This article was originally published in a sponsored newsletter.

In recent years, the landscape of glaucoma therapy has witnessed a transformative shift, departing from traditional reliance on topical eyedrops toward a more diversified approach. This evolving paradigm is marked by a growing emphasis on sustained drug delivery systems, selective laser trabeculoplasty (SLT) and microinvasive glaucoma surgery (MIGS). Studies have identified the challenges of topical drug delivery: While preservative-associated side effects remain a concern, emerging evidence indicates that even preservative-free ocular hypotensive agents contribute to ocular surface toxicity.

Beyond the ocular surface, patients can experience local and systemic side effects from glaucoma therapy. It is not uncommon to have patients describe symptoms such as lightheadedness, dry mouth, respiratory distress and low blood pressure from their glaucoma therapy. This, of course, assumes patients can actually get topical medications into their eye by applying the right amount of pressure on the bottle without missing, and without touching the tip of the bottle to their eye. For patients with osteoarthritis, low vision, cervical spine disease or a myriad of other health concerns, the act of self-administering eyedrops can be prohibitively difficult.

The interventional glaucoma movement has emerged as a series of strategies to reduce dependency on patient self-administration of therapy. With multiple evidence-based strategies to provide high-quality IOP control, providers are now able to take on the ownership of glaucoma management.

Sustained drug delivery systems offer the advantage of ensuring consistent medication levels while reducing the burden of frequent administration associated with eyedrops. For several years, the only FDA-approved sustained drug delivery option for patients was Durysta (AbbVie). Utilizing the well-known molecule bimatoprost, Durysta provides a valuable option for many patients experiencing the challenges of topical drug delivery. Unfortunately, current on-label utilization of Durysta calls for the administration of a single implant per eye, which elutes bimatoprost into the anterior chamber for approximately 16 weeks. While many patients can experience 6 and even 12 months of consistent IOP reduction, the need for a longer-lasting therapeutic is clear.

The landscape for sustained drug delivery has grown recently with the FDA approval of iDose TR (Glaukos). Utilizing travoprost, the iDose TR is placed into the anterior chamber angle under direct surgical gonioscopy. While the product is relatively new to market, evidence suggests sustained drug elution of over 2 years. Early evidence is also beginning to demonstrate potential added value of intracameral sustained drug delivery vs. conventional therapy, with potential modification of the outflow pathways that may outlast the elution of medication. All of this can be achieved without the potential for medication effect on periocular tissues or the systemic environment.

Several other sustained drug delivery systems in the pipeline are working their way through preclinical and clinical trials. From the PolyActiva platform eluting latanoprost to Paxtrava (intracameral travoprost) by Ocular Therapeutix, the sustained drug delivery space will become increasingly exciting in the coming years.

Beyond pharmaceutical alternatives, it is always important to remember the old standard of laser trabeculoplasty. While many iterations of laser trabeculoplasty have come and gone, SLT presents a tried and true non-invasive alternative, utilizing laser technology to enhance aqueous outflow and reduce IOP by augmenting the conventional outflow system. In a landmark randomized prospective clinical trial comparing SLT to topical medications, the group undergoing SLT were more likely to achieve their IOP targets, had less visual field progression and required fewer surgeries.¹ SLT is quickly becoming the standard of care for primary IOP reduction, often being utilized before topical therapy.

With the wide array of options available beyond topical drugs and increasing evidence highlighting the challenges of eyedrop administration, adherence and persistence, physicians treating glaucoma have an opportunity to successfully manage a difficult chronic disease while maintaining patient quality of life and quality of vision.

Reference(s):

1. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Laser in Glaucoma and Ocular Hypertension (LiGHT) trial: six-year results of primary selective laser trabeculoplasty versus eye drops for the treatment of glaucoma and ocular hypertension. Ophthalmology. 2023 Feb;130(2):139-151. doi: 10.1016/j.ophtha.2022.09.009

Beeran Meghpara, MD is co-director of refractive surgery and clinical assistant professor of ophthalmology at Wills Eye Hospital in Philadelphia, PA.

Manjool Shah, MD is program director of the glaucoma fellowship program and associate professor of ophthalmology at NYU Langone Health in New York, NY.