Payment issues may restrict access to new glaucoma treatments
NEW ORLEANS – A panel here at the Ophthalmic Innovation Summit, held during SECO, recognized the dramatic advances made in the field of glaucoma technology and therapeutics but also recognized the challenges with implementation.
Moderator J. James Thimons, OD, said the last decade has exploded with new technologies and pharmacokinetic activities and asked panelists where the new pharmaceutical agents fit into their clinical armamentarium.
Randall Thomas, OD, referred to a statement by Thomas W. Samuelson, MD, in the Dec. 25, 2018, issue of Ocular Surgery News, sister publication of Primary Care Optometry News, “Latanoprostene bunod can arguably stake a claim as the single most potent eye drop available,” which he agrees with.
Murray Fingeret, OD, added, “Vyzulta [latanoprostene bunod ophthalmic solution 0.024%, Bausch + Lomb] is an advance, we have Rhopressa [netarsudil ophthalmic solution 0.02%, Aerie] out, that’s the appetizer, and Rocklatan [netarsudil 0.02% and latanoprost ophthalmic solution 0.005%, Aerie] we’ll see shortly. We have new MIGS [minimally invasive glaucoma surgery] devices on the horizon.
“We’re at the beginning of what will be a very exciting way to treat glaucoma,” he continued, “and I’m just wondering if glaucoma will become somewhat of a surgically treated disease a decade from now, and medicine will be incidental. We’re at the forefront of a lot of change.”
However, accessibility to these new agents is “a complex question” due to reimbursement issues, Fingeret said.
“It’s clearly an advance, but where do these fit in when many patients don’t have access to them?” he asked.
Fingeret said he would prescribe these new agents, “but the bottom line is the U.S. has a cockamamie health care system in terms of reimbursement for medicines, and it’s screwing everything up. We have these new innovations, but how are we going to pay for them?”
Panelist Justin Schweitzer, OD, said any new technology is “a win for doctors and patients because we have more tools to use, as no patient responds the same way to a drop. I would probably back off a little on offering surgery immediately until I have the opportunity to exhaust the new drops. Having the technologies to offer these patients can possibly ward off surgical intervention longer.”
Thimons asked the panelists to comment on the effect of telemedicine on glaucoma management.
“If we can make visual field testing more objective, it will be a huge win for the patient,” Thomas said. “Human beings make terrible patients, and we need delivery systems that take the patient out of the equation.”
“The virtual reality perimeter is an exciting tool,” Fingeret said. “It does have the potential to change the equation. The company that can develop that kind of technology, home testing, that will be the Holy Grail, but it’s still a little ways away.”
Schweitzer said he believes telemedicine will have a place, “but I would tell our residents, students and externs: Remember, you are clinicians at heart. What were you trained to do? Dilate a pupil, look at the optic nerve head with stereopsis with your own eyes. Gain information that way.”
Thimons asked the panel for feedback on MIGS.
“If you’re going to do MIGS with cataract surgery, it’s going to limit the usability of the procedure,” Thomas said. “It’s too early to harbor a lot of excitement for this.”
If a surgeon is going into the eye to remove a cataract, “it makes total sense to have MIGS done,” Schweitzer said.
“I think the cap on procedures like MIGS is the adoption by large-volume cataract surgeons,” Thimons added.
Optometry must be involved in comanagement, Schweitzer said.
“MIGS is a gap filler,” he said. “It’s not going to fix the problem forever, but it’s a filler between therapy with drops and the final stage, which is filtration surgery.”
Schweitzer said he has been at his current surgical practice for 6 years, and patients who had filtration surgery in his first year are now starting to fail.
“I’ve treated patients for 30 years with eyedrops,” Thomas said. “You teach them how to do it. Let’s not give up on it. Patient need to be shown how to do it.”
The panelists concluded by agreeing that treatment modalities that complement drops, such as injectables or drug-eluting implants or plugs hold promise.
“Any time you can take the patient out of the equation, there should be incremental improvement in control,” Thomas said. – by Nancy Hemphill, ELS, FAAO
Thimons JJ, et al. Glaucoma innovation spotlight. Presented at: Ophthalmic Innovation Summit; February 21, 2019; New Orleans.
Disclosures: Fingeret reports he is a consultant for Aerie, Alcon, Allergan, Bausch + Lomb, Carl Zeiss Meditec, Glaukos and Ivantis. Schweitzer reports he is a consultant for Aerie, Alcon, Allergan, Bausch + Lomb and Glaukos. Thimons reports he is a member of the medical advisory boards for Allergan and Bausch + Lomb and a sub-principal investigator for the iStent trial for Glaukos. Thomas reports he is a consultant for Bausch + Lomb and ICare.