Procedural Pharmaceuticals in Glaucoma Management

The advent of procedural pharmaceuticals, which help alleviate the burden of self-administration of topical medications, is poised to continue the ascendancy of a glaucoma treatment paradigm in which drop therapy is used adjunctively, Dr. Sarkisian predicted in a recent episode of Innovation Journal Club.

In his own practice, Dr. Sarkisian said he has largely moved away from offering topical therapy as the de facto first-line option in managing glaucoma. Instead, he prefers to start with selective laser trabeculoplasty (SLT), with procedural pharmaceuticals offered as a second line.

“If you look at what my OR schedule looks like now compared to what it looked like a year ago, it's totally different,” Dr. Sarkisian said, adding that while he is doing phacoemulsification and implanting premium IOLs on a regular basis, his glaucoma procedures mostly include standalone MIGS with or without a procedural pharmaceutical. “I’m opening up new OR days just to accommodate doing that,” he said.

One of the concerns regarding procedural pharmaceuticals is their ability to effect long-term control of glaucoma. However, Dr. Sarkisian said, there is mounting evidence that implants remain effective for longer durations than studied in pivotal trials. For example, he discussed a retrospective, single-site study that evaluated the IOP-lowering efficacy and safety of a single intracameral 10-µg bimatoprost implant (Durysta, Allergan, an AbbVie Company) in 197 eyes among patients followed for 12 months or longer.¹ Eligible patients included those with open-angle glaucoma or ocular hypertension who received the implant in one or both eyes in routine clinical practice. Study endpoints included IOP, IOP-lowering medication and procedure use, and safety outcomes (Figure).

As for safety, the study findings demonstrated that no eye required an implant removal, and there were no cases of treatment-emergent corneal edema after bimatoprost implant administration. It was noted that three eyes (three patients) had uncontrolled IOP with the bimatoprost implant, SLT, and topical medications.

“[These data] are significant,” Dr. Sarkisian said. “If you give someone with ocular surface disease a year off from eyedrops, what happens? Their goblet cells rejuvenate, their stem cells are enriched, and everything sort of becomes healthier. Then, maybe they can be reintroduced to topical medicine, or better yet, if the patient notices a significant improvement in their symptoms off drops, repeat SLT or move on to another procedural pharmaceutical or stand-alone MIGS.”