Evidence-Based Glaucoma Therapy Paul Palmberg, MD, PhD Bascom Palmer Eye Institute, University of...

Evidence-Based Glaucoma TherapyEvidence-Based Glaucoma Therapy

Paul Palmberg, MD, PhDBascom Palmer Eye Institute, University of Miami

What is the Role of Medical Therapy in Reaching Target Pressures?

XIV Jornadas Dr. Benjamin BoydSociedad Panameña de Oftalmologia

Panama, R.P. 2003

Drug ClassDrug Class Proposed Mechanism of ActionProposed Mechanism of Action

Cholinergic agonistsCholinergic agonists

22-Adrenergic agonists-Adrenergic agonists

22-Adrenergic antagonists-Adrenergic antagonists

22-Adrenergic agonists-Adrenergic agonists

Carbonic anhydrase Carbonic anhydrase inhibitorsinhibitors

Prostaglandin FProstaglandin F22

derivativesderivatives

Ciliary muscle contraction (facilitating Ciliary muscle contraction (facilitating uveoscleral outflow and trabecular outflow)uveoscleral outflow and trabecular outflow)

Inhibition of aqueous production Inhibition of aqueous production by the ciliary epitheliumby the ciliary epithelium

Inhibition of aqueous production Inhibition of aqueous production by the ciliary epithelium ± increasing by the ciliary epithelium ± increasing uveoscleral outflowuveoscleral outflow

Increased uveoscleral outflow Increased uveoscleral outflow

Increasing trabecular outflow by a Increasing trabecular outflow by a mechanism that is not completely mechanism that is not completely understoodunderstood

Inhibition of aqueous production Inhibition of aqueous production by the ciliary epitheliumby the ciliary epithelium

IOP-Lowering AgentsIOP-Lowering Agents

Adapted from Kaufman P. Presented at: Glaucoma in the 21st Century 2001.Adapted from Kaufman P. Presented at: Glaucoma in the 21st Century 2001.

Glaucoma Therapy June 2003Glaucoma Therapy June 2003

Ocular Hypertension Ocular Hypertension ((20% IOP reduction used, but lower better)20% IOP reduction used, but lower better)

Ocular Hypertension Treatment Study (OHTS) 2002Ocular Hypertension Treatment Study (OHTS) 2002

Mild, initial POAGMild, initial POAG (35% IOP reduction in CIGTS worked well)(35% IOP reduction in CIGTS worked well) Comparison of Initial Glaucoma Comparison of Initial Glaucoma Treatments Study (CIGTS) 2001 Early Manifest Treatments Study (CIGTS) 2001 Early Manifest Glaucoma Treatment Study (EMGTS) 2002Glaucoma Treatment Study (EMGTS) 2002

Normal Tension Glaucoma Normal Tension Glaucoma ((30% IOP reduction recommended)30% IOP reduction recommended) Collaborative Collaborative Normal Normal Tension Glaucoma Study (CNTGS) 1999Tension Glaucoma Study (CNTGS) 1999

Advanced POAGAdvanced POAG (35-50% reduction did best) (35-50% reduction did best) Advanced Glaucoma Intervention Study (AGIS) Advanced Glaucoma Intervention Study (AGIS) 2000 Antimetabolites in Filtering Surgery Study (AFSS) 20002000 Antimetabolites in Filtering Surgery Study (AFSS) 2000

Major Clinical Trials Demonstrated Better Outcomes at Lower Intraocular Pressures Than Previously Sought

Meta-Analysis of Multiple Trials (UK, Meta-Analysis of Multiple Trials (UK, Scandinavia and USA)Scandinavia and USA)

Percentage of patients reaching a specific target IOPPercentage of patients reaching a specific target IOP

Diurnal IOP at Latanoprost Timolol

end of treatment (n=398) (n=318) Odds ratio15 mm Hg 27 14

2.2*16 mm Hg 39 26

1.8*17 mm Hg 56 38

2.0*18 mm Hg 70 55

1.9*19 mm Hg 83 72

1.9*20 mm Hg 89 81

1.9**

**PP <0.001 (Pearson chi-square test) latanoprost vs timolol<0.001 (Pearson chi-square test) latanoprost vs timolol****PP <0.002 (Pearson chi-square test) latanoprost vs timolol<0.002 (Pearson chi-square test) latanoprost vs timolol

Pharmacia. Data on file.Pharmacia. Data on file.

