DAY 1 HALL 3

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[00:00:06]A very good evening to all of you and welcome to this session on newer drugs and glaucoma and update. We have with us esteemed faculty and our respected chairperson uh Dr. Satansa. For moderators we have Dr. Amit Porwala, Dr. Prasan and our esteemed panelists Dr. Brian Angsa from Singapore, Dr. Dr. Dentalis and Dr. Manish Sha and we have an esteemed line of speakers on this topic and uh we are looking forward to all of the uh wonderful discussions that are going to be and this learning session. I now invite Dr. Sultan Sa for his opening remarks on the topic.

[00:00:49]>> Very good to each and every one of you and a warm welcome to all the audience.

[00:00:54]So it's a great evening and I'm I'm really thankful one for the AIS and to all our international speakers. Your wonderful international speakers we have today and I really want to specifically mention that within a very quick time period that they all have accepted without any hesitation to our request.

[00:01:20]Thank you so much each one of you for accepting our invitation and to be a part of our uh uh you know program today and it is going to be such a great event and I'm sure that all our people whoever is learning from this webinar uh will take it forward in their clinical practice that is what the entire thing is all about because our day-to-day practice whether this all can be used so that it really benefits our population.

[00:01:51]So thanks again to all our speakers and as well as to a and then probably we'll we'll go with our uh uh program. Thank you Nitika and each and everyone.

[00:02:03]>> Thank you sir. I would like to invite Dr. Manoj Matur Sa our esteemed chairperson for uh his opening remarks please.

[00:02:13]It's my pleasure to welcome you all for this glaucoma session on newer drugs in glaucoma.

[00:02:20]It was way back in the 70s that the tim drug timodol was launched and that was probably the only drug complimenting pyocarpine that was used earlier. Since those days till today we have a plethora of antigly medications with diverse mechanisms of actions and now currently preservative free drugs and the fixed combination the d triple combinations and so on. So we have a plethora of combinations available to us. So I am sure that this uh session is going to be of immense value to the audience and they will be knowing in detail about which medicine to use, what combinations of medicines to use, what is the maximum medication that can be used in the present day context and I'm I thank all the speakers international speakers for readily accepting AOS invitation and being present here. Uh I am sure this is going to be a very enlightening session.

[00:03:18]Wish you all the very best.

[00:03:22]>> Thank you very much sir. I I would like to introduce the session coordinators for today myself Dr. Nitika Berry and Dr. Tai Dodum Tara and uh without further ado I would like uh to also inform that Dr. Amit Porwal Sur and Dr. Prasana sir could not join us today and on their behalf I would be doing the moderation. So I would uh like to share my screen and uh do the honors of faculty introduction please. Uh Dr. Ti could you please uh uh unshare your screen please?

[00:04:01]Uh is my screen visible?

[00:04:04]>> Yes.

[00:04:07]>> Thank you.

[00:04:11]So it is with great pleasure that I do the faculty introduction. We have our chairpersons Dr. Manoj Chandra Matura.

[00:04:18]He's an esteemed uh glaucoma and catact specialist and an academic leader and our ordinary treasurer of AIOS. He has won multiple awards and is our guiding light lamp for the AIOS. We've have with her Dr. Satin Paradis and he has more than uh multiple years of experience in ofthmology and is currently the president of Glaucoma society of India and we have a great pleasure and learning from him multiple surgical clinical and academic skills as well. I would like to introduce our moderators for the sessions with Dr. Amit Purval Sa he's head and department of glaucoma at Chiotram Nitro Indor. He's an academic leader and internationally recognized glaucoma specialist with multiple invited lectures and scientific presentations to his name.

[00:05:08]I would like to further introduce Dr. Prasand Wenesh Ramesa. Uh he's moderator. He's editorial and chief for uh for the journal from the Tamil Nadu of Association. the joint secretary of the young coffin multure society of India a very dynamic personality and a recipient of multiple awards as you can see on the screen it's my estee it's my great pleasure to introduce Dr. Brian Nangser from Singapore who's very kindly accepted our invitation. He is the adjunct assistant professor and deputy head of glaucoma services at the national healthcare group of our institute at Singapore.

[00:05:44]He's a fellow of the Royal College of uh of themologist internationally recognized mix experts with multiple publication. He's also had the best video in uh world uh glaucoma congress and he's a clinical scientist and educator. We are very happy to have uh you with us sir.

[00:06:03]I would like to introduce Dr. Dainto Tisa. He's a senior of themmologist with more than 30 plus experience in the field. He's a national leader in glaucoma care and presently the honorary treasurer for the glaucoma society of India. He has a patient centric eye uh approach towards his uh patient and he's a very encouraging person.

[00:06:25]I welcome Dr. Manish Sasa. He is uh the founder and foresight of eye center and glaucoma clinic and a senior consultant with more than 22 years of expertise in the field of glaucoma and anterior segment. He's presently our uh honorary general secretary for the glaucoma society of India. He's a dedicated educator and a mentor. We welcome you sir.

[00:06:48]I would like now like to proceed by introducing our esteemed panel of faculty speakers from various countries.

[00:06:56]Dr. Honki NG we welcome you sir. He's the head in department of opthalmology at the hospital Raja Parmasuri Benham uh please forgive me if my pronunciation is not correct sir from Malaysia. We welcome you sir. He's a gl he's a trained glaucoma fellowship specialist with expertise in glaucoma catact and complex anterior segment surgery. He's an academic leader and researcher. Thank you for accepting our invitation sir.

[00:07:24]I would like to introduce Dr. Shivam Gupta. Sir has very kindly agreed to be a part of the symposium at the last moment. Thank you specially to you sir.

[00:07:34]He's a glaucoma specialist researcher and innovator. He has multiple patents to his name with more than 25 plus publications. He has he's an award-winning academic presenter a young achiever and a part of multiple innovation projects with multiple patents to his name. We welcome you sir.

[00:07:53]Dr. Sham's empty nomen. I'm very pleased to introduce sir. He's a senior glaucoma specialist with uh extensive expertise in medical laser and surgical glaucoma management including congenital glaucoma and glaucoma drainage devices inmates.

[00:08:06]He's an internationally recognized academic and uh academic and educational leader. He's invited speakers at multiple platforms and accomplished researcher and award recipients with multiple publications and awards to his name. We welcome you sir and thank you for accepting our invitation.

[00:08:26]I would like to introduce Dr. Pushbar Raman uh who is a glaucoma and the catact specialist with advanced training from national uh University of Ireland University of Malaya and the prestigious glaucoma fellowship at Sydney Eye Hospital Australia. She's an academic leader and a researcher with expertise in advanced glaucoma surgeries and mix including all the mix I can see here. We welcome you ma'am. Thank you for accepting our invitation.

[00:08:54]I would like to introduce Dr. Andy Tensana Davyi Indra. We welcome you ma'am. She's the director of medical services in RSUP. Dr. Tajutin Chalad Bakaser. Please forgive my uh pronunciation if they go wrong ma'am. Uh she's the consultant and lecturer in glaucoma subdivision the department of themology at the Hassanadin University.

[00:09:17]She's a glaucoma and catact uh specialist with an expertise in laser procedure triclectomy and multiple procedures of the anti segment. She's an active researcher and a professional leader. Thank you for accepting our invitation. Madam, thank you so much. With this, I would like to stop sharing my screen and I would like to invite our first speaker uh Dr. Hong KNG who will be speaking on the topic focus on bronzolamide modern approach to carbonic andhydrates inhibitors innovations sorry thank you over to you sir >> thank you very much Dr. you could come for the kind introductions. Can you see my screen?

[00:10:00]>> Yes sir, we can see your screen.

[00:10:02]>> Thank you very much. So um thank you once again and good evening to all the senior consultants panelist and everyone's on on today. My name is Hon.

[00:10:11]from Malaysia and thank you once again to the AIOS and the IOC organizing committee for the current reputation and today I'm going to share on the focus on Bison the model approaches in the carbon and hydrris inhibitions no financial disclosure in regards to this presentations and this the outline of my talk for this evening basically focusing on the prisolomite versus dozamite in terms of efficacy dosing tolerability adverse event as escalation of treatment options so as we all know Glaucoma is a leading cause of irreversible blindness worldwide and is projected to affect more than 100 millions people globally by the year 2040. The goal of treatment mainly focus on how to preserve the maximum functional visions throughout patient lifetime without sacrificing quality of life and at a sustainable cost by decreasing the IOP.

[00:11:02]So according to the Asia-Pacific guidelines we usually start with the first choice monotropy which is commonly the process.

[00:11:10]Then we need to monitor for tolerability and whether the target IOP is achieved.

[00:11:15]If it's not we can either add on the second agents add to become a fix or the switch monitor therapy. The common second line is beta blocker. However, in certain clinical challenges whereby patients is contraindicated to this beta blocker like for example asthmatic patients have arrhythmia then the option of second line will be either CI or the alpha agonist.

[00:11:40]So the mechanism of action for this fish this CI is inhibit the carbon and paris enzymes in the similary processes to reduce the formation of the bicarb and reduce iron transport and eventually lead to reduce in the equest human productions. The currently two main groups of ci widely available which is toolite 2% and also the later one for prisomite 1%. So how does the prisolomite is better than the zolomite in the modern glaucomy specifically in the prismomite we're talking about the exot whereby the main differences lie on the physical state and the solubility of it. Prisolomite is in the suspension state is hydrophobics and is free to formulate at the neutral pH which means that is translate into a better ocular comfort and lesser effect as well as enhancing compliance. Whereas on the other hand, dolama is solution formulated at a more acidic pH of 5.6 cause ocular surface irritation such as stinging and burning sensation after installations.

[00:12:40]So firstly we focus on efficacy. Can prismite be used as a second agent adjunctive to PGA and or is it as good as by adding timolo as the current practice? These four-week studies compared the princolomite, timolo and primmonine as adjunctive therapy as a second agent onto existing PGA. At week four, princolomite had the greatest reduction of IOP at 22.7% which weigh higher than primate at the 13.4%.

[00:13:07]And furthermore, the binsomite has shown that IOP lower effects were numerically greater than the timolo itself.

[00:13:14]How about dosing itself? Comparing efficacy of binsomite twice a day versus three times a day show that there's no clinically significant differences when I set a threshold of 1 millm mercury.

[00:13:26]Similarly, if we compare with the priselomic twice a day compared with the doselomite three times a day where a difference is also less than 1 mm mill which means that the prisylomic twice a day is as efficacious as the doselomic three times a day dosing which translated means that simplified dosing for patient is easier for patient less exposure to PAK as better tolerance as well as better compliance on the patient site this possible explanation is because the prison is a suspension state is more viscous is more difficult to be washed away and hence is tend to form like a microp particles in the tflum that provide like a sustained release effects in long run.

[00:14:07]Looking into tolerability and hearers is a known fact that the ocular discomfort is a common tolerability concerns with the CIS. This comparative statator of four clinical study have shown that the princolomic container regimes demonstrated consistently a favorable safety profile with significantly less ocular irritation than the toolic container regime itself. When we look into the details of the different adverse events of the CI prisolomite has much reduced ocular discomfort compared to the tool itself which is 3% versus 16%.

[00:14:41]And interestingly also looking at the patient reported tolerability ratings.

[00:14:45]The prisolomics group which is in this study fixed combination of brisolomite and timolo have shown that a more favorable tolerability is shown in the blue color bar which is a very good and good tolerability versus the dosolamite timolo fix which is a lower one up to 33 37%.

[00:15:06]The reason for the tolerably mostly due to the formulation cells whereby for the dosamic is a more acidic pH and this lead to ocular surface imitations.

[00:15:15]The great evidence summary of clinical occlusion is summarized that the princom stimulus combination has a modestly greater monop reduction and less irritation. However, it's also associated with a significantly more blur vision in compared to group as well and is recommended the choice. It depends on individual patients celebrity profile and it require a long-term sta to confirm its comparative outcome. But if we look at the profile metrics between these two CIS is that may have a severe VA drop which equity drop at the beginning of putting the drop which is more than the tool. However, both usually recover to the clinical before dropping the drops about 3 minutes according to the issue studied all and the primary source of the cause why is a blurring in princite because of the suspension preparation cause opac layer whereas on the micro is because of the irritation lead to the reflex tearing and cause of blurring of vision. But you look at it further deeper the princes show a low incidence of moderate to cerv irritation which means patient is more comfortable and thank you for giving them a more tolerable eye drop compared to toolite which is pretty high incident at 71% with moderate and severe irritation. So your patient is happier with as a clinician is also happier because patient has a better compliance which translated into a better glaucoma control. The patient will be seeing you with a prettier eye and less complaint during your OPD visits.

[00:16:46]And the final point is focused on opportunity to escalate treatment by adding another agent into assistance of the um princelomi groups. For example, we do have the fixed combination of princelomite and timolo as well as a fixed dose combination of princelomite and primmonine. So if a patient is already on a non-fixed dose for example on PGA plus with either pinsomite or doselamite and required a further additional class of medications by swabbing that into a fixed dose of the princelomic timmon we give you the additional 21 to 22% further IOP reductions and it's surprising to find out that if B3 is already on PGA and the fixed dose of dosalamic timol group by swabbing it into a fixed dose of the princomic timol group it will give you additional of 10.4% reduction IOP.

[00:17:37]So in conclusion, priselomax family has a strong efficacy and potential temper effect which not inferior to those group and the good thing is is milder to the eye with a physiologic pH advantage which translate to strong tolerability and better adherence and compliance. We can also reduce the dosing to BD to reduce the VA exposure and enhance the tolerability. And lastly, we can play around to step up and as well treatment retention depends on the patient clinical conditions. So before I end, I would like to invite all audience to join us in Malaysia for the Malaysia after Malaya scientific congress 2026 in Koala Lumpur from 10th to 12th July 2026 as well as the Malaysian annual glaucoma symposium which next month in Quantan and the asset of Tony scientific congress in 2027. Am I going to >> Thank you Dr. Honki. Thank you for that wonderful talk. I would now like to invite Dr. Satansa for his comments please and to initiate the discussion.

[00:18:44]>> Yeah. Uh thank you so much for this wonderful presentation. Again the though the both the drugs both the car carbonic and inhibitors the dolomide as well as the as well as the binsolomide has been there for a very long time. uh but in general if you really look at the doselomide acceptance especially in India is much more possibly because of the early introduction of the doselomide than the binsomide. The you have already mentioned that the binsomide as a suspension it has more and though we know that doselomide has higher acidic pH. So that is the reason one of the reasons why the people have more problem in the taste especially the bitter taste comparison to the binsomide.

