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MIGS MAKING NEWS
Minimally invasive glaucoma surgery (MIGS) is one of the new and exciting prospects in the treatment of glaucoma.
It has long been a goal of glaucoma surgeons to perform less invasive procedures that reduce some of the complications of most standard glaucoma surgeries while providing the same reduction in the dependence upon medications as traditional incisional filtration surgery. Many of the new MIGS devices and procedures are designed to be used with patients who have mild to moderate glaucoma in combination with cataract surgery.
It is very common for glaucoma and cataracts to coexist. In both conditions, the risk increases with age. But while vision loss from glaucoma is still irreversible, loss of vision due to cataracts can usually be reversed by surgically removing the cloudy, cataract lens and implanting a clear artificial replacement intraocular lens.
Today, surgeons view cataract surgery as an ideal opportunity to bring a patient's glaucoma under better control. They do this by combining cataract surgery with a minimally invasive glaucoma surgery (MIGS) procedure. The FDA's recent approval of several new MIGS procedures is increasing doctors’ options. The greatest advantage to the concomitant use of a MIGS procedure with cataract surgery is the significant reduction of surgical and postoperative risks and complications, as compared to traditional glaucoma filtration surgery (trabeculectomy).
A growing number of surgeons are combining cataract surgery with newer MIGS, which in clinical trials have been shown to significantly decrease IOP. Among these technologies are the iStent, Trabectome, Kahook dual blade goniotomy, and the recently approved Cypass Micro-Stent device (see following news article) and Xen gel stent. All of these MIGS have shown that they can lower IOP and reduce topical glaucoma medication with a greatly reduced rate of the inherent risks of traditional drainage surgery. Another promising MIGS device, the InnFocus micro shunt, is currently under investigation and FDA trials.
Most importantly, clinical research has shown that by performing a MIGS procedure at the same time as removing the cataract, the surgeon can usually bring the patient’s mild to moderate glaucoma under better control, lower the IOP and/or reduce the medications required to control the IOP.
THE LATEST APPROVED MIGS DEVICE
The Cypass Micro-Stent, approved by the FDA in 2016, is the first microinvasive glaucoma stent designed to lower eye pressure by increasing drainage through the suprachoroidal space of the eye. It was approved by the FDA for use in conjunction with cataract surgery in adults with mild to moderate primary open-angle glaucoma.
Unlike other glaucoma surgical devices, CyPass does not access the Schlemm’s canal or the conventional aqueous outflow pathway. It was designed to create a permanent conduit from the anterior chamber to the suprachoroidal space to drain the aqueous internally. The suprachoroidal space in the eye is located between the sclera, which is the outermost layer that forms the white part of the eye, and the next layer beneath it, the choroid, home to the blood vessels that nourish the retina. The miniscule space between the two is the suprachoroidal space, a promising location for innovative glaucoma treatments. The Cypass Micro-Stent is implanted into the supraciliary space through a clear corneal incision, a technique that avoids formation of a filtering bleb and spares the conjunctiva, the clear, thin membrane that covers part of the front surface of the eye and the inner surface of the eyelids.
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FDA APPROVES NEW GLAUCOMA MEDICATION
The FDA last week approved Bausch + Lomb’s new glaucoma medication, Vyzulta (latanoprostene bunod ophthalmic solution, 0.024%), for the reduction of IOP in patients with open-angle glaucoma or ocular hypertension. The manufacturer expects to make this new treatment option available before the end of the year.
Vyzulta is an eyedrop for once-daily usage but has a dual mechanism of action. Scientists have chemically combined nitric oxide with latanoprost to create a new molecule, latanoprostene bunod, which is a nitric oxide–donating prostaglandin F2-alpha analogue.
The new molecule has mechanisms of action associated with its two components. Vyzulta provides a new treatment option that works to reduce IOP by increasing the outflow through both the trabecular meshwork and the uveoscleral pathways. While the prostaglandin component increases uveoscleral outflow, the nitric oxide component releases nitric acid to increase aqueous outflow through the trabecular meshwork.
FINAL 2017 RESEARCH GRANTS FUNDED
The Glaucoma Foundation has funded its final two research grants for 2017. Since targeting exfoliation syndrome as its research focus five years ago, TGF has funded 22 projects that aim to better understand and to find a cure for exfoliation syndrome and its associated exfoliation glaucoma.
Role of Lysyl Oxidase-Like-1 (LOXL1) Proteolytic Processing in the Development of Pseudoexfoliation Syndrome (PEX)
Principal Investigator: Fernando Rodriguez Pascual, PhD
Centro de Biologia Molecular, Madrid, Spain
Genetic variations in the LOXL1 gene have been strongly associated with exfoliation syndrome (XFS). The protein product of the LOXL1 gene belongs to a group of enzymes which contributes to building the extracellular matrix (ECM) by promoting the cross-linking of elastin and collagens. LOXL1 plays an important role in the formation of elastic fibers, the ECM scaffold imparting elasticity to animal tissues. LOXL1 must be proteolytically processed in order to fulfill its biological function, but how this process occurs, what cellular enzymes (proteases) are involved, and whether this contributes to XFS disease are not yet known, and are the main questions this research will investigate.
Targeted Deep Sequencing of the FLT1 – POMP – SLC46A3 Susceptibility Locus for Exfoliation Syndrome and Exfoliation Glaucoma.
Principal Investigator: Chiea Chuen Khor, PhD
Genome Institute of Singapore
An earlier investigation studied 13,620 XFS patients from 33 countries and identified five new genes contributing to XFS susceptibility. The most significant newly identified loci include a gene encoded for a protein called POMP, which is responsible for ensuring cellular well-being by cleaning up harmful oxidative radicals and degraded proteins. The genetic association mapping to this POMP locus shows clear evidence of interaction with geographical latitude, whereby genetic risk conferred increases with distance away from the equator. This grant, utilizing investigators from six continents, will be used to fully sequence this gene locus.
WE ARE LOOKING FOR STORIES TO SHARE
One of the most popular features of TGF’s Eye to Eye newsletter and electronic newsletter update has been our “Lifestyle Connection/Living with Glaucoma” series, in which glaucoma patients, inspiring and often courageous, have shared their personal stories. We’ve featured a teenager who lives life to the fullest, a triathlete who makes news, an active 90-year-old woman who shared fine advice, among others.
We are always looking for individuals whose lives have been impacted by glaucoma and whose experiences can inform others. If you would like to share your own story, or suggest another, email asteele@glaucomafoundation.org
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