Q:

I have an advanced glaucoma patient who won’t comply with drops, has had SLT and yet continues to progress. What are my options? 

“Daily usage of eye drops can be very difficult for some patients,” says Arkadiy Yadgarov, MD, director of glaucoma services at Omni Eye Services of Atlanta. “There are myriad reasons for suboptimal compliance with glaucoma medications, but the most common include forgetfulness, ocular discomfort and difficulty obtaining the medicine due to cost. Additionally, hand-eye coordination becomes more challenging in the aging patient, and arthritis can add to that trial.”  

With our patient, Dr. Yadgarov explains, the progressive OCT and field changes discovered during the examination were alarming and triggered an extensive discussion with the patient on disease severity and the ramifications of not pursuing a change in current management. Fortunately, compliance was identified as the primary issue. Adding more medicine usually leads to a further decrease in compliance. 

Surgical interventions are classically the next step in stabilizing glaucoma in patients who are poorly compliant. Current options include invasive procedures such as tube shunts and trabeculectomy, which are powerful and effective but rife with complications and adverse effects. Standalone minimally invasive glaucoma surgery (MIGS) procedures such as Omni or iStent Infinite are newer and safer options, with minimal side effects and complications. A drawback of MIGS is achievement of adequate IOP reduction can often be unpredictable, and the treatment effects can wane quickly. Medicines are typically safe and have a predictable dose-dependent response, but compliance is the biggest concern. Dr. Yadgarov points out that an innovative solution to providing a safe and predictable way to lower pressure is to facilitate release of medicine into the eye without the need for patient involvement. 

The iDose as seen implanted in the eye. Photo: Glaukos. Click image to enlarge.

Drug Delivery

Durysta (Allergan) was the first step in that direction. Approved in 2020, it is an in-office injectable implant that slowly releases bimatoprost intracamerally. The therapeutic effect is relatively short-lived, with IOP reduction that is greatest in the first six months and wanes after that. A second implant is typically not recommended or covered by insurance. 

In December 2023, the iDose TR (travoprost intracameral implant 75mcg, Glaukos) was approved by the FDA.  iDose is an implant, similar to the iStent, which contains a prostaglandin analog (travoprost rather than bimatoprost in this case). Once the implant is seated into the trabecular meshwork, the travoprost medication is released slowly over an average period of three years.¹

The FDA label allows for a single administration of iDose per eye to reduce IOP in patients with ocular hypertension or open-angle glaucoma. While the FDA has not yet allowed for a replacement device at the end of 36 months, current studies are underway to evaluate outcomes of implant replacement every three years. At 12 months, 81% of iDose TR subjects were completely free of IOP-lowering topical medications. iDose TR demonstrated excellent tolerability as well. The most common ocular adverse reactions reported in 2% to 6% of iDose TR patients were increases in intraocular pressure, iritis, dry eye and visual field defects, most of which were mild and transient.²

“Cost is the major issue of the implant, with a hefty price tag of $14,000,” Dr. Yadgarov says. “Patients with traditional Medicare with supplemental insurance will have the best coverage, but it will take some time for reimbursement to kick in.” 

Dr. Yadgarov is one of the first surgeons in the country to implant the device on carefully chosen patients and says he looks forward to the results as he follows these patients over time.  He advises that those interested in the device should speak to their local glaucoma specialist to come up with a game plan that will best help the patient.

Dr. Ajamian is board certified by the American Board of Optometry and serves as Center Director of Omni Eye Services of Atlanta. He is vice president of the Georgia State Board of Optometry and general CE chairman of SECO International. He has no financial interests to disclose.