Prostaglandin-associated periorbitopathy syndrome (PAPS): Addressing an unmet clinical need

Predictors of severity in prostaglandin-associated periorbitopathy

OBJECTIVE

To determine the predictive factors for severity in prostaglandin-associated periorbitopathy (PAP) using an objective grading system.

METHODS

The study included patients diagnosed with glaucoma or ocular hypertension who had used a topical prostaglandin analog (PGA) unilaterally for at least three months. Clinical characteristics and PAP signs were compared based on the types of PGAs used. The severity of PAP signs was categorised according to an objective grading system. Univariate and multivariate logistic regression analyses were performed to identify risk factors for different grades of PAP.

RESULTS

Among the 86 patients included in the study, 24 (27.9%) used bimatoprost, 35 (40.7%) used latanoprost, and 27 (31.4%) used travoprost. The most commonly observed feature of PAP was orbital fat atrophy (48.8%), followed by deepening of the upper eyelid sulcus (38.4%), involution of dermatochalasis (32.6%), and enophthalmos (26.7%). Fifty-eight patients (67.4%) exhibited at least one periorbital change associated with PGA use. Multivariate logistic regression analysis revealed that age >60 years (p < 0.05), the use of bimatoprost (p < 0.05) and travoprost (p < 0.05), and PGA therapy duration >1 year (p < 0.05) were independent risk factors for higher grades of PAP.

CONCLUSION

Older age, longer duration of PGA therapy, and the use of bimatoprost and travoprost were significant and independent predictors of severe PAP in patients with glaucoma. Patients with these risk factors should be identified and managed to prevent the development of severe PAP.

The Severity of Prostaglandin-Associated Periorbitopathy Did Not Affect the Surgical Effectiveness of the Ahmed Glaucoma Valve

Introduction: To report the role of prostaglandin-associated periorbitopathy (PAP) severity on the surgical efficacy of Ahmed Glaucoma Valve (AGV) implantation. Subjects and Methods: Retrospective observational case series. Participants were the consecutive 102 eyes from 102 Japanese subjects (55 males, 47 females; mean age ± standard deviation, 74.9 ± 7.8 years) who underwent AGV implantation for primary open-angle glaucoma (POAG), completed full postoperative visits for 12 months, and had information on PAP severity graded by the Shimane University PAP Grading System (SU-PAP). Data were collected via medical chart review. Comparison of surgical success rates among groups stratified by SU-PAP grades (grades 0-3) using survival curve analysis. Failure was defined based on additional glaucoma surgery, IOP reduction in less than 20%, postoperative IOP exceeding 18 mmHg (definition A) or 15 mmHg (definition B), or postoperative visual acuity reduced to no light perception. Results: At 12 months postoperatively, the success rates for grades 0, 1, 2, and 3 were 47%, 43%, 42%, and 73%, respectively, for definition A (p = 0.35) and 35%, 26%, 19%, and 27%, respectively, for definition B (p = 0.64, log-rank test). For definition A, younger age was associated with surgical failure (Hazard ratio = 0.97/year, p = 0.049, Wald test), while no other factors, including gender, preoperative IOP, medications, refractive error, history of conjunctival manipulation procedures, or SU-PAP grade, were associated with surgical failure. For definition B, no factors were found to influence surgical outcomes. Conclusions: The preoperative severity of PAP might not affect the postoperative outcomes of AGV. Given that the success rate of trabeculectomy is influenced by PAP severity, in cases with severe PAP, physicians are advised to consider long-tube shunt surgery as an initial filtration procedure or as a rescue procedure when filtration surgery is unsuccessful.

Clinical Staging of Prostaglandin-Associated Periorbitopathy Syndrome in Glaucoma: A Review from Asia

PURPOSE

Topical prostaglandin analogues are commonly used to treat patients with glaucoma, but may cause periocular and periorbital complications known as prostaglandin-associated periorbitopathy syndrome (PAPS).

METHODS

A literature review was conducted on PAPS. Given the lack of consensus on grading PAPS, glaucoma specialists from Asia convened to evaluate current PAPS grading systems and propose additional considerations in grading PAPS.

