Eyeworld

70 | EYEWORLD | WINTER 2024 C ORNEA Relevant disclosures Galor: Alcon, Bausch + Lomb, Dompe, Novartis, Oculis, Tarsus Pflugfelder: None Sheppard: AbbVie, Alcon, Aldeyra, Bausch + Lomb, Dompe, Glaukos, Imprimis, Kala, Viatris Contact Galor: AGalor@med.miami.edu Pflugfelder: stevenp@bcm.edu Sheppard: jsheppard@cvphealth.com There are an increasing number of preserva- tive-free options for treatment of glaucoma. Preservative-free steroids are needed, he said. Dr. Sheppard said there are also strategies for keeping drops out of the eye altogether, like punctal occlusion, where a temporary or permanent punctal plug is inserted to conserve tear film production. There's also an intranasal stimulant, varenicline (Tyrvaya, Viatris), used twice a day to enhance trigeminal afferent pro- duction of the tear film, thereby avoiding drops altogether. "We have a tremendous variety of procedures that can be done in the office that enhance the lipid layer of the eyes and reduce ocular discomfort," Dr. Sheppard added. In terms of glaucoma, Dr. Sheppard said there is a revolution in drop-sparing therapy to lower IOP. He said the most recent option is iDose (Glaukos), a 3-year travoprost sus- tained-release implant placed into the angle. There is a shorter-acting Durysta implant (AbbVie) using bimatoprost that can be placed into the anterior chamber at the slit lamp in the office. By far, the most common interven- tion has been SLT, which is Dr. Sheppard's first choice for any glaucoma patient. It's extremely safe, and treatment effect endures 1–5 years, he said. He added that there are still some glau- coma medications that are available only with preservatives, but companies are producing preservative-free glaucoma medications, like Iyuzeh (Thea), a preservative-free latanoprost. Another solution to glaucoma and dry eye medications with preservatives is through a compounding pharmacy, Dr. Sheppard said, not- ing that Imprimis and Ocular Science produce a wide variety of medications. "We use their ser- vices for combination glaucoma drops," he said. The glaucoma drop may be preservative free or preserved and contain three medications. It's not FDA approved, but more and more patients seem to benefit from this approach. Dr. Sheppard thinks the advantages of preservative-free therapy for chronic disease far outweigh the inconvenience. Unfortunately, insurance companies and third-party payers generally tier the preservative-free medications despite FDA approval far above the universally preserved generic preparation, and third-party payers never pay for compounded medications, he said. continued from page 69 W. Barry Lee, MD, Cornea Editorial Board member, shared what evolving treatments and techniques in ophthalmology he is excited about: "I am most excited about cultured endothelial cell injections for corneal endothelial diseases. It is estimated that 8 million people are corneal blind, and yet cell injections can treat more than 100 patients from a single donor while avoiding the need for a cornea trans- plant in those with diseased endotheli- um. This technology not only has major implications for our country, but on a global level, it could change the world." EVOLVING In vivo confocal microscopy demonstrating nerve tortuosity and a few activated dendritic cells in a patient with long-standing glaucoma medication use Source: Anat Galor, MD, MSPH

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