Guiding Glaucoma

At AAO 2024 last year, glaucoma and cataract specialist Constance Okeke presented her poster, "Reduction in IOP after switching to latanoprostene bunod in glaucoma patients in real-world clinical practice." The study examined IRIS registry data to evaluate the efficacy of latanoprostene bunod (LBN) treatment – Vyzulta – in glaucoma patients in real-world clinical practice. The Ophthalmologist caught up with Okeke to learn more about what LBN might mean for future glaucoma treatments.

What were the key findings of your study?
 

We were evaluating IOP (intraocular pressure) reduction in patients who had glaucoma or ocular hypertension (OHT) and had been switched to latanoprostene bunod. We began by looking at patients who had open-angle glaucoma and OHT – this was about 4.2 million people, which we whittled down to 833 patients who had been on some kind of glaucoma therapy then switched to LBN. We were able to subdivide this group into two main cohorts – patients who were on a previous prostaglandin analog (PGA) monotherapy (the largest cohort) and those that were on a non-PGA combination therapy before switching to monotherapy LBN (a smaller but still substantial cohort).

For these patients, the mean IOP at baseline was 19.5 and in follow up the mean change in IOP decreased significantly by 2.8 mmHg. We saw on the follow-up visit that around 60 percent of patients in the overall group had at least a 2mm Hg mercury reduction of IOP, and nearly 30 percent of the patients had at least 5mm Hg of mercury reduction. So there was a significant amount of reduction in eye pressure when these patients switched to LBN. In addition, the subgroup that was switched from a non-PGA combination therapy to LBN monotherapy were found to have a slightly higher reduction in mean change in IOP and a higher percentage of patients who dropped by 5 mmHg or more. This is a significant win in both efficacy and enhanced compliance for the patient.

Interestingly, this information supported previous research we’d undertaken, a multi-center retrospective chart review looking at PGA monotherapy patients who had been switched to LBN. In that study, we found that there was around a 25 percent reduction in IOP on two subsequent follow-up visits for this cohort, with a significant IOP reduction that was very similar to the findings we presented at AAO.

And how was the poster received at AAO?
 

There was a lot of interest, especially with such a large real world population involved. Latanoprostene bunod is a drug that's been available for some time, and yet there are a number of people who were not able to touch this medication early on. In many academic settings, a lot of the treatment methods rely on the use of generics, and so some people have just not encountered Vyzulta before, and so are unaware of what the medicine is and why it might be different from other PGAs. So there was interest in understanding that this drug was available as an alternative for these patients.

How do you see LBN fitting into the evolving glaucoma treatment landscape?
 

I'm a big adopter of the whole interventional mindset, being more proactive and action-oriented. But as I discuss this paradigm shift with other thought leaders in the field, I realize that medication is not necessarily going anywhere, because it is part of the beginning, the middle, and the end of the treatment process. There will always be an avenue for medication because sometimes the procedures won't give us what we need, and then we lean towards medicine.

We're looking for medication regimens that are simple, effective, and tolerable – and this is where LBN succeeds. When they're simple, effective and tolerable, medications will be prioritized because they help with compliance, they help with efficacy for the patient, and, most importantly, they improve quality of life.

What other emerging trends in glaucoma treatment are you excited about?
 

Being aligned with the interventional mindset, I was a very early adopter of SLT and MIGS. I’ve already used direct selective laser trabeculoplasty (DSLT) on a number of patients, and this fits nicely into the concept of “treatment first.” The experience is faster and simpler for patients in terms of recovery; you don't have to use a gonioprism, for example, directly on the eyes. You can be very efficient, but the skillset is also simplified. If you are new to SLT, or maybe concerned about knowing the detail of the angle, DSLT takes a lot of that technical skill out of the equation, and thus lends itself to a broader range of adoption.

There are also different mechanisms of action. I was a Cypass user, and so was disappointed when it was withdrawn from use in the US in 2018. There's an upcoming device called CycloPen with AlloFlo, which has been developed by a company called Iantrek. They have devised a way to use scleral tissue to create a cyclodialysis that can help with the increase in uveoscleral outflow and lowering of eye pressure.

Is there anything else you’d like to add?
 

Part of the concept of integration and shifting to an interventional glaucoma mindset relies on us educating ourselves about what's out there. There is a flurry of innovations emerging, and it can be hard to keep up with what is going on. One of the passions I have is educating people, and understanding that when they have the knowledge, they have power. When they have the power to understand something, they can be open to utilizing it.

With this in mind, I created the iGlaucoma YouTube channel that has a series called “MIGS Made Clear.” The purpose of the series was to do just that – to help break down MIGS in a way that's systematic, very visual and clear. The series is coming near to a close and the majority of the videos are published. It’s been very well received by both the medical and optometry world. I believe when there is comfort with advancing technology, then it's easier to embrace it in practice.