touchOPHTHALMOLOGY touchOPHTHALMOLOGY
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Tutorial

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Poll

What do you do when first-line monotherapy for OAG does not achieve the target IOP?

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Switch to another drug in the same class
   
Switch to a drug from a different class
   
Add a second drug from a different class
   
Consider non-drug treatment options
   

Tutorial

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Poll

Which class of drugs do you normally use as first-line treatment for OAG?

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Prostaglandin analogue
   
Beta-blocker
   
Alpha-2 adrenergic agonist
   
Other
   

Tutorial

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Poll

How confident are you in diagnosing different types of glaucoma?

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Not at all confident
   
A little confident
   
Somewhat confident
   
Very confident
   
 
Expert Interviews
Glaucoma CE/CME accredited

touchEXPERT OPINIONS
Experts answer questions with in-depth advice on the current clinical landscape and how new therapies and guidance might impact regional clinical practice. Useful tips below will show how to navigate the activity. Close

Innovations in glaucoma care: Targeting pathophysiology to expand treatment options

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Angelo P Tanna, MD is professor and vice chair of ophthalmology and director of the Glaucoma Service at the Northwestern University Feinberg School of Medicine in Chicago, Illinois, where he has served on the faculty since 1999.  read more

Dr Tanna received his medical degree at the Columbia University College of Physicians and Surgeons. He completed his ophthalmology residency and glaucoma fellowship at the Wilmer Eye Institute of The Johns Hopkins University School of Medicine.

Dr Tanna’s research focuses on the efficacy and safety of glaucoma medications, techniques to modulate wound healing after incisional glaucoma surgery, methods to confirm the stability of the glaucoma disease process over time, abnormalities in ocular blood flow in different types of glaucoma, and the assessment of visual function in glaucoma. Dr Tanna has been a principal investigator (PI) in several clinical trials and currently serves as one of the PIs of the NEI COAST clinical trial. His recent studies in collaboration with biomedical engineers centre around the use of hydrogel polymers to prevent excessive fibrosis after trabeculectomy.

Dr Tanna received the American Academy of Ophthalmology Senior Achievement Award in 2017, the Secretariat Award in 2019 and has received several teaching awards at Northwestern. He has served in various leadership roles in the American Glaucoma Society and also as a member of its board of directors. He previously chaired the American Academy of Ophthalmology’s Basic and Clinical Science Course Glaucoma Committee. Dr Tanna is co-editor of the 3rd edition of Glaucoma Medical Therapy and serves on the editorial boards of four peer-reviewed journals: Ophthalmology, Survey of Ophthalmology, Scientific Reports and Ophthalmology Glaucoma.

Dr Angelo Tanna discloses: Consultancy fees from Alcon (relationship terminated), Apotex, Ivantis (relationship terminated) and Zeiss.

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Courtney E Bovee, MD is a board-certified, Harvard Fellowship-trained ophthalmologist and glaucoma surgeon. Dr Bovee was listed in the 2022 Ophthalmologist Power List, honouring 100 of the most influential people in the world in the field of ophthalmology. read more

Dr Bovee is a leader in organized medicine, an advocate for her patients, an innovator in the pharmaceutical and medical device industry and enjoys teaching cutting-edge ophthalmology techniques.

Dr Bovee was named the 2020 Florida Society of Ophthalmology Outstanding Young Ophthalmologist and awarded the Michael R Redmond Ophthalmology Leadership Award. She has also received the prestigious ‘Excellence in Medicine Award’ from the American Medical Association.

Dr Courtney Bovee discloses: Independent contractor fees from Ocular Therapeutix. Advisory board or panel fees from Radius. Speaker’s bureau fees from Abbvie, Allergan, Bausch and Lomb, Gluakos, Harrow, New World Medical, Sight Sciences and Tarsus. Stock/Shareholder (self-managed) from Abbvie, Gluakos, Eli Lilly, Harrow, Radius and Sight Sciences.

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Joseph F Panarelli, MD is a professor of ophthalmology at the New York University (NYU) School of Medicine who specializes in the treatment of adult and paediatric patients with glaucoma. read more

Dr Panarelli received his BS in Finance from Georgetown University’s McDonough School of Business in 2003 and his medical degree from the Georgetown University School of Medicine in 2007, where he was elected to the Alpha Omega Alpha honour medical society during his junior year. He completed a residency in ophthalmology at the New York Eye and Ear Infirmary, where he served as chief resident during his final year of training. He was awarded the William and Judith Turner Award for excellence in ophthalmologic training. Following a year of fellowship training in glaucoma at the Bascom Palmer Eye Institute in Miami, he joined the faculty at Bascom Palmer for an additional year, prior to returning to New York Eye and Ear as a member of the full-time faculty. For 5 years at the New York Eye and Ear Infirmary, he was active in resident education, serving as the associate residency program director as well as glaucoma fellowship director. Dr Panarelli transitioned to NYU where he serves as the director in the Division of Glaucoma Services.

