When I began my career 11 years ago as a third-generation ophthalmologist, I joined my family’s 40-year-old practice and immediately started seeing a high volume of glaucoma cases. Many of those patients had been on drops for years. They had chronic dry eye, redness, irritation, and fluctuating vision. They were using glasses that couldn’t correct their vision because of ocular surface disease. Glaucoma was severely compromising their quality of life, but their only alternative was invasive trabeculectomy or tube-shunt surgery.

Today, much has changed. New treatment modalities make it possible for glaucoma specialists to control glaucoma with reduced medication and less work and uncertainty for patients. With the advent of new therapies, my mindset has shifted toward achieving not only the desired intraocular pressure (IOP), but also improving patients’ quality of life. If we listen and solve the problems glaucoma is causing for patients and their families, we can improve lives, not just disease state.

How Glaucoma Diminishes Quality of Life

Patients who have spent years in glaucoma treatment often express hopelessness. They’re scared about blindness and afraid they’ll lose their independence. Treatment seems endless and burdensome. This disease and its therapies affect their quality of life in very deep and meaningful ways.

Logistical Difficulties of Eye Drops

Putting in glaucoma drops is a hardship for some patients and their families. As patients get older and their arthritis worsens, they have a harder time instilling drops and remembering when to take them. In some cases, patients have family members coming over every single day to give them their eye drops. The more medications patients are prescribed, the tougher this becomes — and the less likely they are to succeed with compliance.^1,2

Prescription Costs on a Fixed Income

Patients often receive a fixed income. The cost of certain glaucoma medications may not be very high, but older patients often also are paying for systemic medications to treat hypertension, high cholesterol, acid reflux, enlarged prostate, and other common conditions. Some of my patients put half of their income toward medications. That financial stress is a major quality-of-life issue.

Adding to that problem, prescription coverage is variable; our practice is always seeking approval from insurance companies. Patients want to use the medication that was prescribed to them, and uncertainty about insurance coverage adds to their existing fears and stress about glaucoma.

Ocular Surface Toxicity

Not only do glaucoma drops cause some burning, irritation, and redness, but also they can change the corneal epithelium over time, which in turn makes ocular surface disease even more severe.³ One patient of mine actually had scarring to the cornea as a result of stem cell insufficiency from many years of chronic drop use.

It's important not only to evaluate ocular surface disease, but also to really listen to patients and understand how toxicity is affecting their quality of life. Patients often feel frustrated that their eyes are red, and discomfort is affecting their normal activities. Fluctuating vision can be particularly frightening to patients who are still independent and driving. I see some referrals who are taking immunomodulators or low-dose anti-inflammatories to counteract the side effects of their glaucoma medications — an approach that increases the number of drops they must use each day.

Psychological Toll and Depression

Like many chronic, progressive conditions, glaucoma can be depressing, with its endless treatment and threat of vision loss. Depression is more common in patients with glaucoma than it is in the general population.^4,5 The mental health situation is even more urgent for our patients after the extended isolation from the pandemic. Patients need feedback and encouragement. Without it, they’re saying, “I'm doing all these things, but I'm not noticing a difference. This will never get better.” In some situations, they want to give up altogether because of the fatigue of managing glaucoma.

I've wept along with my patients. It was heartbreaking to see one patient crying as he told me, “I would rather go blind than continue down this road.” He was frustrated with redness, irritation, and poor vision, and he could not afford to continue his drugs. He felt that glaucoma was ruining his life.

Alleviating Patients’ Burden

When I talk to frustrated long-term glaucoma patients, I want them to know that there are other options now. They’re comforted to know that we're continuing to stay on top of new therapies. Several approaches are improving my patients’ quality of life, including selective laser trabeculoplasty (SLT), sustained-release medications, and minimally invasive glaucoma surgeries (MIGS).

SLT as First-line Therapy

We don’t need to start newly diagnosed patients on medication. Ample data support the effectiveness of SLT as a first-line therapy,^6,7 making it an easy choice to alleviate the burden of topical medication. I talk to newly diagnosed patients about SLT right from the start. I explain, “We're in this together long-term, and we have some options: 1) We can start topical therapy, in the form of an eye drop, or 2) we can start with an in-office laser treatment that I expect to give you effective pressure control, repeating it if needed.”

This line of thinking has been solidified by the LiGHT study,⁸ where the primary outcome revealed no significant difference in efficacy between medication and SLT. Secondarily, the study found that SLT was a more cost-effective first treatment than eye drops, with 97% probability. Nearly three quarters (74.2%) of patients in the SLT group required no drops to maintain IOP at target, and SLT eyes were within IOP targets at more visits than eyes in the eye drops group. No patients in the SLT group needed surgery, compared to 11 patients who used eye drops. In my practice, we find that about half of patients choose eye drops while the other half choose SLT. Patients love knowing that there are options and that we are thinking about the entire picture when it comes to glaucoma treatment.

