Who’s the right patient for iDose TR (travoprost intracameral implant) 75 mcg?

Ophthalmology 360 presents, “Who’s the Right Patient for iDose TR?” featuring Drs. Blake Williamson, Sahar Bedrood, and Steven Sarkisian.

Blake Williamson, MD, MPH, MS:

Hey everybody. Very excited to be here tonight to talk to two of my dear friends in the MIGS world, Sahar Bedrood and Steve Sarkisian. Maybe just take a second for those who aren’t aware of you guys or friends of you guys like I’m lucky to be. Maybe just talk about where you practice and we’ll start with that, Sahar.

Sahar Bedrood, MD, PhD:

I’m Sahar Bedrood. I’m a glaucoma and cataract specialist. I practice in Los Angeles at a practice called Advanced Vision Care.

Steven R. Sarkisian, Jr., MD:

Hi, I’m Steve Sarkisian, founder and CEO of Oklahoma Eye Surgeons in Oklahoma City.

Blake Williamson, MD, MPH, MS:

You guys make it entertaining and that’s why we’re all together talking about something that I think we all care about, not only because it’s important to glaucoma and the evolution of how we take care of patients, but because it’s something that we all think can be extremely beneficial in a multitude of patients. And that’s the iDose TR. That’s sort of what’s brought us together tonight to talk about the iDose TR. Who might be a good candidate for this, why are we using this, what our early experience has been. Because the reality is to three of us, this is something we’ve been talking about for a really long time.

However, I just got a call from a friend of mine today who does a ton of glaucoma, does more Ahmed valves than just about anybody in my state down here in Louisiana who has yet to put in an iDose TR, not because they don’t want to, but just because for whatever reason they haven’t had access to it yet. And so people really are tuning into things like this to try to understand what this thing is, who do use it for, how they can get it. Sahar, maybe just start with you. Who do you think is a good candidate for iDose TR? How are you choosing this versus an SLT or some other type of surgical procedure?

Sahar Bedrood, MD, PhD:

If you want to get into nitty gritty of who should we actually put these into, yes, we want angles that are open. Think about patients that either can’t tolerate drops or perhaps can’t put them in, or perhaps they don’t want anything surgical and don’t want to rely on drops. I mean, those are candidates that I have thought about and the candidates that I have put them in are people who responded well to prostaglandins, who have open angles and who for whatever reason didn’t or couldn’t put these in. And it’s usually for non-compliance, you’ll see it because a patient will come in, they’ll have some pressure spikes, then you put them back on, the pressure goes down and they have to have an open, honest discussion of can you do this? Can you use these drops? So those have been the candidates for me, but frankly, I mean the label is pretty open and you can use it on any patient that you would normally want drop lowering with the prostaglandin.

Blake Williamson, MD, MPH, MS:

Steve, same question. Who’s sort your fastball in this thing?

Steven R. Sarkisian, Jr., MD:

Glaucoma, our eye drops cause a lot of dry eye. And if you have a patient that is on glaucoma medicine and is also on cyclosporine, you have to think to yourself, what on Earth are we doing? We are creating and curing a problem at the same time. And if you have people that are symptomatic with dry eye and are on glaucoma drops, I think almost every one of those people need to be… you need to offer the iDose TR to them because you can most time effectively get them off a lot of their dry eye medicine and their glaucoma drops. If you look at… I was blessed to be part of the phase 2 and phase 3 trial for iDose and all those patients, I just stopped all their drops. If they were on three drops even, I stopped them all because a lot of times doctors will just keep piling on drops.

They might be a non-responded to one, but they don’t really stop it or one of them is the patients just aren’t taking them. Compliance is horrible. We all know perfect compliance is only 10%, and if you don’t believe that, look at the data. That’s what the data suggests. And people say, “Well, not my patients.” Well, yes, your patients, they’re like brushing their teeth before they go to the dentist. They use their drops before they see you. The pressure’s great and you wonder, why is this? Why are they getting worse? They must have low tension glaucoma. No, they don’t have low tension glaucoma. They’re just not compliant.

So patients that describe difficulty taking dry eye drops, patients with dry eye, I mean half the people you see in any given day with glaucoma are probably excellent candidates for the iDose. And I would stop all those drops and amazingly their pressures would be controlled on no drops with the iDose, and people think, well, what about it’s going to cause a cataract? No one in the study got a cataract and 70.4% of the patients in the study were phakic. Many of my patients were phakic and naive to therapy with elevated pressure and it was like, “Hey, I have this opportunity. Do you want to consider this?” Absolutely. That sounds amazing. They did very, very well and were very happy. And it’s amazing. You’ll find so many patients that are interested, especially now that it’s FDA approved and commercialized.

Blake Williamson, MD, MPH, MS:

Sahar, what about you? Maybe talk about what you’re seeing with the cases you’ve done. How did the early cases go? Was there a learning curve to it? What’d you think?