[00:19:46]So having said that is it a preferred molecule for you that the binsomide is a better molecule that you choose to use to begin with in comparison to the doselomide.

[00:20:01]the the theoretical part to an extent is uh or some of the published article shows that the doselomade slightly has a edge in the IOP as well as on the blood flow uh augmentation.

[00:20:18]Do you go with that or do you do something to say that okay in these cases I would like to go with the doselomide and in these patients I would like to go with the binsomide. Is there anything that you have uh you know like a kind of a marker that you which one you you choose?

[00:20:37]>> Thank you very much doctors for the um comments. So in Malaysia because currently I'm practicing in a public um health systems. So balite is considered as a standard in of CI where the princite is more expensive. So it's only on a case to case basis. So in my daily routine I still use the dosalomite as the first line require CI but for those patients who have um kind of um um face the face problem or complaint of some stinging irritation then sometime I do offer ask them whether to prefer to swab it into is one of the options as well.

[00:21:15]All right. So basically when the patient has uh any issues associated with the doselomide combo then you switch over to solomide combo. Okay.

[00:21:27]So that is going to be the main thing for you. Okay. So is there any any sorry >> the main thing like uh as Satyan said about the vasop perfusion component dozite they it has shown there are established studies of vasop perfusion qualitative studies no doubt uh still the quantification process is yet to be achieved so as far as vasoperusion is concerned dozylomide does have an edge over brzolomide that's what I Thank you sir. Uh quick comment from Dr. Brian sir and Dr. Dentto. Would you like to add anything or shall we move to the next? Dr. Brian sir. Dr. Deans sir.

[00:22:11]>> Thanks very much. Uh I think that was a great talk and a great summary as well. I have some questions perhaps for the panelists as well to get some of your opinions. uh just looking at contra indications or concerns particularly in two main areas in uh corial disease underlying corial disease as well as in patients with renal issues uh would that be a concern for some of you in your practice like to your experience in that >> that's a that's a great question Brian but if you really look at even including the oral acid solomide if you really go through the entire process we really don't have to kind of completely stop unless you see that the the creatinine levels and also how much is the complete renal compromise we we got to be in touch with the nephrologist to understand whether that is really a compromised kidney that we should not be using so I I for especially for doselomide and as a topical solution I don't see too much of a contra indication if the patient has even if the patient has renal compromise Nice but we need to be careful about their uh level of damage and also the creatinine levels. That is one indicator. There's a uh good guidelines given on the bloody how much is the bloody that we should be avoiding the doselomide or the CI and >> if I may add also look at the acidosis levels. So just warn the patient for the acidosis >> markers and that that is there then they should uh seek the opinion. Regarding the endothelium part or the cornal part, I think between you know we we talked to a lot of conneomide and benzolomide and compromised endothelium they generally would go first and leave the last maybe before.

[00:24:18]>> Thank you sir. Generally if there is no other go that we need to use sometimes we do use it but uh majority of the time we try to avoid as much as possible in a compromised cornas >> thanks so much for those inputs in my own practice I I use it on a uh on a basis that uh if I really need to use it then I perhaps would use it in some of these patients the other thing I would add also is uh sometimes if I need to use it I will advise punctal occlusion and that might help to some extent as well to reduce systemic absorption that's the only thing I'll add to the excellent comments. Thank you so much.

[00:24:50]>> Yeah, I think for the wonderful comments.

[00:24:52]>> Yeah, regarding the punctal occlusion, I think we we should advise it for all drugs that we all have some issues. So, that is something we do. Thanks a lot. I think Nikita, you must move on in the interest of time.

[00:25:01]>> Yes, sir. Yes, sir. Uh >> one questions.

[00:25:07]>> Yes madam. We'll have to be little please so that we can I have a patient uh that using brim zolamine for years and then after years he come uh the cojunctifa become hyperma so I stop the drops and I switch to the other eye drops and then uh after that the IOP is not control so I so what do your opinion about that if I get the patient dead like that should I and uh another eye drop is not suitable. So the IOP do you think uh how many I have to change or the patient still want to use that drop because uh it happened after years so I have to stop and when I come use that I drop back the bra solid.

[00:25:56]Thank you. So basically the moment you start having a adverse event of a drug one thing is for sure it is probably even if you want to continue it is going to be only for a short time and we know that glaucoma is not a short-term disease. So somehow we have to see that how soon we can change the drug to either you stop the drug change over to the another drug or you look for the other modalities of treatment like uh laser possibilities and also the surgical options one might have to really look into because it's it's not going to be forever because the patient has to use it for lifetime in case uh we have to give. So we need to see if the patient has an adverse event and it is very notably there significant it is I think we'll have to look at change over to something else.

[00:26:52]>> Yeah.

[00:26:52]>> Thank you sir. In the interest of time I would like to now invite the next speaker uh Dr. Shivam Gupta sir and his topic of presentation is the next present in glaucoma medication. Sir please if you could share your slide.

[00:27:05]Thank you.

[00:27:10]Yeah, I hope my slides are visible.

[00:27:13]>> Yes, >> absolutely sir.

[00:27:16]>> Good evening all. Thank you. Thank you scientific committee. Thank you Satya sir and it's a great honor to be just amongst all the stalwards of the glaucoma and it's a great honor to be here. So I'll just start with my presentation on starting with this this video. This is very disheartening to see in glaucom the patient coming with such eye drop with fungus going on in the tube. So it breaks the heart and then we come out to the that still in 2026 there the the challenges still are there a lot of challenges are there for medical management we have to consider that glaucoma is a lifelong disease and there's a poor patient compliance and adherence is there also which we are discussing recently there is ocular assess toxicity because of the preservatives and all and the cox cost accessibility is also an issue and also there is progression despite normal controlled inocular pressure so like sering Dr. Matus were discussing we have come a long way for colonergic agonist to osmotic agents to oral carbonic and nitrator inhibitors to beta adinergics and recently we are working on rock inhibitors. So what are the unmet therapeutic needs which can be addressed now are the need for neuroprotective agents a sustained disease drugs newer drug delivery systems and need for preserative free drugs. So these two points will be covered in the subsequent talk. So I'll start with the newer drug delivery systems. So it's nothing which is not new. In 1975 already there was a pile of 20 which was used which was discontinued because of tolerability.

[00:28:42]Then bimatrop came with something new which is called bim ring which is continuously eludes matropas from a period of 6 months. The rate of drug elusion is 30 microgram per day for the day insertion to have roughly six mic mcgs till 6 months and it has completed the phase three trials for now.

[00:28:58]Similarly bimatroplast can be used for intracame insertion also. It is a sustained release biodegradable implant that uses noadu drug delivery system in for intrainal use. A rod ship implant is administered into the antia chamber using a 28 gauge single-use profile applicator and artimus one trial has shown both the 10 and 15 mcg non inferior to timol. Similarly we have iidos now in which there which can uh which has a formulation of troplast which can last up to 12 months. The only problem is that we have to take the patient into OT and it lasts for only 12 months. Then we have to again remove it.

[00:29:32]And here you can see that it has three parts. One for the tribicular meshwork insertion, one this titanium capsule and there's a pre-filled area which the drug is eluded.

[00:29:41]Similarly we have ENB5 which has the implant consist of biodegraded drug delivery system releases travel plus for up to 6 to 12 months. Again we are having the same problem that these drug delivery systems only work for a short duration. So similarly we have something which can be used as a punctum plug. The punctum plugs have been long been used for treating dry eyes and we so these plugs have been recently used for using for glaucoma drugs also. So here we are using this traoplast plug which eludes the drop from roughly 90 days. Similar to travoplast we have OTX TP which has also traoplast but it has a modification that it is eludes drop for 10 months period.

[00:30:20]Similarly we have evolute which is a mighty distribution and we load it with lectonoprost and it completed phase 2 trial so that 90% of the had a 12 weeks duration of action. Not only punctal plus we have contact lens based drug deliver system in which silicon hydro contact lens are loaded with drug nanop particles. These drug diffuse into the tear flame and increase the viability up to 50%. Similarly along with catact surgery we can com we have spy glass or the I haptic based drug delivery system in which these heptics are loaded with the drugs like in which also we are using bimatrops but again the drawback to this is it and only for 3 years and then again we have to add some other medication also. Similarly, there are many experimental things which are going on like subcontental injection of dosmite to loaded polymer microparticles. Supraine injection of brimodine latent microsphere, intra injection of brimodine on trioplast nanos having completed successful animal studies. So what are the newer agents which are already coming to matter coming into the market and they are almost there. Some of them are like electron which has nitric oxide donating proton and f2 alpha and which has two mechanism action which increases by nitroxyin mediated conventional outflow as well as f receptor mediator non-conventional outflow pathway is also increased similarly we have proenoid receptor agonist which is omnip which is recently introduced in Indian markets also it decreases IOP by increase the conventional and US outlook so again there are different studies which are voyager study constellation study Apollo study lunar study which have showed non-inferiority to let so coming on to other drugs which are available are septolars which has phase 2 and three clinical trials which is a product activating FP and EP3 receptors similarly we have NCX 470 which is again nitro oxygenic prostitic analog which has been combined with matroprost also along if you are talking about combination recently induced combination is a drugan which is combination of attract with electronoprost Coming on to another drug delivery system and which we can target are the nanop particle range from 1 to 100 in size and these can medications can be piggyat on the various naroparticles and which will help in bypassing the biological barriers. A drug called as kon catonics has been recently studied which has a laterose loaded nanomulation and it use the novas of technology developed by them which can help to bypass the biological barrier and increase the ocular surface penetration and drug effect.

[00:32:50]Similarly, we have adinosine receptor agonist which are coming in the market which are nucleotide that activates deep protein linked to adinosine receptor A1, A2A, A2B and A23. It increases the conventional outflow facility by shrinkage of the cell volume and remodeling the extra cellular matrix in human tribicular meshwork. So now we have drops which are changing the tubicular meshwork in in toto which increase the output pathway by increasing the matrix metal protein which removes the collagen tri.

[00:33:18]So again we have another pathway a small inter interference RNA like bamosin is a sin developed in specifically silence the beta 2 adenic receptor in the slary body thereby reducing the aqueous humor outflow. Again if we are going about genetics we can also think about the stem cell the therapy which has great attention as a potential source of cell replacement in disease that lead to blindness such as glaucoma. So coming on to some studies which are going on stem cells are the intraal misenchyal cell transplantation in advanced glaucoma stem cell of study in MSC DB via subtenons retrievable IV root the effective and safety of adipos derived regenerative cells for treatment of glaucomatus and neut study are being under clinical trials.

[00:33:58]So again it's not just what everything one size doesn't fit at all and now we have to move towards a personalized lockoma management meaning to what we need to do polygenic risk scoring and we have to genomics may have hold the key to unlocking the future biological insights and enabling precision medicine in which glaucoma care is tolerated to the individual patient based on the unique profile map. So in which what we can do is biomeical guided therapy and we have to start thinking about bio pharmaccogenomics and we have to start about what tribular mesh work and why someone is having more fast progressive why someone is a slow progressor and then we have to tailor made to that particular patient. Not only that we have to till that these things are developing we have some innovations to increase the drug compliance. So in this we have a detailed step like this premac developed a drop smart method in which they use a how to apply it along with that we can check whether patient is compliance can be checked by these this method in which there is a bio sensor to check whether the drops have been used properly or not. Another one is a cloud-based AI support method in which the blood drop is being checked. Not only that we all our glaucomma patients are quite old and they are not able to sometimes steal the drop. So there's a technology called smart drop which checks the whether the patient is using the drop properly as well it helps in the tactile guiding of the drop to the directly goes inside the eye along with that what's the easy way which we are doing in the hospital we give some patients all these charts in which patient ticks on what all drops he has used for the month so what will glaucoma medical therapy look like in 2036 that's a big question and I believe it should be a drop- free glaucoma care a sustained disease implant should take over the personalized therapy should be given a more push and there should be AI guided treatment and a more talk about a neuro regeneration. So it falls on and yes I was a very young person speaking among the amongst the all the senior speakers and a great honor but this this problem and this like a goal for us young lama warriors to think about it and yes much has been done and much remains to be done. Thank you.

[00:36:03]Thank you sir for beautifully summarizing such a vast topic in a few minutes of that is 8 minutes. I would like now like to invite our chairpersons for their comments and the panelists please. Thank you.

[00:36:17]>> Yeah. Uh thanks Siv for a quick preparation and then giving the overall view of the next generation of how the glyco medications are going to be and we are all kind of excited for a reason and uh I'll just give you the background why it is important for us. If you really look at the Indian uh typical patient uh profiles uh at the end of uh the first year we lose about 50%age of them close to 50%age of them coming back for uh followup and interestingly at the end of the first year close to about 45%age of the people will require additional medication.

[00:37:07]So there are two interesting things which I have told you now. So having said that when the patient is going to be not coming back for followup some may be still continuing to use the drops but majority of them they don't use the drops. So if we don't have any other way how we can you know reduce the intercal pressure without the medication then we'll look at all other modalities either you go for the laser procedures like SLT in P A or some kind of open glaucomas or you go for the MAGS or traplectomy as a option.

[00:37:46]Now when we have the options of looking at all these kind of uh the implants especially like a sky lens which we also had some idea on and it has come for some kind of a study for us as well. So these are the other ways how we can still use the drug to reduce intra pressure without much of the the compliance as a major issue. So this will really help us. So we are also kind of developing a a newer implant which is completed its uh 5 months phase.

[00:38:23]So we are just looking at uh a minimum drug delivery of about uh 1 year from the implant where we can load five different classes of uh drugs in the single implant which is going to be the subcon implant. As of now, we are not going to probably reveal any of the details unless until we have all the uh outcomes.

[00:38:50]So, this is how uh the things are Nita, you can ask Brian to comment, please.

[00:39:15]>> Yeah, it I'm still there. Okay.

[00:39:18]>> Yes, sir. Your uh >> I thought I lost my >> No, no, no. You you you never lost Dr. Saty. We are very much >> Sorry. I'm sorry. I thought I just lost line. So this is how we should really look into how the implants can really help our uh patients uh you know compliance as well as to control the disease. But this is the new future going to be over to you.

[00:39:45]>> Uh Dr. Brian sir would you like to add any comment?

[00:39:49]>> In the interest of time we'll take Brian sir and then move forward for the next uh session please. Next speaker please.

[00:39:56]>> Thank you. very humbled that um just very quick one or two comments from me.