Sustained-release Medication

For patients who want to use less drops, are struggling with ocular surface disease, or need additional therapy after SLT or MIGS, and for those who are looking for a reset after long-term medication use, I recommend sustained-release medication. Today, that’s bimatoprost (Durysta, Allergan), and I hope to see more options in the future. When I tell patients I can place a biodegradable medication in their eyes that works 24 hours a day and lasts for at least 4 months — possibly 2 years⁹ — they are excited to minimize their drops.

A Tailored MIGS Procedure

For patients who suffer with uncontrolled glaucoma and/or diminished quality of life, minimally invasive glaucoma surgeries (MIGS) offer the opportunity to control pressure while reducing or eliminating drops. I'm passionate about offering patients multiple MIGS technologies so I can customize treatment, choosing the best and least destructive option first with an eye toward maximizing our options long term.

In tailoring MIGS to the individual, I consider the disease state, the severity of visual field loss, pressure stability on medication, ocular surface status, and the patient’s adherence, all of which tell me the patient’s clinical needs and the urgency of reducing the medication burden. For example, for a patient with mild glaucoma who’s taking one medication and needs cataract surgery, I might choose the iStent inject (Glaukos) to potentially eliminate medication. If a patient taking multiple medications has moderate field loss, there may be more resistance in the trabecular meshwork, Schlemm’s canal, and aqueous collector channels. I’ll use an angle procedure such as OMNI Glaucoma Treatment System (Sight Sciences) to try to get the pressure down into the low teens. Finally, if a patient has progressed quickly and we need to get pressure into the 10 to 12 range, I’ll bypass the angle altogether and use the Xen gel stent (Allergan) in the subconjunctival space. Other MIGS in my armamentarium include ab interno canaloplasty (iTrack catheter; Ellex), Kahook Dual Blade (New World Medical), and endoscopic cyclophotocoagulation as an adjunct treatment.

A Better Quality of Life

Glaucoma specialists can’t remove all the worry and stress over treatment from people’s lives. But by listening to how glaucoma affects patients’ quality of life and factoring those problems into our treatment decisions, we can make a difference. We can reduce reliance on medications, which in turn alleviates the inconvenience, financial costs, and compliance concerns that accompany glaucoma treatment, while also lowering the risk of ocular surface disease.

Just knowing that there are alternatives gives my patients hope. The results we achieve raise their spirits even further. The improvement to the ocular surface is clear. My patients are often relieved not to keep hearing, “Your eyes are so red. Did you get any sleep last night?” They're excited that SLT and MIGS are covered by insurance, and their medication costs are reduced or eliminated. They no longer have the inconvenience of filling eye drop prescriptions and putting their drops in every day.

The experience of helping my patients has made me passionate about peer education. We have so many options for treating glaucoma, and together we can make a difference by sharing those options with patients and either performing those treatments or referring patients to a colleague for care. As a profession, we’re excited about the promising future for patients with glaucoma — let’s make sure they feel the same sense of hope.

Deborah Gess Ristvedt, DO, specializes in advanced cataract surgery, glaucoma care, and oculoplastic surgery at Vance Thompson Vision, Alexandria, Minnesota.

References

1. Robin AL, Covert D. Does adjunctive glaucoma therapy affect adherence to the initial primary therapy? Ophthalmology. 2005 May;112(5):863-868. doi:10.1016/j.ophtha.2004.12.026
2. Muir KW, Lee PP. Glaucoma medication adherence: room for improvement in both performance and measurement. Arch Ophthalmol. 2011 Feb;129(2):243–245. doi:10.1001/archophthalmol.2010.351
3. Doğan E, Köklü Çakır B, Özkan Aksoy N, Celik E, Erkorkmaz Ü. Effects of topical antiglaucomatous medications on central corneal epithelial thickness by anterior segment optical coherence tomography. Eur J Ophthalmol. 2020 Nov;30(6):1519-1524. doi:10.1177/1120672120901698
4. Thau AJ, Rohn MCH, Biron ME, et al. Depression and quality of life in a community-based glaucoma-screening project. Can J Ophthalmol. 2018 Aug;53(4):354-360. doi:10.1016/j.jcjo.2017.10.009
5. Gamiochipi-Arjona JE, Azses-Halabe Y, Tolosa-Tort P, et al. Depression and medical treatment adherence in mexican patients with glaucoma. J Glaucoma. 2021 Mar 1;30(3):251-256. doi:10.1097/IJG.0000000000001739
6. Katz LJ, Steinmann WC, Kabir A, et al. Selective laser trabeculoplasty versus medical therapy as initial treatment of glaucoma: a prospective, randomized trial. J Glaucoma. 2012;21(7):460-468. doi:10.1097/IJG.0b013e318218287f
7. Freitas AL, Ushida M, Almeida I, et al. Selective laser trabeculoplasty as an initial treatment option for open-angle glaucoma. Arq Bras Oftalmol. 2016;79(6):417-421. doi:10.5935/0004-2749.20160118
8. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet. 2019 Apr 13;393(10180):1505-1516. doi:10.1016/S0140-6736(18)32213-X
9. Craven ER, Walters T, Christie WC, et al. 24-month phase I/II clinical trial of bimatoprost sustained-release implant (bimatoprost SR) in glaucoma patients. Drugs. 2020;80(2):167–179. doi:10.1007/s40265-019-01248-0