Glaucoma Section Newsletter: Spring 2017

Published November 7, 2017

A message from the AAO
In This Issue

Message from the Glaucoma Section Chair

Review of the Glaucoma Section Symposium Academy 2016 Anaheim

Upcoming Glaucoma Section Symposium Academy 2017 Chicago

Happenings and News

Glaucoma Diplomate Section: an Inside View

An Update on Present and Future MIGS Devices

Glaucoma Section Officers

Lauren Ristin, OD, FAAO

Lisa Young, OD, FAAO
Immediate Past Chair





Jennifer Brown, OD, FAAO

Sarah Dougherty Wood,

Cecelia Koetting, OD, FAAO
Communications Chair

Michael Sullivan-Mee,
Diplomate Chair

Andrew Rixon, OD, FAAO
Program Chair

Steering Commitee

Rex Ballinger, OD, FAAO

Anthony DeWilde, OD, FAAO

Austin Lifferth, OD, FAAO

Rob Morris, OD, FAAO

Jeffrey Walline, OD, FAAO
Academy Board Liaison






































Spring 2017

Message from the Chair

March 2017

Dear Glaucoma Section Member:

Thank you to everyone who made Academy 2016 Anaheim successful, from our section leadership to the members who attended the events. It was so nice to see great attendance at our evening reception and section symposium. It was also exciting to see current and potential diplomate candidates deepen their knowledge base as well as get their questions answered about the diplomate program at our diplomate prep course. I would like to especially thank all of our speakers who spent countless hours making the section events informative, interactive and entertaining.

As the Glaucoma Section Chair, I want to encourage any current or potential members to become involved in our section. From volunteering in the leadership, participating in our Google group discussions, or applying to our diplomate programit is your participation that makes our section strong. If you have questions, comments, or are interested in getting more involved, please contact me. I am happy to help in any way that I can.

Lauren Ristin, OD, FAAO
Glaucoma Section Chair

Review of the Glaucoma Section Symposium at Academy 2016 Anaheim

“Identifying Meaningful Glaucomatous Progression in Primary Eye Care: A Case Based Approach”

On Friday November 11, 2016, the Glaucoma Section sponsored its fifth annual Glaucoma Symposium during the annual Academy meeting. The title of the symposium was “Identifying Meaningful Glaucomatous Progression in primary eye care: A case based approach." The symposium featured representative cases followed by corresponding didactic concepts taught by an expert panel comprised of Drs. Danica Marrelli and Leo Semes. A unique feature of this year’s symposium was its interactive component, led by moderator Dr. Blair Lonsberry. Audience members were provided login information for an app to be employed on their handheld devices allowing them the opportunity to directly respond to questions crafted by the panelists prior to the symposium. This interactive polling facilitated the panelists in customizing how they imparted their knowledge, based on their perception of the audience’s mastery of the individual topics presented. The symposium was both educational and highly informative and the panel exhibited great chemistry which enhanced the experience. The Glaucoma Section would like to thank our distinguished panelists for selflessly sharing their time and wisdom, and also a receptive audience who contributed to another successful Glaucoma Section symposium. We look forward to seeing everyone in Chicago!

Upcoming Glaucoma Section Symposium at Academy 2017 Chicago

MIGS: Emerging Technologies in Glaucoma Surgery

Evolving technologies in the field of micro-invasive glaucoma surgery (MIGS) have set the stage for a shift in treatment approach for qualifying patients with open angle glaucoma. It offers a welcomed new option for patients intolerant to medical management who lack the severity that necessitates the high risks of traditional surgical procedures. Optometrists must be prepared to accurately identify and selectively refer those candidates who would benefit most from this new technology.

Moderator: Joseph Sowka
Panelists: Brett Bence, Sarah Wood, and Madhu Gorla

Happenings and News

Opening the Lines of Communication: Glaucoma Section Google Group

How would you like to get another opinion on a challenging glaucoma case from your peers with similar interests and in similar situations? How about receiving regular access to trending discussion topics that are clinically relevant and evidence-based? Or, do you have something that you recently learned about glaucoma that you could share with the group for all of us to learn? These objectives are just some of the purposes of the Glaucoma Section Google Group site and, as such, we invite your observations, thoughts, and questions to help add breadth and depth to our unique discussions. Regardless of your current clinical situation, experience, or expertise, we welcome your contributions and we look forward to hearing from you soon!

AAO Fellows Doing Research Special Interest Group & Glaucoma Section Collaborate on Research

This coming AAO meeting in 2017, the Glaucoma Section will be leading an interesting research endeavor during the meeting. The proposed clinical question is regarding individuals who undergo inversion bed therapy and whether ocular perfusion pressure (OPP) changes when switching from an upright to an inverted position. We will have a research booth in the exhibit hall to help collect information from willing participants. We are looking for volunteers to help with the organization and implementation of this project. Please contact Lauren Ristin atlaurenristin@gmail.comif you would like to help. So plan to stop by and help make this study strong and successful by volunteering to be a willing participant!

