Despite the COVID-19 lockdown, the FDA has continued to approve new therapeutics, many of which will impact how we manage glaucoma. The approval of Durysta (bimatoprost implant, Allergan), for example, yields the first intracameral sustained-release implant to lower intraocular pressure (IOP). In two Phase III studies, Durysta lowered IOP by approximately 30%; though it dissolves in about three months, the effects continue for years. Many other changes are on the horizon:

Diagnostic advances. Hysteresis, measured with the Ocular Response Analyzer (Reichert), is becoming increasingly useful. Research shows this measurement may be a predictor of glaucoma progression risk.1 For me, it’s often the measurement that determines if I should or should not treat a borderline glaucoma patient, or helps me better understand why they are progressing. 

Another new diagnostic tool for glaucoma is the Eyekinetix (Konan Medical). Most cases of glaucoma involve asymmetric nerve changes, and the device accurately and quickly measures pupils, including subtle relative afferent pupillary defect, overcoming the shortcomings of the swinging flashlight test.2

Treatment updates. Doctors are now closely addressing the ocular surface of glaucoma patients, as chronic preservatives combined with inflammation-inducing drops, such as prostaglandin analogs, can cause discomfort, quality of life issues and poor compliance. Now, more ODs are suggesting selective laser trabeculoplasty or preservative-free drops.3 

Another potentially useful procedure is MIGS at the time of cataract surgery. At this year’s AGS meeting, the four-year Hydrus (Ivantis) pivotal trial data was released, showing that 71.4% of patients (vs. 44.2% who had cataract surgery alone) who started the trial on one medication remain medication free post-op.4

New Tools for DED 

The FDA has also been busy approving new treatment options for dry eye:

The agency accepted the resubmission of the New Drug Application for Eysuvis (loteprednol etabonate ophthalmic suspension 0.25%, Kala Pharmaceuticals) for the short-term treatment of the signs and symptoms of DED.1 Also, the iTear100 Neurostimulator (Olympic Ophthalmics) was approved as a non-drug, external neurostimulator to temporarily increase acute tear production.2 Finally, Bausch + Lomb recently received approval for the Infuse daily disposable silicone hydrogel contact lens, made with a new material (kalifilcon A) designed with those who experience contact lens dryness.

1. Kala Pharmaceuticals resubmits New Drug Application for EYSUVIS for Dry Eye Disease. Business Wire. May 4, 2020. 

2. Olympic Ophthalmics receives FDA clearance for iTear100 neurostimulator. PR Newswire. May 14, 2020.

Telemedicine

 With COVID-19 mandating less time with and greater distance from patients, more clinicians have gone virtual. Not only that, reimbursements for telemedicine exams are now on par with live exams. While glaucoma may not seem to fit the usual virtual visit profile, many opportunities exist. For example, patients may come in for OCT, visual fields, hysteresis and an IOP check—and then schedule a telemedicine visit to discuss the findings. 

Keep in mind that the patient must request the telemedicine visit, which means you need to educate them that you provide virtual care. Document the same way you would with a live visit but record the amount of time spent with the patient. Then, email them a video or voice recording of the discussion, follow-up and any medication instructions. I even include an animation pertinent to glaucoma (via Rendia) that provides them an archivable recording regarding drops and dosing, which decreases call backs and patient confusion.

The world of glaucoma is changing, in a good way. We have myriad new opportunities to improve the lives of our patients with this vision-threatening disease.

Note: Dr. Karpecki consults for companies with products and services relevant to this topic.

1. Medeiros FA, Meira-Freitas D, Lisboa R, et al. Corneal hysteresis as a risk factor for glaucoma progression: a prospective longitudinal study. Ophthalmology. 2013;120:1533-40.

2. Pillai MR, Sinha S, Aggarwal P, et al. Quantification of RAPD by an automated pupillometer in asymmetric glaucoma and its correlation with manual pupillary assessment. Indian J Ophthalmol. 2019 Feb;67(2):227-32.

3. American Academy of Ophthalmology. Selective laser trabeculoplasty effective as a first-line treatment for open-angle glaucoma. www.aao.org/editors-choice/selective-laser-trabeculoplasty-effective-as-first. March 28, 2019. Accessed June 8, 2020.

4. Rhee D. Reduction in incisional glaucoma surgery after 4-years with a Schlemm’s canal microstent combined with cataract surgery for treatment of primary open angle glaucoma. AGS Annual Meeting, Washington, DC; February 27, 2020.