Genentech. Regneneron. Shire. ZeaVision. Reichert/Ametek HPO IOP. u Issues in measuring IOP

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1 Disclosures MEDICAL MANAGEMENT OF GLAUCOMA California Optometric Association Monterey 2018 Leo Semes, OD, FAAO Commercial Interest Nature of Relevant Financial Relationship Maculogix Honorarium Speaker Science Based Health Honorarium Speaker OptoVue Honorarium Speaker B&L Honorarium Advisor Allergan Honorarium Advisor Genentech Regneneron Shire ZeaVision Reichert/Ametek HPO Honorarium Honorarium Honorarium Honorarium Honorarium Stock options Advisor Speaker Speaker Advisor Speaker Advisor Half of what you learn during your training will be shown to be either dead wrong or out of date within five years of your graduation;... NOBODY can tell which half! And... the most important thing to learn is how to learn on your own. David Sackett, MD IOP u Elevated IOP is the greatest risk factor for developing glaucomatous damage u Lowering IOP is the only means currently of managing glaucoma u Topical drops to lower iop are the prefered initial means to treat glaucoma u Issues in measuring IOP u How is baseline IOP established? u What are the influences on an IOP measurement? u What is the sampling rate of IOP? u The future of IOP monitoring A pinhole view of IOP Our working definition of POAG 5 POAG is a progressive, chronic optic neuropathy in adults in which intraocular pressure (IOP) and other currently unknown factors contribute to damage and in which there is a characteristic acquired atrophy of the optic nerve and loss of retinal ganglion cells and their axons in the presence of an gonioscopically open anterior chamber angle. ala AAO PPP, AOA CPG 1

2 There are some other good reasons There are some other good reasons There are some other good reasons And just last year Issues in treating glaucoma Recent publications regarding IOP-lowering influences 11 How much to lower IOP when Glaucoma or OHT is diagnosed Risk of progression indices 12 Week's Best Articles: Glaucoma One week in October Medical Therapy Cost and side effects issues Adherence issues Optimize and maximize protection to match risk Initial therapy Topical PGA? SLT Advancing topical therapy tcai beta-blocker alpha-agonist fixed-combination (FC) drop Comparison of surgical outcomes between phacocanaloplasty and phacotrabeculectomy at 12 months follow-up: a longitudinal cohort study Journal of GlaucomaOcular surface disease in glaucoma: effect of polypharmacy and preservatives Optometry and Vision SciencePupillary responses to high-irradiance blue light correlate with glaucoma severity OphthalmologyTrabeculectomy vs. EX-PRESS shunt vs. Ahmed valve implant: short-term effects on corneal endothelial cells American Journal of Ophthalmology Meta-analysis of selective laser trabeculoplasty versus topical medication in the treatment of open-angle glaucoma BMC Ophthalmology Full Text Evidence-Based Medicine Risk factors for a severe bleb leak following trabeculectomy: a retrospective case-control study Journal of Glaucoma The macula in pediatric glaucoma: quantifying the inner and outer layers via optical coherence tomography segmentation Journal of AAPOS How glaucoma patient characteristics, self-efficacy and patient-provider communication are associated with eye drop technique International Journal of Pharmacy PracticeAssociation between glaucoma medication usage and dry eye in Taiwan Optometry and Vision Science A survey on the preference of sustained glaucoma drug delivery systems by Singaporean Chinese patients: a comparison between subconjunctival, intracameral, and punctal plug routes Journal of Glaucoma 2

3 Case example Mid -50s WM 13 First seen at UAB Eye Care 4/24/ WM Engineer is referred to UAB Eye Care as a glaucoma suspect. Conditions Hernia Sx, Tinnitus Past Medical History Details Hernia Sx - couple years ago, all okay now. Past Hx of bad rxn to Penicillin Past Hx of Tinnitus Pt. thinks he has Sleep apnea? * *SAS ruled out new Dx = heart murmur (cardiac ultrasound) No medications Glaucoma Negative Cataracts Negative Age-Related Macular Negative Degeneration Eye Injury Retinal Disease Other Disease Blindness Strabismus Amblyopia Diabetes Dry Eye Refractive Other Past / Present Ocular History Negative Lattice Degeneration OU Negative Negative Negative Negative Negative Negative Glasses Full-time H/o transient dipl/intermittent dipl, resolved (spectacle adjustment) Date Diagnosed Drugs Alcohol None None Social History Occupation Engineer (currently unemployed) Hobbies Tobacco Smoking Status Writer, Musician, Woodworker Quit smoking 3 yrs ago, uses Nicotine lozenges Former smoker Family History Glaucoma Negative Cataracts Mother, Father ARMD Negative Eye Injury Negative Retinal Disease Negative Other Disease Negative Blindness Negative Strabismus Sister - DV, wears prism in glasses Amblyopia Negative Diabetes Negative Cancer MGM - skin Heart Disease Negative Hypertension Negative High Cholesterol Negative Kidney Disease Negative Stroke Negative Medications Date Name Strength Form S I 4/21/2014 Advil G 6/9/2010 Ibruprofen 4/24/2014 Zyrtec 10 mg Add'l Sig 3