RESULTS

Existing grading systems are limited by the lack of specificity in defining grades and consideration for patients' subjective perception of symptoms. Patient-reported symptoms (e.g., via a self-assessment tool) and additional clinical assessments (e.g., exophthalmometry, lid laxity, differences between tonometry results, baseline measurements, and external ocular photographs) would be beneficial for grading PAPS systematically.

CONCLUSIONS

Effective management of PAPS could be facilitated by a common clinical grading system to consistently and accurately diagnose and characterise symptoms. Further research is required to validate specific recommendations and approaches to stage and monitor PAPS.

Omidenepag Isopropyl 0.002% versus Latanoprost 0.005% in Open-Angle Glaucoma/Ocular Hypertension: The Randomized Phase III PEONY Trial

Purpose

To compare the efficacy and safety of omidenepag isopropyl (OMDI) 0.002% with latanoprost 0.005% once daily in Asian subjects with open-angle glaucoma (OAG)/ocular hypertension (OHT).

Methods

In this Phase III randomized, observer-masked, active-controlled, multinational trial (NCT02981446), subjects aged ≥18 years with OAG/OHT in both eyes and baseline intraocular pressure (IOP) ≥22 mmHg and ≤34 mmHg were randomized 1:1 to OMDI or latanoprost. IOP was measured at 9AM, 1PM, and 5PM at baseline, 1 week, 6 weeks, and 3 months. Adverse events (AEs) were recorded. Non-inferiority of OMDI to latanoprost was tested for primary and key secondary endpoints.

Results

Each group included 185 subjects. Mean diurnal IOP from baseline to month 3 was reduced 7.1 mmHg (28.8%) with OMDI and 7.8 mmHg (31.3%) with latanoprost, with the least-squares mean difference (OMDI minus latanoprost) being 0.6 mmHg (95% CI: 0.0, 1.2 mmHg; p = 0.0366), indicating non-inferiority. Mean IOP reductions at the nine timepoints were -5.8 to -7.3 mmHg (23.5-29.5%) for OMDI and -6.1 to -7.9 mmHg (24.3-31.7%) for latanoprost. Non-inferiority per FDA criteria was also met. Rates of all AEs, ocular AEs, and ocular AEs associated with treatment were 40.0%, 36.8%, and 23.2%, respectively, for OMDI and 29.7%, 21.1%, and 11.9%, respectively, for latanoprost. Conjunctival hyperemia rates were higher with OMDI than latanoprost (11.9% vs 5.4%). Most AEs were mild, with no serious ocular AEs.

Conclusion

OMDI safely and effectively reduces IOP in Asian subjects with OAG/OHT, with mean diurnal IOP at Month 3 and per-timepoint IOP reductions non-inferior to those of latanoprost.

Evolution of first-line glaucoma therapy, 2007-2018: a population-based analysis

OBJECTIVE

To evaluate the long-term evolution of first-line glaucoma therapy (FLGT) initiated by ophthalmologists and optometrists.

DESIGN

Retrospective population-based study using validated provincial health care databases.

PARTICIPANTS

194,759 Ontario residents, 66 years of age or older, who received FLGT between 2007 and 2018.

METHODS

A total of 194,759 individuals from 12 annual cohorts were enrolled, and rates of first-line medical treatment (prostaglandin analogue [PGA], beta-blocker, alpha-2-agonist, and carbonic anhydrase inhibitor) and laser trabeculoplasty (LT) were calculated. Provider (ophthalmologist or optometrist) rates also were assessed.

RESULTS

Across the entire study period, of the 194,759 enrolled individuals who received FLGT, 60.2% initially received medical treatment and 39.8% underwent LT. Approximately 94.6% were treated by ophthalmologists. PGA therapy was the most common therapy prior to 2010, whereupon LT became the most common FLGT. By 2015, LT exceeded the total of all medications as FLGT. The annual rate of initial medication prescriptions by optometrists rose to 101.4 per 100,000 population between 2011 and 2018. In 2018, PGA and non-PGA prescription rates by ophthalmologists were 2.6 and 5.0 times higher, respectively, than prescription rates by optometrists.

