Medication-First Approach for Glaucoma

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During a roundtable discussion, Manjool Shah, MD, moderated a conversation with Tosin Smith, MD, and David Stephens, MD, which covered the evolution of treatment and management of glaucoma.

Manjool Shah, MD:

Great to see everybody. We’re going to have a fun conversation tonight about glaucoma, which is everyone’s favorite afternoon and evening dialogue. I’m joined by Tosin Smith, MD, and David Stephens, MD, of course, from all over the country. My name is Manjool Shah, MD. Good to hang out with you guys.

The glaucoma landscape continues to change. I feel like it’s almost cliche to say that we’re in the midst of a revolution, but it hasn’t slowed down yet. It’s starting to really challenge a lot of our prior dogmas in terms of how we manage glaucoma, how we think about glaucoma, where we utilize these tools, whether they’re medications, surgeries, lasers, etc. I want to start by almost taking a look back, because we’ve all been in the game long enough to have seen this transition develop in front of our eyes. We’ve been part of it as well.

Where do medications, historically, topical medications, fit into the armamentarium? Again, for years and years, way before we were in practice, there were very limited topical medications. There was a time when that wasn’t an option. But as you look back over your journey in the space, where do topical drops fit in comparison to everything else?

Tosin Smith, MD:

I want to say, first of all, thank you for having me, Manjool. It’s always a pleasure to get together and talk about what we do every day. But now, you’re throwing us real back into history, because that’s what it feels like. But I have to cast my mind back to medicines and where they have been in the paradigm of how we treated patients. It used to be first.

For a long time, topical medicines, at least in the USA, was what you initiated glaucoma therapy with. If I cast my mind even further back to the point where, for instance, the prostaglandins showed up on the market, it seemed like it was the birth of something new to us in glaucoma, just because of reasons that you had given about limited number of drops that you didn’t have to dose multiple times. They worked well, so they showed up on the market. That changed, even further cemented that fact about prostaglandins being first.

For somebody who practiced somewhat on 2 continents, I also want to say that medication first is probably something that is very American. In certain other countries, for instance, if we go back to some countries where healthcare is delivered in a different way, surgery or trabeculectomies at that time may have been your first option for treatment for glaucoma. That is what birthed the CIGTS Trial, which is the Collaborative Initial Glaucoma Treatment Study, which wanted to compare what we do on this side of the pond to what they did on the other side of the pond, to see whether one was better than the other.

For me, it was what we did. It got better with the advent of newer, better drugs. Or should I say the prostaglandin class? I was all we knew, until recently.

Manjool Shah, MD:

Yeah. It almost seems like the advent of simple dosing regimen was the MIGS of a different era, right?

Tosin Smith, MD:


Manjool Shah, MD:

That is minimally invasive compared to QID pilocarpine or a trabeculectomy. But yeah, it’s still a part of our dogma. I think prostaglandins have been around for a generation now. Maybe two?

Tosin Smith, MD:

I didn’t want to date myself.

Manjool Shah, MD:

But it’s still, prostaglandins and topical medications in general remain, dogmatically, where we start therapy. David, what have you noticed in your journey?

David Stephens, MD:

I came into ophthalmology a little bit more recently, but when I started residency in 2015, it really was still a meds-first training. Everybody was on glaucoma drops. I can’t imagine having somebody who was medication-free. Laser SLT was like, “Well, we don’t really want to do surgery on this patient and they’re on 2 drops already. I guess we’ll try it.” But that was the advent of MIGS, that time.

iStent original had just come out when I was a third-year resident for residents to use, and so it was this really exciting time. We can do something besides a tube or a trab surgically, or CPC for a patient surgically in the middle. I got to see us starting to bridge the gap between complex medical regimens and tubes and trabs.

In residency, when we learn about all these historic trials, it’s interesting in the context hearing that about CIGTS, but we learned starting with the trab first just seemed crazy in the context of MIGS coming out, to my generation’s mind. But when you have people on QID meds or twice-a-day drops, and especially with the travel burdens internationally, it completely makes sense that you’d be starting with a trab.

I would say, since probably fellowship year and later, that’s really when the laser-first thinking has emerged more in light of the LiGHT Trial and things like that. But still, I think among especially a lot of community eye doctors, referring optometrists, primary eye care providers, it’s still very much, “Hey, you have glaucoma. We’re going to start you on a prostaglandin analog because it’s the best once-a-day medication. If you don’t tolerate it, we’ll switch to a beta blocker.”

Manjool Shah, MD:

The fact is we have really good drops. They do work, but there are failure points, certainly, to just the mechanism of how that drug is delivered, much less the specific drugs themselves. We all work in very different settings, different practices, different parts of the country.

