Is it time to shift from drops to interventional glaucoma?
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Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
Our monthly column focuses on early interventions in glaucoma. Medications are still largely adopted as first-line therapy but are associated with significant side effects and poor compliance. I. Paul Singh, MD, and Nathan M. Radcliffe, MD, discuss alternatives that are potentially more efficacious and may ease the burden associated with eye drops. Is it time to change our mindset?
Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor
SLT as first-line therapy
We have the potential nowadays for a true paradigm shift in glaucoma care, hitting the goal of stable long-term control while maintaining a high quality of life.
New options offer us the opportunity to intervene earlier in a safe way but aggressively enough to protect the nerve from damage. Trial data show us that patients treated early with drop-independent procedures are better controlled and progress less over time as compared with patients treated with drops.
The LiGHT trial highlighted how important selective laser trabeculoplasty is as an early first-line therapy. It is now considered first-line treatment in the United Kingdom and is listed as such in the American Glaucoma Society preferred practice patterns. However, although the data speak clearly, the adoption of SLT as primary intervention is still a little slow, perhaps for fear of being too aggressive or based on the assumption that patients prefer medications.
But what do patients actually want? From my experience, they want to get their pressure controlled and not lose vision. That is what they care about, and it is up to us to explain what we believe is best for them in a language they can understand. We are the experts, and they rely on us to guide their decisions.
To make our patients feel comfortable with adopting first-line SLT, I tell them that this is the most “natural” physiologic way to address their eye pressure. I use a simple explanation: “The eye is like a water balloon and has to make fluid to keep the shape of that balloon. The eye continues to make fluid, and there is a drain where the fluid leaves into the bloodstream. Your drain is getting blocked, so we use a beam of light to stimulate your natural drain that takes a couple minutes in the office. It is covered by insurance, it needs no injections or patches, and it helps the body to release its own natural enzymes to rejuvenate the drain. Your body is repairing itself.” I also tell my patients that SLT may not always work, but it does about 80% of the time. If it does not, we have other options, like drops if need be.
If you are confident and believe in the procedure, this will affect the way you communicate with your patients and how they will perceive your advice. Many ophthalmologists pose the question, “Do you want laser or drops?” Without context, it is no wonder why patients often answer, “No, I want drops.” I do not even use the word laser right away. I say it is a beam of light that rejuvenates. If they ask, “Is it a laser?” I say that it is like a laser pointer, it does not hurt, and it does not cut. It just stimulates the tissue to release enzymes and is so gentle to the tissue that you can repeat it again.
I also make my patients aware that we have a long journey ahead of us and that my job is bring their pressure down to protect their vision and, at the same time, maintain a high quality of life as best I can. I tell them I am going to start with SLT, but I have multiple different options at my disposal that I can use, if needed, along the course of our journey.
If patients are fully made aware of the side effects of topical medications, including meibomian gland dysfunction, allergic conjunctivitis, lash growth, ocular pigmentation changes, goblet cell loss, orbital fat pad loss and droopy eyelids, vs. the adverse events of SLT, most of them would end up saying, “I want SLT.”
I am hopeful that the Eagle laser (Alcon), cleared by the FDA in 2023, will help surgeons who have held off on SLT and now consider this treatment option. The Eagle is an automated, no-contact direct application of the energy through the limbus that is patient- and user-friendly. It does not require gonioscopy and will allow many ophthalmologists who are not comfortable with viewing the angle to perform the procedure.
- For more information:
- I. Paul Singh, MD, president of The Eye Centers of Racine and Kenosha in Racine, Wisconsin, can be reached at inderspeak@gmail.com.
MIGS and sustained-delivery implants
As Dr. Singh eloquently explained, there is no longer a reason to begin chronic therapy for primary open-angle glaucoma with eye drops.
The LiGHT trial clearly demonstrated that SLT for first-line treatment preserves vision, prevents surgery and maintains an excellent quality of life. However, eye drops are still used as the mainstay of therapy in primary open-angle glaucoma, and it is time we question this practice.
Of note, two major therapeutic areas have blossomed in the past decade or so. The iStent (Glaukos) was approved in 2012 and began the era of microinvasive glaucoma surgery, or MIGS. In parallel, new technology platforms for sustained drug delivery have become available. Durysta (bimatoprost intracameral implant, Allergan), our first sustained drug-delivery implant, was FDA approved in 2020, and in December 2023, the FDA approved iDose TR (travoprost intracameral implant, Glaukos), which offers the potential for sustained IOP lowering for years after a single administration. Additionally, many other microincisional glaucoma surgeries, including goniotomy, canaloplasty and other microstents, are approved and available to treat glaucoma as an alternative to topical drop therapy.
The data on topical therapy for glaucoma are unambiguous. Compliance hovers around 50% for patients who use only one medication and drops precipitously after a second or third pharmacotherapy is added. Tolerability remains a major problem with topical glaucoma therapy as well, with hyperemia rates of recently approved therapies in the 50% range. And at least half of patients on chronic topical glaucoma therapy receive a diagnosis of dry eye, which may bring them more symptoms and visual problems than their glaucoma.
In many ways, the reason why glaucoma topical eye drop therapy is so popular is because, to a certain extent, we live in a pharmaceutical culture and because pharmacotherapy is popular in other areas of medicine, such as diabetes, high blood pressure and cardiovascular disease. However, we do well to remember the major differences between orally administered medications, which are generally perfectly tolerated and can be self-administered by almost all people, and topical therapy, which is not so well tolerated, delivers local side effects and, in fact, cannot be accurately administered by most people. The reality of the situation for pharmacotherapy is that it is a temporary therapy, in many cases lasting only 8 hours.
We can do better. Changing the paradigm will require us to educate ourselves, our colleagues and our patients on the relative benefits of sustained drug delivery and MIGS.
- For more information:
- Nathan M. Radcliffe, MD, associate professor of ophthalmology at Mount Sinai in New York, can be reached at drradcliffe@gmail.com.
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