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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.
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