How do you talk to patients about the modern way we manage glaucoma in comparison to what may often be their prior expectations? Whether it’s from family, friends, just their reading and Dr. Googling, etc. I think patients are also often expecting a drop first. They’re not expecting the side effects. How do you navigate those conversations?

David Stephens, MD:

Yeah. I am lucky to do a fair amount of first-time diagnoses, either from our own optometrists or referring optometrists. I do a fair amount of just regular surgical eye care, so I get the pleasure of doing full spectrum glaucoma, but starting them on the glaucoma journey, and you’re right, people come in with the perception that we’re going to discuss medications first. “Here’s a bottle. Take it every day or you’re going to go blind. Bye-bye, we’ll see you later.”

I like to put it a little bit in the context of, here’s how we typically have treated glaucoma: medications. This is how you use them on a regular basis. Then, put it in light of, if I was going to have glaucoma treatment, what would I do in your situation? Everybody’s situation is a little different. There are some people that may be excellent laser candidates, or may do better on drops. Maybe they have low-tension glaucoma or something, pigmentary glaucoma, different reasons for that, but I like to put it in historical context of how a lot of glaucoma surgeons are transitioning from a drop-first approach to a laser-then-drop approach. But there’s still a fair amount of patients who would prefer to start a medication first and see how they tolerate it. I like to go over, “Okay, that’s great. We need to use it every night to make sure that it’s working effectively. These are some of the side effects that will occur potentially early if you use it, and there are some longer-term side effects of drop use.”

I really like having that conversation with young patients who are starting drops: “Hey, you’re 35. If we start a prostaglandin first, you’re probably more likely to get long-term side effects if you’re on it for decades.”

Manjool Shah, MD:

Tosin, you guys are like a tertiary care referral center for a huge, huge area. Very often, your patients arrive on drops, multiple, and you’re trying to sort all that out. How do you disentangle patients from their drops? How do you have that conversation?

I’ll tell you, I notice that when I tell patients, “Hey, my goal is great pressure, is no drops, that’s what I’m fighting for.” They’re nervous letting go of that bottle, even if it’s causing issues. It’s this challenging and interesting space we’re in where we have this dialogue with patients.

We’ll talk a little bit about how we talk to our colleagues about an emerging paradigm, but how do you talk to your patients?

Tosin Smith, MD:

It’s a situation where people are stuck in the rot of what they’re used to. I have patients who get a glaucoma surgery who don’t need drops after the surgery. Somehow, between their visits, they feel the need to just put a drop in their eye because it’s what they’re used to. Conversations, usually, for us, it’s a little different because the patients that come to us, they need something.

Sometimes having a drop conversation is not hard. It’s usually one of going to tell that patient, “We’re moving on to the next thing,” which is usually surgical. In that conversation, it will happen that that next option may very well likely get you off all of your drops. That is always our goal: first and foremost, to get you drop-free.

Before, in taking care of your glaucoma and addressing that issue, we want to address the current high pressure you come in with. But then, also, you have those people who may not be at that point that they need surgery. There are some studies now that actually show that backing off of patient’s drops or modifying regimen, swapping out to give them fewer medicines, that sometimes is a place to start.

You may say, “Okay, let’s go ahead and take you off everything and use this one bottle, and let’s see what happens.” That, sometimes, is a soft landing ground for them, before you then proceed to the next thing. We have options now. We’re spoiled for options. If I see this works for you, this one bottle works for you, how about we swap it out for a dropless option, for instance?

I think the secret to it is knowing what your options are and working with that individual patient. Younger patients are easier to have a discussion with. They have a different history than those people who have done drops for a long time. Just noting who that patient is in front of you and knowing how to present the different options that you have. They’re usually quite excited, actually, the older ones, about the new options that they currently have available. Because their journey through this in managing their glaucoma has been a certain way.

We sometimes underestimate what our patients think in providing new options to them. Some, of course, will sit on the fence, but some are pretty excited about the new options.

Manjool Shah, MD:

I think that’s such a good point, Tosin. I think we, as clinicians, often we’re quick to blame our patients sometimes. “My patient won’t want a standalone MIGS procedure. They don’t want to go to the OR. They don’t want a sustained drug delivery option. They don’t want a laser, they just want their drops.”

But I think a lot of that sometimes is us covering for ourselves. We don’t want to have the conversation. It almost seems like if I’m doing the procedure, I’m assuming a responsibility that it works. That burden is sometimes a little bit extra compared to me writing a prescription for an eye drop. If that doesn’t work, it’s the drop’s fault, not my fault as the physician.