[00:39:59]I think one obviously that was a great talk with a great summary of all the new stuff that's emerging and coming on board and what this does is it gives us options and it gives us options for the future but I think the challenge here is how two things one cost and accessibility and two how do we fit all this new available drugs and technology into our treatment algorithm it's it's not as straightforward we will need a lot of evidence a lot of scientific evidence real world evidence to fit into some form of consensus guidelines for us so we understand how it fits into our current treatment algorithm and I think that will be the next challenge for all of us. There's going to be a lot of things coming up just like MIGs for example and I think the challenge will be for all of us uh to be able to understand them well enough and to use them adequate enough so that we know how it fits best for our patients. Uh those are just my two very short comments uh and it was a very very good talk. Thank you so much Dr. Sha.

[00:40:49]>> Thank you sir. So uh in the interest of time uh we'll move on to the next speaker. So uh Dr. Sham MD Norman uh I would like to please invite to please speak on the topic beyond pressure the new era of antigloma medication over to you please thank you Is it visible?

[00:41:33]>> Yes. Can you make it do slideshow?

[00:41:35]Perfect.

[00:41:36]>> Here you can see.

[00:41:37]>> Oh, I have almost the same presentation uh like a previous presentation because in the uh medical management of glaucoma my topic though. So I will just add something uh with the PBS presentation and thank you for inviting me. This is Dr. Shams Noman. I'm the head of glaucoma Bangladesh Medical University.

[00:42:00]I don't have any financial disclosure.

[00:42:03]So what is the focus of new era of medical management of glaucoma? The first thing is the neurop protection uh sustained release delivery what uh uh Dr. Shivam already discussed dose convenience is a factor. This is the uh because dozing is a great fact factor and patient are very much choosy about the single or uh very little doses and uh obviously adverse effect uh uh is a great thing to uh continue the compliance. So roy inhibitor we know this is the latest innovations uh the natural sudil and reaper sudil uh it is the uh increasing the ability of this cleans canal u endothelial cells to form the pores and uh relaxation of the smooth muscle fiber of the tricular mat that increase the outflow and this is almost available in the in this subcontinent. The most important thing is relaxing muscle by inhibiting the meiosin increase the blood blood flow that causing the neurop protection and inhibition of the fibroblast that is the most interesting thing that may decrease the triclectomy failure. This causes 30% reduction of intracular pressure and fossidil is a newer rokinis inhibitor that is some added advantage like it can be used in the advanced gluccom sustain effect less hypermia and it has available inulate gel format but is still it is an ongoing trial excuse me latinoproin bonote this is available in our country this is uh It has a nitric oxide donating prostaglandin alpha to analog. It has a extra nitric oxide which has a 10 which has a vaso dilator effect. uh for this uh uh uh it has uh in the conventional pathway and also in the postaglanin pathway by both pathway can be uh this drug uh uh can work and uh the special characteristics of this medication is reduce the dional variation and the the side effect is very transient and sometimes the 40% reduction of intracular pressure uh has been uh has been shown uh and Dr. Shiva already told about the newer drug delivery system why the patient who are non-compliant missing doses and for the uh adverse effects. So I think uh that will be a new era for uh in the gluccom medication. Uh theopro implant durista is a noadu technology drug delivery system for the intra cameraal use. You can see uh thanks uh allergen uh for inventing such a uh I don't have any financial interest. Uh this is a mimatrop implant the first approval. Um and uh you can see the device and uh another thing is BMR2 ocular ring. You can see uh there is a ocular ring uh at the level of the phonics and uh and this can uh uh gradually uh u just secreting the bat prostal plug uh oxtpular therapeutics. uh they have uh introduced it. It is a sustained delivery system which works up to 90 days. Then you have it have to be changed. The the most important thing is uh if you implant the punctal plug uh this is uh the hygiene is very much important because for this the punctum can be occluded and uh physibility study of sustained release tabopros punctal plaque for intracular pressure reduction in an asial propolation. Uh the the the the study shows it works uh good and uh you can see troop spontal plug here.

[00:46:13]Usually it uh implant uh into the lower quantum.

[00:46:20]So a nanotechnology a novel of drug delivery that is first evolving nanop particle is 1 to 100 nanometer in size ability to bypass the biological barrier. you know if we can uh uh bypass the biological barriers where is what is the most important uh site of glaucoma uh pathology to substantial injection of dorsalamide loaded polymer microparticles and supraary injection of bimmonidian lein microspheres and intravitral injection of bondidian trapopostrobatoscladin nan sponges have complete successful in animal studies not in human studies And you can see in the different uh site of nanop particle injection some investigation on gluccom medications like canabidide sensitize travvicular meshwork can increase uh increase the perfusion and palm oil ethylomide canabonoid inhaler but in in no role of uh actually drops here it is a uh investigational gluccom medication.

[00:47:33]Adinosin receptor agonist u you know the adinoscentin uh increase the conventional outflow facility by shrinkage of cell volume and remodeling of the extracellular matrix in a human tribicular meshwork cell. It has already been established.

[00:47:48]Posterate receptor agonist of denopac OMDI is a non-postaglan selective postite ep2 receptor agonist known to decrease intracular pressure by increase the conventional and uiscal boat outflow.

[00:48:04]gene therapy uh crispier case 9 RNA gene therapy uh can target uh the genomic changes in the you know some trigger gene or myioeline gene if we can target with those gene therapy then can prevent even gluccom progression stem cell therapy um already discussed.

[00:48:32]Thank you so much. Thank you for the patient hearing.

[00:48:37]>> Thank you very much sir. In the interest of time we'll take one comment from Dr. Dain Tuli. Sir please your expert comments.

[00:48:48]>> Uh Nikita I think because it was very similar to the previous talk and uh Dr. Satya is very nicely summarized I think we should move on for the next one if that's okay with everyone.

[00:48:58]>> G sir. So I will now invite our next speaker Dr. Pushbar Ramen ma'am and the topic for her presentation is solving old frustrations ripas and the new era of glaucoma therapy. We welcome you ma'am you are muted ma'am Dr. Bushba.

[00:49:25]>> Hi. Sorry. Sorry about that. Hi everyone. It's so good to see you on.

[00:49:29]It's so good to see all the familiar faces. I'm Bushba from Malaysia. Um before we dive in straight, so I just want to talk. Recently I ordered a coffee and then they said they have this new rose latte and then uh the picture showing this uh rose latte. So and then it looked familiar enough to be a coffee but it had something unexpected a different aroma a different experience and suddenly something routine felt refreshing again and that's goes to similar to glaucoma I thought about glaucoma we often operate with very familiar algorithm because by nature glaucoma is a chronic monotonous disease but every now and then an innovative product comes along and makes us pause and think whether we can manage patient differently. So that's what I'm going to talk to you about. Um I know the previous speakers covered about reposidadel but I just think that repadil is like my new found obsession and is I see it changes the way I see patient nowadays. So I want to share my own experience and share with uh the panel how repasil can change your family algorithm as well. uh there is no actual financial disclosure but I am a speaker for DKSH and KOA but I don't receive any uh honorarium for current talk. So um as we know yeah glaucoma is either we go by all the channels either you reduce the equest production or you increase the outflow pathway but um as we pointed out earlier the there is a great vacuum in glaucoma drugs but of course in between we have a lot of glaucoma surgeries and MIGs and so many things happening. Um if you see from 1996 until 2001 nothing happened and thank god Bimatros came uh and then we had this repassidel and nasidil repasil came around 2014 nasadil came around 2017 and I think it's about they are game changer because all the while um the current iOS we were of course looking at aquis humor production and and of course we try to reduce the aquis And then we try to see where else uh the water can flow, the aquous can flow scleral outflow and things like that. And actually we totally forgot about the conventional pathway the tbacular meshwork itself. Um and I was so excited when this drugs been introduced because this zerokin inhibitor they right on the point like they improve the conventional uh pathway. So um if you can see like back to basics why there is an IOP increase why the conventional pathway anyway uh because especially primary open angle closure glaucoma and some gluccomomas like steroid or inflammatory or even in case like soda exfoliation glaucoma they actually works on the conventional outflow. So rather than seeing how to bypass this uh conventional outflow uh by doing the uvius scleral and all those things we have to see how to actually improve the conventional outflow. So um as we know uh extracellular matrix in the tmacular mashwork increases in the glaucoma patient. So if you can see the veils uh actually shrinking the ECM extracellular matrix is actually laid on more in the glaucomas patients uh and there is a narrowing of intracellular spaces mainly due to ECM accumulation and of course due to high IOP itself the TM cells get compressed and there is a narrowing of interm cells um so that's how we have increasing resistance in acoumer outflow so there is a closure of collector channels there is a narrowing of uh Schlleam's canal and eventually it leads to increase in uh tbacular meshwork. So again uh that's what we've been doing now like you know all this MIGs they came about because we don't know what to do about this conventional pathway because this conventional pathway you know all the narrowing and all those things. So we tried mix we just tried salty we tried to see how to make this conventional pney more porous to allow more water to flow and this is where exactly um rokynes came in rokin of course some basic biochemistry things I I don't want to go through about it but it's the actin cytokeleton origin and it modify the cell addition and motility practically whatever that we want to happen in tracular meshwork they make it happen uh so eventually ranis inhibitor It causes a morphological change in the tracular meshwork. It dilates the lumen in the shams canal and and also the interesting part is this is the first drug that actually works on episcoral venus. So it causes the episcoral vein to dilate and then they decrease the episcular venus pressure. So if you can see here the rinis inhibitor they act on the stress fiber in the tracular meshwork and then causes the cell morphological changes. So what we can see by when you start rokynise uh is the early effects are same as I mentioned it increases the giant back walls and there is an effect on the endothelial cell. I think our conal colleagues can comment more on that. Uh and then they change the cytokeleton contraction. They there is a effect on the cell gap but in later uh stage it actually reverses the resistance because it inhibit the extracellular matrix layout and then it changes the cell ECM relationship. So eventually reduce the resistance of the conventional outflow and give us the IOP lowering effect. So if you can see compared to placebo and repacidil there is a great reduction in the IOP throughout the 24 hours. So here we able to actually identify the noctturnal effect as well. Um and of course there is a conjunctal hypermia associated with this because that's how the drug works.

[00:55:21]It's visodale. So if you can see the real world study there is a quite good reduction in the IOP from baseline. And what excites me the most is actually it can help us with the normal tension glaucoma and most of the secondary uh glaucoma as well. So here I want to point out whatever the glaucoma that works on the conventional pathway especially exfoliation glaucoma, pigmentaryary glaucoma, uviatis glaucoma, steroid induced glaucoma, I think reposidil or netasodil they stand a good chance because they work on the same pathway as well. They kind of like a counterintuitive effect on this glaucoma type subtypes. Um so the the study shows amazing results um so uh by what as as I mentioned earlier so as we compare to other available medication inhibitor can actually reduce IOP from 15 to 36% and then it's a BD dosing uh but it's just that it's not approved as a first line so most of the time when you combine with the ubiscal puff apg and rohan is they can actually uh results in 30 to 40% IOP reduction in normal cases I think the only place that it doesn't work is normal neovascular glaucoma because as we know neovascular glaucoma the conventional pathway itself is gone like you know there is a membrane there is things going on so there is no point uh adding a ripodil or netasodil on a novascular glaucoma so recently um I was excited enough to be part of the launching of a new fixed combination of bipasadil and bremon in Malaysia Um so the the fantastic part of that this reposible bremonin fixed dose combination is they work on all the three pathways conventional pathway uclar pathway and then they also reduce aquest production. So there are multiple um studies done and then I think everyone is quite excited about how this uh reposidal antagonized effect of the inflammation steroid induced glaucoma.

[00:57:22]So I'm just sharing a quick note on a steroid induced glaucoma as a 32-year-old female that presented with me with the intermittent episodes of anterior uviitis and as you can see there is a uh early changes in the glaucomatus changes in the disc because of the high intraacular presses fluctuations. Uh her peak IOP is 35. So I it's mostly steroid induced glaucoma.

[00:57:44]So we put her on multiple combination drops and then actually planned for glaucoma drainage device. My patient was not keen when actually I added on repass it worked wonders IOP reduced to 15 to 16 and then uh I changed to Limax and when I off the steroid and reduce the potency of the steroid the IOP actually further reduced to 12 um and currently we can actually maintain her on 12 to 15 uh sparing her on the glaucoma surgery yet because she's still young 30 of course if necessary we will do but I'm happy that there is a something that I can do in between to buy some buy some time before the surgery and I think that's the most important thing.

[00:58:22]>> Yeah, >> ma'am I'm sorry but in the interest of time if you could please conclude we have okay and then um the other one is of course in the progressive NTG where I used the combination drop and then I tested it with the water drinking test as well. So these combination drops they actually reduce the fluctuations in the long run. Um so where do you fit in rocks inhibitor is somewhere in between PG beta blocker and then I would go for rock inhibitor before the alpha adrenic and CI because uh they they do have a lot of u uh IOP reduction effectives effects in the real life. Thank you so much for the opportunity. Thank you for overriding. Sorry for overrunning >> thank you so very much. I loved your coffee slide in the beginning. So I would now like to invite Dr. to Manoj Matura for a quick comment as we move to the next speaker after that. Thank you.

[00:59:14]Yeah, >> like pushpa I was also excited when with the launch of rock inhibitors initially but in the Indian subset of the patients some of the patients developed uh gross hypermia even leading to cornel verticilata but what we observed subsequently is the combination with timolol if it is not contraindicated reposial plus timol combination really stabilized the molecule and the patients started tolerating that quite well. So in five drops a day a combination of reposodil antimol with a combination of say brimmonine and binsolamide and a latinoprost or a pg analog use in five drops you can afford a maximum medication especially for cases where trolectomy you need to wait for a little time. So in such situation where the surgery has to be postponed this is a possible combination. So uh good developments about the glaucoma medications in our aramentarium we can use it. Apart from glaucoma IOP lowering effect uh as you said the coral endothelial integrity as well as reduction in macular edema was observed in some cases. So it is of interest to retinologists as well as coral specialist too.

[01:00:34]>> Thank you sir. Now we move on to the next presenter Dr. Andy ma'am and she will be presenting on the topic guardians of the vision Indonesia's evolving approach to glaucoma. We welcome you ma'am. Please share your screen. Thank you.

[01:01:00]Dr. Randy ma'am ma'am is there?

[01:01:06]Yes. Thank you.

[01:01:32]Yeah. Uh good afternoon.

