Digital Insert | Editorially independent content supported by advertising from Santen
Glaucoma Pipeline
A View Into Ongoing Innovation
Iqbal Ike K. Ahmed, MD, FRCSC
“With the potential to reduce or eliminate adherence issues, topical side effects, and the requirement for daily instillation associated with medications, procedural management is quickly becoming a popular option for patients with glaucoma. Lasers, devices, and surgeries also offer the promise of avoiding fluctuation. Lastly, they can be targeted to specific areas along the aqueous pathway where resistance is thought to occur. For all these reasons, development in this area is certainly robust. In this poster, we present the currently available options and a selection of some of the promising procedural options in development.”
Select a number to view the surgical developments in process.
1
Drainage to Ocular Surface
- Sollevio (Alevio)
Investigational
- Beacon Aqueous Microshunt (MicroOptx)
Investigational
2
AQUEOUS OUTFLOW AT MESHWORK
- Trabectome (MicroSurgical Technology)
- Kahook Dual Blade (New World Medical)
- Gonioscopy-Assisted Transluminal Trabeculotomy (GAAT)
- Therapeutic Ultrasound for Glaucoma (TUG, EyeSonix)
Investigational
- Argon Laser (488/514 nm [Argon Laser] or 532 nm [Nd:YAG])
- Selective Laser (532 nm)
- Pattern Scanning (577 nm – Topcon)
- Micropulse Diode Laser / ab externo Micropulse (810 nm – Iridex)
- Excimer Laser (308 nm [Xenon Chloride Laser])
- Titanium:Sapphire Laser (790 nm – Solx)
Laser Trabeculoplasty (laser wavelength):
3
Schlemm Canal
- iStent / iStent Inject (Glaukos)
- Hydrus (Ivantis)
- iTrack; Ab Interno Canaloplasty (ABiC; Ellex)
- OMNI Surgical System (Sight Sciences)
4
Aqueous Production
- Transscleral Cyclophotocoagulation (TSCPC, Iridex)
- Micropulse Diode Laser Transscleral Cyclophotocoagulation (MP-TSCPC, Iridex)
- Endocyclophotocoagulation (ECP, BVI Medical)
- High-Intensity Focused Ultrasound (HIFU - EyeOP1, EYE TECH CARE)
Investigational
5
Supraciliary Drainage
- iStent Supra (Glaukos)
- iSTAR (iStar Medical)
Investigational
6
Subconjunctival
Filtering Bleb Procedures
- Baerveldt Glaucoma Implant (Johnson & Johnson Vision)
- Ahmed Glaucoma Valve (New World Medical)
- Ahmed ClearPath (New World Medical)
- Molteno3 (Molteno Ophthalmic)
- PAUL Implant (Advanced Ophthalmic Innovations)
Investigational
- eyeWatch (Rheon Medical)
US Investigational
- Ex-PRESS (Alcon) external
- XEN45 / XEN63 Gel Stent (Allergan) internal/external
- PreserFlo MicroShunt (Santen) external
US Investigational
- Minimally Invasive Micro Sclerostomy (MIMS, Sanoculis)
US Investigational
TRADITIONAL INCISIONAL SURGERIES
Trabeculectomy
Aqueous Drainage Devices
MINIMALLY INVASIVE BLEB SURGERIES
John R. Samples, MD
“Pharmaceutical management of glaucoma is a tried and true strategy for lowering IOP. As evidenced by the over 100 molecules currently in various stages of development from pre-clinical to late stage, there is abundant interest in bringing novel agents with novel mechanisms to market. This is certainly good news for patients, as newer agents offer the prospect of filling current unmet needs, achieving greater efficacy and/or safety, and, ultimately, helping patients avoid loss of vision.”
Select a symbol to view the pharmaceutical developments in process.