Sahar Bedrood, MD, PhD:

Yeah, my early cases, they went well. I mean, so smooth. If you are comfortable in the angle, then this is a pretty straightforward procedure. Yes, it has some nuances that are a little bit different than putting in a stent or a MIGS. It’s not a MIGS surgery, it’s an implant and you need to make sure it’s anchored well and that it’s not mobile. But honestly, I think the learning curve is pretty straightforward, pretty good.

Patients are very comfortable. I think when I’ve seen them post-surgery, they may even notice that it was such a easy process for them. And then more importantly, they continue to see me and they’re doing well and they’re stable and they’re happy not to take a drop. One of the early cases that I did, it was a patient who had really asymmetric glaucoma. One eye had a trabeculectomy in the past and had some significant vision loss. The other eye was really early glaucoma, and she just would take her one drop, but it was really bad compliance with it, so I presented it to her. I was like, “If you take the drop, you have one drop, you’ll have control. Otherwise, I’ll have to do surgery or I have this option of doing the iDose TR, which is an implant that has the drop inside.” And it was a no-brainer. I mean, it was a quick like, “Yes, I want option number three.” And we did it and it was straightforward and it was like, okay.

Blake Williamson, MD, MPH, MS:

You mentioned that conversation you had, and I was just listening to Steve a minute ago too, just talking about he knows that the patients aren’t taking their drops or doing what they’re supposed to do. You’re seeing them getting worse, I feel like a lot of our colleagues or maybe some of our colleagues know that, feel that, but just don’t quite take that next step to doing something about it even now. Sahar, how did you get that confidence to say, “Yeah, things aren’t going great. They could do better. We’re going to try to do something about it?” Because I just think that next step, even whenever some people recognize that something needs to happen, they just don’t quite do it. It’s almost analogous to in my world, the cataract-refractive world, patients who have these cortical spoking cataracts and can almost sort get them to 20/40, we’ll just push them off another year or two before they have cataract surgeries. They’re just doing the damn cataract for God’s sakes. So how do you teach that? Any words of wisdom for that?

Sahar Bedrood, MD, PhD:

It’s really hard to make that jump, and I appreciate it because all of us have done that, right? There is a leap of faith really in if it’s device that you’re using, if it’s a surgical device, in this case, if it’s the implant, you have to feel confident that it works. And the only way you can do that is by actually doing it and using it in your own hands. So there’s this, I call it an activation energy between wanting to do something and actually doing it. And once you make that and you start doing them, you will realize that you will start to believe in what you’re doing. And that’s the key. You have to believe in what you’re doing, otherwise you can’t offer it with confidence. And I believe in the technology, and I believe that it is straightforward and tolerable to the patients, and I present that as an option for them.

It’s not for every single patient, but if I see that they have ocular surface issues, difficulty remembering the drops, and they don’t need anything major surgically or they don’t want it, then I say, “I have an option to place the drop in your eye and it’s in a tiny little implant and then we take it from there and we monitor you and make sure your pressure never goes up.” And honestly, so many of them say yes. They’re like, “Yes, that’s what I want to do.”

And again, it comes from confidence and it comes from discussion, and it comes from learning and talking to you guys and going to meetings and looking at the data and feeling good about it. Because if you don’t have all of that, there’s no way you’re going to make that leap. You’re just going to sit there and do the same thing you’ve done over and over again. The other thing is that I don’t create a lot of options for patients. I give them my medical recommendation and I say, “This is what I think you should do.” And I think that really helps because if you create options for patients, they’re never going to know as much as me and you and Steve and all the other ophthalmologists out there. They’re going to rely on us. And so we have to move forward with confidence and see how they do.

Blake Williamson, MD, MPH, MS:

Yeah, same question, Steve. In my world of refractive, when you’re taking people to surgery, man, it better be a slam dunk. You better cure them. Get rid of all that myopia and nearsightedness or their astigmatism or else is a failure. And that’s not always the case in glaucoma. How failure or success is described is just way, way different. And I think that I learned that from folks like you early on, and it’s almost like the bar is not nearly as high. What you’re trying to do is do everything you can to get their pressure lower, but they still have an incurable disease, and so you have to kind of take your shot. So that always gave me confidence. It almost felt like more of a retina clinic than a refractive clinic when we’re talking about an incurable disease that I’m just doing everything I can to fight against. But I don’t know. What do you think, Steve? What’s your conversation go like and what gives you confidence to keep going with this stuff?