Glaucoma Diplomate Section: an Inside View

The Glaucoma Diplomate program is built with a mentorship component. Each candidate is assigned a mentor who is charged with guiding and promoting the candidate's professional development within the program. Below is a brief statement from one of the program mentors and one of the active candidates regarding their initial impressions of the diplomate program.

Invited comment from one of our current Glaucoma Diplomate mentors:

Dr. Kathy Yang-Williams

The AAO Glaucoma Diplomate program is designed to recognize the clinical expertise and acumen of our fellow optometric physicians. It takes a significant commitment for a practitioner to embark on this journey-to put 'pen to paper' to present and discuss the diagnosis and treatment of glaucoma. Since there is no single management plan that will work for all patients, this exercise provides a wonderful opportunity to discuss and explore how doctors treat glaucoma and use relevant clinical literature to guide them in their treatment. I am privileged to participate as a mentor in this program and welcome the chance to discuss this fascinating topic with individuals who are equally interested in advancing their understanding of glaucoma.

Invited comment from one of our currently active Glaucoma Diplomate candidates:

Dr. Andrew Sacco

As a primary eye care provider, I knew enough about the diagnosis and treatment of glaucoma to take care of my patients. Or so I thought. Once I dove into the abyss of science and evidence based literature, and tried to regurgitate it into anything resembling sense and logic, I realized how little I really knew about the disease. That was disappointing, but eye opening. Learning to think more critically and make decisions based on what the evidence proves worksnot what I assumed workshas been challenging to say the least. And it has been stimulating, even at this point of my career, when undertaking this seems wholly illogical. Making sense of the science is not so easy without guidance. A tack sharp mentor with command of the literature and the disease in all its forms is the glue that holds this together. Questions are answered with depth and with substance. Without her guidance and critique, I would be struggling to advance my knowledge.

An Update on Present and Future MIGS Devices

Contributed by Justin Schweitzer, OD, FAAO

It is no secret that a majority of patients are non-adherent to their ocular medication dosing regimens, with nearly 50% discontinuing their medications within the first 6 months.1The introduction of microinvasive glaucoma surgery (MIGS) has helped alter the landscape for our glaucoma patients. MIGS techniques are typically used in the management of early to moderate glaucoma, but some new devices are making a push to be used in severe cases of glaucoma. Herein I review a few of the MIGS devices available to patients and some that are in the development pipeline.

iStent (Glaukos Corporation)
In 2012, the iStent was approved by the US Food and Drug Administration (FDA) for conjunction with cataract surgery. This stent was designed to serve as a bypass through the trabecular meshwork to facilitate physiologic outflow of aqueous and thus to lower IOP.2The stent is inserted through the same clear corneal incision used during cataract surgery. Implantation of the iStent at the same time as cataract surgery has a better safety profile than traditional filtration surgeries in combination with cataract surgery.2Adding the device to cataract surgery produced no compromise in the visual outcomes or safety of the cataract surgery procedure.2Studies have shown additional IOP reduction beyond cataract surgery alone and decreased in medication usage when this stent is added to the cataract procedure.2,3Preliminary studies have shown that the iStent, when performed as a standalone procedure, may significantly reduce both IOP and the number of medications necessary.4Although randomized controlled studies are needed, these results suggest that the device may be indicated for all patients with primary open-angle glaucoma independent of their phakic or pseudophakic status.

CyPass (Alcon)
The CyPass stent is a small, fenestrated, polyamide device that was recently approved by the FDA.5The device is placed in the supraciliary space to maximize use of uveoscleral outflow and avoids the trabecular meshwork and Schlemm’s canal.6The device targets the suprachoroidal space, which has a larger absorptive capacity, allowing increased outflow and IOP lowering compared with the trabecular pathway. One recent study concluded the CyPass stent precluded the need for more invasive glaucoma surgery in greater than 80% of patients at 1 year.7Baseline mean IOP in this same was 24.5 in phakic and pseudophakic patients with open-angle glaucoma. With implantation of one stent, mean IOP at 1 year was 16.4 mm Hg, a 34.7% reduction.7

XEN Gel Stent (Allergan)
The Xen implant uses an ab interno subconjunctival approach to lowering IOP. It shunts fluid from the anterior chamber to the subconjunctival space. A small subconjunctival bleb can at times be seen on examination. This stent is different from others in that it bypasses the natural drainage pathway and can produce the lower IOPs that typically are achieved only with trabeculectomy or tube shunt. In a recent study the un-medicated mean IOP decreased from 25.1 mmHg to 15.9 mmHg at 12 months.8Results also indicate the mean number of medications decreased from 3.5 at baseline to 1.7 at 12 months.8

Kahook Dual Blade (New World Medical)
The Kahook Dual blade uses blades and its tapered tip is designed to be eased into Schlemm canal, after which the device slides along the trabecular meshwork. The blade that is in the canal lifts and stretches the trabecular meshwork so that the second blade can safely cut the tissue. This allows for cleaner tissue removal and minimizes damage to adjacent tissue.9

Trabectome (NeoMedix)
The Trabectome is a handheld instrument that uses micro-electrocautery to ablate a 60 to 120 degree strip of trabecular meshwork and the inner wall of Schlemm canal. Irrigation and aspiration is simultaneously performed to remove ablated tissue. The ablation allows aqueous to have direct access to the outflow collector channels of Schlemm canal, thereby lowering IOP.