Dr Panarelli is certified by the American Board of Ophthalmology, and he is a member of the American Glaucoma Society as well as the American Academy of Ophthalmology. He is the recipient of several awards, including the Mentoring for Advancement of Physician-Scientist Award from the American Glaucoma Society, and was selected as a Castle Connolly Top Doctor from 2017–2023.

He has published extensively in his field and is a principal investigator for numerous studies pertaining to the surgical management of glaucoma.

Dr Joseph Panarelli discloses: Consultancy fees from Abbvie, Alcon, AOI Ophthalmics, Corneagen, Corneat, Glaukos, New World Medical, Nova Eye, Santen and Zeiss.

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  • Select in the video player controls bar to choose subtitle language. Subtitles available in English, Brazilian Portuguese, French, Spanish.
  • A practice aid is available for this activity in the Toolkit
  • Downloads including slides are available for this activity in the Toolkit
Learning Objectives

After watching this activity, participants should be better able to:

  • Describe the conventional pathway for aqueous outflow and pathophysiology for ocular hypertension and open-angle glaucoma, including normal tension and steroid-induced glaucoma
  • Outline the different classes of drugs, including rho kinase inhibitors, and their mechanisms of action for the management of ocular hypertension or open-angle glaucoma
  • Discuss the role and efficacy of monotherapy, combination therapy and fixed drug combinations in glaucoma management
Overview

In this activity, three leading experts describe the pathophysiology of open-angle glaucoma, and discuss how it is targeted by current and emerging treatment options, while providing insights on how different agents and combinations are used in practice. read more

Target Audience

This activity has been designed to meet the educational needs of glaucoma specialists and surgeons, general ophthalmologists and optometrists involved in the management of glaucoma.

USF Accreditation

Disclosures

USF Health adheres to the Standards for Integrity and Independence in Accredited Continuing Education. All individuals in a position to influence content have disclosed to USF Health any financial relationship with an ineligible organization. USF Health has reviewed and mitigated all relevant financial relationships related to the content of the activity. The relevant relationships are listed below. All individuals not listed have no relevant financial relationships.

Faculty

Dr Angelo Tanna discloses: Consultancy fees from Alcon (relationship terminated), Apotex, Ivantis (relationship terminated) and Zeiss.

Dr Courtney Bovee discloses: Independent contractor fees from Ocular Therapeutix. Advisory board or panel fees from Radius. Speaker’s bureau fees from Abbvie, Allergan, Bausch and Lomb, Gluakos, Harrow, New World Medical, Sight Sciences and Tarsus. Stock/Shareholder (self-managed) from Abbvie, Gluakos, Eli Lilly, Harrow, Radius and Sight Sciences.

Dr Joseph Panarelli discloses: Consultancy fees from Abbvie, Alcon, AOI Ophthalmics, Corneagen, Corneat, Glaukos, New World Medical, Nova Eye, Santen and Zeiss.

Content reviewer

John Steven Jarstad, M.D., FAAO, FRSM-UK has no financial interests/relationships or affiliations in relation to this activity.

Touch Medical Contributors

Adriano Boasso has no financial interests/relationships or affiliations in relation to this activity.

USF Health Office of Continuing Professional Development and touchIME staff have no financial interests/relationships or affiliations in relation to this activity.

Requirements for Successful Completion

In order to receive credit for this activity, participants must review the content and complete the post-test and evaluation form. Statements of credit are awarded upon successful completion of the post-test and evaluation form.

If you have questions regarding credit please contact cpdsupport@usf.edu 

Accreditations

Physicians

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through a joint providership of USF Health and touchIME. USF Health is accredited by the ACCME to provide continuing medical education for physicians.

USF Health designates this enduring material for a maximum of 0.75 AMA PRA Category 1 CreditsTM.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Advanced Practice Providers

Physician Assistants may claim a maximum of 0.75 Category 1 credits for completing this activity. NCCPA accepts AMA PRA Category 1 CreditTM from organizations accredited by ACCME or a recognized state medical society.

The AANPCP accepts certificates of participation for educational activities approved for AMA PRA Category 1 CreditTM by ACCME-accredited providers. APRNs who participate will receive a certificate of completion commensurate with the extent of their participation.

Date of original release: 08 October 2024. Date credits expire: 08 October 2025.

If you have any questions regarding credit, please contact cpdsupport@usf.edu

 

This activity is CE/CME accredited

To obtain the CE/CME credit(s) from this activity, please complete this post-activity test.

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  • Select in the video player controls bar to choose subtitle language. Subtitles available in English, Brazilian Portuguese, French, Spanish.
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  • Downloads including slides are available for this activity in the Toolkit

Topics covered in this activity

Glaucoma
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touchEXPERT OPINIONS
Innovations in glaucoma care: Targeting pathophysiology to expand treatment options
0.75 CE/CME credit

Question 1/5
You are managing a 67-year-old woman who was diagnosed with NTG two years ago. She has been on topical monotherapy ever since her diagnosis. Upon examination you detect an optic disc haemorrhage in her left eye. What would you do next?