Shape Legend
-
Uveoscleral Outflow
-
Aqueous Outflow: The Canal and Beyond
-
Aqueous Production
-
Aqueous Outflow at Meshwork
Color Legend
-
Commercially Available in US; Predominant Mode(s) of Action
-
Pipeline Candidate
-
Prostaglandins
-
Nitric Oxide-Donating Compounds
-
Rho Kinase Inhibitors
-
Omidenepag Isopropyl (DE-117, Santen)
-
NCX 470 (Nicox)
-
Muscarinic Agonists (Miotics)
-
Beta-Blockers
-
Alpha-Agonists
-
Carbonic Anhydrase Inhibitors
-
ATP Potassium Channel Modulators
-
Autotaxin-Lysophosphatidic Acid
-
AKB-9778 (Aerpio) (Presumed mode of action)
COMBINATION MEDICATIONS
-
Rocklatan
-
Cosopt / Cosopt PF (Dorzolomide HCI & Timolol Maleate; Akorn)
-
Combigan (Brimonidine Tartrate & Timolol Maleate; Allergan)
-
Simbrinza (Brinzolamide & Brimonidine tartrate; Novartis)
(Advantages ↑compliance, adherence ↓preservative, copay)
Extended Duration Options
- • DURYSTA (Allergan)
- • iDose (Glaukos)
INTRACAMERAL DEVICES
- • OTX-TP (Ocular Therapeutix)
- • Evolute (Mati Therapeutics)
- • Latanoprost Punctal Plug Delivery System (L-PPDS, Mati Therapeutics)
PUNCTAL PLUGS
- • GB-401 (Graybug Vision)
INJECTABLE SYSTEMS
- • Eye-D (ViSci)
- • Latanoprost FA SR Ocular Implant (PA5108, PolyActiva)
- • Subconjunctival / Sub-Tenon / Scleral Drug-Eluting Implants and Delivery Mechanisms
OCULAR INSERTS AND INTRAOCULAR IMPLANTS
- • Helios (Allergan)
- • MicroProst (Eyenovia)
- • Drug-Eluting Contact Lenses
- • Long-Acting Drops
OCULAR SURFACE
Potential Candidates in Neuroprotection*
- • Alpha-Agonists (Brimonidine)
- • Rho Kinase Inhibitors (Netarsudil and Ripasudil)
- • Adenosine A1 Agonist (Trabodenoson)
- • Carbonic Anhydrase Inhibitors
PRESSURE-LOWERING MEDICATIONS WITH SUGGESTED NEUROPROTECTIVE BENEFIT†
- • Ciliary Neurotrophic Factor (Delivered by live cells)
- • Recombinant Human Nerve Growth Factor
- • Brain-Derived Growth Factor
NEUTROPHILS AND GROWTH FACTORS
- • Ginko
- • Citicholine
- • Calcium Channel Blockers
BLOOD FLOW REGULATION¶
- • Nicotinamide
- • Ascorbic Acid
ANTIOXIDANTS‡
- • TIE2 Inhibitors (AKB 9778, Aerpio)
- • Caspases
- • Resveratrol
- • Melatonin
- • Goji Berries
OTHER TARGETS AND TREATMENTS
* The quality of the literature supporting neuroprotective benefits of the following is widely variable; these agents and molecules may or may not have neuroregenerative properties, which would be associated with beneficial effect on retinal ganglion cells
† Pressure-lowering drug classes with alleged neuroprotection effect; no human studies have been conducted to date
‡ Nutrient-overlap
¶ Indirect neuroprotective mechanism
R. Rand Allingham MD, Sayoko E. Moroi MD, PhD, M. Bruce Shields MD, Karim F. Damji MD, MBA. Shields’ Textbook of Glaucoma. Wolters Kluwer Health, Inc. 2020.
Outflow at Meshwork/Schlemm Canal
The concept of disease modification has garnered a lot of attention in glaucoma research. The future of pharmaceutical management may well belong to small and large molecules and antibodies capable of addressing the cause(s) of elevated pressure. Based on current evidence, there is potential for such therapeutic targeting in at least three zones:
1. TM – Reverse structural/functional damage to facilitate outflow; Rho Kinase Inhibitors likely exhibit this effect, evidence is emerging that prostaglandins have a similar effect, and newer drugs may stimulate macrophage-like activity by trabecular cells
2. SC / JXT – Reversing SC stiffening in high-pressure glaucoma; ATP Potassium Channel Modulators and Autotaxin-lysophosphatidic acid may work here, either reversing stiffening or increasing function of the extracellular matrix
3. Ostia / collector channels / veins – Several lines of research are exploring targeting potential beyond the canal