Advances in glaucoma care in 2024

Key Takeaways

  • Recent advances in glaucoma include FDA approvals of a new laser for glaucoma surgery, an implant that allows for sustained release of glaucoma medication, a preservative-free eye drop, and a remote glaucoma monitoring system.
  • Therapies in development include lasers, implants, a microshunt, and topical agents.

The Centers for Disease Control and Prevention estimates 3 million Americans have glaucoma. The use of daily eye drops to lower intraocular pressure (IOP) has been a mainstay of glaucoma therapy treatment for decades. However, a 2018 study put the rates of nonadherence as high at 67%. In part to skirt the adherence issue, several approaches have evolved to lower IOP without relying on drops. They include laser treatments to perforate the eye’s trabecular meshwork (the spongy tissue located near the cornea through which the aqueous humor flows out of the eye) and improve the outflow of aqueous humor, minimally invasive glaucoma surgery to create a small tunnel or even insert a shunt to enable aqueous outflow, and, more recently, implantable depots that release IOP-lowering drugs within the eye over months. The following are some recent developments and future directions.

Laser therapy:

The Belkin Eagle Nd:YAG laser, used to do a type of laser surgery that lowers intraocular pressure called selective laser trabeculoplasty (SLT), got FDA clearance in December 2023. Andrew Iwach, MD, a glaucoma specialist in San Francisco and clinical spokesperson for the American Academy of Ophthalmology (AAO), told Medscape Medical News that this is the first innovation in lasers in 20 years in that it eliminates the need for placing a diagnostic lens on the eye itself to direct the laser pulses, a technique called direct SLT. 

ViaLase, another laser in development, offers femtosecond laser image-guided high-precision trabeculotomy or FLigHT.  The VIA-002 study, which completed enrolling patients in October 2023, is comparing ViaLase with SLT to determine reduction in unmedicated IOP at 6 and 12 months.  A small feasibility study published last year found this procedure was safe, with an average reduction in IOP of 34.6% at 24 months.

Microshunts:

Microshunts inserted into the eye also have been used to reduce IOP. An early stage study is evaluating a new-generation, minimally invasive shunt that, once implanted, allows the ophthalmologist to adjust the level of aqueous outflow in an office-based procedure. For more information on this trial, visit https://clinicaltrials.gov/study/NCT05885022 or contact Robert Chang at 1-408-560-2500 or info@myravision.com.

Implants that release glaucoma medication:

Iwach said, “One challenge with glaucoma is its chronic nature. There are different methods that are being looked at to achieve sustained release of drugs — ways you can implant a little bolus (dose) of this medicine.” In December 2023 the FDA approved iDose TR, an implant loaded with the prostaglandin analog travoprost (Travatan) 75 mcg. The implant is scheduled for commercial release in the first quarter of 2024, with a projected wholesale acquisition cost of $13,950 per implant. At 12 months, 81% of iDose TR subjects required no IOP-lowering topical medications across both phase 3 trials used to gain FDA approval.

Also in development is an implant that uses a new technique called the cilioscleral technique to preserve the anterior chamber of the eye, reducing the risk for complications that can occur with other implant procedures. Preliminary results of a 12-month study of 57 patients fitted with a newly designed cilioscleral interpositioning device (CID) showed it lowered IOP an average of 13.9 mmHg. In addition, more than 85% of patients reported being medication free at 12 months. The CID procedure requires only a local incision, according to its developers. For more information on an upcoming trial of the CID, visit https://clinicaltrials.gov/study/NCT05625958.

Topical agents:

As for topical agents that reduce IOP, cannabinoids (marijuana) may soon find their way into the glaucoma specialist’s toolbox. A phase 2 trial evaluating SBI-100 ophthalmic emulsion started enrolling patients late last year. SBI-100 OE is a synthetic form of tetrahydrocannabinol that can bind and activate cannabinoid receptor type 1 in ocular tissues. The trial is scheduled for completion later this year. Last year, a phase 1 trial showed an average reduction in IOP of 24%.

Another area of focus is on the use of preservatives in topical drops. “One big issue we’re dealing with is preservatives because you’re marinating these eyes over years with these drops”, Iwach said. Late last year, the first preservative-free form of latanoprost ophthalmic solution 0.005% was launched in the U.S. Other delivery systems that remove preservatives from topical drops and preservative-free formulations are in the investigative stage, he said.

Remote monitoring:

Glaucoma requires regular monitoring of changes in eye pressure (IOP), Iwach noted. “During COVID, there was an increased interest in doing this remotely.”  Peripherex, a remote monitoring platform, was registered last year with the FDA. It consists of a diagnostic online visual field test that can enable patients with glaucoma to provide data on disease changes from home. 

Source: Richard Mark Kirkner, “2024 will see major advances in glaucoma care.” Medscape Medical News, February 8, 2024, see source article