Steven R. Sarkisian, Jr., MD:

You have to be passionate about what you’re doing. All glaucoma doctors are not created equal. Glaucoma doctors in general are a different group. I mean, there are some people where no amount of evidence is enough for them. And we’ve struggled in… this is not a MIGS obviously, but there’s… it’s MIGS adjacent in that it’s technology and there’s so many things that have come out in the last decade that a lot of doctors still just do trabs and tubes and pile up drops and wait for laser until their patient’s on four drops. And this is a dead paradigm that is not dying. It’s dying one funeral at a time. And Charlie Kelman said it well, and he said, “Doctors debate and patients decide,” right? Doctors debate, the patients decide. When you believe in something, your patients, they believe in you and they’re confident in you and you treat them well, treat them with compassion.

Glaucoma is different though. I mean, even if you’re into new technology, it’s a journey. It’s not a treat them and street them and send them back to whoever. I mean, it’s really, it’s a journey and you have to be thinking, “Well, what am I going to do next? And what’s after that and what’s after that?” So it definitely is different, but I think the key is in believing and do it. And then you know what? The patients will find you. Every day I see a patient that was like, “Well, I was told this and I just can’t believe that this is all there is that I was told I need a trabeculectomy.” And it’s like, well, that can’t be the only option now. And I said, “Look, your doctor is not a bad person. And that may have been a reasonable, certainly an option, but let’s consider what else we have.”

And accepting a paradigm where you have a series of less invasive things that lead to your goal rather than, I mean, you can kill everything with a bazooka, but you’re going to have a lot of collateral damage. And the doctor’s like, well, you’re doing great. Your pressure’s six and your glaucoma’s not getting worse, but they have choroidal folds half the day and they have terrible dry eye from the mitomycin C exposure, the 5-FU exposure. So we just have to care about… we have to have that discussion and lead exactly like what Sahar said. You have to offer this early in the paradigm. Don’t wait for them to be out of control. You don’t want to lose.

You got to protect their visual field, protect their optic nerve, and this falls right up there with first line SLT. You can achieve targeting a lot of patients with mild to moderate and even severe glaucoma with something like the iDose TR. And then if they’re… Keep them off drops and it’s not failure if they were on three drops and you do an iDose TR and they’re on one drop, obviously not a prostaglandin. And it’s straightforward enough that you can, I have lots of doctors that refer me patients now for iDose TR, and then I am totally comfortable sending them back and letting them manage it because there’s really not much to do.

Blake Williamson, MD, MPH, MS:

I think that the most important thing, for us at least, has been understanding who we do this on, why we do it on them, but lastly, getting it in the hands of our surgeons at Williamson Eye, letting them know this is something they can do. For folks who have been confident with iStent inject, iStent infinite, I think the iDose TR, while it’s not a MIGS procedure, I think that anybody can do it. And for me, watching sort of the early returns in terms of IOP lowering, medication reduction, I think that we’re really lucky to have it. I don’t think it’s going away. I think it’s something that we’re going to have for a very long time. So just appreciate you guys hopping on tonight to talk a little bit about it. Thank you very much. And we’re hoping that more and more people get started with this. So thank you Sahar and Steve both.

Sahar Bedrood, MD, PhD:

Thank you for having us. Thanks for the discussion, Blake.

Steven R. Sarkisian, Jr., MD

Thanks, Blake.

IMPORTANT SAFETY INFORMATION for iDose TR (travoprost intracameral implant) 75 mcg

Dosage and Administration

For ophthalmic intracameral administration. The intracameral administration should be carried out under standard aseptic conditions.

Contraindications

iDose TR is contraindicated in patients with active or suspected ocular or periocular infections, patients with corneal endothelial cell dystrophy (e.g., Fuch’s Dystrophy, corneal guttatae), patients with prior corneal transplantation, or endothelial cell transplants (e.g., Descemet’s Stripping Automated Endothelial Keratoplasty [DSAEK]), patients with hypersensitivity to travoprost or to any other components of the product.

Warnings and Precautions

iDose TR should be used with caution in patients with narrow angles or other angle abnormalities. Monitor patients routinely to confirm the location of the iDose TR at the site of administration. Increased pigmentation of the iris can occur. Iris pigmentation is likely to be permanent.

Adverse Reactions

In controlled studies, the most common ocular adverse reactions reported in 2% to 6% of patients were increases in intraocular pressure, iritis, dry eye, visual field defects, eye pain, ocular hyperaemia, and reduced visual acuity.

INDICATIONS AND USAGE

iDose TR (travoprost intracameral implant) is indicated for the reduction of intraocular pressure (IOP) in patients with open angle glaucoma (OAG) or ocular hypertension (OHT).

Please see full Prescribing Information.

You are encouraged to report all side effects to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088. You may also call Glaukos at 1-888-404-1644.

Risk Information

The most common side effect of iDose TR was increased eye pressure. Other common side effects were inflammation of the iris, dry eye, a loss of part of the usual field of vision, eye pain, eye redness, and reduced clearness of vision.

PM-US-2316

The doctors were compensated by Glaukos for their time.