Emmerich KH. Graefes Arch Clin Exp Ophthalmol. 2000;238:19-23.

Emmerich KH, et al. AAO, New Orleans, USA, 1998.

Diurnal IOP Reduction at 3 MonthsDiurnal IOP Reduction at 3 Months

Ch

ang

e in

IOP

Fro

m B

asel

ine

(mm

Hg

)(M

ean

± S

EM

)Latanoprost

(n=85)

Timolol +Dorzolamide

(n=90)

P=0.79

0

-1

-2

-3

-4

-5

-6

Least Square Means (ANCOVA)

Latanoprost vs Timolol in CACGLatanoprost vs Timolol in CACG

% decrease in IOP from baseline% decrease in IOP from baseline

33%33%

30%30%

20%20% 20%20%

00

-5-5

-10-10

-15-15

-20-20

-25-25

-30-30

-35-35

Week 6Week 6 Week 12Week 12

LatanoprostLatanoprost

TimololTimolol

Chew, on behalf of the EXACT Study Group ((2001)

ITT population

0

10

20

30

40

50

60

70

80

15 16 17 18 19 20 21 >21

Latanoprost

Timolol

Latanoprost vs Timolol in CACGLatanoprost vs Timolol in CACG

P<.001

P<.001

P<.002

IOP (mm Hg)

% patients

Chew, on behalf of the EXACT Study GroupGroup (2001)

ITT population

Latanoprost Efficacy in Latanoprost Efficacy in Pigmentary GlaucomaPigmentary Glaucoma

0

1

2

3

4

5

6

7

8

Latanoprost (n=18)

Timolol (n=18)

6 months 12 months

Diurnal IOP reduction

Ch

ang

e in

IOP

Fro

m B

asel

ine

(mm

Hg

) (M

ean

± S

EM

)

Mastropasqua L, et al. Ophthalmology, 1999;106:550-555.

P<0.001 P<0.001

Diurnal IOP Range and Diurnal IOP Range and Disease ProgressionDisease Progression

*The ratio between the incidence of a disease symptom among individuals with a given risk factor to the incidence among those without it.

Relative risk* of disease progression within 5 years

0

1

2

3

4

5

6

1.00

5.76

Diurnal IOP Range3.1 mm Hg

Diurnal IOP Range5.4 mm Hg

Rel

ativ

e R

isk

Asrani S, et al. J Glaucoma. 2000;9:134-142.

Latanoprost qd vs Dorzolamide tid Latanoprost qd vs Dorzolamide tid and Timolol bid Over 24 Hoursand Timolol bid Over 24 Hours

Orzalesi N, et al. Invest Ophthalmol Vis Sci. 2000;41:2566-2573.

Circadian control of IOP

IOP

(m

m H

g)

BaselineDorzolamide

tid

Timolol bid

Latanoprost qd

3 PM 6 PM 9 PM Midnight 3 AM 6 AM 9 AM Noon

Time (Hours)

13

15

17

19

21

23

25

0

Richard Parrish, II, MD, Paul Palmberg, MD, PhD, Wang-Pui Sheu, PhD, and the XLT Investigators

American Journal of Ophthalmology 2003; 135:688-703

Xalatan® (latanoprost ophthalmic solution) Xalatan® (latanoprost ophthalmic solution) Lumigan®† (bimatoprost ophthalmic solution)Lumigan®† (bimatoprost ophthalmic solution)Travatan®† (travoprost ophthalmic solution)Travatan®† (travoprost ophthalmic solution)

OHOH OHOH

OHOH

COOCH(CHCOOCH(CH33))22

PGFPGF22

OHOH OHOH

OHOH

COOHCOOH

LATANOPROSTLATANOPROST

CHCH33

EsterificationEsterification

Phenyl Phenyl substitutionsubstitution

Double bondDouble bondsaturation saturation

10 years

Stjernschantz, IOVS, 2001

Latanoprost: hypothesized mechanism Latanoprost: hypothesized mechanism of actionof action

LatanoprostLatanoprost acid + ester

Latanoprost acid

CorneaCornea

Aqueous humourAqueous humour

c-fos

Collagen collagen fragments

Uveoscleral flowUveoscleral flow

Ciliary muscleCiliary muscle

FP receptor

MMP

Courtesy of Weinreb

OH

OHOH

COOCH (CH3)2


BimatoprostBimatoprost

OH

OHOH

CONHCH2CH

Amide groupAmide group


COO-iPr

HO

HOOH

TravoprostTravoprost

O

HO

OHHO

CF3

COO-iPr

Flouride group

Study DesignStudy Design

• Recruit subjects with POAG, PXE, PG or OAOHRecruit subjects with POAG, PXE, PG or OAOH