Investigational devices

Hydrus Microstent (Ivantis)
The Hydrus is about the size of an eyelash and is placed inside Schlemm canal through a clear corneal incision during cataract surgery. It increases outflow by acting as scaffolding and dilating Schlemm canal over 3 clock hours, allowing aqueous to bypass the trabecular meshwork providing direct aqueous access to multiple collector channels. At 24 months, 80% of the Hydrus subjects achieved a 20% reduction in washed out diurnal IOP compared to only 20% in the cataract surgery-only group.10Plus, 73% of the Hydrus patients were not taking any hypotensive medications, compared to 38% in the cataract surgery-only group.10The mean number of medications post-Hydrus was 0.8, down from just about 2.5 medications.10

iStent inject (Glaukos Corporation)
The iStent inject is a second-generation version of the iStent. The device resembles a rivet or punctal plug. The surgeon injects it through trabecular meshwork into Schlemm’s and more than one of the devices can be implanted. The head resides in the anterior chamber, aqueous will pass through the lumen, and exit the end of the device residing in Schlemm’s canal. Unpublished data (n=57) shows a mean IOP at month 18 ranging from 13.6-14.6 mmHg (down from an un-medicated baseline of 24.4 mmHg) and no medication use.11

iStent Supra (Glaukos Corporation)
A suprachoroidal stent, the iStent Supra is designed to shunt aqueous through the uveoscleral outflow pathway. The stent is a 4-mm tube made of polyethersulfone and titanium, designed to be placed in the supraciliary space. The 12-month data in patients previously uncontrolled on two topical medications found the device to be safe and able to substantially reduce IOP.12

MIGS are being adopted by surgeons around the world for glaucoma management. The devices and procedures described above have reduced complication profiles compared to trabeculectomy and tube shunts, with a powerful ability to facilitate aqueous outflow to lower IOP.

1. Nordstrom BL, Friedman DS, Mozaffari E, et al. Persistence and adherence with topical glaucoma therapy. Am J Ophthalmol 2005;140(4):598-606.
2. Samuelson TW, Katz L, Wells J, et al. Randomized evaluation of the trabecular micro-bypass stent with phaco- emulsification in patients with glaucoma and cataract. Ophthalmology. 2011;118(3):459-467.
3. Fea AM. Phacoemulsification versus phacoemulsification with micro-bypass stent implantation in primary open- angle glaucoma: randomized double-masked clinical trial. J Cataract Refract Surg. 2010;36(3):407-412.
4. Ferguson, TJ, Berdahl JP, Schweitzer JA, et al. Evaluation of a Trabecular Micro-Bypass Stent in Pseudophakic Patients with Open-Angle Glaucoma. Journal of Glaucoma 2016;25(11):896-900
5. Novartis. Alcon achieves US approval for CyPass® Micro-Stent, a micro invasive surgical device to treat glaucoma. Available at: Accessed January 17, 2017. 2016.
6. Vold S, Ahmed, II, Craven ER, et al. Two-Year COMPASS Trial Results: Supraciliary Microstenting with Phacoemulsification in Patients with Open-Angle Glaucoma and Cataracts. Ophthalmology In press 2016.
7. Garcia-Feijoo J, Rau M, Grisanti S, et al. Supraciliary Micro-stent Implantation for Open-Angle Glaucoma Failing Topical Therapy: 1-Year Results of a Multicenter Study. American Journal of Ophthalmology. 2015;159:1075-1081
8. Allergan. Allergan receives FDA clearance for the XEN Gel Stent, a new surgical treatment for refractory glaucoma. Available at: Accessed January 18, 2017., 2016.
9. Saheb H, Ahmed IIK. Micro-invasive glaucoma surgery: current perspectives and future directions. Curr Opin Ophthalmol. 2012;23(2):96-104)
10. Pfeiffer N, Garcia-Feijoo J, Martinez-de-la-Casa JM, et al. A Randomized Trial of a Schlemm's Canal Microstent with Phacoemulsification for Reducing Intraocular Pressure in Open-Angle Glaucoma. Ophthalmology 2015;122(7):1283-93.
11. Lindstrom RL. Use of Second Generation Trabecular Stents as Sole Procedure in Eyes with Open-Angle Glaucoma on 1 Preoperative Medication: 18-Month Report. American Society of Cataract and Refractive Surgery. New Orleans, LA. , 2016.
12. Kammer JA, Mundy KM. Suprachoroidal devices in glaucoma surgery. Middle East Afr J Ophthalmol 2015;22(1):45-52.