4 Ophthalmic findings BSCVA 20/20 20/ X X 090 Pupils normally reactive w/o RAPD IOP history (Goldmann) 13/14 (4/24/2014) 16/15 (7/22/2014) Pachymetry: 587u, 586u Anterior segment unremarkable ACA open; AC - D&Q Ophthalmic findings Lens (LOCSIII) : NO 1 / NC2 CS 0 PSC 0 (OD = OS) Optic disc VF OCT What do you expect? Reliable data? (Where s the blind spot?) GHT, PSD, PD significance Good scan quality Note segmentation markers Symmetry Ave RNFL thickness ONH size C/D! Disc margin Note RNFL defects. RNFL profile And, RNFL average sectors are within reference range, But clock hour IT OS, OS show thinning. 4

5 Excellent scan quality What are our next steps? Note the island of GCC thinning IT OD that corresponds to RNFL defect. AND, the raphe respect. And, RNFL average sectors are within reference range. Reviewing the data Good VA (-) family history of glaucoma? SAS / (+) heart murmur // no beta-blocker meds. Normal IOP Apparently clean VF Evidence of ONH / RNFL damage Diagnostic labeling Glaucoma suspect Glaucoma Pre-perimetric glaucoma? Repeated visual field!!! Reliable data? Reliable data? GHT, PSD, PD significance GHT, PSD, PD significance 5

6 Reconciling the data-od Correlating the data-os Management Critical questions Degree of damage Burden of treatment Life span Management Critical questions Degree of damage Burden of treatment Life span Alternatives No treatment at this time Follow, repeating all tests X 6 mo? Other? Most recent visit IOP = 19/20 June 23, 2015 Updated disrupted sleep status diagnosed with SAS and using CPAP device. Reportedly, feeling much better. Does this change our thinking? 6

7 June 23, 2015 Would CH be a useful diagnostic data point? Remember: Risk increases as IOP increases & Risk is compounded with lower CH Source: Corneal Hysteresis in Glaucoma Predictive of Progression in Prospective, Longitudinal Study (DIGS) 41 Percentage per year change in VFI The Effect of IOP on rates of progression was dependent upon Corneal Hysteresis 42 What about complementary techonologies? How would OCT-A influence your management? IOP of 30 is not so bad with a CH of 11. IOP of 20 is very bad with a CH of 6 What about electrodiagnostic testing? Medeiros FA et al. Ophthalmology. 2013;120: Vessel density (OCTA) and VF loss correlation in glaucoma Considerations in management Yarmohammadi A, et al., Relationship between Optical Coherence Tomography Angiography Vessel Density and Severity of Visual Field Loss in Glaucoma.Ophthalmology 2016;123: Does the patient understand the risks and benefits of treatment? What is the risk of vision/sight loss over his lifetime? (25 years?) What is his likelihood of adherence to treatment if offered/accepted? What would be his target IOP? With what would be the initial treatment option? 7

8 45 Another example To treat or not to treat and if so, how? RB 9/24/1938 (AA/F) ONH (5/2006) PACHYMETRY: 642/591) VF Series 1: 2004 (baseline) VF Series 2: 2005 RB 9/24/1938 (AA/F) - IOP Range Frequency Doubling Technology (FDT) Perimetry Results (4/6/05) (OD) (OS) Threshold No flags (OD, OS) PACHYMETRY: 642/591 8

9 (4/6/05) RB 9/24/1938 (AA/F) Retest! (OS) VA 20/20 to 20/20- with mild NS changes BP good PR: 60 Dilemma? or Direction? 4/08 As OHT (IOP range 17-24, 15-21): Risk calculation (1-5% - low) VF Series 3: 2/ (Bad day or progression? Fundus photos 4/5/2006 5/10/2011 Repeat the VF! (5/10/2011) 9

