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    Device makers swing for fence with new technologies

    Minimally invasive glaucoma surgery devices (MIGS) are no longer new. The iStent and Trabectome have been on the market for several years and other devices are nearing approval in European and the United States.

    “The next device will probably be the CyPass (Transcend Medical), which we hope will be on the market late this year or in the first quarter of 2017,” said Steven D. Vold, MD, who is in private practice in Fayetteville, AR. “On the horizon is the Xen implant (Allergan). And farther off are other implants and new technologies. We are starting to see real progress in treating glaucoma. As we move from 1.0 devices to 2.0 devices, this is going to be a transformative time in the ways we take care of patients.”

    More from Glaucoma 360: Navigating beyond glaucoma company mistakes

    Dr. Vold co-moderated “New Horizons in Glaucoma Devices” at the 2016 Glaucoma 360 meeting with Malik Y. Kahook, MD, professor of ophthalmology and director of the Glaucoma Service, University of Colorado. Some of the companies that presented are already in human trials and some have yet to produce a prototype, but all are pushing the boundaries of glaucoma care.


    Conventional wisdom says glaucoma is the result of elevated intraocular pressure (IOP). What if conventional is wrong, or at least incomplete? The latest data suggest that the optic nerve damage seen in glaucoma results from an imbalance between IOP and intracranial pressure, not from elevated IOP alone. The pressure imbalance inhibits axonal transport that supports the metabolic needs of the optic nerve.

    “If the IOP is too high or the intracranial pressure is too low, there is a pressure gradient across the optic nerve and its metabolic needs cannot be met,” said John Berdahl, MD, founder and CEO of Equinox. “The nerve slowly withers and dies. If we can decouple IOP from intracranial pressure, we can restore balance to the optic nerve and treat glaucoma.”

    In glaucoma, IOP is higher than intracranial pressure, blocking axonal transport. Astronauts aboard the International Space Station have the opposite problem, intracranial pressure being higher than IOP. But the effect is the same, impaired axonal transport and potential damage to the optic nerve.

    Dr. Berdahl’s solution is to restore the pressure balance using goggles to provide negative or positive pressure to the eyes.

    More: How success in glaucoma innovation must come from within

    Reducing ambient pressure reduces the elevated IOP seen in glaucoma, reducing the pressure gradient across the optic nerve and restoring axonal transport. If the problem is elevated intracranial pressure, increasing ambient air pressure on the eye increases IOP, likewise reducing the pressure gradient at the optic nerve to restore axonal transport.

    The process works in cadaver eyes, Dr. Berdahl said. The next step is a device that can deliver the precise ambient air pressure needed to offset differences between intraocular and intracranial pressures to restore axonal transport function.


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