[01:01:38]Thank you very much for the AOS for the invitation. Um today I will share the topic is uh quite different with the others. Today I will present about uh preserving vision. This is the Indonesian journey of glaucoma care.

[01:02:00]So as a introduction, glaucoma is the second leading core cause of blindness in Indonesia affecting about five four until five out of 1,000 people. 6 million affected individual with approximately 1 million suffering from bilateral blindness and many patient come to us with the at advanced stages and Pag and Pac are still the major types.

[01:02:34]So this is the six pillar of Indonesian heart transform by the minister of art of Indonesia that adopt by uh WHO. So uh we do uh six uh things that uh running now. The first is primary healthcare transformation, referral health services transformation, health resil resilience system transformation, health uh financing transformation, health human resources transformation and how technology uh transformation.

[01:03:08]So uh there's uh many uh some challenge that uh we uh have in Indonesia. The first is uh primary care or physical training. So we uh so we done uh the things and did that uh these things and then uh we also do uh gluccom screening initiative and also technological ad uh advancement in diagnosis.

[01:03:37]So uh uh challenges in Indonesia community screening program in primary healthcare >> uh we do uh identify higher risk patient and then if we uh help identify patient we refer suspect to the ofthalmologist.

[01:03:57]So it will improving quality of the referral and then in primary care they do IOP check acid and ofoscope examination and because in Indonesia we have about uh 16,000 of islands. So uh we do telementoring a for GP and nurses to reach rural area and uh they will find cases and then best uh learning. So uh this is a screening program for ATIC Indonesian uh population. So we do public private partners partnership and then uh if uh we do uh diabetic resinopathy co screening with glaucoma screening and then uh we focus on geriatric population in a primary egg care.

[01:04:48]So this is uh the glaucoma in Indonesia that uh data that one year data of a new secondary glaucoma patient of top peral high hospital in Indonesia and uh they found that uh the second is because of the uh patient come late to do the cataract surgery and then uh medical management that uh available in in Indonesia is uh prostaglanding analog and then beta blocker carbonic anhyas alpha agonist and fixed combination. So for the uh newest uh glaucoma drops that uh we have now available in Indonesia is uh Omni but in Rokenas we don't uh we still don't have for the surgical trends u MIGS and SLT so we do uh b up internal needle gonotomy gonotomy with a micro hook and also gat combined with FCO procedure related to cataract development and then uh trapolctomy is still the remain standard for the surgery and then for GGD implant for referratory gluccom also MPCPC and also TCPC.

[01:06:15]So we also have a collaboration international collaboration program and then for the innovation uh so in 2019 Indonesia launched its own locally developed glaucoma in France that we call FNA Fiji. So uh invented by uh Dr. Ferna and uh uh Roto company. So the FGI lower cost about lowering the cost about uh 7 75% and then uh the FGI is uh noninfile uh PMI and then uh they placement between the mascarus. So this invention won the world intellectual property organization in 2018.

[01:07:06]So this is the uh experimental study and then uh the subject about 252 uh subject.

[01:07:18]So for future direction LS uh fund screening portable in PHIC and then national prevention programs also invision in MIG procedure.

[01:07:32]Thank you.

[01:07:36]Thank you ma'am. I would now like to invite Dr. Brian Langer for his comments.

[01:07:45]>> I think thanks very much Dr. Dr. Deb. I think that was a an excellent summary and talk. Thank you for sharing uh you know to talk about your presentation but I think what your presentation does for me is it it it highlights for me the the various nuances and differences in gloma screening and care across countries and I I personally am humbled to you know realize how much we can and really should be learning from one another that can only come about collaborations at really all levels and I think this platform uh is just one example of how this can happen. So thank you very much for sharing.

[01:08:19]>> Thank you.

[01:08:22]>> Yeah.

[01:08:23]Yeah. It's it's it's good to see that all kind of developing countries everybody faces the same kind of an issue. Uh but I think the way we start treating the glaucoma is going to be completely different from now on because we are just not going to focus only on medications.

[01:08:44]The new trend especially in India slowly is picking up is the SLT for the P though we have the studies been there for quite quite some time though we don't really use much in Indian context I I do use it but but then there availability of the equipments and instruments also plays a role but the SLT is kind of emerging in Indian uh market then the Next thing is on the emergence of the MGS where the uh not only the glaucoma people are doing the non-gloma people are also >> of the mucous membranes of the >> yeah non-glma people are also kind of started doing that is one of the main things that it is happening in India so that is good to see provided that we really don't damage too much without understanding but then the troplectomy is going to stay which gives a solid drug solid result for a pretty long time. So I I in my personal view the role of SLT, MAGS and the traplectomy is going to be the key factors in the long-term you know keeping the progression at a bay otherwise the with the rate of uh the compliance when we did the study at the end of 10 years the followup rate is only about uh 10%age.

[01:10:23]when you have such a poor followup then I think it is better we look at a medication I mean we look at a procedure that can really help uh to you know see the people for long enough because it is such a chronic disease and especially those with the younger age group we are almost going to be sure that they're going to go blind if this kind of a fall rate is there so we need to understand that glaucoma needs to be looked at in a much uh you know different way than what we just think. Many times we try to say that okay use the drug and come back. Do you think they just have to come back?

[01:11:02]They don't really have to come back cuz they don't really feel comfortable with you. You are just ordering somebody to use the drops for your own convenience.

[01:11:10]But we really don't involve the patients in decision making of what they really like to have. It is our decision that they have to do this or they have to go for something else. But I think it is the way that we need to change ourself to make sure that we involve our patients in uh their decision making of how they want to get treated.

[01:11:35]>> Yeah.

[01:11:35]>> Thank you sir. I would now like to invite our program coordinator Dr. Rolik ma'am and Dr. Ti the session coordinator to ask uh questions and their comments please.

[01:11:48]No, no, Nita, please go ahead. You're doing great. And you can take over if you have any questions.

[01:11:55]>> Yeah, I have two questions uh open for all. First is there any role of repacid in patients with glaucoma with diabetic retinopety.

[01:12:04]Then the second question is uh basically I'm just asking whether anyone practicing like reposidal use in patients with glaucoma with diabetic retinopety. Second is what is the best parameter uh that will be used to assess any neurunctional improvement if really we have a medicine or a drugs that will uh that is considered as a neuroprotects >> Dr. Dr. Pushba ma'am would you like to take that?

[01:12:33]>> I'll take the first question the repasidal question. Um as I said of course we are excited about the uh endothelial cell effects of the repacid the royes and all but so far we don't really have any strong clinical studies to actually recommend and we don't have a real world data as well even from our retina colleagues. So I mean of course there is no harm the I mean as I put it out uh reposet really help with the outflow and conventional pathway but I'm I I I don't think there is a clear evidence to say yeah it helps with the diabetic retinopathy >> Dr. Pushka, if I just put you this question, would you really give uh repuls in many of your patients still knowingly this has so much of hypermia because all of us kind of almost stopped giving >> unless otherwise there is a you know like no other option.

[01:13:42]hypermia unfortunately in Malaysian eyes it actually only lasts for 30 minutes.

[01:13:49]So we we do it as that how they put it first come to us is 1 hour. So we I actually asked them to by go the be dosing. So they put uh glutath I mean the ripassadel first thing in the morning uh when they shower go to work the eyes white and then the last doses before the bait so that no one >> oh such a blessing that Malaysian has >> yeah but I I agree because the Indians are the one that the worse off the Malays and the Chinese patient they seems to do better uh but of course uh because of the vessilation effects and all uh yeah my Indian patients they they suffer a little Oh, that's great.

[01:14:30]>> Thank you ma'am. For the second question, any comments from the esteemed uh uh panelists and uh the other faculty speakers please on the neuroprotect >> established uh research demonstrating neurop protection especially in bremonine the rat crush model that is always cited it used 2% uh bremonine as an intraaronial uh injection. So whereas the brimidine that we use in ey drops is just 0.1.

[01:15:02]So the neurop protection effects are really yet to be established and I don't see any rational of uh expecting too much but as a like in situations where you expect some sort of neurop protection or a vasoperfusion these drugs may have some role but uh any parameter to quantify neurop protection I don't think uh we can establish or demonstrate as of now >> it is a basically the visual fields as a parameter that they use actually than any other parameters like they're not going to study in you know like anatomical distractions but basically when you are using timal when the IOP drop is as same as how you see with the briminine and how the visual fields are much more stable with the brim is kind of the way that they were trying to establish that the possible effects of uh neuro protection. So it's it's already been uh uh published to some extent we can kind of really believe that uh but we really don't have anything been published from our side.

[01:16:19]So I think there's a reasonable belief that there's a possible effect on this.

[01:16:26]>> Thank you sir. Brian Anger would you like to add something?

[01:16:31]just one each uh comment. So I think to the question about hypermia maybe it's Singaporean eyes are quite similar to Malaysian eyes as well. Um so I I I do get hypermia but like uh Dr. Pushba I recommend the same to patients. I think managing expectations is important as well and you tell the patient to expect it. Um however I would agree that it's not necessarily my first line uh drug.

[01:16:54]they would still remain progressed unlocked for most part as per consensus guidelines.

[01:16:59]>> To both of you >> uh to both of you Dr. Brian and Dr. Pushba, >> do you really see a kind of any surgical outcome change after you you have used the reposin? Is that you expect more failures or have you been seeing?

[01:17:22]Actually it's the other way. Uh because um when I went to Japan I realized that they use reposetil prior to mix because it's open ups the conventional pathway and when you actually uh do a gonotomy or a stent uh you allow water the fluid to flow better. So actually I'm doing current study uh what is the effect of using a repositor prior to the mix and actually quite convincing with that. But uh uh the tbacular timing part is the same. We use we stop all the medication two one week before put them on bread and put in dox and all. So but I think rep the the roinees has a role prior to mix. Brian did did you try any anything like that like trying repacid before the mix and all?

[01:18:11]>> Yeah actually my question was about rock inhibitors after mix. I think there have been a couple of studies about that.

[01:18:16]Actually kind of makes sense because the angle based mix tackles the proximal uh resistance and then now finally we have a drug that tackles the distal pathway.

[01:18:24]>> It acts on the episcal venous pressure as well. So it opens up all the way until the distal pathway. I think the Japanese coming with a quite good studies on that. We have to wait for the results.

[01:18:37]>> Thank you all. Oh >> yes Nikka going >> yes in the interest of time I'm sorry I and the next session is also there so I would like to ask from the esteemed faculty if there's any other quick comment or else I would like to then close with the closing remarks and vote of thanks so any other comments from the other esteemed uh panel speakers please >> I think you can go ahead with your final comments >> so I thank uh each and every one of you the esteemed faculty chair my persons panelists and the speakers I special thanks to Dr. Roam program director my session coordinator Dr. I without whom this was not possible and uh I am extremely grateful to each one of you. I now hand over the uh session to the next uh session coordinators uh and the topic for that is mix the current status. So before we leave a quick photograph please so uh because they start at 7:30 we still have two three minutes for a quick photograph for memory sake.

[01:19:42]over to you. You can go ahead and take the screenshot. But thank you so much everyone for a wonderful session. I think it ran very smoothly and we ended it perfectly on time. Courtesy everyone.

[01:19:55]Thanks to all the international speakers as well who took their time out. Thank you so much.

[01:20:01]>> Thank you all.

[01:20:02]>> You can go ahead with the >> Thank you all. Dr. Ti, could you please do the honors?

[01:20:08]>> So I request everyone to please put on their videos and Dr. She will take the screenshot.

[01:20:20]So once you're done, let us know. We are waiting with a smile plastic.

[01:20:31]>> Done.

[01:20:32]>> Done.

[01:20:33]>> Yes.

[01:20:35]So thank you to each and everyone and I now hand over the session to the next uh speakers and the program director. Thank you very much.

[01:20:44]>> Thank you sir. Thank you.

[01:20:44]>> Thank you so much. Goodbye.

[01:20:47]>> Thank you all. Thank you.

[01:21:12]Hello Dr. Shamira.

[01:21:14]>> Hi there. Can you hear me? Hear me and see me?

[01:21:17]>> Yes, sure. Can hear you. Hi Sunita. Hi Peter.

[01:21:21]>> Hi.

[01:21:22]>> Hi Siban. Hi Manish.

[01:21:24]>> Hi.

[01:21:26]>> So Rolika they have the uh option to share their slides and just check it. Hi David.

[01:21:31]>> Hi. Yes ma'am we do.

[01:21:33]>> Ma'am we are live so we can continue.

[01:21:36]>> Yeah. Um ma'am we are going to be live continuously so they can uh share the screen and check and we start sharp at 7:30.

[01:21:46]>> Okay. All right.

[01:21:47]>> Right ma'am.

[01:21:49]>> Oh the speakers can just check the slides once.

[01:21:54]>> Okay. Should I do it first?

[01:21:56]>> Yeah please.

[01:21:56]>> All right. Let me try.

[01:22:00]Interesting. Okay.

[01:22:04]All right. Do we see it with the monkey?

[01:22:08]>> Yes. Yes, we do.

[01:22:10]>> Okay. Good. Then I can stop sh Well, let me go to uh slideshow just to make sure it plays. All right. You see the actual slide?

[01:22:19]>> Yes.

[01:22:20]>> Yeah.

[01:22:20]>> Okay. And do you see my cursor moving or no?

[01:22:23]>> Yes, we do.

[01:22:23]>> Yes.

[01:22:24]>> Okay. Perfect. Perfect. Perfect. Let me unshare.

[01:22:29]Who's next in the lineup?

[01:22:34]>> You can go ahead, Dr. Pereira.

[01:22:36]>> Okay, thanks a lot. Uh, see, I just want to check you've got uh this on the presenter view.

[01:22:58]Okay. Can you see everything?

[01:23:00]>> Yes.

[01:23:01]>> Yes.

[01:23:02]>> But none of the text in the It's >> in a present mode. Can you just make it in a slideshow mode on from top?

[01:23:09]>> Oh, I wanted it in presenter mode.

[01:23:11]Sorry. But not to show it. How do I do that?

[01:23:14]>> On top. You can change the the from top.

[01:23:19]H >> how do I do that?

[01:23:22]>> Yes, that's good for us. Is it okay for you?

[01:23:25]>> Not so good for me, but it will do.

[01:23:27]Okay.

[01:23:28]All right.

[01:23:31]>> Okay, I'll stop sharing then.

[01:23:36]>> Yeah, thanks. Um, who else? De. No, De doesn't. Bash has one, isn't it? Bash, would you like to share yours?

