Identifying Gaps in Diagnosis and Management of Glaucoma for Glaucoma Awareness Week

World Glaucoma Week is celebrated March 6-12th 2022 to raise awareness about glaucoma and the need for early diagnosis. It is the leading cause of irreversible blindness worldwide, with an incidence of 1 in 200 among people aged 40 years, and 1 in 8 among people aged 80 years.

Treatment and care for glaucoma are expected to be the focus over the next few years. According to Global Data, over the 10-year forecast period (2020-2030), there is a total forecast growth of $657.8M by 2030 in the seven major pharmaceutical markets- US, France, Germany, Italy, Spain, UK, and Japan.

Glaucoma Clinical trials with Navitas Life Sciences

Navitas Life Sciences has the technological investments and the required facilities to conduct efficient glaucoma clinical trials. Our qualified experts have vast experience and understand the complexities in a glaucoma clinical trial and can manage challenges effectively.

Equipment needed for conduct of Glaucoma Clinical Trials

  • Ultrasound Pachymetry
  • Humphrey Field Analyzer
  • Slip Lamp Biomicroscopy
  • Gonioscopy
  • Ophthalmoscope
  • IOP (Goldman Applanation Tonometry)

In support of World Glaucoma Week, we interviewed Dr. M A Rani Sujatha, Professor & HOD Department of Ophthalmology, Dr.B.R.Ambedkar Medical College and Hospital, Bangalore, to understand the gaps in diagnosis and the management of glaucoma.

What are the gaps in diagnosis and the management of Glaucoma?

There is a need to identify processes that allow early diagnosis of primary open angle glaucoma to facilitate faster access to treatment. The use of stereoscopic disc images and reliable perimetry requires skill to ensure that the data collected is of high quality. Such screening procedures may require longer patient visits and may be more expensive. However, screening procedures that use non-mydriatic single field (monoscopic) photography are found to be efficient, irrespective of whether they are used with or without screening perimetry. The use of such techniques will improve screening for glaucoma and may be carried out in the office by the primary care provider.

Improving Screening for Glaucoma

Portable non-mydriatic fundus cameras - Monoscopic disc photos

Wireless internet - Transmission of Images

Automated Software - Grading the optic nerve

Dr. MA Rani Sujatha

Professor & HOD Department of Ophthalmology

Dr.B.R.Ambedkar Medical College and Hospital, Bangalore.

The advent of such technology and its improved use will aid in cost effective screening for glaucoma at the office by the primary care provider or during eye camps for earlier detection of primary angle glaucoma.

What are some of the reasons for confusing Glaucoma cases with other cases?

Physical findings will aid in improved diagnosis, so history taking is vital. It can differentiate between successfully managing the condition and failing to do so.

In chronic open angle glaucoma, most cases are asymptomatic, however, in acute glaucoma symptoms such as redness, pain, and blurred vision may exist. Incidences of migraine with intermittent pain and disturbance to vision may be present in sub-acute attacks of angle closure glaucoma. Incidences of previous trauma to the eye may produce a disease that is identical to chronic open angle glaucoma. Corneal thickening could lead to low intraocular pressure readings when recorded using the Goldman applanation tonometry.

Tell us something about the wrong dosing of the drug (timing and frequency)

The prescribed drugs should be used at the right dosage and at the right time. For example, a beta blocker is not effective in lowering eye pressure at night so it should not be prescribed for the night.

Another error in prescribing drugs is the use of prostaglandin analogues. Prescribing two different prostaglandins, or dosage in the morning or twice a day is erroneous. For optimal effect, a prostaglandin inhibitor in combination with a beta blocker should be given in the morning.

Aqueous secretions from the eye are lowered by carbonic anhydrase inhibitors, but optimally when they are prescribed thrice a day instead of two, as they are effective when greater than 99% of carbonic anhydrase is inhibited.

Please elaborate about Drug Combinations

"No medication is Best medication and Least medication is Best alternative." This should be followed while treating glaucoma as well.

The European Glaucoma Society (EGS) guidelines have stated that it is unlikely that there will be additive effects of two or more pharmacological molecules with multiple active molecules among patients who take up the drugs reliably. There should be a synergistic effect of the combination of drugs taken by the individual.

For example, the mechanism of action of alpha-adrenergic agonists and beta blockers are the same, which is to reduce aqueous production. This will not result in a synergistic effect. However, when taken as a combination of drugs including PG inhibitors, which lead to higher uveo-scleral outflow, while there is a reduced aqueous production by the beta-blockers, there is improved efficacy.

Give us insights about early detection and diagnosis

Early detection is vital for glaucoma as the since the anatomical and functional are largely irreversible. Imaging devices can be used to assess optic nerve structure while perimetry can be used to study optic nerve function.

Further, there are new strategies that complement these widely used methods, like in-vivo detection of the apoptosis of retinal ganglion cells and retinal nerve fiber layer analysis. The retinal nerve fiber layer can be objectively measured using the spectral-domain optical coherence tomography. This has been shown to give a resolution of 3–6 μm, though it is dependent on functional and structural relationships.

Please provide some details on Non-adherence and non-persistence to glaucoma treatment

The target pressure range of patients should be adjusted, determine and maintained in glaucoma care. Patient adherence to medication is very important, for example, if a patient restarts medication, after a gap in medication, briefly before a follow up visit to the doctor, it may seem that the pressure is optimal but there may be changes to the visual field progression. This would make it difficult to ascertain pressure goals, whether it should be raised or lowered.

The clinical course of glaucoma is variable, and it is further affected by improper medicine dosage. There is a need for greater awareness about adherence to medication and patients should be suitably counselled to ensure that they follow the medication schedule as advised.

Leverage Navitas Life Sciences’ Support for Glaucoma Clinical trials

Recent Glaucoma Trials: There are multiple clinical trials that we have conducted. An interesting clinical trial involves the use of Drug-Delivering Contact Lens in Patients with Primary Open-Angle Glaucoma or Ocular Hypertension that would limit the need for daily application of eye drops.

A recent clinical trial that is being conducted in Russia had a successful start and already has 25 patients enrolled.

Appreciation received from a Global Pharma for the phase II protocol on an Investigational agent for glaucoma.

“The synopsis developed was critically reviewed by medical lead and accordingly important changes were suggested in the type of study population, comparator agent and interim analysis. Also, considering the SEC meeting requirements, the turnaround time was extremely fast and quick collaboration was done with KOLs to ensure that highly efficient protocol can be developed even within the very short timelines.”

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