62 EW GLAUCOMA
Pharmaceutical focus
Experts discuss new drops
O
ver the next few years,
many developments will
occur in the glaucoma
pharmaceutical space,
with several new drugs
set to emerge, according to Nathan
Radcliffe, MD, New York University
Langone Medical Center, New York.
“They all involve medications that
aid in the outflow of the aqueous
humor through the trabecular path-
way,” Dr. Radcliffe said. The idea
likely resonates with those doing
MIGS procedures because practi-
tioners are trying to do many of
the same things, namely reestablish
natural outflow of aqueous humor
through the trabecular pathway.
Constance Okeke, MD, Eastern
Virginia Medical School, Norfolk,
Virginia, pointed out that there
hasn’t been a new glaucoma medica-
tion in years. “Even though we have
this explosion of new minimally
invasive glaucoma surgeries, there’s
still a huge window of opportunity
for a new drop,” Dr. Okeke said.
This may be especially true for the
patient who is apprehensive about
surgery, has allergies, or has devel-
oped tolerances to drops.
Vyzulta on deck
Of three new agents being explored,
the first to emerge will likely be
Vyzulta (latanoprostene bunod,
Bausch + Lomb, Bridgewater, New
Jersey), Dr. Radcliffe noted. “It’s a
nitric oxide donating prostaglan-
din analogue,” he said, adding that
as far as the FDA is concerned, it’s
going to be classified as a prosta-
glandin analogue, which may have
implications for insurance. “It may
be tough to get for our patients
because Bausch + Lomb will have to
compete with the other prostaglan-
din analogues,” Dr. Radcliffe said.
“But it has potency that looks to be
better than latanoprost, and that
could make it a very appealing first-
line treatment for glaucoma.”
Dr. Okeke agreed that Vyzulta
is an intriguing new agent. “It has
a dual mechanism of action; one is
similar to prostaglandins, which is
increasing the uveal scleral outflow
pathways,” Dr. Okeke said. “The
other exciting thing about it is its
September 2017
Glaucoma medications update
by Maxine Lipner EyeWorld Senior Contributing Writer
effect on nitric oxide.” In addi-
tion to relaxing tissue within the
trabecular meshwork, the nitric
oxide mechanism has an effect on
Schlemm’s canal that enables it
to regulate the volume within the
canal. “Those two mechanisms can
help to increase the outflow of the
aqueous humor,” she said. “By in-
creasing nitric oxide, it has an effect
that can increase how much aque-
ous humor goes out of the outflow
channels.”
Pressure lowering with Vyzulta
is about 7 to 9 mm Hg from base-
line, Dr. Okeke noted. This may give
practitioners even more reason to
consider it as a first-line medication,
she thinks.
Various mechanisms of action for common ocular hypotensive agents used in the treatment
Dr. Radcliffe said that the new
of glaucoma and the classes of medication associated with those actions
agent could be particularly appeal-
Source: Constance Okeke, MD
ing for a younger glaucoma patient
in whom practitioners would like
able, we’re hoping to see a fixed five- to six-point range. With Rocla-
to keep fluid going through the
combination of latanoprost and tan the pressure-lowering ability is
pathway with the nitric oxide mech-
netarsudil, dosed once daily.” Since even greater, she said. “One study
anism; this could help from the
practitioners have never had a pros- looking at Roclatan versus Rhopres-
standpoint of trying to maintain the
taglandin analogue in fixed combi- sa alone versus latanoprost alone
normal level of physiologic outflow.
nation, this also will be very novel. showed the reduction in pressure
Dr. Radcliffe thinks that some
“They both work on outflow, the for Roclatan was 35–40%, whereas
practitioners may want to use this
prostaglandin antagonist through with latanoprost it was 28–30%,”
for the next several years until the
the uveal scleral pathway and the Dr. Okeke said, adding that some of
patient has a stent placed or under-
netarsudil through the trabecular the studies for Rhopressa alone have
goes some other trabecular outflow
meshwork,” he said, adding that this indicated that this may not be as
procedure.
should be the most powerful agent strong as latanoprost by itself.
in a single bottle available. Still, even if it is not as robust
New class of agents Dr. Okeke likewise views the as a single agent, there will likely be
Dr. Radcliffe thinks Rhopressa
emergence of this new class of a place for it, Dr. Okeke thinks. “Be-
(netarsudil, Aerie Pharmaceuticals,
agents, the rho kinase inhibitors, as cause of its slightly different mech-
Irvine, California) may potential-
an important step in glaucoma treat- anism of action and how it could
ly offer a paradigm shift. This rho
ment. This has a couple of different work adjunctively with different
kinase inhibitor will be the first new
mechanisms of action. “It can help agents, it’s something that one could
class of pressure-lowering agents to
with increasing outflow through the consider,” she said.
hit the market since 1996. “That
trabecular meshwork, and it can also In Dr. Radcliffe’s view, Roclatan
makes it unique and exciting,” he
help with lowering episcleral venous could be a new primary option for
said.
pressure,” Dr. Okeke said. some. “In patients who are young-
Rhopressa will likely be market-
She pointed out that while ne- er, have more severe glaucoma, or
ed as an adjunctive agent. “It has a
tarsudil alone will have an impact, any patient where we don’t want
little less efficacy than latanoprost
a new fixed combination will likely progression, this could be the first
like most adjuncts that we have,” Dr.
reduce pressure even more. This therapy,” he said.
Radcliffe said. “But it has once-a-day
new fixed-combination agent, called Dr. Okeke pointed out that the
dosing and a good systemic safety
Roclatan, includes Rhopressa plus once-a-day dosing of Roclatan will
profile.” The main side effect to be
latanoprost. make it unique. “Right now all of
on the lookout for is hyperemia.
On its own, the Rhopressa agent the fixed combinations that we have
It also has appeal as an option for
can offer glaucoma patients relief. are typically multi-dosed,” she said.
potentially restoring flow through
“It has been shown in a number of With this fixed combination dosed
the natural pathway, something
studies that netarsudil can signifi- just once a day and compliance be-
practitioners are very interested in
cantly lower eye pressure from base- ing a constant issue, anything that
maintaining and enhancing.
line,” Dr. Okeke said. Pressure-low- can simplify the regimen and be
“That makes netarsudil by
ering tends to be most effective for more robust is desirable for both the
itself exciting,” he said. “Within 1
those who have pressures less than patient and the doctor.
or 2 years of that becoming avail-
25 mm Hg, with a reduction in the
 September 2017 EW GLAUCOMA 63