CONCLUSION

LT therapy has become the most common FLGT for Ontario residents 66 years of age or older. PGAs remain the most frequently prescribed glaucoma medication. While ophthalmologists continue to provide the majority of FLGT, optometrists now provide a small but growing fraction of FLGT following the introduction of glaucoma medication prescribing privileges.

Selective laser trabeculoplasty: An updated narrative review

Selective laser trabeculoplasty (SLT) has experienced a resurgence in interest, primarily driven by promising findings from the Laser in Glaucoma and Ocular Hypertension Trial. By offering SLT as an initial drug-free treatment option, we may be able to thwart issues such as adherence and persistence that plague our current medical management protocols. In this comprehensive narrative review, we delve into the current body of literature that explores the utility of SLT across a wide spectrum of scenarios and glaucoma subtypes. We present evidence that provides valuable insight into the efficacy and benefits of SLT, positioning it as a viable option in the management of glaucoma. Careful consideration of the associated risks and challenges is also necessary for successful adoption into clinical practice. Despite the ample evidence supporting SLT's efficacy, some questions remain regarding its long-term effects and the potential need for retreatment. This review aims to shed light on these aspects to guide clinicians in making informed decisions and tailoring treatment plans to individual patient needs. This review also provides the readers with a bird's eye view of the potential impact of SLT and adds clarity to the various therapeutic protocols that one can follow to ensure optimal clinical outcomes for our patients.

Cystoid macular edema associated with omidenepag isopropyl in a phakic eye with an implantable collamer lens: a case report

BACKGROUND

Cystoid macular edema is a known complication of omidenepag isopropyl usage. Omidenepag isopropyl is a selective prostanoid EP2 receptor agonist, and its association with macular edema has mainly been identified in pseudophakic eyes. Herein, we report a case of cystoid macular edema caused by omidenepag isopropyl use in a phakic eye with an implantable collamer lens.

CASE PRESENTATION

A 38-year-old woman was diagnosed with left eye glaucoma and prescribed omidenepag isopropyl. She had undergone bilateral implantation of implantable collamer lenses approximately 12 years prior to the glaucoma diagnosis. After 9 months of using omidenepag isopropyl, she presented with blurred vision in the left eye; swept source optical coherence tomography revealed cystoid macular edema in this eye. Omidenepag isopropyl usage was discontinued, and bromfenac sodium hydrate was administered twice daily instead. After 2 months, the patient's visual discomfort was completely ameliorated. Additionally, an optical coherence tomography examination confirmed that the macula had normalized.

CONCLUSIONS

We report a case of cystoid macular edema development after omidenepag isopropyl use in a patient with glaucoma who had undergone bilateral implantable collamer lens implantation. This case shows that the possibility of cystoid macular edema occurrence should be considered when omidenepag isopropyl is used, even in phakic eyes, after the insertion of implantable collamer lenses.

Prostaglandin-Associated Periorbitopathy Symptom Alleviation After Switching Prostaglandin F Receptor Agonist to EP2 Receptor Agonist in Patients with Glaucoma

Purpose: Prostaglandin-associated periorbitopathy in patients with glaucoma is reportedly not caused by EP2 agonist, but it has been a cosmetic problem with prostaglandin F receptor (FP) agonists. In this study, patients with prostaglandin-associated periorbitopathy on FP agonists were switched to EP2 agonist and changes were investigated. Methods: Patients complaining of prostaglandin-associated periorbitopathy were included. The FP agonist was switched to EP2 agonist (omidenepag isopropyl), and patients were followed up for 7 months. Frontal photographs were taken at every visit, and objective changes in deepening of the upper eyelid sulcus were assessed by three observers. Subjective questionnaires (self-awareness of deepening of the upper eyelid sulcus, eyelid/peri-eyelid skin pigmentation, eyelash elongation, and conjunctival hyperemia) were acquired at the start and the endpoint. Factors associated with the change of prostaglandin-associated periorbitopathy were investigated using logistic regression analysis. Results: Included were 23 eyes of 23 patients (17 women; 60.6 years). At 7 months, objective deepening of the upper eyelid sulcus improved by 76%. The subjective questionnaires showed that deepening of the upper eyelid sulcus improved in 95%, eyelid/peri-eyelid skin pigmentation in 76%. The less extent of myopia was a significant factor in the eyes with improved eyelid/peri-eyelid skin pigmentation. After switching, no change in intraocular pressure or visual acuity was observed (P ≥ 0.22). Conclusion: Switching to omidenepag isopropyl increased patient satisfaction and might be the first step to lightening deepening of the upper eyelid sulcus and eyelid/peri-eyelid skin pigmentation. It was suggested that pigmentation may be more easily improved in nonmyopic eyes.