But I think you’re absolutely right. When docs are open-minded and start thinking a little bit more creatively, patients are excited. They sense your excitement also, your desire to optimize their quality of life, and I think they jump on board.

David Stephens, MD:

Yeah. I think there’s 2 aspects to what you hit on. One is, especially from an initial treatment standpoint, when a patient elects to start with the laser, they’re motivated to stay off meds, control their pressure. There’s a chance that it’s not going to be effective. SLT is not 100% effective, and so I think letting them know a lot of times. There’s no drop-free life with glaucoma, but a lot of these things that we do can minimize the amount that you need over the time of your life. Maybe we’re going to use meds to get us the next level.

“Hey, we didn’t quite get what we wanted with your laser. Let’s add a medication.” Or, “It totally wasn’t effective. Let’s start you on a drop until we get to the next thing.” Patients know that they’re probably going to be on and off meds for their life, but we have all these other things that we can do to limit them. It can be helpful. I’ve made the mistake sometimes of being so excited to keep people off meds that when we have to add them back, they’re like, “Wait, why is this a failure?” It’s like, “Well, your glaucoma is getting worse. Your disease is progressing. You’re going to just need more and more and more therapy, and a lower pressure as you age.” That is really part of the conversation. That can be valuable with them. It’s really this mesh of surgical, interventional, and medical therapies.

One thing you mentioned is just tailoring patient’s drop regimens when they come in on multiple meds, or pilocarpine 4 times a day and things like that. It’s like, “Hey, let’s change it to one branded medication. Maybe you’re just getting tons of preservative toxicity and very minimal effect from the additional 2 meds.” A lot of times, people come back with pretty similar pressures on one drop and they think you’re a hero.

Manjool Shah, MD:

Yeah. I think this opens that possibility of reviewing, “Hey, how does your eye feel? How does your body feel? How do you feel differently? How’s your life different when you’re on a reduced number of meds?” I think both of you guys shared that scenario. That, I think, for my patients who are on 3 bottles and they say, “Doc, I do them every day, it’s part of my life,” those folks, when we start to take a bottle away or another bottle away and you query, “How are you doing?” They notice what they’ve been missing. They notice how much better their eyes feel.

I’ve had people not realize that their shortness of breath was because of their beta blocker until the beta blocker is gone. Now they’re like, “Oh, I’m breathing better. I didn’t know I had a problem.” Things of that nature that really open the door. Then, open that door to that broader conversation about quality of life, too. Yeah, I think that’s great.

How do you guys talk to docs? You guys work with, alongside, and in communities where you’re leaders among the ophthalmologists and glaucoma care providers in your sphere. Again, there’s this dogmatic drop, drop, drop, maybe throw a laser in. I think the view that you outlined is still quite prevalent.

When you’re talking to docs, when you’re talking to colleagues, referring docs, etc., you’re obviously having a different conversation than when you’re facing the patient. How are you integrating what you know about medications versus lasers versus MIGS procedures and sustained drug delivery into your dialogue about what you offer? What’s out there for the glaucoma provider?

Tosin Smith, MD:

Having that conversation has become easier and easier for me. Because if I look to see how actually my colleagues have impacted the way that I practice, then I realize that sometimes it’s, first of all, an introduction to the topic. Then, one of the good things about the change in the paradigm is that we have so much more science behind it now that there is no reason not to change what you do.

My conversations usually surround, first of all, introducing the fact that I am personally doing more of maybe lasers first now. Occasionally, I’ll have the conversation as to how I do it, personally. I think, just like you said, it was a personal conviction. When I saw the 6-year results of the LiGHT Trial, there was no reason for me not to offer that first to every single patient who walked in the door who was appropriate for a laser. That’s what I started to do.

You came in, you were diagnosed, you got a laser first, and then we moved on to the drops as the other option. Having a discussion with colleagues about my experience, sometimes people want to hear… They want to know where the data is. You’ll be surprised that there are still people who do not know the LiGHT Trial and the results that came with that trial, but also what your experience is, and your conversations, and how you’re able to integrate that into your clinical practice.

I think MIGS has been around long enough now where there is a change in our outlook and in the way we handle patients, for instance, who have cataracts. There was a time early in the MIGS phase where people would do cataract surgery on someone and they would not do anything for their glaucoma. Now, that almost seems like that doesn’t happen quite so often.

Manjool Shah, MD:

It probably does, but probably, it’s starting to be frowned upon. I would say, now, I think the standard of care is shifting. You’re absolutely right.

