History of glaucoma
 OHTN/Early Glaucoma
 CCT= 567, 571
 Pre- Tx IOP ~ 30 mmHg OD, OS
 With PGA:


– Always 20-23 mmHg x 5+yrs
– Good Compliance
Photos (initial)
M. Chaglasian, OD
Photos (5 yrs later)
18
Clinical Pearls for Challenging Cases
MOA 2014
Can you see the change?
VF
GPA
Case EG Discussion
Cirrus OCT
RTVue 100
M. Chaglasian, OD

Is this progression?

Other things you’d like to see/do?

Options for adjunctive treatment?
SECOND LINE AGENTS
19
Clinical Pearls for Challenging Cases
MOA 2014
No Nocturnal IOP Lowering with Timolol
Options for Adjunctive Therapy
Sitting
Supine
Sitting
No treatment
Trusopt®
1.2 mm Hg3
16
14
Beta-blockers
2.7 mm Hg4
Timolol
1:30 PM
2.1 mm Hg2
11:30 AM
Azopt®
18
7:30 AM
Carbonic anhydrase inhibitors (CAIs)
20
9:30 AM
3.3 mm Hg2
ALPHAGAN® P
22
5:30 AM
Alpha-agonists
24
3:30 AM
5.2 mm
Hg1
1:30 AM
Cosopt®
26
9:30 PM
6.9 mm Hg1
11:30 PM
Combigan®
7:30 PM
Fixed Combinations
Timolol gel
5:30 PM
(at 3 months)
3:30 PM
Products:
28
Habitual IOP (mm Hg)
Additional Mean IOP Reduction
when Added to a PGA
Clock Time
1. Nixon et al. Curr Med Res Opin. 2009; 2. Day. Curr Med Res Opin. 2008;
3. Maruyama and Shirato. J Glaucoma 2006; 4. Miura et al. J Glaucoma 2008.
Liu, Am J Ophthalmol. 2004;138:389-395.
Criteria for the Choice of
Adjunctive Therapy

Incremental efficacy
– The main reason for changing initial
monotherapy is the need for additional IOP
lowering1
– The purpose of adjunctive therapy is to obtain
target IOP2

Alpha Agonists

Alphagan-P 0.1% (Allergan)
–  BAK Purite ( toxicity)
– Less ocular allergy

Aqueous suppressant and:
»  uveoscleral outflow
» ? Neuroprotection?
Other considerations
– Compliance
– Tolerability
– Safety
Bid vs. Tid dosing
 NO Neuroprotection!

1Rouland
JF et al. Eur J Ophthalmol. 2003;13(suppl 4):S5-S20;2 European Glaucoma Society.
Terminology and Guidelines for Glaucoma. Savona, Italy: DOGMA Srl; 2003.
Topical CAIs
Beta Blockers as Adjunctive Therapy
to a Prostaglandin Analogue

Currently available:
- Brinzolamide (Azopt)
- Dorzolamide (Trusopt)
» Generic availability

Consistent, moderate, monotherapy IOP
reductions
» (15-20%, 4 to 6 mm Hg)
------ p = 0.15-------

FDA Labeled as TID agents
J Glaucoma 1999;8:24-30.
M. Chaglasian, OD
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Clinical Pearls for Challenging Cases
MOA 2014
Advantages of
Fixed Combinations
Post Dose: IOP Change from Baseline

Dosing—1 drop vs 2 drops
Convenience

Potential to improve compliance1

No risk of washout from second drug2
– Washout impedes absorption, thereby

reducing efficacy3

Possible cost savings
– Only 1 copay
Ophthalmology 2007 July; 114(7):1248-54
Best Adjunctive Therapy?
1. Razeghinejad et al. Expert Opin Pharmacother. 2010; 2. Choudhri et al. Am J Ophthalmol. 2000.; .3 Khouri. Drugs Aging. 2007.
Timolol Fixed Combinations

Cosopt®

Generic dorzolamide / timolol
maleate ophthalmic solution
– Dorzolamide hydrochloride/timolol maleate solution
Overall =
CAI
Tanna AP, et al Arch Ophthalmol 2010;128:7:825-33.
Adjunctive Therapy Conclusions
Fixed Combination: Combigan
1) PGAs are often not enough
2) BB don’t work at night if measuring
in the supine habitual position
3) An Expert panel Suggests:
-Adding CAIs is an agreeable option to a PGA
-Adding an alpha agonist is less agreeable
-Adding Fixed Combination should be reserved
for failure of adding a single agent ???

