Speaker: Prostaglandins, SLT good first-line treatment choices for glaucoma
NEW YORK – Either a prostaglandin or selective laser trabeculoplasty is an effective primary treatment for glaucoma, “but once you get past the primary therapy, there are 44,000 different combinations of glaucoma medications you can prescribe,” said a speaker here at Vision Expo East.
Ben Gaddie, OD, owner and director of Gaddie Eye Centers, discussed how to treat the newly diagnosed glaucoma patient.
“We’re typically quick to treat, but we don’t stay aggressive in our treatment,” he said. “The higher the pressure, the more reduction I want. If it’s above 30 mm Hg, I want a 50% reduction.”
Gaddie cautioned against reluctance to treat an elderly patient.
“Some say with a new diagnosis of glaucoma at the age of 80 years, why put the burden of therapy on the patient?” he said. “Well, what if they live to be 95 and go blind? They risk falls, a reduced quality of life.”
Gaddie referred to prostaglandin analogs as a “mainstay of treatment.” He said if he begins treatment with a prostaglandin, and the patient meets the target IOP, he monitors for progression. If he does not see the response he wants, he performs SLT – and vice versa.
Gaddie said it is important to know that 12 different U.S. manufacturers make generic latanoprost.
“One of the issues I see is that the patient gets a different supply every time they go to the pharmacy,” he said. “When I start to see fluctuations with generic latanoprost, I start to wonder about the source. Some of the generic companies are very good at making eye drops. Some of them are not.”
Patients on prostaglandin drops may also get a “sunken in” look in their eyes, Gaddie said, as well as iris color change and eyelash growth. He also sees more rosacea, meibomian gland dysfunction and Demodex in these patients.
“Something about the inflammatory response the prostaglandin analog provides may cause that,” he said.
“SLT reduces IOP by increasing trabecular outflow in a single, painless outpatient procedure with a good safety profile and limited recovery time,” Gaddie said.
The LiGHT study (Gazzard et al.) showed that 95% of SLT-treated patients and 93% in the medication arm were at target pressure at 3 years, he said. Eighty percent of the SLT patients required no medication, while 64% in the medication arm were still on a single medication.
Another newer option is Durysta, a bimatoprost sustained-release intracameral implant from Allergan.
“You can put in one pellet, and in some patients it lasts 2 to 3 years,” Gaddie said. “Optometrists can do this in eight states. I do it in Kentucky.
“However, if the angle is too narrow to do SLT, it’s too narrow for Durysta as well,” he added.
- Gazzard G, et al. Lancet. 2019;doi:10.1016/S0140-6736(18)32213-X.