[01:23:52]>> Uh, Dr. Tik has yet to join and Dr. Jonathan has yet to join. Yeah.

[01:24:02]>> Va can >> I texted him? Let me call him.

[01:24:05]>> Okay. Vad, can you hear us?

[01:24:08]>> Yes, ma'am.

[01:24:09]>> Yeah. Can you you want to you want to share your slides just for >> Yeah, sure.

[01:24:16]We're waiting for Dr. Tar to come.

[01:24:23]That corn on Looks good.

[01:25:14]Hello.

[01:25:17]>> You'd like to put it on slideshow?

[01:25:20]>> Yes. Uh, is it visible?

[01:25:21]>> Yes. Yes. Done. All right. Yeah, that's fine. So, it's moving.

[01:25:32]>> Yeah, you can you can unshare. I think now he's still waiting for Dr. Tar.

[01:25:38]Yeah, >> I think he's not able to get the link actually the faculty link.

[01:25:46]>> Oh. Uh, >> so I posted in the WhatsApp group.

[01:25:51]What happened?

[01:25:52]>> I posted there probably he not having the faculty link. So if he don't have faculty he can't join. So I posted the MIS group just inform him.

[01:26:01]>> Okay. This is Dr. T.

[01:26:07]>> I will send him an email as well.

[01:26:12]>> I just forwarded the email to him just now.

[01:26:16]>> Okay.

[01:26:16]>> Good evening ma'am.

[01:26:17]>> Good evening.

[01:26:18]>> Hi. Hi Shaban. I have techni and I I can still not see you. I can only see you.

[01:26:30]>> Yeah.

[01:26:32]>> Here I am.

[01:26:32]>> Nice.

[01:26:39]>> Lovely.

[01:26:49]The problem with the males now sushmita in a day there will be 100 from the yo you don't really look at it >> I know >> when it's real real >> even I couldn't find the mail actually I just asked there are so many males >> yeah I think they How is heat in different parts of the world weather?

[01:27:21]>> Apparently Europe is quite hot. So that's that's funny.

[01:27:26]>> I I can testify to that. I'm on holiday in Tuskanyany right now. So >> Oh, okay.

[01:27:33]It's this time the the weather is very weird and uh it's very oppressive.

[01:27:40]We had a very pleasant May initially and now it's come back with a vengeance.

[01:27:46]I have the latest news.

[01:27:48]>> My my heavy theory all the burning oil wells are contributing to the >> greenhouse effect >> and it's becoming super super ill. You know, >> can somebody mail to Dr. Uh >> I did I did forward the to the mail what he has sent >> but I think >> I got a message from Jonathan to Harina saying that he's in the room but somebody needs to let him in. I don't know if uh is there a waiting room function?

[01:28:25]>> So Neil can you help with that?

[01:28:28]>> Yes ma'am.

[01:28:32]Hello.

[01:28:34]>> Okay.

[01:28:34]>> Yeah. So, Jo Dr. Tarina says he's in the he's logged. He said in the room but not logged in the speaker.

[01:28:43]>> Dr. >> I'm here. I'm here guys. How are you?

[01:28:47]Lovely seeing you all.

[01:28:48]>> Sorry about >> Sorry about the suspense in the last second. Thank you, Vaya.

[01:28:56]>> Uh I won't blame you. You get so many mails. So I'm sure it is difficult for me to locate >> and they do many things at the last second. So I'm guilty as charged >> just for safety. Can we send another email to Jonathan to Herina?

[01:29:14]>> Do do you want me to send the link in the WhatsApp group? Will he get it then?

[01:29:20]>> Uh send it as email.

[01:29:22]>> Okay.

[01:29:23]>> Yeah, if if that's possible. Thank you.

[01:29:26]He's pretty techsavvy. So if he couldn't get in, something must be happening.

[01:29:36]>> He's already What did say? I mean, he's already in the group. Can you let him in if he's >> sent us email?

[01:29:42]>> I think I made it. Dr. Ch.

[01:29:43]>> He's here. He's here.

[01:29:44]>> He's here.

[01:29:45]>> Hey, good.

[01:29:46]>> Yeah.

[01:29:47]>> He's pretty techsavvy, so he could get in something. Must be >> Yeah.

[01:29:53]>> Yeah. We are already live. So if you would like to proceed, we can proceed.

[01:30:00]He's already in the group. Can you let him in if he's >> send us email?

[01:30:03]>> I think I made it. Dr. Chang, >> he's here.

[01:30:05]>> He's here.

[01:30:06]>> Good.

[01:30:08]>> He's pretty techsavvy. So he could getting something.

[01:30:14]>> We already live. So if you would like to >> I think the last few seconds are playing up again.

[01:30:22]If that is right, good evening everybody and welcome to this evening session on the most um exciting development where glaucoma surgeons are concerned and we who've gone through the gamut of only the traps and tubes era and for us it's more exciting but I'm sure the youngsters are getting more exposure than we did. So I'm happy to hand over the session for opening remarks to Dr. Vijaya and Dr. Tarik who would open it and then we'll go through with it. We have a very exciting four lectures and two uh residents are going to present their cases from the PGI and the Baskam Palmer. So I'm sure it's going to be a great session. Over to you ma'am and Dr. Tariq.

[01:31:06]>> Tikk you're the guest. You >> Oh thank you. Thank you. Thank you very much. Uh well I mean usually ladies are better and first but let me just say that I'm extremely proud to be part of this uh illustrious group of fantastic glaucoma surgeons. Every time I attend anything physically in India or virtually over the internet I'm always learning a lot from my Indian colleagues. uh and always the topics of uh your meetings are incredibly pertinent and to the point. Um so our session today is mix the current status trying all of us together to make some sense of what does that mean to our practice and what does that mean to our practice in different places around the world. So I hand it over to ma'am and thank you very very much for having me with you. Yeah, thank you Tariq. I think which without wasting too much of time and we are looking forward for the different views from across the world.

[01:32:13]I'm sure this will contribute to our better understanding of application of mix in our country. Thank you Sushmita for putting the program together. Thank you very much.

[01:32:26]>> Um thank you and with that I it's a pleasure to invite Dr. Shabira Pereira.

[01:32:34]He's well known in the circle of glaucoma and also in the smaller circle of mix from uh Singapore and I invite him to give his opening talk.

[01:32:47]>> Thank you. Thank you very much for the for the kind introduction. I'll just go and get my slides up.

[01:32:58]>> Okay.

[01:33:00]Here we go.

[01:33:04]>> Okay. Can you see my slides?

[01:33:06]>> Yes.

[01:33:07]>> Okay. Thank you very much. So, I'll be speaking on the topic of health economics and disparities with MIGs and the developing world. This actually a talk I gave um quite recently in in India and I brought it up to date with a few more pieces of facts as well. These are my financial disclosures.

[01:33:23]So India currently is a rapidly developing country and it is bounding towards its developed status especially over the last 10 years and if you look at in the situation with India at the moment there is several problems which are inhibiting this growth firstly there's a low rate of insurance the expenses of MIG devices and the poor access to MIGs especially rural communities and the roll out of devices even in India has been very very slow some states were very few in terms of local government subsidies and also training opportunities are very rare.

[01:33:55]Not only is that but there's a discrepancy in the region as well as you can imagine the amounts that local government give in terms of um Chennai and the southern Indian region of Tamil Nadu is very different to Bihar and Patna.

[01:34:12]When we look at the global middle-ass wave, you can look at that blue wedge there from India and you can see that this is rapidly expanding and it will overtake all of the other wedges into the middle class uh group. Now the middle class in India in in this group is divided as households with an annual income of between six and 18 lakhs and I've heard that this is about the salary of a cook in a restaurant.

[01:34:36]Now when you look at how India is is proposed to grow in that particular group uh which includes salaries between 1,000 to 12,000 per year in India that middle income group is more closely defined by an annual income between uh 7.5 uh lakhs and 15 lakhs. But look at how it's going to grow over the next uh 10 years. It will surpass that of China.

[01:35:01]Now although China's income distribution looks much much better at the moment that will quite likely change especially in the next 15 years and in the next billion entrance into the middle classes 88% of them will be from Asia that means 350 million from China and 380 million from India so we have at a very difficult time point for glaucoma at the moment where we do have the tools and the diagnostics to beat this incredibly blinding disease especially in low middle inome countries the blindness is still the biggest cause of irreversible blindness in um in the world because of glaucoma disease and only 5% receive timely intervention and the cost is the main primary barrier. So for MIGs there are several other barriers as well just not just the cost but it's the availability infrastructure and training and the accessibility over eye drops.

[01:35:58]What really matters is the economics and glaucoma is not just a chronic costly disease but it also requires a lot of health economics to support it. In lower and middle inome countries, this means out-ofpocket spending predominates and this can lead to catastrophic outcomes on patients lives because they can't afford it. Now I'm going to go through a few details of health economics here and I'll try and break it down into a simple terms. So I want to introduce this this concept of the IER the incremental cost utility ratio and that's the incremental cost per quality gained. Now you have highly cost-effective interventions which have a cost which is less than the per capita GDP and the cost effective ones are there when the cost is between one to three times per capita GDP and then not cost effective when the cost is over three times per capita GDP and then there's other well this thing called willingness to pay that's the consumption value of health now when you look at areas around the world this per capita GDP is very different USA is 85,000 Singapore 90,000 India only 2,696.

[01:37:05]In Africa it's less than 2,000. So what may work in Singapore will not work in Bangalore. China has another problem with its um difference in the rural and urban populations. So what may work in a uh urban population may not work in a rural population. And when you look at these per these um these costs at 5 years and 10 years these AIAS you can see actually between the different treatments of tra AGV aic and gats they don't vary that much and that's because one paper from uh poor helotal shows that actually it's due to the fact that a lot of the costs are actually brought up by the transport costs and also the the clinic cost let alone the actual intervention itself.

[01:37:48]So let's do some back of the envelope calculations for India. The I cur for the IENT is about 400,000 per qual at 5 years and 300,000 per quality at 10 years. The willingness to pay is less than half of that. And remember that the perspective annual health spend in India was only 6,600 rupees. That's $80 per year in 2022.

[01:38:13]Remember for generic medications that's elen 6,000 perom as well. So what does it tell us that for now mix is not cost effective for low middle inome countries. But what can change that equation? Well firstly costs can decrease or complications uh can decrease and there may be a need for fewer surgical interventions that means that I decreases. However if medication becomes more expensive or less effective for that matter then the increases. Now there's a separate section about the innovation the the intersect between innovation and advocacy. This has meant um massive changes to people's lives because of things like um local innovation like the ARDI which cost us $40 being one six of the cost of the barber which it represents. And we actually do have to thank those people like the ones from from from uh uh the oral lab who have made these devices and brought them into the realm of the average uh surgeon and the patients as well. So look out for other innovations coming out through them from the RVN system and LVPI of catheterss and other devices to help us. So what do you want from our mix? Yes, we all want that low risk profile, the short hospital stay and the minimal postoperative hospital visits and short recovery period. That's for sure. But in reality the device costs which are incredibly high compared to tacletomy and the insurance gaps causes some problems. Furthermore surgeon training has not really been brought through very smoothly in India either yet we still want our calorie freedom.

[01:39:46]We know that techniques such as gat bang KDB the reusable catheterss offer some opportunities for deviceless mix that might be most appropriate in India. Let me take you back to the US situation.

[01:39:59]Total inflationadjusted Medicare and part B expenditure rose from 52 to 179 million in 2007 to 2017. That's huge by any stretch of the imagination and actually most of the cost was that was due to the eye center. The total payment contributed by tractomy and glaucoma devices decreased from 70% to 21%. So the future must be equitable and not just rely on expensive devices. There are this ideas of local innovation. Yes.

[01:40:26]and task shifting will hopefully mean that the general opthalmologist and not as expensive specialists could be utilizing these devices and using them in the peripheries. There are also policy levers in other words that the the hospital should also be closely involved with government and the politicians and they need to change the structure for equitable access. So what's going to be there in the future?

[01:40:48]We need to advocate for training and local research on MIG outcomes in low middle inome countries. industry needs to have things like for example tier pricing where the cost of devices become cheaper the more that we use and there needs to be a tech transfer to the low middle inome manufacturer so you bring the manufacturing onsite in these poorer countries and we also need to advocate for insurance cover and changes in the governmental systems so there's a bit more um less of a postcode lottery than you have in the different regions and we also include MIGS in essential medicines list and universal health coverage Look at what is happening in today's world with application of precision medicine. You have a wedding here that cost $600 million US. The the the the groom's mother wore a necklace that was $7.5 million US. Yet less than an hour away is Gandi's birthplace. Look at the disparity there. So what's happening and what's happening to me? My predictions for the future. Well, I think the GAT is going to really come and and really burst onto the scene that's being used now more and more and I can see that there's probably going to be a shift rather from the slicing produced like the KDB and the um micro hook to things like GAT. Of course, you have Bang which is very very cheap and effective, but they do cause a damage to the tacular mesh back wall. And I think this is what GAP will probably give you improvement on. you get a bigger bang for your buck in terms of IP luring with the bang with the gap procedure and especially when it's performed with cat surgery it's also very low cost with favorable results despite the inevitable problems of bleeding so just to go back to Gandhi again one of his most famous sayings was recall the face of the poorest and weakest man you have seen ask yourself if this step you contemplate is going to be of any use to him so thank you for your attention and hopeful action thank you very Thank you Dr. Shameira that was um this gives us a lot of food for thought and um many of us here would say yeah we understand uh that mix without a device would be a boon and we have Dendra here who who is the greatest proponent of that now um I think we'll just take questions at the end we'll have the first three talks because all of them are sort of interrelated and then we can have a good discussion at the end of them so I now call upon Yeah, I call upon uh my good friend Peter. He'll go next uh to gat or not to gat since Dr. Shamira talked about it and then we'll of course go on to mix in the era of traps or rather trabs in the era of mix. So Dr. Peter is from Baskam Palmer and I my personal friend and I have a lot to thank him for for allowing me to go into the GAT world and uh I dare say stick my head in as well. Thank you for coming on Peter.

[01:43:45]>> Thank you for that kind introduction and for the kind invitation. Um and with no planning whatsoever, I thought Dr. Pereira's talk was a wonderful segue into my talk to get or not to get that is the question and uh I used the uh monkey photo which is of course dressed up as Hamlet who asked to be or not to be because my own mentor Dr. Hodab once mentioned that we can teach a monkey how to operate. The key is teaching them when not to operate. Hence this picture and I have the financial disclosure in that I am the um royalty holder for the textbook clinical decisions in glaucoma but that's not relevant to this uh presentation.

