Advances in Excimer Laser Trabeculostomy within the Landscape of Minimally-Invasive Glaucoma Surgery.

Primary open-angle glaucoma (POAG) is currently treated with a variety of surgical and non-surgical approaches. Minimally invasive glaucoma surgery (MIGS) involves several devices and procedures that lower intraocular pressure (IOP) by increasing aqueous outflow. The first laser-based MIGS procedure, Excimer Laser Trabeculostomy (ELT), has emerged as a safe and effective treatment option. This article reviews ELT within the context of alternative MIGS procedures and focuses on the historical development of ELT, principles and techniques of the ELT procedure, safety and efficacy data, comparison to other outflow procedures, and future augmentations to expand the use of ELT. Performed alone or as an adjunct to cataract surgery, ELT has minimal complications and has shown long-term effectiveness in lowering intraocular pressure in thousands of patients. The non-thermal laser-tissue interactions of excimer lasers minimize peripheral tissue damage and ensure outflow channel patency without requiring foreign body implants or creating blebs. The development of 2D optical and 3D optical coherence tomography (OCT) guidance systems will eliminate the need for a goniolens to visualize angle structures and enable thousands more surgeons to perform ELT in the future.

Eight-year follow-up of excimer laser trabeculostomy alone and combined with phacoemulsification in patients with open-angle glaucoma.

PURPOSE: To describe the 8-year results of excimer laser trabeculostomy (ELT) alone and ELT in conjunction with phacoemulsification (phaco). SETTING: University hospital. DESIGN: Retrospective review. METHODS: 308 nm excimer laser energy delivered through an intraocular fiber-optic probe created channels through the inner wall of Schlemm canal. 2 groups were studied: ELT alone and ELT + phaco. Inclusion criteria were adult patients with open-angle glaucoma or ocular hypertension on 1 or more intraocular pressure (IOP)-lowering medications and, in the ELT + phaco group, presence of visually significant cataract. Primary outcome measures were change of IOP from baseline and number of IOP-lowering medications. RESULTS: 164 eyes in 2 groups, ELT alone (n = 90) and ELT + phaco (n = 74), were followed up for 8 years. Baseline IOP was 22.17 ± 7.0 mm Hg and 21.9 ± 6.44 mm Hg in the ELT alone and the ELT + phaco groups, respectively. IOP in the ELT alone group decreased to 16.84 ± 5.2 mm Hg at 1 year (n = 69) and remained at 15.9 ± 3.5 (n = 19) at 8 years. IOP in the ELT + phaco group was 14.04 ± 4.1 mm Hg at 1 year (n = 63) and 13.7 ± 2.8 mm Hg at 8 years (n = 13). The number of IOP-lowering medications at baseline in the ELT alone group was 1.85 ± 0.8 and decreased to 1.19 ± 1.10 at 1 year and 1.4 ± 1.4 at 8 years. In the ELT + phaco group, it was 1.58 ± 0.8 at baseline and decreased to 0.97 ± 0.95 at 1 year and 1.85 ± 0.7 at 8 years. CONCLUSIONS: ELT demonstrated long-term IOP lowering and decrease in the number of IOP-lowering medications. Benefits of this laser-based implant-free microinvasive glaucoma surgery procedure included a high safety profile and long-term efficacy.

Influence of new treatment modalities on adherence in glaucoma.

PURPOSE OF REVIEW: It is well known that glaucoma patients are not adherent to their therapeutic regimens. The issue of nonadherence is multifactorial and includes inadequate communication between doctors and patients, resulting in significant costs associated with enhanced disease progression. Therapeutic regimens are risk factors which often influences adherence rates. Thus, alternative treatment modalities, especially those risk factors that do not rely on patients' cooperation, may enable improvements in long-term outcomes of glaucoma in patient. RECENT FINDINGS: The studies selected for this review were divided into new medications, especially advancements in pharmaceutical approaches to treat glaucoma and new ways of delivering the medication, new surgical methods, especially minimally invasive surgery methods for glaucoma, and new studies about adherence in glaucoma. SUMMARY: Surprisingly, a very few studies on glaucoma medication or surgery addressed the concept of adherence. However, adherence is discussed in studies which consider psychological aspects of patients or communication issues between doctors and patients. Although these studies were performed in clinical settings, the issue of adherence is not addressed; despite it has significant effect on long-term outpatient care. A combination of both aspects, adherence and miscommunication, should be considered in studies.

Twenty-four hour intraocular pressure measurements and home tonometry.

PURPOSE OF REVIEW: IOP is the only treatable risk factor contributing to glaucoma and most management and treatment of glaucoma is based on IOP. However, current IOP measurements are limited to office hours and control of glaucoma in many patients would benefit from the ability to monitor IOP diurnally so as not to miss abnormal pressures, which occur outside of office hours Consequently, to improve patient care, the ability to enable accurate and minimally disruptive diurnal IOP monitoring would improve caring for these patients. RECENT FINDINGS: The studies we selected for this review can be divided into three categories: self-/home-tonometry, continuous invasive intraocular pressure measurements, and continuous noninvasive ocular measurements. SUMMARY: The desire to obtain better insight in our patients' true diurnal IOP has led to the development of home-tonometers, in addition to extraocular and intraocular continuous pressure measurement devices. All of the devices have respective advantages and disadvantages, but none to date completely fulfills the goal of providing a true diurnal IOP profile.Video abstracthttp://links.lww.com/COOP/A27.