IOP, intraocular pressure; NTG, normal tension glaucoma.

Disc haemorrhages have been associated with progression of damage to the optic nerve or visual field.1 While it is not possible to treat disc haemorrhages, increased clinical monitoring and intensification of IOP-lowering therapy is warranted.2

Abbreviation

IOP, intraocular pressure.

References

  1. Gedde SJ, et al. Ophthalmology. 2021;128:P71–150.
  2. American Academy of Ophthalmology®. Optic Disc Hemorrhage. 2023. Available at: www.eyewiki.org/Optic_Disc_Hemorrhage (accessed 10 September 2024).
Question 2/5
Which class of glaucoma agent works by increasing AH outflow via the trabecular meshwork, decreasing episcleral venous pressure and reducing AH production in the ciliary body?

AH, aqueous humour; NET, norepinephrine transporter; ROCK, Rho kinase.

β-blockers and carbonic anhydrase inhibitors work by reducing AH production from the ciliary body. Cholinergics act on the trabecular meshwork to increase AH outflow.1,2 ROCK/NET inhibitors act at three distinctive sites: they increase AH outflow via the trabecular meshwork, reduce episcleral venous pressure and decrease AH production in the ciliary body.3,4

Abbreviations

AH, aqueous humour; NET, norepinephrine transporter; ROCK, Rho kinase.

References

  1. Jóhannesson G, et al. Acta Ophthalmol. 2024;102:135–50.
  2. Schmidl D, et al. J Ocul Pharmacol Ther. 2015;31:63–77.
  3. Ren R, et al. Invest Ophthalmol Vis Sci. 2016;57:6197–209.
  4. National Center for Biotechnology Information. PubChem Compound Summary for CID 66599893, Netarsudil. 2024. https://pubchem.ncbi.nlm.nih.gov/compound/Netarsudil (accessed 20 September 2024).
Question 3/5
You are managing a 67-year-old woman with newly diagnosed OAG. Upon examination of her medical history you find she suffers from asthma. Her general practitioner has noted that she is sometimes forgetful when it comes to taking her medication. Which of the following agents would you prescribe?

OAG, open-angle glaucoma.

Prostaglandin analogues are often considered the first choice topical treatment of OAG owing to their once-daily dosing and robust IOP lowering effects (25–35%).1–3 A β-blocker may also be considered, but its use is contraindicated in patients with asthma, chronic obstructive pulmonary disease and certain cardiovascular conditions.2,3

Abbreviations

IOP, intraocular pressure; OAG, open-angle glaucoma.

References

  1. Jóhannesson G, et al. Acta Ophthalmol. 2024;102:135–50.
  2. Gedde SJ, et al. Ophthalmology. 2021;128:P71–150.
  3. The International Agency for the Prevention of Blindness. Latin America Guide to Primary Open Angle Glaucoma. 2019. Available at: www.iapb.org/learn/resources/latin-america-guide-to-primary-open-angle-glaucoma/ (accessed 3 September 2024).
Question 4/5
What is the optimal approach for managing a patient with severe OAG who has not achieved target IOP after 2 months on a prostaglandin analogue?

FDC, fixed-dose combination; IOP, intraocular pressure; OAG, open-angle glaucoma.

When a monotherapy is well tolerated and effective but fails to reduce IOP to the target pressure, a second drug of a different class should be considered. Using multiple topical agents may decrease adherence, which is important to achieve treatment goals. Thus, when available, FDC therapies are preferable. This may be particularly beneficial in cases of advanced glaucoma and/or very high IOP where target pressure is unlikely to be reached with one agent.1,2 Guidelines recommend that medical therapy and/or laser trabeculoplasty are tried before surgical intervention.1

Abbreviations

FDC, fixed-dose combination; IOP, intraocular pressure.

References

  1. European Glaucoma Society Terminology and Guidelines for Glaucoma, 5th Edition. Br J Ophthalmol. 2021;105(Suppl 1):1–169.
  2. Gedde SJ, et al. Ophthalmology. 2021;128:P71–150.
Question 5/5
You are determining which treatment to provide a patient with OAG. Which of the following factors should you consider when selecting a therapy?

OAG, open-angle glaucoma; QoL, quality of life.

Treatment for glaucoma should be individualized and decided upon in partnership with the patient. Clinicians should account for the efficacy of an agent, cost of treatment, dosing regimen as it pertains to adherence, side effect profile, degree of optic nerve damage and patient factors, such as QoL.1–3

Abbreviation

QoL, quality of life.

References

  1. European Glaucoma Society Terminology and Guidelines for Glaucoma, 5th Edition. Br J Ophthalmol. 2021;105(Suppl 1):1–169.
  2. Gedde SJ, et al. Ophthalmology. 2021;128:P71–150.
  3. Jóhannesson G, et al. Acta Ophthalmol. 2024;102:135–50.
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