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BobbySaenz,O.D.,M.S.,F.A.A.O.

MitchIbach,O.D.,F.A.A.O

Disclosureslide

Glaucoma•  Agroupofdiseasesthatdamagetheeye’sopticnerveand

canresultinvisionlossandblindness

•  2ndleadingcauseofblindnessinUSA–  PATIENTSDON’TEVENKNOWTHEYHAVEIT!!

•  3millionAmericanshaveglc,

butonlyhalfknowtheyhaveit

•  2ndleadingcauseofblindness– PATIENTSDON’TEVENKNOWTHEYHAVEIT!!

•  3millionAmericanshaveglc,

butonlyhalfknowtheyhaveit

Arepatientsgoodattakingeyedrops?

Howgoodareyourpatientsattakingdrops?

What’stheproblem?

• Education?

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What’shappeninginglaucoma?

•  Over-production?•  Under-drainage?

Whyareourpatientsnottakingtheirdrops?

What’stheproblem?•  Education

• Numberofgtts?

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Conclusions:...lessfrequentdosingregimensresultedinbettercomplianceacrossavarietyoftherapeuticclasses. Persistenceandadherencebestwithprostaglandins

What’stheproblem?•  Education?•  Numberofgtts?

• Cost?

HwangD,LiuCJ,PuC,ChouY,ChouP.PersistenceofTopicalGlaucomaMedication:ANationwidePopulation-BasedCohortStudyinTaiwan.JAMAOphthalmol.2014;132(12):1446–1452.doi:10.1001/jamaophthalmol.2014.3333

75.8%!!!!!!!!!!Includingthecost!

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Patientsreportedfarhighermedicationusethantheiractualbehavior.

NearlyHALFptsuseddropslessthan75%ofthetime.

Theabilityofthephysiciantoidentifywhichpersonsarepoorlyadherent….

ISPOOR

Andforthosewhoactuallydoputineyedrops?

Infact,upto80%ofpatientscontaminatetheirdropsbytouchingtheirface,upto61%donotinstillexactlyonedropand,mostcritically,upto37%misstheeyewiththedrop.

Sideeffects?

Howcanwehelpourpatients?

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DrugDelivery

•  Rings(BimatoprostRings)

•  Punctalplugs(travoprostpunctumplug)

•  Contactlenses(latoprostelutingcontactlens)•  Intracameralinjections

iDose Implant

iDose resides in the anterior chamber angle, anchored into the scleral tissue just behind the trabecular meshwork

FirstiDoseimplantintheU.S.performedbyDr.JohnBerdahlM.D.inSiouxFallsSD,

VanceThompsonVisiononMarch29,2016

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CataractSurgery

RemoveCataract

CorrectRefractive

ErrorMIGS Happier

Patients

AreasofAqueousOutflow

Outflow Pathway Disease State

Trabecular Meshwork Mild-to-Moderate

Suprachoroidal Space Progressive

Subconjunctival Space Refractory

1

23

Benefit-to-risk ratio is the ultimate criterion in

determining MIGS treatment algorithm

MIGS devices can be used to restore outflow through:

1

2

3

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Schlemm’sCanal/TM 1. Bypass– iStentinject

2. Dilate-Omni3. Cut/Ablate–KDB

ISTENTINJECTTRABECULARMICRO-BYPASSSTENTSYSTEM

v  Twotrabecularbypassstents;abinternoimplantation

v  Multiplestentplacementdesignedtoincreaseaccesstomorecollectorchannels

v  Multipleoutletlaterallumensprovideexitrouteforaqueousfromanteriorchamber

iStentinject

IOPREDUCTION

1.6 1.5

0.4

0.8

No.Meds

47%

reduction

75%

reduction

MEDICATIONBURDEN

0.4

0.8

Preop(n=380)

M23(n=357)

M23(n=109)

Preop(n=118)

50%FewerMeds

withiStentinject+PhacoatMonth23

iStentinject+Phaco(n=357)

Phaco

Alone(n=109)

iStentinject+Phaco PhacoAlone

84%ofiStentinjectsubjectsweremedication-freeat23months

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Post-OpAdverseEvents

iStentinject+Phaco

N=386

n(%)

PhacoOnly

N=119

n(%)