Ocular hypotensive effect of the novel EP3/FP agonist ONO-9054 versus Xalatan: results of a 28-day, double-masked, randomised study.

BACKGROUND/AIMS: ONO-9054 is being developed for the reduction of intraocular pressure (IOP) in patients with ocular hypertension (OHT) and open-angle glaucoma (OAG). This study compared the novel dual EP3/FP agonist ONO-9054 with the FP agonist Xalatan. METHODS: Adults (n=123) with bilateral mild/moderate OAG or OHT, with unmedicated IOP of ≥24 mm Hg at 8:00 hours, ≥21 mm Hg at 10:00 hours and ≤36 mm Hg, were randomised 1:1 to receive ONO-9054 (0.003%, 30 µg/mL) or Xalatan (0.005%, 50 µg/mL) once daily for 28 days. RESULTS: Day 29 mean diurnal IOP was -7.2 mm Hg for ONO-9054 vs -6.6 mm Hg for Xalatan. At 08:00 hours, the IOPs were comparable, and at all later time points the decrease in IOP was greater for ONO-9054. On day 29, the odds of a mean IOP reduction of ≤-25%, ≤-30% and ≤-35% for ONO-9054 were 2.39, 2.37 and 4.85 times more, respectively, than the odds for Xalatan (p<0.05, post hoc analyses). The percentage of subjects achieving target IOPs on day 29 (≤17, ≤16 and ≤15 mm Hg) was greater for ONO-9054 than for Xalatan; the odds of achieving an IOP ≤15 mm Hg for ONO-9054 were 2.4 times more than the odds for Xalatan (p<0.01, post hoc analysis). CONCLUSIONS: Subjects randomised to receive ONO-9054 were more likely to achieve a greater per cent reduction in IOP and were more likely to achieve target IOPs than those receiving Xalatan. The effects of ONO-9054 in reducing IOP appear to persist longer than those of Xalatan. TRIAL REGISTRATION NUMBER: NCT02083289, Results.

Increasing healthcare costs: can we influence the costs of glaucoma care?

PURPOSE OF REVIEW: Despite a decrease in real average growth rates per capita since 2009, healthcare costs continue to rise worldwide. Numerous patient-related and doctor-related factors have contributed to this rise. Glaucoma is the leading cause of irreversible blindness and requires chronic, usually lifelong treatment. As with other chronic diseases, the adherence to prescribed treatment is often low and maybe influenced by the cost of the therapy. The purpose of this review is to seek potential solutions to best control the escalating costs of glaucoma care. RECENT FINDINGS: The studies we selected for this review can be divided into four different categories: costs of diagnostic tests; costs of direct comparisons between drugs or laser and conventional surgery; patient-related factors (such as adherence); and general aspects regarding costs: theoretical models and calculations. SUMMARY: It is challenging to find reliable studies concerning this subject matter. As patients are under the umbrellas of variously organized healthcare systems which span different cultures, the costs between countries are difficult to compare. However, one common aspect to lower costs in glaucoma care is to improve patient adherence. Theoretical models with actual patient studies could enable cost reductions by comparing multiple diagnostic and therapeutic scenarios. VIDEO ABSTRACT: http://links.lww.com/COOP/A22.

EP3/FP dual receptor agonist ONO-9054 administered morning or evening to patients with open-angle glaucoma or ocular hypertension: results of a randomised crossover study.

BACKGROUND/AIMS: The novel prostaglandin E (EP) 3 and prostaglandin F (FP) receptor agonist ONO-9054 is effective in lowering intraocular pressure (IOP) in patients with ocular hypertension and open-angle glaucoma when administered once daily. This study compares the effects of morning (AM) versus evening (PM) dosing of ONO-9054 on tolerability and IOP lowering. METHODS: This was a single-centre, randomised, double-masked, two-sequence, placebo-controlled crossover study in 12 subjects with bilateral primary open-angle glaucoma or ocular hypertension. Two 14-day crossover regimens were separated by a 2-week washout: ONO-9054 (1 drop to each eye) in the morning (07:00) and vehicle in the evening (19:00) and vice versa. IOP was measured multiple times during select days. Ocular examinations also evaluated safety and tolerability. RESULTS: Mild ocular hyperaemia, reported by six subjects with PM dosing, was the most frequent adverse event. Mild to moderate dryness was also slightly more frequent after PM dosing. Maximum IOP reduction from baseline occurred on day 2 with decreases from baseline of -7.4 mm Hg (-30.8%) for AM dosing and -9.1 mm Hg, (-38.0%) for PM dosing; after 14 days, mean reduction in IOP was -6.8 mm Hg (-28.6%) for AM dosing and -7.5 mm Hg (-31.0%) for PM dosing. CONCLUSIONS: PM dosing of ONO-0954 was associated with a slightly increased frequency of mild hyperaemia and mild to moderate dryness. Both dosing schedules provided sustained reduction in IOP. TRIAL REGISTRATION NUMBER: NCT01670266.