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Glaucoma may transition to surgery-first management
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The medical treatment of primary open-angle glaucoma by the ophthalmologist has some similarity to the treatment of hypertension by the primary care physician.
On the positive side, in both cases the physician has multiple medication options with different and synergistic mechanisms of action. On the negative side, patient compliance with the recommended regimen is universally poor, as no immediate positive quality-of-life impact is noted when the medication is taken, nor is any immediate negative impact on quality of life experienced when doses are skipped. Thus, there is only the somewhat nebulous long-term fear of chronic damage to sensitive structures, including the heart and kidneys, and the increased risk of stroke to motivate the patient with hypertension and the fear of chronic optic nerve damage or a retinal vascular occlusion in glaucoma to motivate good compliance.
Study after study confirms that these motivations are inadequate to ensure good compliance in these patients. The ophthalmologist is more fortunate than primary care colleagues because highly effective laser and incisional surgical treatments are available as alternatives, and with the recent U.S. Food and Drug Administration approval of the Glaukos iStent, we have a new and safe option that can reduce IOP and medication burden.
As we add effective and safe surgical treatment options over the next decade, I expect glaucoma to be more frequently managed by surgery in the future, but medical therapy remains the core treatment option today. Just as in hypertension, in which lowering blood pressure is the primary method of treatment, lowering IOP is the mainstay of glaucoma therapy. The primary care physician would love to have a safe and effective medication that makes the blood vessels, heart, kidneys and brain less sensitive to the long-term damage of untreated hypertension, but to date no such medication exists.
The same is true in glaucoma, in which neuroprotection has been a graveyard for many promising pharmaceutical agents. Some patients and physicians turn to over-the-counter nutritional supplements such as ginkgo biloba, but good data supporting its use are lacking, and chronic use of this herbal remedy is not without risk. I am not optimistic that we will see the market release of a truly effective neuroprotective agent in the foreseeable future.
Thus, other than continuing to treat more glaucoma patients with laser and incisional surgery, which in my opinion is a trend that is firmly in place and quite defensible, we are faced with the challenge of enhancing patient compliance. On the positive side, we have topical medications that are quite safe and effective. On the negative side, no amount of encouraging, cajoling or threatening seems capable of getting many, if not most, patients to take them. We do know that once-daily or at most twice-a-day medications have a higher compliance rate than those that require more frequent administration, and fortunately we have drugs such as prostaglandin analogues and beta blockers that require only once-a-day dosing. As we add second and third medications, compliance goes down, and combination drops can be helpful in this regard.
I personally would like to see more combination drops available, and even though not more effective than each drop taken individually, the enhanced ease of use, potential reduced cost with fewer co-pays and compliance make them attractive to many patients and physicians. In many cases, such as postsurgical management of infection and inflammation, significant differences in dosing regimen and duration of treatment make a combination product less logical. In glaucoma, two once-a-day medications given as a single dose can be expected to enhance compliance significantly.
There is new research that suggests that daily reminders to take a medication can enhance compliance significantly, and I find the concept of increased use with such reminders quite promising. Now that my iPhone and I can have a constructive conversation, I look forward to the day when it can routinely remind me and my patients to complete tasks such as taking medications in a timely fashion. I recently heard of an application called iDrops that is designed to do exactly that.
Finally, tremendous amounts of financial and human capital are being invested in developing drug delivery devices that will make our concerns with patient compliance a historical footnote. Sustained drug delivery devices include implants; injectables into the anterior chamber, vitreous, suprachoroidal, subconjunctival and sub-Tenon’s space; refillable reservoirs; contact lenses; implants in the conjunctival fornices; and punctal plugs, to mention only a few. These devices hold the promise of enhancing compliance, but increased cost will be an issue. In addition, if we are seeing our patients once every 6 months, we need a high level of confidence that the sustained-release device will remain in place and continue to operate reliably throughout the treatment period.
While topical drops taken reliably work well, as will many of the sustained-release devices in development, I must admit that I am most excited about the new generation of minimally invasive glaucoma surgery devices and look forward to resolving the compliance issue by making more of my patients independent of medication by operating on them. I admit that I have a surgical bias in the treatment of disease, but if I could undergo a procedure as low risk as selective laser trabeculoplasty or iStent implantation to cure my hypertension, I would be scheduling surgery next week. Successful surgery has much to offer patients, physicians and society, including enhanced quality of life without the hassle of medication refills and management, elimination of compliance issues, and potentially reduced cost. As safer and more effective glaucoma procedures evolve, transitioning to a surgery-first approach for glaucoma is extremely attractive.