10 Change analysis 5/10/2011 look closely OS OD 5/10/2011 look closely Treat or not? Need more evidence? OCT RNFL MRNFL (GCC) ONH 10

11 5/10/2011 look closely 11

12 Update Choosing an initial treatment strategy 11/11 IOP: 18/13 Switch to Lumigan 0.01% 12/11 IOP: 20/14 Continue L. 0.01% 1/12 IOP: 21/15 Switch to T-Z 2/ 12 IOP unchanged: Switch to Combigan qam 3/12 IOP unchanged: Switch to Azopt tid 5/12 no IOP response = SLT recommendation 6/13 IOP = 17 mm Hg OD, OS. 6/14 IOP 17/15 mm Hg OD, OS 6/15 IOP 14/15 mm Hg OD, OS 70 The trouble with the world is that the stupid are cocksure and the intelligent are full of doubt. ~Bertrand Russell * Realini T, Fechtner R. Ophthalmology (editorial) 2002; 109: * 71 Guidance on initiating therapy - Delphi Panel 72 Which PA is best? It depends! Alasbali T, Smith M, Geffen N, Trope GE, Flanagan JG, Jin Y, Buys. Discrepancy between results and abstract conclusions in industry- vs nonindustry-funded studies comparing topical prostaglandins. Am J Ophthalmol Jan;147(1): Singh K, Lee BL, Wilson MR; Glaucoma Modified RAND-Like Methodology Group. A panel assessment of glaucoma management: modification of existing RAND-like methodology for consensus in ophthalmology. Part II: Results and interpretation. Am J Ophthalmol Mar;145(3): Meta Analyses suggest slight superiority of bimatoprost. (e.g., Aptel F, Cucherat M, Denis P. Efficacy and tolerability of prostaglandin-timolol fixed combinations: a meta-analysis of randomized clinical trials. Eur J Ophthalmol May 19:0. 73 Considerations in the medical management of glaucoma/ OHT Baseline IOP? Target IOP Severity of damage at initial presentation Burden of treatment Ocular surface Side-effects / Systemic issues Cost of medications Likelihood of adherence to regimen* Potential lifespan 74 Adherence... for the long term 12

13 Adherence... for the long term Factors influencing IOP 75 Physiological factors CCT Diurnal variation Arterial (pulse) pressure Posture Blood Flow Exercise Accommodation Axial length / refractive error Corneal dystrophies Situational influences on IOP Extraneous influences on IOP Eye rubbing Necktie Head position Fluid intake Medications Weight lifting Scleral indentation Wind instrument playing Sambala sirsasana Journal of Glaucoma + spontaneous Extraneous influences on IOP And

14 81 An additional confounder surrounding IOP and our sampling 82 An Implantable Intraocular Pressure Transducer QUESTION: How many seconds elapse in the quarterly interval from one visit to the subsequent one for a patient whom you are monitoring for glaucoma progression? ANSWER: about 8,000,000. [8 million] An Implantable Intraocular Pressure Transducer 83 Image credit: um=1&hl=en&sa=n&biw=1101&bih=538&tbm=isch&tbnid=vyr8xy3etzh4cm:&imgrefurl= >/= 3 measurements (each device) Continuous-Intraocular-Pressure-Monitoring/ &docid=WSm-sv0wMjQpnM&imgurl= profiles12/607447/projects/ / f7b82ec1e4716d0a05f e8735d.jpg&w=600&h=400&ei=rdpot_rca9gtgqf1qowoda&zoom=1&iact=hc&vpx=274& vpy=108&dur=84&hovh=183&hovw=275&tx=158&ty=80&sig= &page=2&tbnh=146&tbnw=182& start=9&ndsp=15&ved=1t:429,r:6,s:9,i:109 Example Example 53 yo treated glaucoma patient (PGA qhs + timolol/tcai comb); excellent reproducibility for two overnights blue & yellow. Mansouri K, Medeiros FA, Tafreshi A, Weinreb RN. Continuous 24-Hour Monitoring of Intraocular Pressure Patterns With a Contact Lens Sensor: Safety, Tolerability, and Reproducibility in Patients With Glaucoma. Arch Ophthalmol. 2012; 13: YO Asian female glaucoma suspect (PGA qhs Rx d but may have been noncompliant); good reproducibility pattern for two overnights blue & yellow. Mansouri K, Medeiros FA, Tafreshi A, Weinreb RN. Continuous 24-Hour Monitoring of Intraocular Pressure Patterns With a Contact Lens Sensor: Safety, Tolerability, and Reproducibility in Patients With Glaucoma. Arch Ophthalmol. 2012; 13:

15 Example Sensimed Triggerfish FDA cleared 88 FDA News Release FDA permits marketing of device that senses optimal time to check patient s eye pressure Increased eye pressure is associated with nerve damage common in glaucoma Poor reproducibility in a 20 GS for two overnights with spikes (n.b., pt has poor sleep habits). [app on your iphone] LS For Immediate Release March 4, 2016 Mansouri K, Medeiros FA, Tafreshi A, Weinreb RN. Continuous 24-Hour Monitoring of Intraocular Pressure Patterns With a Contact Lens Sensor: Safety, Tolerability, and Reproducibility in Patients With Glaucoma. Arch Ophthalmol. 2012; 13:1-6. Home tonometry- more frequent data gathering but not continuous. News / FDA Cleared Icare HOME, An Innovative Device Poised To Revolutionize IOP Self-Monitoring Baseline IOP 91 Establishing a baseline IOP with several measurements guards against making the wrong call. For example, a single IOP of 34mmHg might suggest the need for a treatment recommendation and encourage a reduction to 20mmHg (>30%) when that initial measurement may be an aberration. So, baseline IOP is critical to establish. 15

16 Practical Considerations Recent thoughts on baseline IOP 93 Establish the diagnosis Use multiple IOP measurements to determine a baseline IOP Consider charting a diurnal IOP pattern Use all data available (History, medications, vocational and avocational activities, physical findings including stereo photos and digital imaging as well as VF testing.) 94 Asymmetry is damped with MULTIPLE IOP measurements. Predictions of efficacy are impossible but may be more accurate when more data are gathered. King AJ, Uppal S, Rotchford AP, Lakshumanan A, Abedin A, Henry E. Monocular trial of intraocular pressure-lowering medication: a prospective study. Ophthalmology Nov; 118(11): Baseline IOP suggestions measure twice, cut once 95 Study visits 96 Determining Target IOP King AJ, Uppal S, Rotchford AP, Lakshumanan A, Abedin A, Henry E. Monocular trial of intraocular pressure-lowering medication: a prospective study. Ophthalmology Nov;118(11): Target IOP Defined the pressure at which the patient shows stabilization (i.e., no progression) Canadian Perspective Target IOP is a dynamic concept, needing constant reevaluation. What is lacking are established guidelines for determining the target IOP range that can be used in general practice. Damji KF, Behki R, Wang L; Target IOP Workshop participants. Canadian perspectives in glaucoma management: setting target intraocular pressure range. Can J Ophthalmol Apr;38(3):

17 An alternative suggestion ( market IOP ) What it means: With a high risk of vision loss, the emphasis on lowering IOP increases. Alternative target IOP guidance Target IOP needs to be individualized as progression is highly variable and IOP is only partly responsible. If there is a relatively lower risk of vision loss, then there is greater emphasis on guarding against the risks of therapy. Singh K, Shrivastava A. Early aggressive intraocular pressure lowering, target intraocular pressure, and a novel concept for glaucoma care. Surv Ophthalmol ;53 Suppl1:S Once rate of progression has been determined (by a sufficient # of VFs) and treatment advanced accordingly. [e.g, slower progression for NTG but faster for PXG] Rossetti L, Goni F, Denis P, Bengtsson B, Martinez A, Heijl A. Focusing on glaucoma progression and the clinical importance of progression rate measurement: a review. Eye 2010; 24: s1-s7. Hyman L, et al. Natural History of IOP in the EMGT. Arch Ophthalmol. 2010;128(5): What about advancing therapy? 102 What about advancing therapy by adding another medication? Options include Switching to an alternative topical therapy or adding additional topical drops SLT Trabeculectomy Single agent? Consensus guideline suggests tcai A constellation of drops? Using additional dosages is likely to decrease adherence Fixed combination drop? Beta-blocker containing or BB-free? Consider this scenario 103 Ophthalmic Generics The pharmacist calls you and asks, Can I give your patient a generic equivalent of this PGA? Your response would be: A. Sure, they are bioequivalent B. No, they only have the same active ingredient as the original product C. Go ahead, we ll see how it performs D. No, my child is on a NAMEYOURFAVORITEPHARMA scholarship at Vanderbilt 17

