58 EyeWorld Asia-Pacific | March 2025 “I think the important thing is to explain what the treatment is, why you picked that treatment, and what has to be done. Show them how to take drops, and make sure they understand why you’re doing visual fields. Usually, I’ll advance treatment if the eye pressure isn’t adequately controlled, based on the target pressure. I’d either substitute or add a drop or do a laser,” he said. For patients who can’t put in drops but need a drop, there are some newer devices available. These include Durysta (bimatoprost intracameral implant, AbbVie) and iDose (travoprost intracameral implant, Glaukos). “Both require making a little hole in the wall of the eye and implanting these devices. Durysta is a little pellet that dissolves over time that contains a prostaglandin. It can last for months. iDose is a refillable implant; it’s small, and it’s placed in the area of the eye where fluid leaves slowly over time [and] gives a constant amount of a prostaglandin analog.” Dr. Robin noted the expense of both of these products. The question is how to decide if a patient needs surgery. He said this depends a lot on the patient’s age. “If they’re young and healthy, I want to be more aggressive in the sense of keeping their pressure low because their life expectancy is longer. If someone loses a little bit of visual field every year, if they’re 90 years old and have a 5-year life expectancy, they’re not going to go blind. But if they’re 40 years old and have a 40-year life expectancy, they could go blind or be visually disabled in their lifetime.” Depending on the amount of damage and the rate of progression, the surgeon chooses which surgical intervention to go with, he said. There may also be physician preferences at play. Sometimes a surgeon may need to try multiple treatment options for the patient. The main reason to move onto another treatment, Dr. Rosdahl said, is when what is currently being done is not working due to side effects, documented progression (on visual field or optic nerve imaging), or high risk of progression (for example, if the IOP is higher than the target). Another reason to try a different treatment, she said, is if the patient is having cataract surgery; patients with mild to moderate open angle glaucoma might be able to decrease their eye drop burden if they get a MIGS device along with their cataract surgery. Challenges In Patient Education “I think the most challenging thing for me is to know whether a patient is adherent,” Dr. Robin said. We have to improve compliance, he said, adding that this is on both the patient and the doctor. He stressed the importance of physicians instructing patients how to put drops in correctly. Dr. Robin also emphasized the importance of protecting the optic nerve. There’s a lot of research currently going on looking at the best ways of protecting the optic nerve. There are companies with all different approaches, he said, adding that he hopes there will be a new development soon to make this easier. Patients are afraid of going blind, Dr. Rosdahl said. “For some people, that is motivating to have surgery, to decrease the long-term risk of vision loss; for other people, that is a huge barrier to having surgery, with the fear of shorter-term risk of postoperative complications and vision loss,” she said. “The hardest part of patient education for glaucoma, though, is not having treatment options to bring vision back that has been lost.” She recommended a number of resources from the American Glaucoma Society, the National Eye Institute, the American Academy of Ophthalmology, and others that offer handouts, podcasts, workshops, educational videos, and more. About the Physicians Alan L. Robin, MD | Emeritus Associate Professor of Ophthalmology and International Health, Johns Hopkins University, Baltimore, Maryland | robin@glaucomaexpert.com Jullia Rosdahl, MD, PhD | Associate Professor of Ophthalmology, Duke Eye Center, Duke University, Durham, North Carolina | jullia.rosdahl@duke.edu Relevant Disclosures Robin: None Rosdahl: None This article originally appeared in the December 2024 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Lorraine Provencher, MD, Glaucoma Editorial Board member, shared what evolving treatments and techniques in ophthalmology she is excited about: “We’ve had the suprachoroidal space on our wish list since the recall of CyPass [Alcon]. I’m excited to once again have the option to harness the power of uveoscleral outflow, either by endoscleral allograph reinforcement of a cyclodialysis cleft (available in the U.S.; Iantrek) or by a novel silicone stent, like the MINIject (not yet FDA approved; iSTAR Medical).” GLAUCOMA
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