Tosin Smith, MD:

Now, even the patients, when they become aware that there was an option that wasn’t offered to them, they have questions about that. The awareness is stretching out to everybody. Everybody’s becoming more aware. That’s the education part.

Then, science is coming out to back some of that awareness. Whether it’s in the trials that show us that visual field progression is less in people who have got a mixed procedure, along with their cataract surgery, or that the outcomes in those people who got a laser first early on in disease, they were less likely further down the road, at least the extent of the trial, to need a surgical procedure.

It’s very reassuring, and so it makes you then change what you do and encourage your peers to do the same in a way that is really based on size.

David Stephens, MD:

Yeah. When I started practicing about 5 years ago, I had some local docs who’d been seeing patients, and I was talking to them about starting with laser first. “Well, it doesn’t really work. SLT doesn’t work.” I said, “What do you mean SLT doesn’t work?” Because it’s not a visible sign that anything’s happened from the laser. It’s like, “Well, that’s generally how we start.”

Over time, the docs in the community, our primary doctors, our optometrists who do a lot of routine eye care, would see the results of these. Like how I started practicing, my practice patterns results from the laser: people coming back happy that they were off drops. Over the time, it’s just changed where they, “Oh, you have glaucoma? Let’s send you to Dr. Stephens. He’s probably going to recommend doing a laser. He might recommend starting drops.”

The practice patterns evolve as thought leaders, or people who are trying to be progressive, we change our practice patterns. Then, the downstream effect is the referring doctors seeing that change, experiencing the benefits, and then following in a way.

From our standpoint, and especially standalone MIGS, offering those things to patients, it takes a lot of time, I think. Still, I do see people who had standalone cataract surgery and glaucoma, and I’m thinking, “Oh, we missed an opportunity here.” But it’s becoming pretty unusual now to see, thankfully.

Manjool Shah, MD:

Yeah. That’s great. I think you guys are absolutely right, there is still a challenge in the community. But again, it seems like we’re not meeting as much resistance in terms of this, because we have this broadening evidence base.

Again, we have these outcomes data, like you mentioned, Tosin, about whether it’s visual field data, likelihood of needing secondary surgical intervention, perhaps better diurnal stability. Again, those are great at the end of the game. But as the person not doing the trabeculectomy or tube genre, or dealing with that catastrophic visual field fail, again, primary eye care providers, etc., may not be as worried about that. Obviously, they care, but that’s down the road.

But there are other considerations, like quality of vision, ocular surface, diurnal stability, compliance and things of that nature, that very much are within the wheelhouse of the primary eye care provider. How do you integrate that into your conversations with both patients and docs in terms of what our options are?

Tosin Smith, MD:

The interesting thing is that all of those things are the reasons why we have MIGS and why we have alternative drug delivery platforms now. Those are problems that we have dealt with, and we all deal with, in taking care of patients with chronic disease like glaucoma. You have patients come in, noncompliance, nonadherence. That’s a big issue with glaucoma patients. With that, patients will progress. Patients have stuck with the quality of life and ocular surface issue because of a lack of choice. But this generation is speaking up more to the fact that they need options that provide better quality of like.

The way I like to discuss it is that these are problems that we’ve always been faced with and we’ve always looked for solutions for. Well, we now have some solutions. We have ways of addressing some of these issues that have been put before us, complex dosing regimen. We’ve had them around long enough that we know what the effect of all of these things are. Well, now, you’re faced with how to take care of it, how to address it. It’s not really up to you, as that physician, to take care of the problems that your patients are presenting to you when they sit in your chair.

That is one way of thinking about it, that now, you have solutions for some of these long-lasting problems we’ve had. But unfortunately, the topical medications are real and they’re there, whether it’s anything from cost. They’re real and they just have to be addressed in a way that is beneficial, ultimately, to the patient.

David Stephens, MD:

Yeah. I like to say, jokingly, to other docs, whether we’re chatting or doing a formal talk, or even patients, that unfortunately, with glaucoma, we’re treating an asymptomatic disease at first. Patients only really see the effects of the therapy that we do, and so the only way I can make someone better in their glaucoma is by minimizing their medication burden.

If I get you off drops, that’s going to make you better. It might actually improve your vision a little bit with ocular surface disease. Understanding that we have a chance to help someone’s quality of life potentially by simplifying their drops, or reducing them with prolonged drug delivery or standalone MIGS is really exciting for us as glaucoma surgeons who’ve really been treading water for a long time with them and really struggling in clinic.