18 Ophthalmic generic qualifications ala FDA Ophthalmic generic qualifications ala FDA 105 Generic ophthalmic medications contain the same active ingredients as their brand-name predecessors. 106 Generic ophthalmic medications contain the same active ingredients as their brand-name predecessors. But, is the bioavailability the same? (i.e., what is the other %?) What influences bioavailability? Which would you choose? 107 Excipients Buffers Antioxidants Thickening agents ph Preservatives Tonicity Drop size Bottle composition q=coca+cola&hl=en&tbo=d&source=lnms&tbm=isch&sa=x&ei=hbqvuc LvL5OO9ASlooHQDw&ved=0CAcQ_AUoAA&biw=1126&bih=633#imgrc =ynyqmoo2gbb76m%3a%3bajpa_bsl75wi9m%3bhttp%253a%252f%25 2Fwww.thetimes.co.uk%252Ftto%252Fmultimedia%252Farchive%252F0037 4%252FVIDEO_Cocacola_add_374157a.jpg%3Bhttp%253A%252F%252Fwww.thetimes.co.uk%2 52Ftto%252Fhealth%252Fnews%252Farticle ece%3B1024%3B576 manfoodblog.files.wordpress.com/2011/04/ p jpg&imgrefurl= manfoodblog.wordpress.com/2011/04/08/storebrand-cola-shootout/ &h=1536&w=2048&sz=1343&tbnid=am6yxexn7ck ZrM:&tbnh=90&tbnw=120&zoom=1&usg= c2jltv QyrU4bBmsFWEjTAKSQYm4=&docid=5vjRaELR8N GEkM&hl=en&sa=X&ei=IRUVUfjtBIze8ATUxoDICw &ved=0cdaq9qewaa&dur=0 Issues with generics Approaching the generic substitution issue with patients $/Pharmacy substitution Insurance coverage Medicare part D vs. Private Pay Some patients prefer a branded product When $ is a consideration, discuss the situation Generics may not have equivalent bioavailability, so monitor more closely/frequently Ask patients to bring their bottles to visits Have the dispensing pharmacist understand why what you have prescribed for the patient 18

19 111 Approaching the generic substitution issue with patients Consider options Pharmaceutical manufacturers plans/coupons Other classes of drugs Fewer doses / day, and other offlabel options, etc. 112 Impact of generic latanoprost Impact of the Introduction of Generic Latanoprost on Glaucoma Medication Adherence. Stein, JD, et al. Am J. Ophth.Published Online: February 10, 2015 Conclusions Given that cost can significantly deter adherence, switching patients to generic medications may help improve patients' drug-regimen adherence. A considerable number of patients discontinued glaucoma drug use altogether when generic latanoprost became available. [We] should work with insurers and pharmacists to prevent such discontinuation of use as generic forms of other PGA agents become available. Lipid Family Receptors 115 What about weed? Information is current as of Sept. 14, Lipid Family Receptors Cannabinoids Prostaglandins Prostamides State with legal medical marijuana State with decriminalized marijuana possession laws 114 State with both medical and decriminalization laws AGS position statement AGS position statement Treatment modalities (to lower IOP) Medication Laser Surgery Marijuana as an alternative Frequent dosing SEs Inadequate topical formulations May be neuroprotective Jampel H. American glaucoma society position statement: 11 marijuana and the treatment of glaucoma. J Glaucoma Feb;19(2):75-6. Bottom line: NO scientific evidence for its use to treat glaucoma Jampel H. American glaucoma society position statement: marijuana and the treatment of glaucoma. J Glaucoma Feb;19(2):

20 Perfusion to the ONH 119 Example comparing DOPP and mean OPP 120/80 IOP = 20; DOPP = 60 [ 80-20] Nocturnal hypoperfusion as a glaucoma risk factor What IOP do we measure? diastolic Significant difference between DOPP and MOPP Which to use??? Perfusion to the ONH 120 Example comparing DOPP and mean OPP 120/80 IOP = 20; DOPP = 60 [ 80-20] What IOP do we measure? diastolic Comparing DOPP to MOPP calculation MOPP = 2/3[DBP = 1/3 (SBP-DBP)- IOP 2/3[80 + 1/3 (40)] 20 results in (monkeys) 122 *Recent association between nocturnal BP dips and ODH in NTG over-dippers = progressors Kwon J, Lee J, Choi J, Jeong D, Kook MS. Association Between Nocturnal Blood Pressure Dips and Optic Disc Hemorrhage in Patients With Normal-Tension Glaucoma. Am J Ophthalmol Apr;176: doi: /j.ajo Epub 2017 Jan

