Overcoming the Daily Struggle of Adherence to Glaucoma Therapy

Gagan Sawhney, M.D.

Cataract and Glaucoma Specialist, Georgia Eye Partners

About Author

There is nothing that brings me greater joy as an ophthalmologist than when I can be confident I have protected a patient’s vision. Nevertheless, as a glaucoma specialist these cases are few and far between. The progressive nature of glaucoma means my patients and I need to remain vigilant, and the goal is not to cure but to delay progression.

Glaucoma remains one of the primary causes of irreversible vision loss and blindness in the world, which means there is much more work for us to do as glaucoma specialists.¹ I’ve seen first-hand the impact that this devastating disease can have on patients, and it is not only blindness that worries me. We see the consequences of this slow vision loss all the time in our practice – patients losing their independence, the ability to drive and turning to family members for help with routine tasks. Individuals with glaucoma have a three times greater risk of falls and a six times greater risk for auto accidents.^2,3,4 Worse yet, the brain adapts to vision loss in the early stages of the disease, which means that patients often do not present to me until after they have already lost some vision.^5,6

I like to say glaucoma is only young once, which is why we must take the opportunity to treat it early and aggressively and ensure our patients get the full benefit of treatment.

Adherence with Topicals: Easier Said Than Done

We know that reducing intraocular pressure (IOP) and sustaining this reduction is the only proven way to slow the progression of glaucoma.⁷ Topical medications are standard of care, but efficacy depends largely on the ability of the patient to administer the medications correctly and consistently.  Although most patients with glaucoma readily agree to do whatever it takes to help control their disease, up to 80% of patients do not use drops as prescribed.⁸

Whenever I prescribe drops, I always do my best to demonstrate proper technique to my patients and ensure they feel prepared to self-dose after leaving my office. However, there is not much I can do for my patients in between appointments.

Unlike other conditions such as allergy or dry eye where drops provide near immediate relief or improvement, many glaucoma patients do not see a noticeable impact from their eye drops and do not feel like they are halting progression. For many, drops can be burdensome, especially if multiple medications are needed and/or require administration multiple times a day.  In fact, the average American over the age of 65 takes four prescription medications, and nearly 40% take five or more.⁹  Given the population affected by glaucoma skews older, patients may also have difficulty administering drops due to factors such as an impaired ability to read directions, arthritis or dementia.  Lastly, patients may experience stinging, burning, blurred vision, uveitis and other adverse events that lead them to deviate from their prescribed regimen.

Taking Drops – and Adherence – Out of Patients’ Hands   

It is an exciting time for glaucoma specialists.  We are now living in a glaucoma renaissance.  Practically every day I read an article about a new glaucoma medication, modality of administration, or a minimally invasive glaucoma surgery device.  We now have more tools to treat patients more effectively and safely. We can now even remove the burden of adherence and assume full control over our patient’s treatment.  

In June 2020, I became the first ophthalmologist in the state of Georgia to implant DURYSTA (bimatoprost implant), an innovative drug delivery system that I believe will lead to a paradigm shift in the way we treat patients with open-angle glaucoma and ocular hypertension. The drug delivery technology ensures patients consistently receive the medication they need to manage their condition.  

I am excited to offer my patients this intracameral implant as an alternative to topical glaucoma medications. The tiny biodegradable implant is preloaded into a single-use applicator to facilitate administration directly into the anterior chamber of the eye.  Once administered, the implant rests in the inferior angle, ultimately degrading to lactic and glycolic acids. 

What fascinates me about DURYSTA is that like all prostaglandin analogs, it lowers IOP by increasing the outflow of aqueous humor via the trabecular meshwork but also through the uveoscleral routes. The implant provides a consistent dose of medication over several months, and some patients saw a sustained reduction in IOP for up to two years in clinical trials. DURYSTA helps eliminate the fluctuations in IOP associated with drops. I have found that the implant takes the guessing and inaccuracy out of the patient’s hands and gives me peace of mind they are getting consistent medication over a sustained period. My patients, in turn, have been quite receptive and motivated to try the implant since it is a simple and straightforward procedure that is less invasive than surgery. They are also happy to give up their drops for a few months.  

