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Dr. Van Tassel:
Achieving target IOPs with minimal treatment burden is key to helping our patients maintain good vision. So how should we use some of the recent advances in topical therapies and sustained release implants to achieve this?
This is CME on ReachMD, and I'm Dr. Sarah Van Tassel.
Dr. Schweitzer:
And I'm Dr. Justin Schweitzer, and I really care about the treatment burden for my glaucoma patients, trying to reduce that and make it easier for them and their quality of life. I'm going to share a case with you. So this particular case was a patient of mine that had normal-tension glaucoma. It was getting worse in the right eye, as you'll see with the visual field in the OCT here in a second. They also had a disc hemorrhage that was noted, which also was a sign to me that there's progression, not stability. Pressure was 15 and 14, down from 17, and the medication that this patient was on was latanoprostene bunod once a day in both eyes.
The cup-to-disc ratio is 0.80, with that disc hemorrhage at 10 o’clock. When we look at OCT progression here, there is thinning that's occurring, both in the temporal superior quadrant as well as the temporal inferior quadrant, and this was really occurring over a 3-year period with a ganglion cell defect. And then, we really had a good structural match here as well. So structural versus functional here. And you're looking at the visual field. You can see a paracentral defect there and the pattern standard deviation increasing over time. And so this is a patient we had to do something for. We have to intervene; we have to change the treatment that we're doing. And so there's a lot of considerations. Could we do surgery? Maybe. Could we do laser? Maybe.
But for me, I decided let's just switch to a different medication, try to make sure I don't change their life a lot. We switched to a combination agent of latanoprost and netarsudil once a day. They took this at night.
Their pressure check in 6 weeks, as you can see here, 11 in the right eye, 10 in the left eye. We were able to get that pressure down about 3 more points and hopefully, in a tough patient with normal-tension glaucoma, slow down or at least stop progression.
Dr. Van Tassel:
Wow, great case. That's a great example. Some patients are good candidates for sustained-release therapy rather than changes to their topicals. I have here a case of a 91-year-old pseudophakic lady, best corrected 20/40, 20/30. My impression is that her target pressure is around 14 in both eyes, and we have been able to achieve that with a fixed-dose combination dorzolamide-timolol and latanoprost, but it was really causing a hardship for her. Installation was a burden to her, her caregiver, her daughter, and her ocular surface was bone dry. So we elected to go with bilateral sequential intracameral bimatoprost for her. Her starting pressure was 14. About 3 months later, still 14. And I wrote here the quote from my electronic medical record to just share how happy she was, she really did say it was life-changing to her. So hopefully we will see a plateau in her progression, which I really think was more about a compliance issue rather than failure to truly meet her target.
Dr. Schweitzer:
Yeah, these treatments are powerful. You look at this particular video of bimatoprost SR insertion here, and we've already done a betadine wash. This patient has a few drops of proparacaine in their eye, and it's a 28-gauge needle. And it's going in about two bevel lengths. Once it's in two bevel lengths, the actuator button is pressed and you'll see the implant come out. It'll settle down in that inferior angle. Aqueous will start to penetrate it. It will start to swell a bit and medication is being released. And so a really nice procedure that doesn't necessarily have to be done in the operating room. This can be done behind the slit lamp as well.
Dr. Van Tassel:
Yeah, this is a great example.
As we wrap up here, I'd like my glaucoma colleagues to remember that sustained-release options may not be at the forefront of your therapy algorithm, but it's really important to keep them in mind and to start to adjust our algorithms because they're safe, they're effective. They make patients really happy.
Dr. Schweitzer:
Yeah. I'd like for optometry colleagues to know that medications, we have great options. But now we have great options like drug delivery, and to work with ophthalmologists in your community that are providing these technologies because it can make a huge difference for your patients.
Dr. Van Tassel:
Thanks to our audience and thank you, Justin, for being here.
Dr. Schweitzer:
Great to discuss treatment options with you, Sarah.
Dr. Van Tassel:
I'm Dr. Sarah Van Tassel and this has been CME on ReachMD.
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