Drug-delivery innovations are helping to expand patients’ drop-free choices
Inder Paul Singh, MD, and Savak Teymoorian, MD, weigh in on the importance of decreasing the role of topical medications in the setting of glaucoma and cataract surgery.
Dr. Singh Says…
Drug-delivery modalities and other procedures that allow us to reduce or avoid the burden of topical drops for our patients are crucial tools in our toolbox. For glaucoma patients, a variety of technological approaches allow us to intervene earlier, stabilize intraocular pressure (IOP), and reduce the risk of poor compliance. I believe we underestimate the rate of noncompliance and how much it affects disease progression.
No Drops = Less Progression + Better Quality of Life
The 6-year extension of the LiGHT Study illustrates the role of treatment compliance in worsening glaucoma.1 Despite the same average 30% IOP reduction with initial selective laser trabeculoplasty (SLT) versus latanoprost, fewer SLT patients progressed to needing incisional surgery or experienced progression of their disease. SLT was also associated with less overall cost to the healthcare system.
There’s no doubt that eliminating drops lessens the chance of disease progression, and we also know that reducing the drop burden improves patients’ quality of life. Post-hoc analysis of iStent inject® (Glaukos) phase 3 studies found patients not taking drops had better scores on the Vision Function Questionnaire (VFQ-25) and Ocular Surface Disease Index (OSDI) questionnaire.2 Similar results were seen with the Hydrus® Microstent (Alcon).3 Compliance must be considered in terms of disease progression and quality of life.
Drug-Delivery Options
With drug-delivery technology, we can intervene even earlier right in the office. Durysta® (bimatoprost intracameral implant 10 mcg; Allergan, an Abbvie Company) is a 1-mm solid polymer matrix that releases the drug for 4 months. A phase 4 study of the implant found that 25% to 30% of patients continue to have effective IOP control for almost 2 years.4
iDose® TR (travoprost intracameral implant 75 mcg; Glaukos) is a drug-eluting intracameral implant anchored in the scleral wall through the trabecular meshwork that releases a proprietary formulation of travoprost. We found that 70% of patients in the phase 2b trials were still controlled at 3 years with the same or fewer medications.5 For ophthalmologists who perhaps do not feel comfortable with minimally invasive glaucoma surgery (MIGS) and working in the angle, iDose is an opportunity to intervene during cataract surgery and reduce the drop burden for patients.
Another biodegradable implant placed in the intracameral space, Paxtrava™ (travoprost 26 mcg; Ocular Therapeutix), uses the company’s Elutyx™ proprietary bioresorbable hydrogel-based formulation technology. Although the placement and technique are similar to Durysta, Paxtrava is unique in that it resorbs consistently at 6 months. The vehicle of Durysta may, on the other hand, last longer than the release of medicine. Ultimately, we would prefer the drug and the vehicle to release at the same time, a benefit for repeated administration. Recent phase 2 data show consistent and sustained reductions in IOP, statistically significant (P<.0001) through 6 months, with clinically meaningful reductions of 24% to 30%.6
Improving Ocular Health
Even taking patients off drops for 4 to 6 months spares the conjunctiva, cornea, and trabecular meshwork from preservative toxicity. If they have to go back to drops, they will be more comfortable and more likely to adhere to their regimen. We’ve also seen when you take someone off the drops, they’re much more willing to do something different to keep that drop-free world.
I tell patients there are many things I do along the course of their lifetime to help maximize their quality of life and still protect them from losing vision. It is important to set the stage that no one procedure or technology will stabilize their disease forever.
We need drops, of course, but now I think of them as a bridge—not as our mainstay therapy. It’s adjunctive therapy to SLT, drug-delivery technology, and MIGS. They are there if we need them.
Cataract Surgery With Fewer Drops
In cataract surgery, we are focused on obtaining accurate measurements prior to the procedure for precise results, so we emphasize optimizing the ocular surface. The same scrutiny and attention to detail we apply preoperatively should be applied postoperatively. After all, the same set of challenges exist with postoperative cataract surgery topical medications. Ultimately, a lack of compliance can limit or delay healing and cause visual symptoms.
Dextenza® (dexamethasone ophthalmic insert 0.4 mg for intracanalicular use; Ocular Therapeutix) intracanalicular insert offers multiple benefits following ophthalmic surgery. The bioresorbable hydrogel matrix, Elutyx, expands to the size of the canalicular system and treats inflammation and pain following ophthalmic surgery by releasing a slow tapering dose of preservative-free dexamethasone to the ocular surface for up to 30 days. The insert is an advancement in steroid treatment designed to allow for physician-controlled administration and enhance the patient’s postoperative experience.