Efficacy and safety of DURYSTA were evaluated in the ARTEMIS clinical trials that supported the recent FDA approval.  These two 20-month studies – with 8-month extended follow up – compared the implant and timolol 0.5% drops BID in more than 1,100 patients with open angle glaucoma and ocular hypertension. About one-quarter of the patients in the implant group were on two or more glaucoma medications. At 15 weeks, the implant demonstrated a mean IOP reduction of approximately 5-8 mmHg in patients with a mean baseline IOP of 24.5 mmHg IOP, about a 33% reduction.   

The most common ocular adverse reaction observed in patients receiving DURYSTA in the ARTEMIS trials was conjunctival hyperemia, which was reported in 27% of patients. Other common ocular adverse reactions reported in 5-10% of patients were foreign body sensation, eye pain, photophobia, conjunctival hemorrhage, dry eye, eye irritation, intraocular pressure increased, corneal endothelial cell loss, blurred vision, and iritis.

The implant can be used across the entire spectrum of disease severity. I find it particularly useful for patients who are forgetful, struggle or need assistance with drops; those who are unable to tolerate drops; those with fluctuations in IOP; and patients who haven’t yet tried or are concerned about the daily burden of drops.  

Other Strategies to Improve Adherence

Drops remain a good option for many patients, and the goal is to alleviate the challenges associated with administration. I would like to offer some simple strategies that I have found effective in helping patients better adhere to topical medications. 

1. Use detective work: Uncovering the specific reasons a patient does not use their medication as directed can help with personalized approaches to overcome the obstacles.  Side effects? Consider switching medications.  Forgetting? Help design a drop routine linked to something they do every day like brushing their teeth.  
2. Simplify: Trying different drug formulations or dosing regimens may help.  If appropriate, prescribing once daily or fixed combinations of medications can greatly increase the chance that patients stick with their prescribed therapy.  
3. Educate: Review proper eye drop technique to optimize the amount of drug that reaches the ocular surface; make adherence education part of every visit; simplify and reiterate your message about the importance of consistent medication use to protect vision. 

Sentinel glaucoma studies tell us that early aggressive treatment can help prevent disease progression.  By being proactive, we can ensure we are not missing the window of opportunity when we can do the most for our patients with glaucoma. Fortunately, with an increasing number of treatment options, we can tailor the right therapy to the right patients based not only on clinical factors but also a patient’s personal circumstances. 

References:

1.   World Health Organization. (2011). Glaucoma is second leading cause of blindness globally. Retrieved from https://www.who.int/bulletin/volumes/82/11/feature1104/en/
2.   De Luna, R, Mihailovic, A, Nguyen, A, Friedman, D, Gitlin, L, Ramulu, P. The association of glaucomatous visual field loss and balance. Transl Vis Sci Technol. 2017;6(3):8.
3.   Haymes, S. A, Leblanc, R. P, Nicolela, M. T, Chiasson, L. A, Chauhan, B. C. Risk of falls and motor vehicle collisions in glaucoma. Invest Ophthalmol Vis Sci. 2007;48(3):1149‐1155.
4.   National Academies of Sciences Engineering Medicine. (2016). Making eye health a population health imperative. Retrieved from https://www.nap.edu/catalog/23471/making-eye-health-a-population-health-imperative-vision-for-tomorrow.
5.   Hoste, A. M. New insights into the subjective perception of visual field effects. Bull Soc Belge Opthalmol. 2003;(287):65-71.
6.   Varma, R, Lee, P. P, Goldberg, I, Kotak, S. An Assessment of the health and economic burdens of glaucoma. Am J Ophthalmol. 2011;152(4):515-522
7.   Weinreb, R. N., Aung, T., & Medeiros, F. A. The pathophysiology and treatment of glaucoma: a review. JAMA. 2014;311(18):1901–1911. doi:10.1001/jama.2014.3192.
8.   Gomes, B. F, Paredes, A. F, Madeira, N, Moraes, H. V. Jr, Santhiago, M. R. Assessment of eye drop instillation technique in glaucoma patients. Arq Bras Oftalmol. 2017;80(4):238‐241.
9.   Charlesworth CJ, Smit E, Lee DS, Alramadhan F, Odden MC. Polypharmacy Among Adults Aged 65 Years and Older in the United States: 1988-2010. J Gerontol A Biol Sci Med Sci. 2015;70(8):989-995. doi:10.1093/gerona/glv013.

Dr. Gagan Sawhney is a board-certified, highly respected, fellowship-trained ophthalmologist based in Atlanta who specializes in cataract surgery as well as the medical and surgical management of glaucoma from early to advanced disease.