Combigan (Allergan)
– Brimonidine 0.2%
and timolol 0.5%
– BID dosing

Less allergy than
brimonidine alone
– timolol is a buffer
Singh K. et al. Am J Ophthalmolgy. 2008.
M. Chaglasian, OD
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Clinical Pearls for Challenging Cases
MOA 2014
Introducing... SIMBRINZA™ Suspension
Photos
A fixed-dose combination of brinzolamide 1% and brimonidine 0.2%
Additional 1-3 mm Hg IOP-lowering compared to
the individual components1-3
Delivers 21-35% IOP-lowering efficacy1-3
Only fixed-combination without a beta blocker1-3
Adverse events profile consistent with those of
its individual components1-3
Creates new treatment possibilities for lowering
IOP
1.
2.
3.
Katz G, et al. Three‐Month Randomized Trial of Fixed‐Combination Brinzolamide 1%/Brimonidine 0.2%. JAMA Oph. 2013.
Nguyen QH, et al. Phase 3 Randomized 3‐Month Trial With an Ongoing 3‐Month Safety Extension of Fixed‐Combination Brinzolamide 1%/Brimonidine 0.2%. J Ocul Pharmacol Ther. 2013;29:290‐7.
SIMBRINZA™ Suspension Package Insert. MG13241SK
127
Left
Case GS
SAP VFs
Right
GDx
55 yo C, F, Seeking second opinion
 History of being treated for glaucoma

– Currently on PGA and beta blocker
– Was recommended to have laser
trabeculoplasty
No insurance currently
 IOP= 17 mmHg

– Reports PreTx IOP around 21mmHg

CCT= 555µ
M. Chaglasian, OD
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Clinical Pearls for Challenging Cases
MOA 2014
Several Years Later:
Left
Matrix FDT VFs Right
Case GS

More aggressive treatment was
recommended, including:
– Adding Alphagan
– Adding CAI
– Switching to Cosopt (Combigan not available yet)
– ALT/SLT

Patient wanted a third opinion
M. Chaglasian, OD
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Clinical Pearls for Challenging Cases
MOA 2014
Next Steps

Treatment Options

Longer Term Considerations
Scleral Ring and Disc Size

Scleral Ring=
Outer Disc Margin
– What is the right target pressure?

First Step in
Determining Disc
Size
Scleral Ring and Disc Size
Clinical Pearls
Optic Nerve Evaluation
“The 5Rs”
Ring, Rim, RNFL, Region, Retinal disc heme

At the Slit Lamp
Volk Lenses:
60D = x 1.0
78D = x 1.1
90D = x 1.3
Adapted from FORGE program
R. Weinreb, F. Medeiros, R. Susanna
http://www.optometryjaoa.com
Scleral Ring and Disc Size
Small
Average
Large
Disc/Cup Size ≠ Risk
M. Chaglasian, OD
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Clinical Pearls for Challenging Cases
Rule #2: Size of Neuroretinal Rim

MOA 2014
Width of the NRR around the disc
Rim Width=
– Distance between outside border of disc
and bending of blood vessel on inner rim
ISN’T Rule:
Inferior> Superior>Nasal>Temporal
 Localized Notching / Thinning
 Color of Rim

CASE EB
Neuroretinal Rim

Rim Width:

Distance between
border of disc and
position of blood
vessel bending

57 yo, woman
Annual Exam
 Normal Slit Lamp
 Open Angles
 GAT= 21 OD 21 OS
 Pachs = 540 µ
Localized Rim Thinning/Notching
Case EB
Notch
M. Chaglasian, OD
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Clinical Pearls for Challenging Cases
MOA 2014
Five years later
Case EB
M. Chaglasian, OD
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Clinical Pearls for Challenging Cases
MOA 2014
Questions / Discussion
[email protected]
M. Chaglasian, OD
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