[01:44:33]So GAT or goniocopy assisted transluminal trapiculottomy was first introduced in 2014. So a good 12 years ago by um actually a personal friend Dender Grover and the Texas group and it is basically a modified gonoattomy that shares advantage with gonottomy in that it incizes the angle and spares the conjunctiva but uh it also allows circumferential treatment of the angle and there are some disadvantages of um g compared to other types of glaucoma surgery. One is that you need to have adequate visualization of the angle. And there's always a risk of injury to the cornea, iris, and the lens because there's quite a bit of acrobatics that were performing inside the anterior chamber. At least for me, this was somewhat of a difficult technique to acquire.

[01:45:28]Now, in my personal vocabulary, GAT really is an umbrella term. Okay? It means a circumferential opening of the tbvicular meshwork using some type of a filament assisted device. And this filament could be the illuminated micro catheter which was the original description of GAT. It could be a blunted polyropylene suture or it could be one of the newer oneand filament device. So all three of these in my vocabulary equated as GAT.

[01:46:01]Now in general GAT is technically doable if the patient has an open angle and that you can see the angle and in fact for children gat is considered the first line surgery when you have a patient with early onset or juvenile onset glaucom. However you can doesn't mean you should always when do we think twice whenever we're going to do gat? Well, the big question is will the patient be harmed by common complications? So, we need to consider what the common complications are whenever we perform gap and the big three that always comes to mind will be hyma pressure spike after surgery and coral injuries as alluded to earlier and we'll dissect these one by one. So hyphimma depends on which study you look at the risk of post-operative hyphimma after GAT could be as high as almost 70%. And at least some studies suggest that this is uh relevant to the extent of angle in size in that if you do if you do a hemi gat the risk of bleeding is perhaps lower compared to a circumferential gat.

[01:47:16]However, there's really no other major risk factors. Now, some might argue that if a patient is anti-coagulated or they have a bleeding diiathesis, um, hyphimma will be more severe. Yes, we're talking about the degree and the duration of the hyphimma, but not the incidence of hyma.

[01:47:36]And why is this bad? Well, uh, as mentioned, if the hyma persists for a long time, then the eye that we operated on would have decreased vision for a much longer period of time. And this is most pertinent if the patient is a moninocular um and we are operating on the surgical uh we're operating on the only seeing eye. On the other hand, if the patient's a fake kick or if they have any type of zular issues a pseudo fake kick or a fakeic patient with zylolopathy, there's a risk of the hyphimma spilling over into the vitrius and end up being a persistent vitrius hemorrhage. Here I have a video um of GAT that I perform using the illuminated micro catheter. And what I want to demonstrate is not actually the technique itself, but rather what happens after you perform the GAT. So here we propagated the catheter all the way around. I'm grabbing the distal end and I'm going to cleave the angle by pulling on the extracular um end.

[01:48:39]So the tubicular meshwork has been cleaved. Now if we put the gonial prism back on, you can see these little red dots beginning to form. These are blood that is beginning to reflux into the anterior chamber. And what we can learn from this is where the red dots are actually where the collector channels are. Okay? And we are not getting a hyma because we have somehow inadvertently broken a blood vessel. This is different than a traumatic hyphen per se, but rather a reflux of blood from the episcoral venus system.

[01:49:14]In this next video, I did a very similar procedure. And you can see that in contrast to the first video, rather than having a very small amount of blood that is slowly forming plumes inside the eye, this one, the bleeding is a lot more exuberant.

[01:49:33]And what can cause this? Well, many different things. Um, if the patient is awake and somehow they're performing a valva maneuver or if the patient's head were somehow lower than the body, you can see all that bleeding, much more exuberant compared to the first one. Um, the uh patients placed on trendenburgg for example, you can have a much more exuberant bleeding. So, that's where the hyma comes.

[01:49:58]How about IOP spikes? We all have the experience where we perform the perfect GAT and the patient's pressure is good.

[01:50:04]maybe the first day after but then promptly comes back with elevated intraocular pressure. IOP spike following gas is defined as pressure that is 10 millimeters of mercuries or more compared to their preop pressure and it can occur up to about a third of the patient and usually occurs quite quickly within the first 10 days or so.

[01:50:27]And here are two studies I'm going to site. The first one you see is the one where they show that there's about a third um a third of the patients after GAT can have um pressure spikes after surgery. And on the right hand side is our own in-house study from a few years ago looking at the risk factor of pressure spikes after um GAT. And turns out that if you were to um have a child or have a patient who did not receive or use their anti-inflammatory medication, they have a high risk of pressure spike.

[01:51:01]And uh if they use steroid as their anti-inflam anti-inflammation medication compared to uh NSAIDs, uh they actually have a higher risk also. So no anti-inflammation or using steroid as their anti-inflammatory medication. And why is this bad? Of course, high pressure spikes can cause glaucoma progression. So, I want to um go over a quick case. Um this is a young man with a uh traumatic uh glaucoma. Um he's uh drafted uh to our university because of his um talent in playing baseball and of course got hit in the eye with a baseball and develop high pressure. So, my colleague performed GAD using one of the one-hand device. And here you can see that postoperatively the pressure remained quite elevated in the 30s with one episode up in the 40s. And this went on for about three weeks. And then after that we ended up um performing a fairly emergent uh uh glaucoma drainage device implantation. And it's a little bit like a game of choosing your own adventure.

[01:52:08]Then the patient promptly became hypotenous and required um at least one revision of the glaucoma implant. But the most heartbreaking part is throughout this ordeal, even though his pressure had only been high for about 3 to four weeks, his visual field progressed significantly. He went from having a partial superior arcua defect that completely spares the fixation to having a fixation involving skatoma. And so um that's the danger of ILOP spikes.

[01:52:40]Now lastly, corneial injury. I'm actually going to show you this video first and show you what happened afterwards before we dive into the subject itself. This is a young woman with juvenile open glaucoma and uh she had a history of um epidemic hero conjunctivitis. So you see a couple of suboplial infiltrates on the cornea. And here we're doing the gonotomy which went well. You can see the landmark, the wide back wall of the Schlim's canal. And uh um we place a catheter into the Schlim's canal, propagate it very nicely, and we grab the distal end just like we would all the other cases and finish the cleavage. And she has a little bit of blood uh refluxing, and all that's normal and good. And post up day one this is what we see some high feema but what you cannot see very clearly is that there are two peculiar lines on the cornea and when we imaged it turns out that she actually have large areas of decimate detachment. After further analysis we realized that when we were doing the gap using illuminated micro catheter we were um injecting visco elastic really quite significantly and that might have been why the decimate got detached. should recover normal vision without intervention. But that's one of the reasons why we have to watch out for uh corial injury uh when we're performing GAT. Very lastly, uh this is a a case of a patient who had multiple uh filtering procedures in the past and were performing uh angle surgery using the one hand filament device. And you see there some kind of a cliff seems to have been formed. I thought no fear let's go on to the trapicular meshwork and uh cleave the trapicular mesh work in both direction. You see the bone white back wall. So the procedure itself went well. What I didn't realize focus on top of the screen is that this patient had so much mitoin exposure in the past that the filament actually created a full thickness scurl perforation that took months to heal. He ultimately did well but that taught me a lot this case. So in summary, we want to think twice when we perform GAT. If there's a high risk of persistent of spill over hyphimma, if the patient already has severe glaucoma because they may not survive the pressure spike, if they have corial coorbidities, or if there's a presence of thin or abnormal scara. Thank you very much for your time.

[01:55:16]Thank you so much uh Peter for uh alerting us to when not to do it and uh we'll come to the discussion in a bit. I think Dr. Tar if you were to come on with your talk on where we stand where do the trabs and tubes stand in this era of mix and then we'll take the questions.

[01:55:37]So Dr. Dr. Tarik of course is the head of the glaucoma service at the University of Geneva and he we're very happy to that you've joined us. Thank you.

[01:55:45]>> Oh, it's an absolute pleasure. Can you actually see my slides and hear my voice?

[01:55:50]>> Yes. Yes.

[01:55:51]>> Very good. So very murky waters of glaucoma surgery. God knows it has always been uh murky since we started doing glaucoma a few decades ago. But let's try to chart the current currently uncharted uh waters and discuss together uh where does something like a trap nonpenetrating gloma surgery and tube actually lies now in the um in in in the current days where everybody's so excited about new devices and uh and paying extra money for something that might be useful and in many cases is not useful at all. So coast is always an issue all all around the world. And this does not mean that when we are considering practicing in India, Egypt or Switzerland that the the the equation is extremely different. Uh now with the aging populations, everybody wants to reduce the cost of of surgery. uh yet we want to uh preserve a certain degree of efficiency and our ability to uh serve our patient and teach our residents. So we now have an ever expanding chart of different devices, different stances, different operations. Good old days when you had tra and then you had uh you know bolt and ahmed and deep screctomy were just a kind of a a new kid on the block are gone. And uh although all those new devices come with multiple options for us, but they also come with a lot of challenges of uh how to figure out what to do and uh to make sure that you're spending your uh days trying to learn something new is actually profitable for your patients and uh results into a a positive impact on our patients. We have not reinvented the wheel. We still do operations that do a subil subconjunctal filtrations or we open the angle as you have seen with uh GAT uh and open the tracular mesh work putting something in the supraoidal space or basically uh turning off the tap and reducing production of aquis in the form of all sorts of cyclloestructive procedures and most of all and actually all of that we can do AB internal from inside the eye or ab external from outside of the eye. And ever since uh the you know the um the invention and publications of tracerectomy that started with a flap in a funny place and now and was changed into a properly placed flap by Peter Watson, the person who actually taught me tractomy. there. We we created or we uh received a gold standard and everything else we have been really comparing with tracelectomy and with all that we have now it is very pertinent to ask ourselves is tblectctomy still uh of importance of relevance and uh if it is still something that we should uh you know work on teach our residents and offer to our patients. I mean, of course, Trab has gone through multiple uh tweaks and uh you know, improvements including the morfields uh way of doing at less at the end the same. We are drilling a hole in the clear and partially in the cornea and doing an iridctomy. With that there are certain challenges and we have to accept that even when we try to get out of perforating and doing a nonperforating where we are just removing the inner wall of Schllem's canal and the jakalicular traculum which makes perfect sense because this is the site of maximal obstruction in both primary and secondary open angry gluccom. We still had one achilis heel for both triclectomy and deeplectomy and that's the bleb. We all look at our blebs in many cases with o and pride when we should be ashamed of ourselves because blebs are not a good thing.

[02:00:23]Blebs are basically an insult on the otherwise almost perfect ocular surface uh of the eyes of our patients. So why not go for something else? And we had the micro shunt uh actually introduced something significantly smaller than uh an Ahmed or a barvel which is basically a tralectomy in disguise uh with the advantage of not putting of not creating an idctomy but with the disadvantage of having a tube. So inside the eye. So how how did we do with that? Well, you can see in the randomized control trials that tracelectomy outperformed the micro shunt significantly. I mean remember that uh many big key opinion read leaders in gluccom always stress the importance of the 1 millimeter of mercury difference. Here we have significantly more than one millimeter when we are comparing a micro shunt pressor frolectomy which means that traicaltomy still is something that is absolutely pertinent for our patients. Now the other thing is uh we now have new devices like uh the pole implant like the eye plate like the clear path which we can always use uh for more advanced serious cases especially in reoperations but you know all those new devices even the small humans one uh that that we have been using come with a price and the price for the tubes and for the micro shunt pressure flow is that we are significantly and progressively losing indothelial cells. You are not just paying in rupees or dollars or Swiss Franks, you are paying in indothelial cells. Every time you're putting something into the antique chamber, be it small or big, be it traversing the sclera into the subconal space or be it just going into the schle's canal, anything that is protruding inside will result in a loss of endothelial cells.

[02:02:48]And this is something that is progressive and continuous where if you compare that to a trachelectomy, trachelectomy, yes there is an endothelial cell loss but it is a one episode that stabilizes very rapidly.

[02:03:02]But you put a micro shunt, you put a tube and as we used to put something like the express and every single day the patient wakes up paying for some of his endothelial cells. And that's why of course if you put that in a child and Peter will agree you can actually calculate how many years before you start putting your first keratlasty and how many keratoplasties would the will the child need if you put something into the eye with that actually we we compared the new devices the pole implant to Ahmed implant knowing that both of them are efficacious in a way But one of them is significantly smaller in diameter into the anti-chamber. And yeah, I mean there was no uh inferiority for the pole versus the Ahmed, I would say. So, but I I have to be very honest with you and say that I do not from the data that I'm seeing now for the 3 years foresee a significant improvement in terms of endothelial cell loss. So again we can go smaller and we can go smaller but the actual presence of a device inside the ant chamber has a price. Now uh again we are getting smaller and smaller in devices. Now we have the eye plate XS that has a 04 outer diameter compared to a 46 uh with a pole. And now and and it it becomes a little bit funny because I do not see from all that I've seen and known and and and have done that a 06 mm difference between tubes will make such a big deal. So, uh, if you're asking me about if, uh, traps still is pertinent, I'm sorry to tell you that I'm not sure that you can handle the truth. And I can tell you that yes, of course, we have to continue to practice and teach tralectomies. But we have to with the opportunities that we have today to actually always teach better traps, better deep scies. And we can always consider the tubes in advanced cases. And we have to make sure that we do not overuse any of those new devices not just because they're expensive but because the in terms of efficacy as you've seen the micro shunt which is probably one of the most efficacious new devices is still significantly less than a triclectomy.

[02:05:44]So with that in mind, I will tell you that uh uh in a lifetime of glaucoma surgery, I still believe in traps. And I finish with having spared one second.

[02:05:57]Thank you very much.

[02:05:59]>> Thank you Dr. Tarik. I think uh we all sort of echo that u you know learning traps and tubes is going to stay. Um having said that I think we'll take a couple of questions on the first three talks and um after 10 minutes we'll take on the two cases and have discussion there also. I'll start off with Sunita who's u at the SH charity center Delhi and she has fair amount of experience in the KDB and other tribicular stripping as well as she's lucky enough to have an experience of devices. So Sita does the efficacy matter between a device and between say a KDB oblique tenito or a GAT? Of course a GAT I expect to be more but does the efficacy really matter >> for you?

[02:06:53]>> Yeah.

[02:06:55]Can I speak?

[02:06:56]>> Yes. Yes, please.

[02:06:58]>> Yeah. So efficacy in a glaucoma patient does matter because we always tend to set the target intracular pressure depending on the severity of glaucoma.

