Eyeworld

116 | EYEWORLD | DECEMBER 2020 G UCOMA each mediation addition, I make sure to review alternative options, such as SLT or MIGS," Dr. Provencher said. Dr. Brubaker said the practice of adding single therapies as an adjunct is fading. "For me, it's typically moving on to a com- bination medication. … You'll get more bang for your buck and you'll get to a lower target in those cases. That's where my practice has shifted, rather than adding one drop at a time," he said. Both Dr. An and Dr. Provencher said they opt for a once-daily prostaglandin analog, when they can. "Rhopressa [netarsudil ophthalmic solution, 0.02%, Aerie Pharmaceuticals] is great for that reason as well, and now we have Rocklatan [netarsudil/latanoprost ophthalmic solution, 0.02%/0.005%, Aerie Pharmaceuticals], if a patient needs more than one class and the con- venience of a single drop. I have been excited to see that insurance coverage of Rhopressa and Rocklatan is improving. I also consider Vyzulta [latanoprostene bunod ophthalmic solution, 0.024%, Bausch + Lomb] if patients do better with once-daily dosing but need a bit more IOP control than a PGA alone provides," Dr. Provencher said. Dr. Brubaker said Vyzulta shines in its side effect profile. Dr. An had a similar thought as well. She said compliance can be poor with Rhopressa and Rocklatan due to redness or changes in vision. She said Vyzulta is a good alternative for these patients, but it's often not her primary choice because it's not quite as effective, though still better than latanoprost alone. All the physicians EyeWorld spoke with said it's rare that they use miotic agents, outside of when the miotic effect is needed. Sustained-release medications Durysta (bimatoprost implant, 10 mcg, Aller- gan) was the first and is currently the only sus- tained-release, injectable glaucoma medication. Dr. Brubaker said he considers this, along with SLT, a first-line therapy, though he does think patients should trial on a prostaglandin drop to assess tolerance and what it's like to administer regular eye drops. Dr. An said she also offers SLT to patients with more severe glaucoma as well. "I offer it to all patients regardless of se- verity, especially if they are experiencing side effects, issues with cost and compliance," she said. Dr. An cautioned overgeneralizing the LiGHT trial's results because only 5% of the patients in the trial had more severe glaucoma. She reviewed data from her own patients, a sample size that included more cases of ad- vanced glaucoma, looking for predictive factors that could impact outcomes of SLT and found patients with higher baseline IOPs had great- er success rates and mean IOP reduction with SLT. 2 She also said it's important to monitor these patients closely because the effect of SLT can wear off, and the attrition rate is different for each patient. Dr. Provencher also said she mentions the importance of regular follow-up to SLT patients. "A feeling of being medication-free has been one of the biggest concerns raised with first-line SLT and now more recently with intracameral delivery," Dr. Provencher said. "Without the responsibility of a daily medication, will patients forget they have glaucoma and fail to follow up? Without proper counseling by their physician, it's very possible." When counseling patients of their options, Dr. Provencher said she discusses the life-long compliance, side effects, and cost of drops in addition to the risks of SLT. "I've found that most patients flinch at the word laser, but if you take the time to counsel on what to expect with SLT (painless, creates bubbles, takes under 5 minutes, etc.), they often reconsider. It is important to create an honest dialog about what treatment will work best ac- cording to each individual's lifestyle and ability to adhere to the plan," she said. Different classes of drops No drop is off the table for Dr. Provencher, who often treats complex glaucoma cases. In fact, most of the physicians who spoke with EyeWorld also said beta blockers, carbonic anhydrase inhibitors, and alpha agonist drops still have a place in their practice. "I do discuss the decrease in compliance that occurs as we add on medications. With continued from page 115

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