In our office, we also find that eliminating a drop significantly improves staff efficiency. Patient access has never been better, and Ocular Therapeutix works with our staff to find a pathway for every payer type. They no longer have to worry about insurance coverage and extensive patient instructions outlining the tapering regimen and refill information. Published studies have validated that drops add more time to patient encounters and negatively affect the flow of the practice.7
Dr. Teymoorian Says…
With a host of options available for avoiding or minimizing drops, whether lasers, drug-delivery technology, or MIGS (with or without cataract surgery), I tell my patients, it’s like making a pizza. In the past, we had cheese and pepperoni. Today, we can pick any topping we want. It can even be gluten-free! We can now tailor care according to what is important for our patients.
Solving Problems
We all know about the compliance challenges and multitude of reasons why. Ultimately, I am a problem-solver for my patients. Why are they on drops? Have they been offered other options? I let patients decide the modality.
With drug-eluting technology like iDose or Durysta, or the pre-FDA-approved Paxtrava, the best option can depend on the type of glaucoma. I often use this approach when SLT loses its efficacy. As with Dr. Singh, I have also seen that once patients use a non-drop method, they never want to go back on their drops again and are much more open to other options.
We need to remember that, just because we are considering alternatives early on, doesn’t mean the patient has. Drops are what most patients are familiar with. I consider Durysta—or even iDose or SLT—to be the gateway to everything interventional glaucoma I’ve always wanted to do, but the patient wasn’t ready. Now they will be much more open.
Too Many Drops
Cataract surgery is another setting in which drops and compliance come into play. Surgeons might use postoperative antibiotic drops dosed four times daily (QID), a steroid also dosed QID, and a nonsteroidal anti-inflammatory drug (NSAID; branded, daily otherwise that’s also QID). That could be upwards of 12 drops a day! We take advantage of any opportunity to choose non-drop options, whether the antibiotic is an intracameral injection during surgery or for the postoperative steroid. I use Dextenza, although there are other options.
A normotensive glaucoma patient having cataract surgery will already be on more than 1 drop. The studies from the Baltimore Eye Studies show these folks need 2 categories to get good coverage. That’s 3 more drops for this poor patient who is now on 15 drops post-surgery. Glaucoma patients often forget their glaucoma drops because they are so concerned about their cataract drops.
Instead, we can use an intracameral antibiotic and Dextenza, then the patient is only on a topical NSAID post-cataract surgery. If the patient had an SLT or a drug-delivery device, they already have their glaucoma therapy in place. A complicated patient is now down to 1 drop a day. We know anytime you add 1 more drop, regardless of what it is, compliance goes down—not linearly, but almost exponentially. Add in quality of life and second-eye surgery and it becomes a disaster for older patients.
Conclusion
Compliance challenges associated with topical drops, regardless of what they stem from, are a huge obstacle to consistent and reliable disease control. Removing drops in favor of hands-free options that remove patient adherence from the equation and are tailored to meet individual needs has advantages beyond better IOP control and an improved and more predictable postoperative course. Quality of life for our patients should also be a priority.
Inder Paul Singh, MD, is at The Eye Centers of Racine & Kenosha. He can be reached at [email protected].
Savak Teymoorian, MD, is at the Harvard Eye Associates in Orange County, California. He can be reached at [email protected].
References
- Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Laser in glaucoma and ocular hypertension (LiGHT) trial: six-year results of primary selective laser trabeculoplasty versus eye drops for the treatment of glaucoma and ocular hypertension. Ophthalmology. 2023;130(2):139-151. doi:10.1016/j.ophtha.2022.09.009
- Samuelson TW, Singh IP, Williamson BK, et al. Quality of life in primary open-angle glaucoma and cataract: an analysis of VFQ-25 and OSDI from the iStent inject® pivotal trial. Am J Ophthalmol. 2021;229:220-229. doi:10.1016/j.ajo.2021.03.007
- Medeiros FA, Walters TR, Kolko M, et al. Phase 3, randomized, 20-month study of bimatoprost implant in open-angle glaucoma and ocular hypertension (ARTEMIS 1). Ophthalmology. 2020;127(12):1627-1641. doi:10.1016/j.ophtha.2020.06.018
- Montesano G, Ometto G, Ahmed IIK, et al. Five-year visual field outcomes of the HORIZON trial. Am J Ophthalmol. 2023;251:143-155. doi:10.1016/j.ajo.2023.02.008
- Ichhpujani P, Thakur S. iDose TR sustained-release travoprost implant for the treatment of glaucoma. touchREVIEWS in Ophthalmology. 2023;17(1):4-7. Doi:10.17925/USOR.2023.17.1.4
- Ocular Therapeutix™ announces positive phase 2 PAXTRAVA™ glaucoma data at the American Society of Cataract and Refractive Surgery 2024 Annual Meeting. April 6, 2024. Accessed September 5, 2024. https://www.biospace.com/article/releases/ocular-therapeutix-announces-positive-phase-2-paxtrava-glaucoma-data-at-the-american-society-of-cataract-and-refractive-surgery-2024-annual-meeting/
