Practitioners aim to reduce medication burden in patients with glaucoma
It should be the goal of every ophthalmologist to reduce the medication burden for patients with glaucoma, whether through early detection, a reliance on new devices or a combination of treatment options.
“Think again about all treatment options available and how you make a selection. For early-stage patients, consider alternatives to medications. Moderate-stage patients, some may be adequately controlled without medications and some controlled with fewer medications due in part to the newer nonmedical treatment options. For late-stage disease patients, we need to consider the more invasive surgical options,” Janet Serle, MD, said at the virtual American Glaucoma Society annual meeting.
The goal of glaucoma treatment is to achieve IOP that prevents progression and achieves stability. Target IOP guidelines have been established from many large prospective clinical trials, but these are general guidelines. In each patient, it is important to assess risk parameters in addition to their disease stage, she said.
The range and duration of efficacy for alternatives to medical therapy have been evaluated in many studies. Selective laser trabeculoplasty has been shown to reduce IOP to a mean 16.6 mm Hg in the LiGHT trial, with 78% of patients remaining medication-free at 3 years.
“Prior to the introduction of MIGS, cataract surgery alone was observed to lower IOP. The control groups, cataract-only in the COMPASS-XT and HORIZON studies, supported the finding that some patients do have sufficient IOP control and do remain medication-free following cataract surgery alone,” Serle said.
However, the number of patients with adequate medication-free IOP control after cataract surgery is smaller than the number of patients who had a MIGS device added to the cataract surgery. IOP reductions also wane over time, she said.
Numerous studies show the efficacy of MIGS devices, with the mean postoperative IOP in the 11 mm Hg to 20 mm Hg range. However, the large range of efficacy in IOP duration is due in part to patient and procedure selection, as well as surgeon experience, she said.
More invasive surgical procedures, such as antimetabolite-enhanced filtering surgery and seton surgery, demonstrate postoperative IOP in the 13 mm Hg to 16 mm Hg range with reduced medication requirements with follow-up of up to 5 years, she said.
“Practitioners have to be comfortable with all treatment options. You must have experience with other options and be comfortable with the literature. You must believe in the choices before presenting them to a patient,” Serle said during a live discussion during the meeting.
Now is not the time to abandon invasive procedures, as they do consistently reduce IOP, and ophthalmologists cannot achieve successful IOP control in all patients without medical therapy, she said.
But the medication burden can be reduced. A more robust means of identifying patients with glaucoma, particularly early in the disease, can reduce dependence on eye drops, she said.
Collapse
Serle J. Glaucoma treatment: No eyedrops! Presented at: American Glaucoma Society annual meeting; March 4-7, 2021 (virtual meeting).
Read more about