First-line treatment for glaucoma is typically pharmacologic and aimed at lowering intraocular pressure, which is the only modifiable risk factor to date. However, successful treatment with traditional topical glaucoma medications may be limited by their well-known barriers of adverse effects and poor patient adherence to drop instillation. Tune in to hear Dr. Qi Cui and Dr. Davinder Grover discuss the novel pharmacological therapies and minimally invasive glaucoma surgery procedures that can lower treatment burden and increase compliance.
Lessening Glaucoma Treatment Burden: Clinical Cases (Part 1)
Lessening Glaucoma Treatment Burden: Clinical Cases (Part 1)
Welcome to CME on ReachMD. This episode is part of our MinuteCME curriculum.
Prior to beginning the activity, please be sure to review the faculty and commercial support disclosure statements as well as the learning objectives.
This is CME on ReachMD, and I’m Dr. Qi Cui. Adherence is one of the biggest challenges we face in our patients with glaucoma. How can we go about selecting treatments that will help patients to stay on therapy, control pressure, and preserve vision? Let’s consider some patient cases.
First, let’s discuss the case of an 85-year-old being treated for low-tension glaucoma with baseline pressures averaging 18 mmHg in both eyes. She has mild visual field loss and is currently using latanoprost for intraocular pressure control. She also has early Alzheimer’s and relies on her son to administer the drops after he gets back from work each night. She recently received selective laser trabeculoplasty, which was unfortunately ineffective. Despite good medication compliance, her IOP [intraocular pressure] has been consistently above her goal of 14 mmHg. For her, adding more drops during the day is not a good option because she cannot administer them herself on a consistent basis.
How might we go about managing this patient’s intraocular pressure control? Well, we can consider a combination of netarsudil/latanoprost for her.
Netarsudil is a rho-kinase inhibitor that is thought to increase aqueous humor outflow through the conventional pathway, while the prostaglandin analog latanoprost reduces intraocular pressure by increasing uveoscleral flow. MERCURY-1 and 2 studies are phase 3 superiority trials comparing a fixed dose combination netarsudil 0.02% and latanoprost 0.005% to monotherapies of either netarsudil or latanoprost for 12 weeks. Results show that combination therapy surpassed monotherapy with respect to IOP lowering. In particular, the number of patients who achieved at least 30% intraocular pressure reduction after combination therapy was approximately double that of latanoprost monotherapy. Given limitations faced by this patient, combination therapy is likely to provide additional pressure control without needing to increase the frequency of medication administration. It is worth discussing with the patient and caretaker; however, the ocular side effects, including conjunctival hyperemia and corneal verticillata, are more common than with latanoprost alone.
Next, let’s consider the case of a 61-year-old business executive with mild primary open-angle glaucoma. His job requires frequent travel. He has had cataract surgeries in both eyes, as well as selective laser trabeculoplasty twice, with limited efficacy. He is currently using latanoprost in both eyes for intraocular pressure control with good effect, but often forgets his medications while traveling for work. His intraocular pressures were above his goal IOP during his last visit. He has also noticed more ocular irritation and redness around the eye. Is there something we can do to improve his intraocular pressure control?
Durysta is a biodegradable drug-eluting implant that contains 10 μg of bimatoprost and is injected into the interior chamber. It has been shown to be noninferior to topical timolol after 12 weeks of treatment and has demonstrated long-term efficacy even with a single injection.
Let’s think about patient selection for this implant to determine whether it might be appropriate for our patient.
The implant is indicated for intraocular pressure control in patients with open-angle glaucoma and ocular hypertension, which applies to our patient. Advantages of the implant include a single treatment with continuous drug delivery that does not rely on good compliance. Drug levels stemming from the implant on the ocular surface and periocular tissues have been found to be decreased compared to those after topical bimatoprost application, which may also decrease ocular surface and periocular irritation in our patient. Finally, it is contraindicated in those at risk for corneal endothelial cell loss, with narrow angles, disruption of the posterior lens capsule, a history of intraocular inflammation or macular edema, and an allergy to prostaglandins – none of which applies to our patient.
In a patient like this one with mild to moderate glaucoma, whose intraocular pressure is well-controlled on prostaglandin analogs, the bimatoprost intraocular implant is a good treatment alternative. One thing that should be discussed with the patient is that at present, the implant is only approved for one-time use, which means that repeat injections would incur out-of-pocket cost for the patient.
Well, that’s all the time we have for today. Thank you for joining me.
You have been listening to CME on ReachMD. This activity is provided in partnership with the National Eye Institute of the National Institutes of Health, of the U.S. Department of Health and Human Services along with Prova Education, and is part of our MinuteCME curriculum.
To receive your free CME credit, or to download this activity, go to ReachMD.com/Prova. Thank you for listening.
In accordance with the ACCME Standards for Integrity and Independence, Global Learning Collaborative (GLC) requires that individuals in a position to control the content of an educational activity disclose all relevant financial relationships with any ineligible company. GLC mitigates all conflicts of interest to ensure independence, objectivity, balance, and scientific rigor in all its educational programs.
Qi Cui, MD, PhD
Assistant Professor of Ophthalmology
University of Pennsylvania
No relevant relationships reported.
Davinder S. Grover, MD, MPH
Glaucoma Specialist, Ophthalmologist
Glaucoma Associates of Texas
Fort Worth, TX
Advisory Board: CATS Tonometer, iSTAR Medical, Sanoculis, Versant Health
Consulting fees: Allergan, New World Medical, Nova Eye Medical, Olleyes, Reichert, Sanoculis
Research: Allergan, New World Medical
- Stephen Chavez has nothing to disclose.
- Cindy Davidson has nothing to disclose.
- Elizabeth Lurwick had nothing to disclose.
- Andrea Mathis has nothing to disclose.
- Colleen Resnick has nothing to disclose.
- Robert Schneider has nothing to disclose.
- Stephanie Wenick, MPhil, has nothing to disclose.
After participating in this educational activity, participants should be better able to:
- Describe topical therapies and sustained-release formulations of antiglaucoma medications that may improve patient adherence
- Recognize minimally invasive glaucoma surgery (MIGS) uses and indications
- Evaluate clinical data of recently approved topical therapies, sustained-release formulations of antiglaucoma medications, and MIGS for patients with early- to moderate-stage glaucoma
- Implement strategies to individualize therapy for patients with early- to moderate-stage glaucoma
This activity is designed to meet the educational needs of ophthalmologists and optometrists.
In support of improving patient care, Global Learning Collaborative (GLC) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.
Global Learning Collaborative (GLC) designates this enduring activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Global Learning Collaborative (GLC) designates this activity for 1 nursing contact hour. Nurses should claim only the credit commensurate with the extent of their participation in the activity.
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This activity is supported by independent educational grants from AbbVie, Inc and Alcon.
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