• Perform washoutPerform washout

• Determine eligibilityDetermine eligibility

• Baseline diurnal curveBaseline diurnal curve

• Randomize to the three treatment groupsRandomize to the three treatment groups• latanoprost 0.005%latanoprost 0.005%

• Bimatoprost 0.03%Bimatoprost 0.03%

• Travoprost 0.004%Travoprost 0.004%

Medication instilled daily at 8 Medication instilled daily at 8 PMPM

1.1. Parrish RK et al. Parrish RK et al. Am J Ophthalmol.Am J Ophthalmol. In press. In press.

Unadjusted Mean IOP Levels by Treatment and Unadjusted Mean IOP Levels by Treatment and Measurement Time at Baseline and Week 12Measurement Time at Baseline and Week 12

Intent-to-Treat PopulationIntent-to-Treat Population

8:00 AM8:00 AM

Mea

n I

OP

M

ean

IO

P ±

SE

M±

SE

M (

mm

Hg

) (

mm

Hg

)

12 Noon12 Noon 4:00 PM4:00 PM 8:00 PM8:00 PM

Measurement TimesMeasurement Times




1515

16161717

18181919

202021212222

2323

24242525

2626

Week 12Week 12

BaselineBaseline

IOP & IOP Change (mm Hg)IOP & IOP Change (mm Hg)Unadjusted MeansUnadjusted Means

LatanoprostBimatoprostTravoprost LatanoprostBimatoprostTravoprost

(n=136) (n=136) (n=138) (n=136) (n=136) (n=138)

8 AM 17.09 17.03 17.59 -8.65 -8.70 -7.92

Noon 16.49 16.19 16.84 -7.17 -7.60 -6.78

4 PM 16.72 15.98 16.44 -6.23 -6.84 -6.30

8 PM 16.30 15.80 16.10 -5.91 -6.52 -5.72

Diurnal 16.71 16.35 16.81 -7.00 -7.33 -6.72

Week 12 IOP IOP Change: Baseline to Week 12

Adapted from Parrish RK et al. Adapted from Parrish RK et al. Am J Ophthalmol.Am J Ophthalmol., 2003:135:688-703, 2003:135:688-703

-0.05

-0.33

Distributions of Reductions From Baseline Distributions of Reductions From Baseline to Week 12 in 8 to Week 12 in 8 AMAM andand Diurnal Diurnal Mean IOP Levels by Treatment Mean IOP Levels by Treatment


LatanoprostLatanoprost BimatoprostBimatoprost TravoprostTravoprost LatanoprostLatanoprost BimatoprostBimatoprost TravoprostTravoprost

8 8 AMAM DiurnalDiurnal

Mea

n I

OP

Ch

ang

e (m

m H

g)

Mea

n I

OP

Ch

ang

e (m

m H

g)

-30-30

-25-25

-20-20

-15-15

-10-10

-5-5

00

55

1010

******

**

**** ****

******** **

**

**

** ****

**

**

**** **

**

******

Percent of Patients Receiving Percent of Patients Receiving IOP-Reducing Medication at ScreeningIOP-Reducing Medication at Screening


0

10

20

30

40

50

60

Latanoprost (n=136)

Bimatoprost (n=137)

Travoprost (n=138)

Pat

ien

ts (

%)

Pat

ien

ts (

%)

Prost

agla

ndin

Prost

agla

ndin

anal

ogs

(n=2

05)

anal

ogs

(n=2

05)

Carbo

nic

anhy

dras

e

Carbo

nic

anhy

dras

e

inhi

bito

rs (n

=142

)

inhi

bito

rs (n

=142

)

-ad

rene

rgic

rece

ptor

-adr

ener

gic

rece

ptor

anta

goni

sts

anta

goni

sts

((-b

lock

ers)

(n=1

16)

-blo

cker

s) (n

=116

)

Adren

ergi

c re

cept

or

Adren

ergi

c re

cept

or

agon

ists

(n=5

5)

agon

ists

(n=5

5)Com

bina

tion

Combi

natio

n (n

=14)

(n=1

4)

