EyeWorld India March 2021 Issue

48 EWAP MAR C H 2021 GLAUCOMA to counsel on what to expect with SLT (painless, creates bubbles, takes under 5 minutes, etc.), they often reconsider. It is important to create an honest dialog about what treatment will work best according to each individual’s lifestyle and ability to adhere to the plan,” she said. Different classes of drops No drop is off the table for Dr. Provencher, who often treats complex glaucoma cases. In fact, most of the physicians who spoke with EyeWorld also said beta blockers, carbonic anhydrase inhibitors, and alpha agonist drops still have a place in their practice. “I do discuss the decrease in compliance that occurs as we add on medications. With each mediation addition, I make sure to review alternative options, such as SLT or MIGS,” Dr. Provencher said. Dr. Brubaker said the practice of adding single therapies as an adjunct is fading. “For me, it’s typically moving on to a combination medication. … You’ll get more bang for your buck and you’ll get to a lower target in those cases. That’s where my practice has shifted, rather than adding one drop at a time,” he said. Both Dr. An and Dr. Provencher said they opt for a once-daily prostaglandin analog, when they can. “Rhopressa [netarsudil ophthalmic solution, 0.02%, Aerie Pharmaceuticals] is great for that reason as well, and now we have Rocklatan [netarsudil/ latanoprost ophthalmic solution, 0.02%/0.005%, Aerie Pharmaceuticals], if a patient needs more than one class and the convenience of a single drop. I have been excited to see that insurance coverage of Rhopressa and Rocklatan is improving. I also consider Vyzulta [latanoprostene bunod ophthalmic solution, 0.024%, Bausch + Lomb] if patients do better with once-daily dosing but need a bit more IOP control than a PGA alone provides,” Dr. Provencher said. Dr. Brubaker said Vyzulta shines in its side effect profile. Dr. An had a similar thought as well. She said compliance can be poor with Rhopressa and Rocklatan due to redness or changes in vision. She said Vyzulta is a good alternative for these patients, but it’s often not her primary choice because it’s not quite as effective, though still better than latanoprost alone. All the physicians EyeWorld spoke with said it’s rare that they use miotic agents, outside of when the miotic effect is needed. Sustained-release medications Durysta (bimatoprost implant, 10 mcg, Allergan) was the first and is currently the only sustained-release, injectable glaucoma medication. Dr. Brubaker said he considers this, along with SLT, a first- line therapy, though he does think patients should trial on a prostaglandin drop to assess tolerance and what it’s like to administer regular eye drops. There are several other sustained-release options still in the pipeline, including iDose (Glaukos), a bimatoprost- eluting ring (Allergan), the Evolute intracanalicular insert (Mati Therapeutics), the intracameral implant ENV515 (Envisia Therapeutics), and the intracameral implant OTX-TIC (Ocular Therapeutix). Durysta and the status of these pipeline product was in “Sustained- release making inroads in glaucoma” in the May 2020 issue of EyeWorld . Open conjunctiva ab externo placement of a XEN Gel Stent. This technique can achieve a low target IOP, reducing or eliminating drops, while still providing a rapid visual recovery and favorable safety profile. Source: Lori Provencher, MD