Stentobstruction 24(6.2%) NA

Intraocularinflammation 22(5.7%) 5(4.2%)

BCVAloss≥2linesat/afterM3 10(2.6%) 5(4.2%)

IOPincrease≥10mmHgat/afterM1 8(2.1%) 1(0.8%)

Cornealabrasion 8(2.1%) 4(3.4%)

Goniosynechiae 7(1.8%) 0(0.0%)

IOPincreaserequiringoralmedsorSSI

at/afterM11(0.3%) 3(2.5%)

SecondaryglaucomasurgerySLT

Trabeculectomy/Expressshunt

2(0.5%)

4(1.0%)

3(2.5%)

1(0.8%)

SAFETYOUTCOMESOcularAdverseEventsofInterestThrough24Months

Noreportsof:

• Myopicshift•  FlatAC•  Choroidalhemorrhage/effusion•  Cyclodialysis•  Hypotony≥1month•  Hypotonymaculopathy•  Stentdislocation•  Significanthyphema•  Cornealdecompensation

Don’twantpatientstomissoutonthis

iStentinjectPost-OpImages

CourtesyofDr.MarcToteberg2-yearpost-op

CourtesyofDr.GeorgeReiss

HENGERER(3YEAR)Long-termIOPReductionat3Years1

1.  HengererFH.PersonalExperiencewithSecond-GenerationTrabecularMicro-BypassStentsinCombinationwithCataractSurgeryinPatientswithGlaucoma:3-YearFollow-up.ASCRS2018Presentation.

37%

37%reductionfrom

preopIOP

100%ofpatientswithIOP≤18mmHg

•  IntraocularPressureOverTime

AblateorViscodilateKahookDualBlade

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•  Successrate68.8%•  1week>10mmHg:10%

Hydrusmicrostent

•  MildtoModPOAG

•  BypassanddilatesSC

OmniAreasofAqueousOutflow

Outflow Pathway Disease State

Trabecular Meshwork Mild-to-Moderate

Suprachoroidal Space Progressive

Subconjunctival Space Refractory

1

23

Benefit-to-risk ratio is the ultimate criterion in

determining MIGS treatment algorithm

MIGS devices can be used to restore outflow through:

1

2

3

AreasofAqueousOutflow

Outflow Pathway Disease State

Trabecular Meshwork Mild-to-Moderate

Suprachoroidal Space Progressive

Subconjunctival Space Refractory

1

23

Benefit-to-risk ratio is the ultimate criterion in

determining MIGS treatment algorithm

MIGS devices can be used to restore outflow through:

123

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Xengelshunt XenGelStent

BlebitisCase1:60yoHM–cataractevaland

OHTN•  +3.00sph20/30OU•  IOPOD28OS27

iStentinject

•  Mildtomoderateopenangleglaucoma

•  Needdocumentation(HVFandOCT)toprovetotheinsurancethatthepatienthasglaucoma

•  Needstobeondroppriortosurgery

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Case1:s/pCEOUandiStentinject

•  IOPOD17OS19•  IOPreduction39.2%OD•  IOPreduction29.7%OS

Doweneedtoaddanotherdrop?

Case2:72yoWMcataracteval•  OMDsaidIOPundercontrolandhasbabycataracts•  OD31mmHgOS31mmHg

–  LatanoprostqhsOU,BrimonidineTIDOU,CosoptBIDOU•  Gonioopen•  Averagepachs•  (+)FamHx•  BCVA20/25OU,BAT20/50OU

s/pLensARtoricIOLOUandiStentinjectOU

•  1dayOSIOP:32mmHg

•  3dayOSIOP:15mmHg

•  1weekOSIOP:16mmHg

•  6weekOSIOP:10mmHg

Nowwhatdowedo?

RememberptonCosopt,Brimonidine,and

Latanoprost

MIGStips•  BeawareofMIGS•  Determineifpatienthasglaucomabeforesendingforcataractevalifpossible

•  SendtosurgerygroupwhodoesMIGS•  Don’tchangedropstilabout6weekspostop

–  BeawareofIOPelevationat1dayduetovisco–  BeawareofIOPelevationafterduetosteroidresponse

RoleofODsisonlygoingtoget

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