Considering Trabodenoson manufacturers, Dr. Radcliffe thinks which is best in what situation, he Contact information
Another agent under consideration practitioners will be able to advocate concluded. EW Okeke: iglaucoma@gmail.com
is Trabodenoson (Inotek Pharmaceu- for the use of these medications. Radcliffe: drradcliffe@gmail.com
ticals, Lexington, Massachusetts), Then it will be a question of doing Editors’ note: Dr. Okeke has no finan-
an adenosine cyclase agonist. “It’s comparative studies to determine cial interests related to her comments.
going to increase outflow again
through the trabecular meshwork,”
Dr. Radcliffe said.
Dr. Okeke pointed out that

Transforming your practice

Trabodenoson uses a different
mechanism of action from the
rho kinase inhibitors. “In the trials

with technology that‘s

so far, its pressure reduction has not
been quite as robust as what has
been seen with the rho kinase inhib-
itors,” she said. “Pressure reduction
with Trabodenoson is more in the
range of 3 to 5 mm Hg.” That may
be seen as more of an adjunctive
easy on the eyes.
medication than a first-line agent,
Dr. Okeke noted, adding that this
agent is not as far down the pipeline
ZEISS ReLEx SMILE
as the others.
The fact that outflow is en-
hanced with this (different from
some of the other available drops)
should not be overlooked, Dr. Okeke
thinks. Keeping the trabecular mesh-
work working is something that has
been talked about in other circles.
“One of the things that has been
discussed recently is the concept of
doing laser treatment first because of
the effect of the laser treatment on
the trabecular meshwork, allowing
it to be utilized and enhanced,”
she said, adding that some aque-
ous-inhibiting medications simply
reduce the amount of aqueous
humor going through the trabecular
meshwork over time, which can lead
to some level of debilitation. Drops
that enhance outflow and keep the
trabecular meshwork and Schlemm’s // INNOVATION
canal moving, rather than taking MADE BY ZEISS
an inhibitory path, may be more
advantageous.
Dr. Radcliffe views the new op-
tions as exciting. “It doesn’t take too
ReLEx SMILE from ZEISS
much for a patient to not be able
to use one or two of the medicines The first minimally invasive laser vision correction solution
that we consider our staples,” Dr.
Radcliffe said. “Even though we may ReLEx® SMILE is the first and only small incision lenticule extraction (SMILE)
have five agents available right now, laser vision correction solution currently available. The VisuMax laser from ZEISS
an asthmatic who develops an aller-
is the only femtosecond laser that can be used to perform SMILE in addition to
gy to brimonidine, which would be
creating LASIK flaps. More options for you and your patients to SMILE about.
20% of asthmatics, would be down
to three.” It’s not hard to see how a
patient could end up needing these www.zeiss.com/us/relex-smile
emerging new medications. Armed
with good quality data from the

Carl Zeiss Meditec, Inc. 800 342 9821 www.zeiss.com/med

REL.9084 ©2017 Carl Zeiss Meditec, Inc. All copyrights reserved.