Newly or switching effect of a selective EP2 agonist on intraocular pressure in Japanese patients with open-angle glaucoma

PURPOSE

To evaluate omidenepag isopropyl (OMDI) for its efficacy in intraocular pressure control (IOP) and adverse reactions following administrations in Japanese patients with open-angle glaucoma (OAG) over a 3-month period.

STUDY DESIGN

Retrospective observational study.

SUBJECTS AND METHODS

Group 1 included untreated OAG patients, Group 2 included OAG patients treated with prostaglandin F (FP) receptor agonists (monotherapy) and Group 3 included OAG patients treated with multidrug therapy, including FP receptor agonists. OMDI was newly administered in Group 1, and FP receptor agonists were switched to OMDI in Group 2. In Group 3, all other ocular hypotensive medications were continued except FP receptor agonists. IOP changes were examined, and adverse reactions were retrieved from the medical records.

RESULTS

Group 1 included 32 eyes, Group 2, 20 eyes and Group 3, 17 eyes. In Group 1, the baseline IOP was 15.7 mmHg (95% confidence interval [CI] 14.7-16.8 mmHg). After eyedrop treatment, the IOP was 14.1 mmHg (P < 0.001) at 1 month and 13.7 mmHg (P < 0.001) at 3 months. By contrast, in Group 2 and Group 3, switching FP receptor agonists to OMDI did not result in significant IOP changes (P ≥ 0.71). Six patients developed adverse reactions (hyperemia, headache, ocular pain, and swollen eyelids).

CONCLUSIONS

New administration of OMDI significantly reduced the IOP. Furthermore, the IOP did not change after switching from FP receptor agonists to OMDI, including multidrug therapy. OMDI can be used as a first-line drug and is comparable to FP receptor agonists in Japanese patients with OAG.

Efficacy and Patient Tolerability of Omidenepag Isopropyl in the Treatment of Glaucoma and Ocular Hypertension

Current therapeutic approaches for glaucoma aim to reduce intraocular pressure (IOP), which is the only available and reliable strategy proven to control the risk of disease development and progression. Omidenepag isopropyl (OMDI) is a novel topical ocular hypotensive agent that was launched onto the market for the treatment of glaucoma and ocular hypertension (OHT). After topical instillation and during corneal penetration, OMDI is converted into the active metabolite omidenepag (OMD), which behaves as a non-prostaglandin, selective E-prostanoid subtype 2 (EP2) receptor agonist. The topical administration of 0.002% OMDI once-daily (QD) possesses a 20–35% IOP-lowering effect, comparable to that of prostaglandin analogs targeting F-prostanoid (FP) receptor QD, which are the current first-line for pharmaceutical reduction of IOP. However, the mechanism of action and adverse events (AEs) of OMDI are different from those of FP receptor agonists. OMDI reduces IOP by enhancing both conventional trabecular and uveoscleral outflow facilities without complications of prostaglandin-associated periorbitopathy (PAP) seen with FP receptor agonists. Moreover, OMDI was also effective and well-tolerated in non-/poor responders to latanoprost and showed a stable IOP-lowering effect for one year, and its concomitant use with timolol enhanced the IOP-lowering effect. OMDI demonstrated acceptable safety and tolerability with good adherence and can be used in almost every patient. However, OMDI has some AEs such as conjunctival hyperemia, corneal thickening, macular edema/cystoid macular edema and ocular inflammation. Moreover, OMDI is contraindicated in patients who are allergic to the product, in aphakic or pseudophakic eyes, and in combination with tafluprost eye drops. If used appropriately in the right patients, OMDI could be an effective treatment option for glaucoma and OHT as a first-line alternative to FP agonists. Here, we summarize the results of clinical studies of OMDI and discuss its efficacy and patient tolerability in glaucoma and OHT in this review.