[02:07:09]So it depends like what type of glaucoma you're dealing with and if it is a moderate to advanced glaucoma then you want to reduce the pressure to maximum to achieve the target intracular pressure. So I do believe that the devices uh we generally use in mild to moderate glaucoma as compared to the uh to get which is much more efficacious as compared to devices. So yeah uh I >> put it the other way around. Yeah.

[02:07:37]>> If you're saying ticular stripping is more efficacious.

[02:07:41]>> Yeah.

[02:07:42]>> Really need to implant a device then.

[02:07:45]>> Yes. So uh see again we have different types of patients and now uh the concept of interventional glaucoma. So devices I use mostly when I'm doing catact surgeries and the patient is on one or two medication mild to moderate glaucoma where I don't want to do a procedure like GAT which can lead to complications like high feema and it is actually not required to strip off 360° of tricular mesh work then devices can u perform much better they're much more safer and with as good an outcome as cataract surgery in terms of complications like you do not get to see high feema the next day. So that way I prefer devices in patients with mild to moderate and with catact surgeries >> and suppose you just did a you know 100° stripping or something KDB versus >> yes you can do stripping then again Dr. Shamira talked about the health economics and uh then you have to choose patients the patients who are insured who can afford devices then I may still go for devices and because you know devices are much more expensive. So um if the patient can afford it, he the patient is insured for that then definitely I think uh I would like to prefer more safer uh technique which I feel that devices are slightly better in terms of safety because they do not cause hyma and all the next day uh and the uh because the patients expect very good vision but yes I do a lot of KDPs and uh 90° or 120° KDP is equally good.

[02:09:27]So um either of these but I would not like to do GAT in those patients where the glaucoma is mild to moderate. So the indications may differ.

[02:09:36]>> So Manisha I'll take it to you. Does implanting your device in your patient depend solely on economics or is there a patient in which you would say I would put a device only?

[02:09:50]I think in our practice the approach has been key I think in in India MIS is still evolving and so many newer things are coming we are also trying we have been doing bang visco bang we also have the tantor the even the hook also we have be using so I think as a surgeon I feel we are also evolving and understanding amig better and getting our own data how we are getting the results over time in our practice we offer the patient everything the implants the KDB even the bang gat like Dr. Suna I said we don't offer it for mild to moderate glaucoma so it's not something which we offer with cat surgery again more so because maybe we are not that comfortable with that we are more comfortable with the KDB and the implants and we have to think since gauma patients are with us for a very long time so we also have to look into the value cost and the IOP is to value relationship like Dr. Samira was telling very nicely that uh in price of one eye stand you can do five tribes in India.

[02:10:55]So we have to look into that aspect and when we talk about per capita income where in India is around 20,000 the price of one eye is like 7 to 8 months salary of an individual. So thinking that aspect we do offer implants to patients for MIGS but when patient ask us what is your preferred we generally go with KDB. we tell that this is good enough because it this is gives you a very good IP reduction and most studies have shown that KDB is as good as the implants if not better. So we are not compromising on the efficacy and we are giving you a same thing at a much reasonable cost. So this has been our approach. So Shita you want to add in terms of efficacy the drugfree part also because that also is a part of efficacy >> when you do a glaccomma surgery you have to look at that in that context can Peter comment about long-term outcomes of GAT in adult glaucomas >> yeah so um wonderful discussion and it's actually great to hear different view points point and have my own assumptions challenged which is always interesting.

[02:12:09]Um long-term efficacy data I forget is actually not terribly robust. Okay. Um and my the set of data that I'm most familiar is those with early onset glaucoma. I think the success rate if you push it out really really far and you're looking at all cause glaucoma fiveyear success only about 60%. And this is qualified success right? So complete success would be even less than that.

[02:12:36]>> However, the qualifier being um >> if you look at just a subset of developmental glaucoma, the ones who you want to have done the best for the longest time without a bleb without hardware, the primary congenital and the juvenile open angle, those success rate could actually be quite decent up to 70 to 80%.

[02:12:59]I think the study out of Walesai Institute, Walesai Hospital and out of Texas show that in adults with primary open glaucoma onset after age 50. So that's sort of the population that we as a group here are talking about, it's only about 50%. Now I do want to offer one insight about that though. you know 50% outcome over three to five years for a glaucoma procedure does not seem terribly robust but if you are dealing with an elderly population many of them might not need anything more just based on their life expectancy so for some patient that might be good enough without heading down the road of blood management blood bleaks corial transplant etc so that's my two cents Um I'll go on to Dr. Deender and ask you the same question that Dr. Peter asked.

[02:13:56]When not to get because I think he's 100% GT if I'm not wrong.

[02:14:02]>> Thank you. So not only get I not only do get I do also do KDB I do tonito I do my own dual. So do Chang really beautifully put out the things in a very nice way.

[02:14:15]He picked the all the three he talk about three things. First hyphimma IIP spike conal injury so I say one by one so hyphima the most are transient 50 to 60% resolve in a within a 2 to 3 days only high feimma they require the AC wasp in more than 2 mm and that also you can be just choose the AC wasp and clear it and you don't have further so we did one study where we did observe the 623 patient out of them 20 got the hyphimma they required AC was but the outcome at the one year in terms of IP control use of antiglo medication BCBA everything was similar so I don't think hyperma is a big deal when we dealing of any kind of MIG surgery then coming to IP spike I think there's a transient you can resolve within a within a treatment of 5 to 7 days with diamox antent glaucom medication coming the very important point you told about the conalial injury. So really why we get conal injury in the g when you use the catheter. So when you use catheter catheter diameter around the 200 micron while we use the fibropoline switcher the diameter range from company to company is 100 to 100 to 125 to 150 micron. So really we do yeah we do a lot of thousands of thousands get really we didn't get any kind of coral injury we don't get hydrodialysis we don't get such kind of complicates what you're talking about and one more thing I Peter I will want to enlight you to get is not restrict to only P even you can explore in the PACG also after doing the gioinicalis and last comment if we talk about the effic efficacy mig Yes, mig is the only procedure which will give you the 40% of I reduction your 70 to 80% of the patient at the end of 3 years are drug free I think there's a fear for the get to do >> coming back to you when would you not do it >> yeah yeah so really I don't venture because my past experience especially with a neoscar glaucoma and total sinical lingual closure These are the two things I don't venture or I have limited success in silicon induced glaucoma otherwise each and every case before trap and tube I do the get >> can I ask a question to Peter Sushita because sure we have a lot of questions in the mind when they you said the 3 to five years it's 50%.

[02:17:04]when they fail does the IOPS becomes very high because of the damage to the tvicular meshwork I'm curious do you think they they respond very poorly to the uh medication you may have to end up doing another procedure >> yeah so that's a good question first of all the study definition of failure in the ones I'm citing does not mean glaucoma became out of control okay it just means said there's a predefined pressure lowering and the eye is no longer at that level. Okay, that's what they meant by failure means that the effect of the surgery went away. Doesn't necessarily mean that the eye require another glaucoma surgery. Okay, in fact I think >> the when of all the eyes that failed in GAT we're talking about adult with open angle glaucoma only about a third require more glaucomas.

[02:18:00]>> Yeah.

[02:18:00]>> Okay. So that's that cohort. As far as reason for failure, I think that's open for speculation.

[02:18:06]>> One thought is that when you have chronic glaucoma, open angle glaucoma, we believe that tbvicular mesh work is one of the sites for increased resistance, but not the only site. The episcoral venous system can also be damaged by chronic inflammation, especially ironically from drug induced chronic inflammation. And um just as a spoiler, I'm just about to complete a study looking at the efficacy of uh whether a patient responded to SLT as a predictor of whether they're going to respond to GAT. Turns out that if they don't respond to SLT, meaning that they might already have um a poor distal outflow system, they typically don't respond terribly well to so I think >> I ask one thing. Yeah, >> what this had taught me about GAT in a way where it's not just at the trapicular mesh work, but also we got to think about what's going on in the downstream. And in my in my opinion, that's why it tend to work so well for juvenile open glaucoma, you know, and Sushina, you know this too. You have patients coming in with three degrees of visual field, juvenile open glaucoma, never had one eye drop in their life because they just got diagnosed and you do a gat and 10 years later they still have a pressure of 10 on nothing. And you just don't see that on patients who have multiple medications. I think because it somehow damages their episcal venous system. And another small thought on the episcal thing. I've noticed that one would like to think that steroid induced glaucomas is a travicular damage procedure and a gat would work well. But sometimes steroid induced glaucomas continue to have high pressures if you put them on steroids. So it's possible that the outflow also has receptors like the TM for steroids. So I'm very very u uh scared of putting you know them on steroids and I've I've reduced my steroid uh drops to them to almost just two or three days and then put them on NSAIDs after I read Peter's paper and it makes a difference. So reducing steroid we know that all Po AGs and Gags are high steroid responders as well. So there something to the outflow being not good enough I think.

[02:20:17]Yeah, the the thought is that the glycosaminos glycans can very easily narrow or olude the collector channels just as the effect it has when you have a intact tropicular mesh.

[02:20:30]>> Pathophysiologically it seems to make sense to have steroid response after cleaving open the tropicular mesh work.

[02:20:39]>> Yeah. Apart from that that get has very very good outcome. PX accept glaucoma.

[02:20:43]PX glaucoma you do the get your success at more than 70 to 75% at the end of three years you we have the outstanding results in PXF glaucoma this are already reported in the literature thank you I think in the interest of time we'll move on to the cases now um we have two fascinating cases by two fellows across the globe uh one the first one is by Dr. Vashad, he's just finishing his senior residency. Vashad, are you wrong?

[02:21:14]>> Oh yeah, there he is. So he's just finishing his senior residency and unfortunately he's ready to fly over to Peter and I'm not happy about that at all. But anyway, so my we'll have your case and then we'll go on to Jonathan's.

[02:21:28]>> Thank you.

[02:21:38]Good evening everyone.

[02:21:41]Today I'll be discussing mix in advanced secondary glaucoma. Hope I talk here to stay. An 11year-old girl child who is in a known case of JA associated aviatis with glaucoma under both cat surgery five years ago and some method injections left3 and had between of IOP of between 2 and 7 but was maintained at 6 by 9. Sorry, Vak. Is anybody else logged in in that room because there's a lot of eco. I'm sorry.

[02:22:16]>> I have two uh system. I'm just shooting the >> Yeah, because there's a lot of eco. I think I think there are logged in in the same room. If you could just Yeah. Okay.

[02:22:27]Carry on. Thanks.

[02:22:28]>> Now, is it okay?

[02:22:30]>> Yeah.

[02:22:33]>> So, sorry for that. uh so her right started rising from August 2025 and the aims were added accordingly so her best was 6.9 in with IOP of 44 on four AMs and half a and ratio of 7.8 And the left eye was two of agents with around8 she had iris bombay of uh 60° in the right eye and the cornoscopy showed closed angles in all four quadrants and the ASOC also showed iris Bombay and closed closed angles in all four quadrants. So what are the options that we have? Can we do just a surgical PI?

[02:23:15]As she was a child, she was not competitive for laser periodum and it was a case of second panic closure with dysfunctional team. A simple PI may not be enough in that case and she may need surgery and GA just as the surgical PI doesn't work. So we opted not to do that. The other option was to try a trap but there's high risk of failure as it is invited glaucoma and there is was a high risk of hypertonic as she had hypertonia in the other previous. So we try to not do that as well. The other option was to try GD but she may need repeat surgeries later. So why use the last bullet first and there is high risk of hyperonic as she had hyperonic in the other way with GD. So we tried not to do that as well. So our thought process was can we hazard a mix in this case something like cat will have a low risk of hypotic maybe enough combining with the surgical pi will preserve the conjunctiva for future surgery and pathologies at the level of tm so removing that might just be enough but might as well be safe and effective. So plan B has added try if you see a TM table.

[02:24:23]So on table after doing the signal license we did a surgical TI following which the AC got demon and after putting visco inside the AC a good team was visualized and the corny was done.

[02:24:48]And the protein suture was introduced into the schleng canal and after about 10 to 15 360° shanks were canulated and the other end is grasped within with using mast forceps and the 360° gap was completed in the child.

[02:25:18]Following which pre-place corn cones were placed and irrigation and respiration was done and the corner switches were completed and a thorough AC wash was done to remove the high fea and the air bubble was kept in the case. So on the post of day one her activity was and motion close to face with IO of 24 facings but she had some loose splits and air bubble inside the post of day one. After two weeks the hashima has disappeared with visity of 6 by 24 and IP of 14 and she had very deep uh deep AC and the uh cat uh cleft was visible in all the four even after 3 months her voc is made under 61 and the of 10 of agents and the AC is adequated deep even after 3 months. So the uic secondary closure glaucoma is difficult to manage often requiring multiple surgical interventions especially if they presenting in childhood it will be more difficult to manage and there is high risk of hyperony with crab angle cat often tackles the pathology with low risk of hypotonic and is effective in such cases. Thank you everyone and have a great day.

[02:26:37]>> Thank you Vash. I think we'll go on to the next case which is also on GAT and then we'll open it up for discussion till the end. Um Dr. Jonathan happy to have you go ahead. Dr. Jonathan is also from Baskin Palmer. So we'll hear his case. We were actually debating today evening before going home. What does retroillumination mean? So let's see what it means really.

[02:27:01]>> Hello everyone. Thank you for having me.

[02:27:03]Um I am one of the glaucoma fellows. I work with Dr. Chang very closely. So, we'll be sharing. Um I didn't realize that my case was going to seem so much like uh an example of when not to do GAT that after Dr. Chang's talk, but uh we'll talk about what we think about that here. So, um this is a technique I developed with Dr. Bitrian uh one of our other attendees at Mask Palmer who is um kind of on the opposite end of the spectrum in terms of wanting to always gut everything. So, this is our talk is entitled the light on the other side of the tunnel gat using retro elimumination of the tbecular silhouette. We have no financial disclosures. Um, our talk starts with a 36-year-old male patient with a history of developmental delay, strobismic gamblopia in the right eye and a history of chronic eye rubbing.