I think it speeds up your clinic day, too, if your patients aren’t on 3 or 4 medications. It takes us forever just to go through the drops. Then, by the time I come in, they’re telling me something different than the technician. They’re like, “Oh, no, I’m actually using that and not this.” I’m like, “Wait, but the technician wrote this down?” They don’t know. There are family members in the room who doesn’t know.

We’re in southwest Florida, where a lot of people spend their retirement years. As people age, just forgetfulness becomes a big problem, or dexterity, or needing caregivers to instill drops. Middle-of-the-day dosing is really hard for them. Even twice-a-day or once-a-day dosing can be very helpful for the caregiver who can’t make it that many times a day to instill their drops.

I think there’s a lot of these unknown ways that we can help our patients, but it really takes getting on their level and trying to figure out how we can meet them where they’re at.

Manjool Shah, MD:

A couple closing thoughts here. When we have so many options available to us, SLT, standalone MIGS, we have drug delivery, where do you start? I can almost imagine, especially when you’re jumping into the game here, you are a little bit paralyzed. You have so many good options, and everyone’s saying that this one’s the best and this one’s the best.

Tosin, David, where do you guys start? New patient. New patient to you, obviously. Where do you embark on the journey, and how do you navigate your patients in that first conversation as to where this journey is going to go?

David Stephens, MD:

I have stolen a little riff from my colleague, Brian Shafer. He likes to say, “There’s 3 ways we lower your pressure. There’s medications, lasers, and surgeries. There’s medications we put on your eye and medication put in your eyes. There’s little lasers and big lasers, and there’s little surgeries and big surgeries. Throughout your whole life, you might need one or a combination of those things. This is just the start of your glaucoma journey. I personally usually like to start your glaucoma journey with a small laser we do in the office called SLT.” I’ll go into that a little bit.

I think if someone is just starting out, if a physician was opening their own practice and they want to do interventional glaucoma, the easiest thing to do would be to add SLT to their practice. I think the simplest thing, if you’re going to add standalone MIGS, is probably to start doing goniotomies. If you’ve never placed an iStent or something, that’s probably a really good place to start with cataract surgery. Now, we have the ability to do iStents as standalone and refractory glaucoma. I think those two simple additions to a practice would help a ton of patients, especially in areas where they don’t have providers doing those.

Tosin Smith, MD:

Those are great ideas. I think that the one thing that I will add to it is, first of all, delivering the categories that way, but also remembering to consciously always remember to change our individual mindset. It is an intentional process. There’s always a tendency to gravitate back to the mean and what you’ve always known or what you’ve always done. But always keep my toolbox in front of me.

Sometimes, when you have all of those options, you tend to forget something. All of a sudden, you’re taking care of a patient, you may have used some of the earlier options. Then, you suddenly remember, you know what, I still have other options that will help me achieve whatever goal it is that I’m trying to achieve. Whether I’m trying to keep that patient drug-free because they have poor tolerance, or they have poor adherence to their medicines. Or you go onto the bigger things. They need a big type of glaucoma surgery.

I think just keeping things in the forefront, all your options in front of you, once you’ve learned what skills you can garner. Knowing that the fact that you’ve done big surgery doesn’t mean you can’t go back and tack on a small glaucoma surgery to it. I’ll give an example of a patient that I saw today, who has had a trabeculectomy.

I looked to see, okay, we know we can do SLTs after trabs, but she’d had SLT several times. Not effective. But I then thought about it. She has a cataract I need to go take out. She’s on 2 drops. I could either needle her bleb, but what else could I do? I could actually do a goniotomy on this patient. Because I know that GATTs in patients who had prior trabeculectomies or tube shunts will work to lower pressure as well.

That was me remembering all the things in my toolbox. Apart from that initial phase, I would say, always remember the tools you have in your toolbox there. We’re at a place where you can actually mix and match. You can add things at different points to help to keep your patients’ pressures controlled and prevent them from progressing from glaucoma.

Manjool Shah, MD:

Totally, and I love that. That’s a perfect way to close. Because what you described there not only is remembering all the tools in our ever-growing toolbox, but also remembering to challenge dogma. We were told for a long time that goniotomies don’t work in adults. We were told for a long time that the angle is dead once you filter.

Again, the list of dogmas and prior beliefs that we’re challenging over and over again. Like, “You got to start with a PGA first,” “You got to start drop, drop, drop,” “Laser doesn’t work,” as folks in all of our communities have said in the past. Over and over again, we’re realizing that this toolkit is broad and there’s a spot for everyone. It’s an exciting time. I think we touched on a lot. Thank you all so much for a fun conversation.

Tosin Smith, MD:

Thanks for having us.

David Stephens, MD:

Thanks so much.