Topical medications are often used as first-line treatment for glaucoma, despite numerous limitations and consequences that diminish their effectiveness—such as non-adherence, instillation difficulties, local and systemic side effects of preservatives, treatment costs, complex dosing regimens, diurnal fluctuations, and diminished quality of life. As the number and availability of minimally invasive treatment options have increased, however, so have opportunities for ophthalmologists to take a more proactive, procedural approach to glaucoma management.

Such procedural interventions com- prise selective laser trabeculoplasty (SLT), minimally invasive glaucoma surgery (MIGS), and sustained-release procedural pharmaceuticals. In the last category, there are currently two intracameral implants approved by the FDA: Durysta (bimatoprost, Allergan), approved for a single intracameral administration in March of 2020; and iDose TR (travoprost, Glaukos), approved in December of 2023. Both implants are designed to slowly release their respective medications within the anterior chamber, thereby delivering medication directly to the target tissues. In studies, Durysta has been shown to last anywhere from 3 to 12 months (typically 6 to 9 months) after a single administration, usually in the clinic, at the slit lamp. iDose, on the other hand, is typically implanted in an operating room and has been shown to last from 1 to 2 years, if not longer.

The focus of this article will not be on the data, however. Instead, we will discuss how to optimize clinic flow around scheduling patients for these implants, and how to navigate the billing and insurance landscape to ensure coverage of the procedures.

Patient Selection

Durysta and iDose each can benefit a wide range of patients, as they are both FDA-approved for use in any stage of open-angle glaucoma or ocular hypertension; in any lens (phakic or pseudophakic); at any level of preoperative medication burden or surgical history; and in both  standalone and combined procedures.

Beyond clinical factors, it is helpful to consider the positive impact of sustained-release therapy not only on patients’ IOPs, but also on their
quality of life compared to the physical, logistical, and recurring financial burdens of maintaining a topical medication regimen.

Clinical Education and Workflow

When incorporating any new technology or procedure into a practice, it is wise to educate the diverse entities involved. In an ophthalmology practice, this can include the surgeon; current and prospective patients; technicians and scribes; surgical schedulers; and staff from the call center, front desk, billing department, and surgical center. The entire team should be familiar with the procedure and able to field patients’ basic questions. It is also important for referring optometrists to be aware that the practice is offering the procedure, and to be able to advise patients—especially if the OD and MD are engaging in collaborative care.

With proper training by surgeons who understand anterior segment anatomy, both of these medications can be implanted relatively efficiently. Durysta can be administered in clinic or in a minor procedure room using the 27-gauge injector though the cornea, while iDose TR is implanted in the operating room by a surgeon who is adept at angle-based glaucoma surgery. Both implants can be delivered in a relatively efficient manner that provides minimal disruption to one’s clinical or surgical flow. Postoperative care is streamlined as well, with providers often seeing the patient a few days and a few weeks after surgery, depending on whether the fellow eye requires treatment as well. If the iDose implantation is combined with cataract surgery and/or MIGS surgery, then follow-up may be more frequent.

Nuances of Surgical Scheduling and Billing

There are several nuances involved in billing for these intracameral implants, especially when a facility outside one’s practice is involved. Thankfully, both Allergan and Glaukos have billing teams willing to support physicians and their office personnel in navigating this sometimes-complicated system. Given the limited resources and staffing challenges of most ophthalmology practices, partnering with a drug manufacturer’s billing specialists can take the burden off one’s own staff.

If the physician feels a sustained released implant is appropriate for the patient, it is important for the scribe and/or physician to adequately document the reasons for the recommendation. For example, these may include above-target IOP despite treatment; difficulty with drop instillation due to physical limitations (such as arthritis) or cognitive challenges; a history of non-adherence to therapy or non-persistence with refilling prescriptions; intolerance or hypersensitivity to eyedrops; glaucoma medication history; history of other glaucoma procedures; and, possibly, lack of or limited response to other medical and pharmaceutical treatments.

Next, it is helpful for the patient to see the surgical scheduler that same day. The scheduler can review expectations for the procedure day and the postoperative period, then can answer any other questions the patient has. Typically, the procedure is scheduled for 1-2 weeks later, to allow time for insurance prior-authorization, if needed. 

Conclusion

In my real-world experience, I have found both sustained-release options to be beneficial additions to my practice. Whether the implant is administered in the clinic or in the operating room, patients can be easily incorporated into the surgical day; postoperative care is reasonable; patients are able to reduce their topical medication burden; and office staff experience fewer medication-related phone calls, prescription refill requests, or non-covered issues. With an ever-expanding armamentarium of procedures, it may be possible to avoid or lessen the burdens of topical medications through earlier intervention to preserve patients’ vision. Moreover, it is essential that we continue to support innovation in the field of sustained-
release medication because these technologies will hopefully continue to improve—and, one day, we may have sustained-release combination anti-glaucoma medications (with 2-4 agents) that can last 3-5 years. OM

REFERENCES

1. Sarkisian SR Jr, Ang RE, Lee AM, Berdahl JP, Heersink SB, Burden JH, Doan LV, Stephens KG, Kothe AC, Usner DW, Katz LJ, Navratil T; GC-010 Travoprost Intraocular Implant Investigators. Phase 3 Randomized Clinical Trial of the Safety and Efficacy of Travoprost Intraocular Implant in Patients with Open-Angle Glaucoma or Ocular Hypertension. Ophthalmol. 2024 Feb 27:S0161-6420(24)00161-1.

2. Medeiros FA, Walters TR, Kolko M, Coote M, Bejanian M, Goodkin ML, Guo Q, Zhang J, Robinson MR, Weinreb RN; ARTEMIS 1 Study Group. Phase 3, Randomized, 20-Month Study of Bimatoprost Implant in Open-Angle Glaucoma and Ocular Hypertension (ARTEMIS 1). Ophthalmol. 2020 Dec;127(12):1627-1641.

Davinder S. Grover, MD, MPH practices ophthalmology at Glaucoma Associates of Texas (GAT) in the greater Dallas-Fort Worth area, where he specializes in the medical and surgical management of complex glaucoma as well as complex cataract surgery. His research interests include international ophthalmology, innovative glaucoma surgeries, and clinical outcomes in medical and surgical glaucoma management.