Mas

ked

inve

stig

atio

nal

Mas

ked

inve

stig

atio

nal

med

icat

ion

(n=1

0)

med

icat

ion

(n=1

0)Cho

liner

gic

agon

ists

Cholin

ergi

c ag

onis

ts

(n=4

)

(n=4

)

Ocular Hypotensive Medications at ScreeningOcular Hypotensive Medications at Screening

Before randomization to:

Mean IOP at Screening by IOP-Reducing Mean IOP at Screening by IOP-Reducing MedicationMedication


151617181920212223242526 Latanoprost (n=136)

Bimatoprost (n=137)

Travoprost (n=138)

Mea

n I

OP

(m

m H

g)

Mea

n I

OP

(m

m H

g)

Prost

agla

ndin

Prost

agla

ndin

anal

ogs

(n=2

05)

anal

ogs

(n=2

05)

Carbo

nic

anhy

dras

e

Carbo

nic

anhy

dras

e

inhi

bito

rs (n

=142

)

inhi

bito

rs (n

=142

)

-ad

rene

rgic

rece

ptor

-adr

ener

gic

rece

ptor

anta

goni

sts

anta

goni

sts

((-b

lock

ers)

(n=1

16)

-blo

cker

s) (n

=116

)

Adren

ergi

c re

cept

or

Adren

ergi

c re

cept

or

agon

ists

(n=5

5)

agon

ists

(n=5

5)Com

bina

tion

Combi

natio

n (n

=14)

(n=1

4)

Mas

ked

inve

stig

atio

nal

Mas

ked

inve

stig

atio

nal

med

icat

ion

(n=1

0)

med

icat

ion

(n=1

0)Cho

liner

gic

agon

ists

Cholin

ergi

c ag

onis

ts

(n=4

)

(n=4

)

Ocular Hypotensive Medications at ScreeningOcular Hypotensive Medications at Screening

Distributions of Reductions From Baseline to Distributions of Reductions From Baseline to Week 12 in 8 Week 12 in 8 AMAM Mean IOP Levels by Treatment Mean IOP Levels by Treatment

and Prostaglandin Therapy at Screening and Prostaglandin Therapy at Screening Intent-to-Treat Population; Post Hoc AnalysisIntent-to-Treat Population; Post Hoc Analysis

1010

No pro

stag

landin

No pro

stag

landin

anal

og

anal

og

-30-30

-25-25

-20-20

-15-15

-10-10

-5-5

55

Mea

n I

OP

Ch

ang

e (m

m H

g)

Mea

n I

OP

Ch

ang

e (m

m H

g)

00

******

**** ***

***

********

LatanoprostLatanoprost BimatoprostBimatoprost TravoprostTravoprost

Prost

agla

ndin

Prost

agla

ndin

anal

og

anal

og

No pro

stag

landin

No pro

stag

landin

anal

og

anal

og

Prost

agla

ndin

Prost

agla

ndin

anal

og

anal

og

No pro

stag

landin

No pro

stag

landin

anal

og

anal

og

Prost

agla

ndin

Prost

agla

ndin

anal

og

anal

og

Hyperemia Grading ScaleHyperemia Grading ScaleDoctor’s AssessmentDoctor’s Assessment

Adapted from Parrish RK et al. Adapted from Parrish RK et al. Am J Ophthalmol.Am J Ophthalmol. 2003;145: 2003;145:

Patient’s Assessment of Patient’s Assessment of HyperemiaHyperemia

• ““Have you or anyone else noticed any Have you or anyone else noticed any redness in your eyes since the last visit?”redness in your eyes since the last visit?”

• If yes: If yes:

“ “To what extent does the redness bother To what extent does the redness bother you?”you?”

– not at allnot at all

– small amountsmall amount

– moderate amountmoderate amount

– a great deala great deal

Mean Hyperemia Score by Treatment and Mean Hyperemia Score by Treatment and VisitVisit Investigators’ AssessmentsInvestigators’ Assessments

BaselineBaseline

Mea

n H

yper

emia

Sco

re

Mea

n H

yper

emia

Sco

re ±

SE

M±

SE

M

Week 2Week 2 Week 6Week 6 Week 12Week 12VisitsVisits

00

0.10.1

0.20.2

0.30.3

0.40.4

0.50.5

0.60.6

0.70.7

0.80.8

0.90.9

1.01.0LatanoprostLatanoprost



‡‡

‡‡

‡ ‡ P=P=.001, Latanoprost vs Bimatoprost..001, Latanoprost vs Bimatoprost.

