EyeWorld Asia-Pacific September 2020 Issue

GLAUCOMA 46 EWAP SEPTEMBER 2020 IOP-lowering drug beyond 1 year. Another drug delivery option in the works is a bimatoprost- eluting ring (Allergan), an ocular surface insert that fits around the ocular fornix. This ring completed Phase 2 clinical trials a few years ago, with data published in 2016, showing a reduction of 3.2–6.4 mmHg from baseline (compared to a reduction of 4.2–6.4 mmHg in the timolol group) over a 6-month period. 2 In addition, Brandt et al. looked at 13 months of two cycles of using the bimatoprost ring. 3 Safety, according to the study authors, was good, and patients reported the ring to be comfortable or at least tolerable. The median IOP reduction in the 13 months of follow-up was 4 mmHg. Punctal plugs are already being used to elute steroids after cataract surgery for management of pain and postop inflammation, but they could someday be used for glaucoma therapy as well. Ocular Therapeutix is in Phase 3 testing stages with OTX-TP, a travoprost insert designed to deliver the drug for up to 90 days. Mati Therapeutics with Evolute is in clinical trials to deliver latanoprost through an intracanalicular insert. Similar to Durysta’s delivery as an intracameral implant is Envisia Therapeutics’ ENV515, which is in Phase 2 trials to release travoprost over an 11-month period. Ocular Therapeutix’s OTX-TIC, an intracameral travoprost implant with a targeted drug duration of 4–6 months, is also under clinical evaluation, recently completing its Phase 1 clinical trial. Further work is being done on a range of injectable drugs (Clearside Biomedical/ Santen, IBI-60089, EyePoint Pharmaceuticals, GB-401, Graybug Vision), gel-forming drops (SoliDrop, Otero Therapeutics), intrascleral implants (Ophthalmic MicroPump System, Replenish), and latanoprost-eluting contact lenses, among the other possible sustained-release drug delivery options. Stratifying products As with MIGS when many options were coming to the market, Dr. Al-Aswad said she thinks there will be a place for various modes of delivery. “I think we’re going to see what survives from these, how will they work, their side effects, the compliance with them, and the complication rates. According to that, we will decide what will work for us,” Dr. Al-Aswad said. “In addition, by having all of these options, we can tailor it to the patient’s needs. … Depending on their needs and other factors, that might push us in one direction or another.” Dr. Williamson envisioned a product like iDose being paired with MIGS procedures, because the surgeon would already be inside the eye. In terms of the day to day clinic, that’s where he thinks products like Durysta would come into play. As with any procedure and medication, there will be risks, but Dr. Williamson said it’s important to think about it in terms of the benefit-risk profile. “Does the potential risk of having an implant outweigh the risk of the alternative, which is topical therapy that they’re not taking? I would argue that the risk of not taking a drug and risking further visual field loss and blindness is worse than any potential issue with the implant or biodegradable itself,” he said. Dr. Williamson said sustained drug delivery is the future for glaucoma pharmacologic therapy. “I don’t think anyone is going to be using eye drops in our traditional form 25 years from now. It’s my prediction that everything is going to be moving toward drug elution or surgical solutions,” he said. Another thing he said he would look forward to in the future is a sustained drug delivery option that addresses inflow. “If we’re combining drug elution with MIGS, all of the MIGS devices work on outflow, so it would be cool to pair that with a drug-eluting device that works on inflow,” Dr. Williamson said. Dr. Al-Aswad said sustained- release has the potential to change how physicians think about glaucoma. For example, does a patient really need two medications to lower/maintain IOP or will improved compliance with a sustained-release option allow patients to use only one drug? What’s more, she said it truly has the potential to change a patient’s quality of life. “One time I had a patient who was taking four types of drops for glaucoma and I did surgery and he said, ‘You don’t understand how much you’ve freed me. I have now free time that I don’t know what to do with,’” Dr. Al- Aswad said, speculating that sustained- release drugs could have a similar effect. Dr. Al-Aswad said she thinks patients will be comfortable with sustained-release options because they’re already becoming more familiar with them for other ocular conditions that they or their friends might have. Dr. Williamson said the potential to improve compliance and lower IOP without a surgical procedure will be attractive to patients as well. “In my practice and in other surgeons’ practices who like the idea of having 100% compliance every time for glaucoma therapy, I think this is going to be a first- line treatment,” Dr. Williamson said. EWAP References 1. Glaukos. Accessed March 11, 2020. s21.q4cdn. com/471661912/files/ doc_presentations/2019/Glaukos- Presentation_January-2019.pdf 2. Brandt JD, et al. Six-month intraocular pressure reduction with a topical bimatoprost ocular insert: results of a Phase II randomized controlled study. Ophthalmology. 2016;123:1685–1694. 3. Brandt JD, et al. Long-term safety and efficacy of a sustained-release bimatoprost ocular ring. Ophthalmology. 2017;124:1565–1566. Editors’ note: Dr. Al-Aswad is professor of ophthalmology, director of teleophthalmology, artificial intelligence and innovation, New York University Langone Eye Center, New York, and declared no competing interest. Dr. Williamson practices at Williamson Eye Center, Baton Rouge, Louisiana, and has interests with Allergan and Glaukos.