New Strategies for the Management of Ocular Surface Disease in Glaucoma Patients

Laura Voicu; Sarwat Salim


Curr Opin Ophthalmol. 2021;32(2):134-140. 

In This Article

Advances in Glaucoma Interventions and Application to Patients With Ocular Surface Disease

Traditionally, reducing medication burden in glaucoma patients has been challenging. Bleb-based glaucoma surgeries have been associated with a significant postoperative risk profile and may not be ideal for patients with mild to moderate glaucoma.[43] With the advent of MIGS and sustained-release medications, reducing preservative burden to the ocular surface in glaucoma patients is becoming possible earlier in the disease course. Durysta (Allergan plc, Dublin, Ireland) is the first intracameral, sustained release medication implant to be approved by the FDA.[44–46] Durysta is a bimatoprost implant which is administered under aseptic conditions under magnification through injection into the anterior chamber in patients with open angle glaucoma or ocular hypertension. This implant is approved for one-time injection per eye and is reported to be effective for 4–6 months. The ARTEMIS 1 study found noninferiority of Durysta to timolol over the 12-week study period with up to two additional administrations at 4-month intervals. An animal study has shown low concentrations of bimatoprost in the ocular surface tissues and increased concentration at the ciliary body compared to topical administration. Durysta may be particularly helpful in giving patients with glaucoma and OSD a period of respite from topical prostaglandins in order to give the ocular surface time to improve and minimize inflammation, during which period glaucoma surgery could be performed or preservative-free drops could be tried.

A multicenter randomized controlled trial (LiGHT) recently investigated the role of selective laser trabeculoplasty (SLT) versus eye drops for first-line treatment of ocular hypertension and glaucoma and highlighted the utility of SLT early in the management of glaucoma.[47,48] This study analyzed 718 patients who underwent SLT or eye drops for initial treatment of open angle glaucoma or ocular hypertension. The study demonstrated a higher percentage of patients with intraocular pressure at target, fewer patients requiring glaucoma surgery, and 74.2% of eyes requiring no drops at 36 months in the SLT group. This study supports SLT as a first-line treatment for glaucoma. Repeat treatments were also demonstrated to be efficacious.

Multiple trabecular bypass and angle-based MIGS procedures are now available and have the potential to greatly reduce glaucoma drop burden in patients with mild and moderate disease. Given the safety and efficacy of these approaches, patients may be candidates for earlier surgical intervention. The reduction in eyedrop burden postoperatively after iStent Inject (Glaukos Corporation, San Clemente, CA, USA) or Hydrus Microstent (Ivantis, Inc, Irvine, CA, USA) is reported to be significant.[49] The COMPARE study demonstrated an average medication reduction of 1.6 drops after implantation of the Hydrus compared to reduction of 1 drop in patients who received the iStent Inject (P = 0.004). Implantation of iStent Inject at the time of cataract surgery has recently been linked to improvement in signs and symptoms of OSD, likely due to reduced postoperative medication burden.[50] Patients who underwent iStent implantation in this study had an average medication reduction of about 1 drop with significant improvement in OSDI scores, tear break up time, and corneal and conjunctival staining. Performing MIGS earlier with or without cataract surgery may reduce ocular toxicity related to chronic drop administration. This may also minimize subconjunctival scarring and optimize surgical outcomes if bleb-based surgery is required in the future. MIGS may also avoid potential tear film circulation issues, bleb dysesthesia, and side effects of antifibrotic agents that are often seen with traditional glaucoma surgeries.[43] For those patients suffering from OSD without visually significant cataract, SLT is often a good first step. Goniotomy, viscocanaloplasty, GATT, trabectome, and endocyclophotocoagulation are available as standalone surgical options without the need for concomitant cataract extraction.