[02:27:45]Uh, as well as a history of keraticonus that ended up having two uh PKPS bilaterally two years prior to seeing our service. Uh, he did develop an episode of acute graph rejection in the left eye one year following uh, which was treated with topical subtenons and oral steroids which ultimately resulted in him developing a steroid response. uh his pressure in that eye was 44 at maximum. Luckily stabilized in the high teens, low 20s on three agents, three classes of pressure lowering drops and a switch to load predinol. Uh unfortunately he did develop bullis keratopathy, recurrent corneial edema and a PSC cataract. Eventually was referred to our service to optimize for potential desc. Um this is the fellow eye and with plus minus migs if we were able to by doing a fico. This is the fellow eye. Looking at the operative eye here you can see an an OCT through this region shows the corial edema ble formation as well as a deep AC because his axial length is about 26. Um best corrected visual acuity in this eye was 2200 uh with a pressure of 23 on three classes in the preop visit. Um his angle status we are uh unable to gonio him very well in clinic but we're thinking that we have a sufficient view temporally at least to try for a nasal anglebased procedure if we're able to get through the fico safely. Um severity and staging were very difficult because he had difficulty with fixation and uh wouldn't do a visual field because of the developmental delay. So we feel that probably this eye has better visual potential than the other eye given that he had the history of stbismic amilopia on the fellow side. Um, our ultimate plan was a FICO plus minus GAT. And um, this is a representative case. This is not the exact same case actually. I was adjusting the lighting settings on our case so much that I turned off the microscope camera for that portion. But um, we use very similar techniques on this uh, corial opacity case where we're using tripan blue. We're minimum hydro dissection, minimal rotation, using fico chop techniques and trying to get everything super capsular if we can. Um ultimately we uh would rather the uh endothelium take a hit uh instead of the posterior capsule. Um so often these cases the cornea becomes relatively steamy and we end up using a light pipe as pictured here um to give us a better view. Um in this case we ended up putting a three-piece in the sulcus but in our case which is we're returning to here I was able to get a one piece in the bag after using the indoluminator assisted technique for the fico portion.

[02:30:02]Unfortunately, this is the view that we were left with uh after uh we had finished the FIO. So, our options here, we were, you know, planning to do a gat, but uh our view is looking very foggy and we decided we were thinking about potentially stopping just with the FO that may be sufficient given that his pressure wasn't extremely poorly controlled. Um we thought about converting to an ab external approach.

[02:30:23]Um we thought about doing a transclaral or an indoctc even. Um we thought about uh converting to you know a sub incisional uh subconjunctal incisional based approach but in this gentleman's case uh he did have the history of developmental delay and eye rubbing. So we wanted to avoid those if possible and uh we could also just call it good and and I uh you know leave the country. We decided to get creative um which is Dr. Bitrian's specialty. We did see uh we had already had the indoluminator light out for the fico portion and when I applied it to the scara opposite the incision we cleared the heem we realized we could actually start to see this sort of shadow of the tbecular meshwork here which we've come to call the tbacular silhouette uh and we've used this many times since on cases especially pediatric cases with corneial strea that makes the view difficult to see um so I go in I take another attempt at getting this uh superior hemigat done but um I end up prematurely uh ripping the tracular mesh work a little bit. We're seeing that I'm getting some traction.

[02:31:22]So, we decide to go for the inferior hemigat here. And I'm able to canulate it successfully. You can start to see that tbacular cleft forming right there.

[02:31:29]And we don't get quite 180° tear, but pretty close. And so, we're really happy uh at this point that we've got the inferior hemigat. We debated calling it good, but we decided that we're going to go for the superior again. So when we zoom in here, you can actually see um the canula goes down or posterior uh because I had already prematurely ripped the tracular mesh work there a little bit, but now it's it's fully canulated and again not quite 180° tear, but we get a really good superior hemigat as well. And you can track the progress with the indoluminator all the way to there. Here we're inspecting our work.

[02:32:02]We can see that sort of bone white back wall that we always talk about and the tbecular cleft has formed after we've been able to get that done. So we clean out the visco elastic, hydrate our wounds given eye rubbing. We decided to use this here. We soo the wounds to make sure that he doesn't rub uh and cause any problems with iris prolapse afterwards. This is the technique with lightly pigmented rebecular mesh work.

[02:32:24]Just demonstrating that it can help you see those angle structures that otherwise would be difficult to view.

[02:32:28]Sometimes we even turn the microscope light off in order to help with the visualization initially. This is how we apply it on the scara and his final visual acuity was 2030. um IOP of eight on just cos and we've avoided or dorsal myimal and we've avoided repeat PK. So this technique helps with visualization through corial opacities or red or poor red reflex in the case of a cataract surgery. You can position it the indeluminator outside the AC or inside the AC with a separate incision for retrolimination of the tracular silhouette. It helps in this case when you're doing an anglebased procedure with corial opacities in the way. uh you can also maximize coaxial lighting and minimize diffuse and uh it may be helpful not just for gap but any other anglebased procedures. Thank you.

[02:33:11]>> Thank you. So now we know what retro illumination means. Uh do you do that routinely? Do you need the endoilluminator of the vitroctomy system or can any illuminator work or do you need >> started doing it? This actually was the case that kind of inspired us to to start doing it and we've done it actually a good amount um since then uh with cases where they have either had uh corial transplants or if they just have congenital primary cenal glaucoma with corial strea um you can use a uh the endoluminator probe either attached to a separate machine or just to the laser.

[02:33:48]Um but we have we have been using the endoluminator probe. One opthalmologist who I showed this to told me that he sometimes will do this in clinic with the um muscle muscle uh muscle light uh when he's gonoing and you can see kind of a similar outline but interoperatively we've only used the light pipe.

[02:34:04]>> Okay.

[02:34:05]>> Right. If you could just unshare so we'll start the discussion. Thank you.

[02:34:10]So I'll go on to Dr. Shamira if is Dr. Shamira there.

[02:34:15]>> Yeah. Hi.

[02:34:16]>> Yeah. Hi. Um, Jonathan, could you please unshare your screen please so that everybody can >> Yeah.

[02:34:22]>> trying to unshare.

[02:34:30]>> So, in the meanwhile, while he's doing that, can can somebody from the back end help me to unshare his presentation?

[02:34:37]>> I'll I'll do that. One second.

[02:34:39]>> Thank you.

[02:34:39]>> Thank you.

[02:34:41]>> I'll just try that.

[02:34:42]>> Then we can have everybody on screen.

[02:34:45]So, Dr. Shamita what I was asking was u this seems to have become a GAT session rather than a MIG session isn't it but uh yeah so uh would you would you uh think about any MIGs as a secondary procedure once your primary has failed?

[02:35:04]>> No, I don't think so. I think that once you've given it a good shot with the first one, I mean it has to be a good shot of course, right? then um you have have probably had your your best go at it and I don't think that people are really doing um a second um MIG procedure in any case in many of the device companies it's it's actually contraindicated anyway >> all right and uh since you would you practicing in Singapore you would have your share of angle closures as well what would be your take on mix after sinis and angle closure because >> yeah it's quite interesting um so so I mean we we produced a study from Singapore for a fico gsl versus plain fico study a few years back main author was from SNC Rahain and they actually showed that in that group of patients the um whether we did GSL or not in patients with over 90 degrees of PS it didn't really make much of a difference so the theory after that was that we shouldn't do it but when you look at the sub analysis of the two groups um we found that actually there was quite a large difference you know those patients who had significant glaucoma and who had chronic chronic angle damage and those who had you know just acute attack basically or very short subaccute attacks and PS formation they did well.

[02:36:16]So the ones who did badly were the ones chronic not surprisingly and the ones with the acute spikes you know to do very well. My personal preference of choice is to do as much as you can in the angle with your fico. So I'm a big proponent of fico gsl and gonotomy. Now remember that slightly different in these eyes because the goniosis has led to some bleeding sometimes and it gets a poor view. Your best shot is your first shot and the angle actually physically does seem smaller in these angle closure eyes. The dimensions physically are smaller and so you might find it difficult to go all the way around but nevertheless I will try and go for as much as possible fico gsl and gonotomy >> and the gonotomy would be a KDB tenito or >> no no a gat. A gat >> it would be a gat. Okay.

[02:37:01]>> It would be a gat. Yeah. Do as much as you can >> whilst you're there.

[02:37:04]>> Yes. um we've actually found that uh in angle closure eyes they seem to do better than the bagis and I don't know but it's possible that the outflow is less affected in bacgis than possibly in bis but that's I I don't know how to prove that but that's the only explanation I would have um Dr. Oh sorry yeah car get car get car get car get car get car get car get car get car get car get carry on sorry sorry you were saying something >> no I think if if you look at you know uh Sulan's work from from China I mean it's very promising and she you know um has a control study versus trabelectomy and uh very very similar results but I think you know you have to be have to be a bit cautious she's she's doing a lot of them she's very good at it you know and people uh who have not yet seen the complications that can happen you know do need to be a bit careful >> sure uh Dr. Tik, I was asking you um do you see GAT or any MIGs in the advanced glaucoma space or would you always always bat for a trap because GAT seems to work even in some advanced glaucomas?

[02:38:07]Um yeah I am I mean when you have an advanced glaucoma case and it has a virgin conjunctiva and a decent conjunctiva uh there are not you know a thousand options when when it's an advanced case all of the so-called MIGs uh are not us are not really the optimum option for advanced cases. So again you are left with a deep screctomy a ticlectomy a tube or uh a gat. Uh again uh primary tubes is something that you have to be very cautious about. Um if the conjunctiva is really bad then that is actually something that pushes you more towards a gat in an advanced case. But there's also the other argument of trying a gat in advanced cases leaving the uh conjunctiva for a traplectomy. I do not believe that once you do or I do believe that once you do a gat a deep sclectomy is no longer an option. So again it's it all depends on the uh the the knowledge base of the surgeon. what the surgeon is comfortable with what the surgeon have practiced and have done I mean anybody who's very comfortable with a deep scerectomy or triclectomy then I am no I think it they are absolutely a valid option for advanced glaucomas now somebody that is wellversed in a gat I don't I wouldn't criminalize a gat for advanced glaucoma cases >> so if I if I flip the Christian and uh at least for us who are working in institutions the advanced glaucoma that we get are those who've been on years and years of meds and finally they can't take it anymore so they come for a second opinion. So they have really bad they have even pats they have red corn and a hot eye. So do would you put your would you tilt your scales a little more for an ab internal thing in that even with advanced glaucoma?

[02:40:27]>> Sure. I mean in in a case where the conjunctiva is terrible I would always consider a gat in in these cases but the the trick is to to identify bad conjunctivas from good conjunctiv because sometimes it can be very deceptive. And I always say that to my fellows that you need to use the lid margin and try to mobilize the conjunctiva. See how good it is. You can always put a topical anesthetic and use a a cotton bud and try to move the conjunctiva. It's really really important to acknowledge that the conjunctiva in most of our practice is our you know raw material. It's our bread and butter. So before going to the operating theater, not knowing what conjunctiva you're dealing with is shooting yourself in the foot.

[02:41:19]>> I think we have the last four or five minutes left. Ma'am, your take on both cases.

[02:41:26]>> No, it's very interesting, very good discussion. So coming back to tarik's comment about uh the knowledge and experience I think that's an very important point and ultimately the aim is not to harm the patent.

[02:41:41]>> Yes.

[02:41:42]>> So in that context because there are couple of people from Basam Farmer here years back when we used to have a glaucoma forum. So one of the comments Dr. Douglas Anderson made at that time with the discussion about a complex case. What works best in your hand is the best for the patient. I think that has to be kept in mind when we are offering as a last resort in advanced glaucomas. So I am a proponent of bringing in the knowledge and then new techniques. We have to keep changing our practices with the time. There is no doubt we have to adopt the new techniques. At the same time we have to keep it in mind that what you are capable of in offering the treatment not to yield to the pressure from the others. I think these are we are we are going to use different techniques. Each person will have their choices. I think ultimately the safety of the patient is the most important. C can I I mean I I I think uh this is a a very fair point that we should not at all neglect. Peer pressure is uh one of the sources of multiple evils. So if if a person can be wise enough to protect himself and shield his patients from taking decisions under peer pressure, I think it's it it goes well for everybody.

[02:43:12]Any any other last minute comments? We have about a couple of minutes more before we wind up with the >> Let's share a quick thought that actually was forming as this forum has started about an hour ago. Um, it was interesting to be talking about GAT, watching the techniques, watching TK's videos about traps and tubes, which is focusing on that individual eye that we're dealing with, while having the preamble of Shamira's excellent talk about the health economics of the entire society. And sometimes I find myself at odds in that a patient will come in with a lot of resources. is you know Baskin Palmer we get a lot of the the medical tourism patients who come in want to try the best in newest even though I told them that this is not likely to work they said I can afford it let's try it it's a decision that you make when you're facing the patient sometimes goes against the odds of what is the best decision for the society as a whole isn't it because you're utilizing resources that the next less resourcerich patient could possibly use, but because this patient is willing to pay for it, you try the GAT knowing that maybe there's a 10% chance of it working, but he does not mind coming back later for a tube shunt. So, you go through their algorithm one by one. But if we were to have a singlepayer system, you know, the UK for example, I would believe that some of the procedures where the likelihood of success is deemed to be too low would not even be allowed to be done. And that's making a decision on a societal level such that we as a group will be able to help the highest number of people to stay cited without going blind without utilizing extra resources. And I find this this conflict very interesting. You know, when do you when are you a good citizen versus when are you the good doctor that the patient wants to hug because you did what they ask. I I don't know. This is this is something that I'll be struggling with at least for the near future. I mean I I if I may say Peter, you know, with with some of the devices that are very expensive and not at all efficacious, you can still be a a good clinician to your patient and a good citizen. I mean, they help you with that being not that effective.

[02:45:40]>> Yes. Happiness doesn't always come with lowered IOP. Yes, I agree.

[02:45:44]>> Yeah.

[02:45:45]>> I will add Peter one more thing. You talk about the monocular present. So the when the VFI is seven five or 9 10 really I'm the very confident to doing the trap doing the get instead of the trap and the tubes because really trap how good we do we don't know what's going to happen next day actually even being the experienced of thousands of thousand surgeries but you do that get you know max of what will happen only high feema that you can clear of so >> that's exactly right that's exactly right yeah >> so I think we'll have to wind up. Thank you very much. I wish this was a five hour session because we would have had lots more fun but uh I are we ready for a picture with smiles and we can all say that or mix?

[02:46:32]>> Yes. I'm I'm going to just honor the distinguished gathering here. We've had a great discussion and although we are ending the session here, I'm sure the ideas that we've shared will go far beyond this room. Thank you so much. The picture is done.

[02:46:51]>> Thank you.

[02:46:52]>> Thank you.

[02:46:52]>> Thank you all.

[02:46:53]>> That was very enjoyable.