EyeWorld Asia-Pacific March 2021 Issue

GLAUCOMA EWAP MAR C H 2021 47 by Liz Hillman Editorial Co-Director Where do eye drops fit in the era of interventional glaucoma? Contact information An: anja@health.missouri.edu Brubaker: jbrubaker@saceye.com Herndon: leon.herndon@duke.edu Provencher: LProvencher@cvphealth.com This article originally appeared in the December 2020 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. W here do drops fit in the era of interventional glaucoma—a time when there are new technologies, new drug delivery systems, and several MIGS options? It’s a time where patients’ treatments can be fine-tuned based on their need and availability of these newer agents, said Leon Herndon Jr., MD, but he, Jella An, MD, Jacob Brubaker, MD, and Lori Provencher, MD, all said there is still a significant place in their practice for drops. “From my standpoint, I think that medications serve a couple of roles,” Dr. Brubaker said. “One of them is if patients need adjuncts; in the more moderate to severe glaucoma, they, in a lot of cases, need more than one medication to be controlled. In those patients where they’re on 2–3 medications, it’s less likely that [selective laser trabeculoplasty (SLT)] or a sustained-release is going to be sufficient.” Dr. An said more than half of her patient population at a university center in the Midwest has advanced glaucoma and a lot of other comorbidities. “Drops still have quite an important place in my patient population,” she said. Dr. Herndon said different treatment options are recommended for patients based on their current and target pressures. Paradigm shift to first-line SLT Where interventional glaucoma has its prime time, Dr. An said, is early in the disease process. All of the physicians said they offer SLT as a first-line therapy to newly diagnosed patients. Each mentioned the LiGHT trial as shifting the paradigm toward laser being considered a first- line therapy. 1 Dr. An said she also offers SLT to patients with more severe glaucoma as well. “I offer it to all patients regardless of severity, especially if they are experiencing side effects, issues with cost and compliance,” she said. Dr. An cautioned overgeneralizing the LiGHT trial’s results because only 5% of the patients in the trial had more severe glaucoma. She reviewed data from her own patients, a sample size that included more cases of advanced glaucoma, looking for predictive factors that could impact outcomes of SLT and found patients with higher baseline IOPs had greater success rates and mean IOP reduction with SLT. 2 She also said it’s important to monitor these patients closely because the effect of SLT can wear off, and the attrition rate is different for each patient. Dr. Provencher also said she mentions the importance of regular follow-up to SLT patients. “A feeling of being medication-free has been one of the biggest concerns raised with first-line SLT and now more recently with intracameral delivery,” Dr. Provencher said. “Without the responsibility of a daily medication, will patients forget they have glaucoma and fail to follow up? Without proper counseling by their physician, it’s very possible.” When counseling patients of their options, Dr. Provencher said she discusses the life-long compliance, side effects, and cost of drops in addition to the risks of SLT. “I’ve found that most patients flinch at the word laser, but if you take the time