Eyeworld

24 | EYEWORLD BONUS ISSUE | FEBRUARY 2025 G UCOMA by Liz Hillman Editorial Co-Director About the physicians Jason Bacharach, MD North Bay Eye Associates Inc. Sonoma County, California Jacob Brubaker, MD Sacramento Eye Consultants Sacramento, California If first- or second-line SLT doesn't work, Dr. Brubaker moves on to drops. Dr. Bacharach said in his initial consultation with a POAG patient, he thinks about what the goals are for each patient's therapy and custom- izing his treatment to reach that goal. "I will have a discussion with the patient, talk about the different treatment options that are available, whether it's SLT or pharmacother- apy, and I'll think about the different modalities of the way to treat the disease," he said. Drop options and algorithms When it's clear a glaucoma patient needs drops, Dr. Bacharach said he follows a philoso- phy called "MIDS"—minimal instillation drop strategy. This term he coined, which is a play on MIGS, focuses on efficacy and tolerability that doesn't involve additional (or more than absolutely necessary) drops. "I love streamlin- ing drop therapy. It improves compliance and adherence, then there are the added excellent benefits of mechanism of action enhancements that are now available to us," he said. Dr. Bacharach said with drops, he begins with a prostaglandin. He's especially interested in newer drops that combine with a prostaglan- din and focus on trabecular meshwork outflow restoration. He mentioned VYZULTA (latano- prostene bunod 0.024%, Bausch + Lomb) and rho-kinase inhibitors, such as Rocklatan (ne- tarsudil and latanoprost ophthalmic solution, 0.02%/0.005%, Alcon). Dr. Brubaker also starts with a prostaglan- din. "If they are doing well but maybe need something extra, it's either going to a combi- nation product with Rocklatan, or if you're not going to do Rocklatan, keeping the prostaglan- din and adding a combo drop, like Combigan [brimonidine tartrate/timolol maleate ophthal- mic solution, 0.2%/0.5%, AbbVie] or Cosopt [dorzolamide/timolol, Merck & Co.]," Dr. Brubaker said. Dr. Bacharach mentioned that Harrow (formerly Imprimis Pharmaceuticals), a 503A pharmacy, has a lot of preservative-free mix and match offerings that can be an option that's "economically feasible for patients where insur- ance is an issue." Where drops fit in the interventional glaucoma era A 2024 survey sent to ASCRS mem- bership found that nearly three- fourths of respondents (73.6%) turn to topical medication as a first-line treatment for primary open angle glaucoma. 1 This data comes 5 years after the LiGHT trial found SLT to be more efficacious clinically and cost effective compared to drops as a first-line treatment. 2 While the mindset is shifting toward a more interventional one—with the same ASCRS survey finding that respondents who more re- cently completed ophthalmology residency, who performed more MIGS, or who had a significant glaucoma patient base (25% or greater) were more likely to perform SLT as first line—Jason Bacharach, MD, and Jacob Brubaker, MD, say the use of drop therapy is alive and well. It is actually trending toward finding a new home as an adjunctive therapy as more oph- thalmologists are beginning to figure out what pharmaceutical and procedural combinations best suit their patients. "Drops won't go away," Dr. Bacharach said, answering where he thinks they fit in the era of interventional glaucoma. "Drops will morph, as they always should have been, as an adjunctive therapy to procedural-based management. If you use drops, it doesn't mean you don't have an interventional glaucoma mindset, but what drops you choose and how you pair them with procedures matters." Drops or SLT Dr. Brubaker said up to 4 years ago, he was still giving newly diagnosed glaucoma patients the option of SLT or drops as a first-line therapy. However, as he's now providing more infor- mation to patients about the efficacy of SLT compared to drops and the compliance and tolerability issues they may face with drops, he's found more patients are choosing SLT. "This is the way we should be doing it, telling this is what's better," he said. That said, Dr. Brubaker noted, "SLT doesn't work on everybody. … Generally, I think that's the juncture in which drops need to be used," he said, adding, however, that recent research seems to support efficacy of repeat SLT for ini- tial non-responders.

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