Distributions of Reductions From Baseline Distributions of Reductions From Baseline to Week 12 in 8 to Week 12 in 8 AMAM Mean IOP Levels by Mean IOP Levels by

Treatment and Occurrence of Hyperemia Treatment and Occurrence of Hyperemia Intent-to-Treat Population; Post Hoc AnalysisIntent-to-Treat Population; Post Hoc Analysis

-30-30

-25-25

-20-20

-15-15

-10-10

-5-5

55

1010

Mea

n I

OP

Ch

ang

e (m

m H

g)

Mea

n I

OP

Ch

ang

e (m

m H

g)

00

****

****

****

****

**

**

****

********

**

HyperemiaHyperemia NoNoHyperemiaHyperemia



LatanoprostLatanoprost BimatoprostBimatoprost TravoprostTravoprost

Patients’ Assessments of HyperemiaPatients’ Assessments of HyperemiaAll Randomized PatientsAll Randomized Patients

0

10

20

30

40

50

Baseline Week 2 Week 6 Week 12




Per

cen

t R

epo

rtin

g

Per

cen

t R

epo

rtin

g

An

y R

edn

ess

in E

ye(s

)A

ny

Red

nes

s in

Eye

(s)

VisitsVisits

§§ PP<<.01, Latanoprost vs Bimatoprost..01, Latanoprost vs Bimatoprost.11

|| || PP<<.03, Latanoprost vs Travoprost..03, Latanoprost vs Travoprost.11

§§

Adapted from Parrish RK et al. Adapted from Parrish RK et al. Am J Ophthalmol.Am J Ophthalmol. 2003;145 2003;145

1. 1. Data on file. Pharmacia & Upjohn Company, Kalamazoo, Data on file. Pharmacia & Upjohn Company, Kalamazoo, MI.MI.

§, §, |||| §, §, ||||

Summary of Efficacy Summary of Efficacy RResultsesults11

• Mean IOP levels at baseline were not Mean IOP levels at baseline were not significantly differentsignificantly different

• Mean IOP levels at 8 AM at week 12 were not Mean IOP levels at 8 AM at week 12 were not significantly different significantly different

• Mean IOP levels at week 12 were not Mean IOP levels at week 12 were not significantly different at any time pointsignificantly different at any time point

• Mean diurnal IOP levels at week 12 were not Mean diurnal IOP levels at week 12 were not significantly differentsignificantly different

• No racial differences in response to No racial differences in response to treatments were observed (exploratory treatments were observed (exploratory analysis)analysis)

1.1. Parrish RK et al. Parrish RK et al. Am J Ophthalmol.Am J Ophthalmol. 2003;135:411-417. 2003;135:411-417.

ConclusionsConclusionsAt week 12 At week 12

• IOP reduction from baseline was not IOP reduction from baseline was not significantly different in patients treated significantly different in patients treated with latanoprost, bimatoprost, or travoprostwith latanoprost, bimatoprost, or travoprost

• All 3 agents were generally well tolerated All 3 agents were generally well tolerated systemicallysystemically

• Significantly fewer patients reported Significantly fewer patients reported symptoms of ocular hyperemia with symptoms of ocular hyperemia with latanoprost treatmentlatanoprost treatment

• Investigators reported ocular hyperemia in Investigators reported ocular hyperemia in significantly fewer patients treated with significantly fewer patients treated with latanoprost than with bimatoprostlatanoprost than with bimatoprost

IOP Reduction as DemonstratedIOP Reduction as Demonstratedin Head-to-Head Trials of PG Analogsin Head-to-Head Trials of PG Analogs

1Parrish RK et al. Am J Ophthalmol. 2003;135:411-417 .

XLT Study:(XALATAN® [latanoprost ophthalmic solution], Lumigan, and Travatan)—a multicenter, randomized, parallel-group, masked-evaluator trial in patients with open-angle glaucoma (OAG) or ocular hypertension (OHT) and a baseline IOP of 23 mm Hg; study drugs dosed once daily at 8 PM.


1Parrish RK et al. Am J Ophthalmol. In press. 2Netland PA et al. Am J Ophthalmol. 2001;132:472-484.

A phase III, 4-arm, randomized trial in patients with OAG or OHT; travoprost and latanoprost dosed once daily.