21 *Recent association between nocturnal BP dips and ODH in NTG 125 How should glaucoma be managed comprehensively? First, lower IOP over-dippers = progressors è Kwon J, Lee J, Choi J, Jeong D, Kook MS. Association Between Nocturnal Blood Pressure Dips and Optic Disc Hemorrhage in Patients With Normal-Tension Glaucoma. Am J Ophthalmol Apr;176: doi: /j.ajo Epub 2017 Jan 12. New directions in glaucoma treatment Nov. 2, Yes, treatment Beyond IOP reduction, regulation of blood flow... Systemically (regulating blood pressure and monitoring perfusion pressure) Locally endothelial-cell activity by modulating Nitric Oxide (NO) This is the NEXT BIG THING! n Regulation of aqueous dynamics at the trabecular meshwork by vascular modulation n In addition, the application of NO-donating compounds for the lowering of IOP directly 128 Future options for medical management targeting the site of glaucoma, the TM 129 Future options for medical management targeting the site of glaucoma, the TM Rho-kinase inhibitors (Rhopressa and Roclatan, (netarsudil/latanoprost ophthalmic solution) 0.02%/0.005%, Aerie) Completed 12-month safety evaluation, Rocket (Canada) Completed 3-month efficacy study (USA), Mercury FDA-Approved December 2017 Rho-kinase inhibitors (Rhopressa and Roclatan, (netarsudil/ latanoprost ophthalmic solution) 0.02%/0.005%, Aerie) Completed 12-month safety evaluation, Rocket (Canada) Completed 3-month efficacy study (USA), Mercury FDA-approved December 2017 *MOAs increase fluid outflow through the trabecular meshwork, (1 0 drainage) increase fluid outflow through the uveoscleral pathway, (2 0 drainage) reduce fluid production in the eye, and reduce episcleral venous pressure (EVP). 21

22 130 Other future directions for medical management of glacuoma 131 How should glaucoma be managed comprehensively? Drug delivery (continuous, episodic) Neuroprotection & Neuroregeneration Second, consider increasing perfusion (may be a consequence of lowered IOP) Topical treatments? (betaxolol, brimonidine, brinzolamide, Gingko Biloba) Exercise, weight loss Lower cholesterol, blood sugar levels Treat underlying vascular disorders (HT, SAS, CVD) Etc. Anti-oxidant/Supplement formulation Study design 132 Harris A, Gross J, Moore N, et al. The effects of antioxidants on ocular blood flow in patients with glaucoma. Acta Ophthalmol Aug 3. doi: /aos [Epub ahead of print] patients with confirmed glaucoma on IOPlowering treatment (placebo controlled, X-over) Baseline and post-administration 1 month) measurements IOP OPP Retrobulbar (ultrasound) and retinal capillary (Doppler) blood flow Results SO, what were they given? 134 Increased peak systolic and/or end diastolic velocities among the active group (but not placebo) Reduced vascular resistance in central retinal and short posterior ciliary arteries Increased superior and inferior temporal retinal artery mean blood flow Enhanced retinal capillary density

23 136 SO, what were they given? 137 How should glaucoma be managed comprehensively? Third, reduce oxidative stress (Ca ++ blockade [BUT, not systemic β-blockers], supplements) 138 NON-SELECTIVE Beta-blockers: Significant additional precaution Consider this: Topical β-blockers administered at night to those taking systemic β -blockers may reduce perfusion to the ONH plus β -blocker therapy to reduce IOP is ineffective at night. Is glaucoma AION that happens over a lifetime? OR Is AION glaucoma that happens overnight? Which brings us to... Hayreh SS. Effect of nocturnal blood pressure reduction on retrobulbar hemodynamics in glaucoma. Graefes Arch Clin Exp Ophthalmol. 2002; 240: Remember Adherence and life span are increasingly parts of our management paradigm. Technology is allowing us better diagnostic (earlier) and progression (monitoring) algorithms. A number of options for initial and advancing treatment are available and considerations include systemic and financial factors. Liu C-H, et al. Comparison of the Retinal Microvascular Density Between OAG and naion. IOVS. 2017;58: DOI: /iovs

24 142 Thank you! 24