Dropless glaucoma treatment: An elusive path to ease burden

Reviewed by Dr Janet B. Serle.

Being able to treat glaucoma without eyedrops has long been a goal for ophthalmologists. However, whilst it may be possible one day, it is not yet a reality and anti-glaucoma drops currently remain the first-line choice for many ophthalmologists.

Numerous surgical procedures and minimally invasive devices are also available to lower intraocular pressure (IOP). Some have been around for a long time, but within the past few years, numerous devices have entered the market with unknown long-term results and there are more still in the pipeline.

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Despite great progress in the field, the question remains as to which glaucoma treatment(s) can achieve and maintain the desired IOP level and prevent progression, according to Dr Janet B. Serle, professor emeritus of ophthalmology, Icahn School of Medicine at Mount Sinai, New York, United States.

Guidelines for clinicians

Clinicians can adhere to the general guidelines that have been established for target IOPs for different glaucoma stages, however, how well they work for individual patients remains to be seen. “For each patient, it is important to assess the risk parameters in addition to the stage of the disease,” Dr Serle said. “In some patients, we can hopefully get ahead of progression by treating the glaucoma aggressively, and in other patients we may be able to step back, accept higher target IOPs and carefully assess the most appropriate therapies.”

Many large clinical trials have evaluated specific procedures over different follow-up periods of time. The trials have generated widely varying outcomes regarding medication use and wide-ranging IOP results postoperatively. These range from no medications needed in 78% of patients followed for 3 years after selective laser trabeculoplasty (SLT)¹ to studies of minimally invasive glaucoma surgeries (MIGS) and gonioscopy-assisted transluminal trabeculotomy that resulted in a wide range of medications needed postoperatively.

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Dr Serle suggested that surgeons look outside the treatment box, rethink the current order by which they select treatment and determine if they should adjust that order. For example, should surgeons consider an SLT, an earlier SLT or a MIGS procedure, if appropriate, or should patients be treated more aggressively earlier in the disease process, especially in the case of young patients with potentially longer life spans? Another challenge, she pointed out, is identifying and diagnosing patients with early disease.

“I do not think it is time to abandon the traditional more invasive procedures, particularly in advanced disease, because these more consistently result in lower IOPs,” she commented.

Currently, however, although there are numerous non-medical options that are available for glaucoma management, physicians cannot now achieve successful IOP control in all patients without relying on medical therapy.

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Dr Serle emphasised that to manage and control glaucoma without eyedrops, there must be a more “robust” way to identify patients with glaucoma, especially those with early disease. Acceptance and incorporation of other, newer treatment options by patients and physicians should occur.

If intervention is successful, the progression curve may change, she said, and she noted the importance of demonstrating that surgical devices and procedures achieve satisfactory target IOPs for long durations during a patient’s life. The current devices meet the target IOPs in some patients, but the long-term results are unknown.

Conclusion

Dr Serle said that it should be a goal to reduce the medication burden as much as possible. “Physicians can think about how they select treatment,” she said. “For patients with early-stage glaucoma, consider options other than medications.”

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She added: “In moderate and late-stage disease, treatment with laser and/or MIGS and/or traditional surgery may reduce or eliminate the need for medications in some patients. For late-stage disease, more invasive surgeries may be more successful at achieving the required IOP with fewer or no medications.”

Reference

Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet. 2019;393:1505-1516.

Janet B. Serle, MD

e: janet.serle@mssm.edu

This article is adapted from Dr Serle’s presentation at the American Glaucoma Society’s 2021 virtual annual meeting. Dr Serle is a consultant to Aerie Pharmaceuticals, Allergan, Bausch + Lomb and Qlaris.

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