2. Company: Aeon Astron Europe B.V. Date: Apr-15-2013 Management of Glaucoma Surgery: Indian Perspective

3. Overview Background Glaucoma overview Are we ready to meet challenge Surgery Forward – A “Cutting” edge solution? Trabeculectomy and its limitations New surgical trend and collagen implant Scientific merits Moving forward

4. Glaucoma Overview Glaucoma is the second leading cause of blindness in India(Vijaya et al., 2006) India est. to host 20% world glaucoma ppl by 2020 (Quigley & Broman, 2006) Estimated approx. 12 million affected in 2010, and est. to reach 16 million in 2020 (Vijaya et al., 2006)

5. Are We Ready to Meet Challenge? Many public & private hospital offer high quality care by well trained residents, BUT More than 90% glaucoma remain undiagnosed contrary to 50-60% in developed countries (Ramakrishnan & Mona, 2011) In 2001, est.12,000 ophthalmologists (i.e., 1/100,000 pt) with few glaucoma specialist (George etal., 2010) Most ophthalmologists (70%) locate in urban cater only 23% ppl (Anderson & Douglas, 2003) Medicine side lead to decreased QoL, poor compliance, along with life-long cost burden

6. Surgery Forward – The “Cutting” Edge Solution? Suggested glaucoma surgery to overcome socio-economic burden with controlled IOP outcome (Ramakrishnan & Mona, 2011) Ideal surgery is Easily performed by all surgeons Requiring simple instrumentation Minimal complications Replicable technique with short learning curve Economic with long term success outcome

7. Trabeculectomy – Golden Standard Option Trabeculectomy remains the “gold standard” surgical option for reduction of IOP after failed maximal tolerated medication However, episcleral fibrosis and subconjunctival scarring are the major causes of surgical failure

8. Limitation of MMC MMC and 5-FU are the most commonly used adjunctive for the inhibition of fibroblast proliferation to prevent scarring Chemo toxic and teratogenic Blebs is thinner with more irregular epithelium, breaks in basement membrane, fewer goblet cells, and atrophic and avascular stroma Blebitis or endophthalmitis commonly associated with thin, avascular, leaking blebs

9. Comprises > 90% atelocollagen and< 10% glycosaminoglycans Highly porous structure with pore sizes ranges between 10~300µm Good pliable strength to maintain the surgical space Biocompatible and biodegradable Ready for use What is ologen ® Collagen Matrix

10. What’s Mechanism of Action in Collagen vs. MMC? Thin epithelium Non-selective cell death results wound healing with thin avascular epithelium Wound bed Cell death with reduced cell migration Wound bed with spongy collagen scaffolds Proliferation and migration encouraged Porous scaffolds provide spacious binding sites for fibroblasts attachment to enable healthy tissue regeneration Physiological wound healing

11. 10 Surgical technique remain unchanged. One LOOSE stitch over the scleral flap (keep 1-2 mm edge open) is recommended Simply place ologen ® on the top of the scleral flap under conjunctiva 123 456 How is ologen ® Collagen Matrix used?

12. Comparison Between ologen ® CM and MMC ologen ® CMMMC No clinical significant risk known Non-toxic origin Non-teratogenic Natural wound healing without MMC Physiologic, vascular bleb Comparable surgical success rate as MMC Biocompatible Biodegradable Quick deployment without preparation Save operation time Teratogenic Toxic to ciliary body, corneal endothelium Thinning of conjunctiva & bleb wall Avascular bleb Increased risk to infection & endophthalmitis Preparation required Prolong surgical time in handling, application & disposal Special facility required for handling (Hume hood)

13. Accreditations & Merits CE marked, FDA 510k cleared, Canada approved Over 150 scientific publications in academic conferences & journals Discussed in 2 textbooks Diagnosis & management of Glaucoma Basic concepts of glaucoma Other ongoing studies

14. Research – 2-year Randomized Controlled Study Prospective randomized controlled trial Postop. visit at 24±4 hours, 7±1 days, 2 weeks, and 1, 2, 3, 6, 12, 18 and 24 months Outcomes: IOP target ≤ 21, ≤ 17, ≤ 15 mm Hg (complete or qualified success) Moorfields bleb grading system; SD-OCT (Topcon 3DOCT-1000) Number of glaucoma medications Postoperative adjunctive procedures Complications Published in Eye Sep-16-2011

15. 2-year Study of ologen ® Collagen Matrix MMC groupOLO groupP 3 rd month 14.7(3.9; 12.9-16.4) 44.5% 15.0(3.8; 13.3-16.7) 45.1% 0.806 6 th month 14.7(4.3; 12.7-16.6) 44.5% 14.1(3.1; 12.6-15.4) 48.4% 0.615 12 th month 15.0(3.0; 13.6-16.4) 43.4% 15.2(2.8; 13.8-16.4) 44.3% 0.828 24 th month 16.0(2.9; 14.6-17.4) 39.6% 16.5(2.1; 15.5-17.4) 39.5% 0.536

16. 15 Looking Forwards Promote glaucoma awareness Improved early diagnose rate Save patients before vision loss Collect clinical data to study socio-economic burden Welcome opportunity to allies Vision Foundation across Taiwan, Japan to initiate glaucoma care program