1Parrish RK et al. Am J Ophthalmol. 2003; 135;411-417. 2Netland PA et al. Am J Ophthalmol. 2001;132:472-484. 3Gandolfi S et al. Advances in Therapy. 2001;18:110-121.

A multicenter, randomized, investigator-masked, parallel-group study in patients with glaucoma or OHT and a mean baseline IOP of 25.7 mm Hg; study drugs dosed once daily in the evening.


1Parrish RK et al. Am J Ophthalmol. 2003;135:411-417. . 2Netland PA et al. Am J Ophthalmol. 2001;132:472-484. 3Gandolfi S et al. Advances in Therapy. 2001;18:110-121. 4Noecker RS et al. Am J Ophthalmol. 2003;135:55-63.

A multicenter, randomized, investigator-masked study in patients with OHT or POAG; study drugs dosed once daily.

†P<.001.

Mean Diurnal IOP ReductionsMean Diurnal IOP ReductionsLatanoprost Phase III vs Noecker et alLatanoprost Phase III vs Noecker et al

-8.5-8

-6.7-7.2

-8.6

-10.5

-8 -8.2

-5.4

-10

-8

-6

-4

-2

0

UK(6 mos)

n=179

Scandinavia(6 mos)

n=183

IOP

Red

uct

ion

(m

m H

g)

Mea

n ±

SE

M

USA(6 mos)

n=128

Reduction of Diurnal IOPReduction of Diurnal IOP

Japan(3 mos)

n=89

Philippines(3 mos)

n=30

Mexico(3 mos)

n=57

Korea(3 mos)

n=38

China(3 mos)

n=63

Noecker(6 mos)

n=136

Responder RatesResponder Rates

Noecker ParrishNoecker Parrish

Xal Lum Xal Tra LumXal Lum Xal Tra Lum

> 15% 72% 89% 91.9% 91.3% 91.9%> 15% 72% 89% 91.9% 91.3% 91.9%

>20% 62% 79% 86.8% 84.8% 87.5%>20% 62% 79% 86.8% 84.8% 87.5%

at 8 AM at end studyat 8 AM at end study

Achieving Target PressuresAchieving Target Pressures

Xalatan Travatan LumiganXalatan Travatan Lumigan

• 13 mm Hg 11% 12% 10% AGIS13 mm Hg 11% 12% 10% AGIS• 14 mm Hg 19% 19% 18%14 mm Hg 19% 19% 18%• 15 mm Hg 27% 26% 29%15 mm Hg 27% 26% 29%• 16 mm Hg 40% 33% 43%16 mm Hg 40% 33% 43%• 17 mm Hg 52% 46% 59% CIGTS• 18 mm Hg 65% 60% 68%18 mm Hg 65% 60% 68%• 19 mm Hg 77% 72% 77%19 mm Hg 77% 72% 77%• 20 mm Hg 84% 80% 82%20 mm Hg 84% 80% 82%• 21 mm Hg 90% 83% 90% 21 mm Hg 90% 83% 90%

More Aggressive Medical TherapyMore Aggressive Medical Therapy

Advanced Glaucoma Intervention Study Advanced Glaucoma Intervention Study (AGIS)(AGIS) supports a supports a 35-50%35-50% IOP reduction IOP reduction

Collaborative Normal-Tension Glaucoma Study Collaborative Normal-Tension Glaucoma Study (CNTGS)(CNTGS) supports a supports a 30%30% IOP reduction IOP reduction

Comparison of Initial Glaucoma Treatment Study Comparison of Initial Glaucoma Treatment Study (CIGTS)(CIGTS) supports a supports a 35%35% IOP reduction and IOP reduction and EMGTEMGT would seem to support would seem to support more aggressive control.more aggressive control.

Ocular Hypertension Treatment Study Ocular Hypertension Treatment Study (OHTS)(OHTS) supports a supports a 20-30%20-30% IOP reductionIOP reduction

IOP vs 5 Yr Risk of ProgressionIOP vs 5 Yr Risk of Progression

0

20

40

60

10 12 14 16 18 20 22 24 26 28CIGTS

CIGTS POAG NTG OHTS

Evidence-Based Glaucoma Therapy Paul Palmberg, MD, PhD Bascom Palmer Eye Institute, University of...

Documents

Transcript of Evidence-Based Glaucoma Therapy Paul Palmberg, MD, PhD Bascom Palmer Eye Institute, University of...