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New medications and treatment alternatives are changing the landscape of glaucoma management.
Eye doctors have traditionally started with medication eye drops as first-line treatment for newly diagnosed glaucoma patients. For patients who have difficulty with eye drops, doctors then have typically proceeded to selective laser trabeculoplasty (SLT) treatment, and for difficult or advanced glaucoma cases they will consider incisional surgery to effectively lower their patient’s intraocular pressure (IOP) in order to protect the optic nerve from further damage.
In recent years, however, the medical management of glaucoma has been changing for many doctors and patients. New types of glaucoma medications have become available to patients, the use of selective laser trabeculoplasty (SLT) as first-line treatment is increasing, and several new, safer surgery options in the “micro-invasive glaucoma surgery” (MIGS) category have changed the traditional landscape of glaucoma management.
For nearly two decades, prescribing a prostaglandin analog medication eye drop has been considered first-line therapy for many reasons. Prostaglandin analogs are effective in lowering IOP with once-daily dosing and relatively minimal side effects. Two new categories of glaucoma medications, the nitric oxide-donating prostaglandins and Rho kinase inhibitors, challenge this traditional practice. These categories of medications have proven to be effective in lowering IOP with once-daily dosing and few side effects. These new categories of medications present a novel mechanism for improving drainage of fluid out of the eye. They have shown to lower IOP significantly and compare well to other established medications.
Latanoprostene bunod ophthalmic solution 0.024% (Vyzulta; Bausch + Lomb) was approved by the FDA in November 2017 for the reduction of IOP in open-angle glaucoma and ocular hypertension. This medication has a dual mechanism of action that works on both increasing uveoscleral outflow and enhancing trabecular meshwork outflow in part via a nitric oxide mediator.
The Rho kinase inhibitors, netarsudil 0.02% ophthalmic solution (Rhopressa; Aerie Pharmaceuticals) and netarsudil 0.02% ophthalmic solution + latanoprost 0.005% ophthalmic solution (Rocklatan; Aerie Pharmaceuticals), are yet another category of novel glaucoma medications. Netarsudil was FDA approved in December 2017, and netarsudil + latanoprost was FDA approved in March 2019 for the reduction of elevated IOP in open-angle glaucoma and ocular hypertension. Netarsudil, dosed once daily, lowers IOP through three mechanisms of action: (1) increasing outflow via the trabecular meshwork, (2) decreasing production of aqueous humor, and (3) decreasing episcleral venous pressure.
How will eye doctors use these new medications when treating their patients? Latanoprostene bunod and netarsudil + latanoprost are two of the most effective medications available, with once-daily dosing and minimal systemic side effects. These medications can be seen as first line for highly elevated IOPs as well as IOPs that are already within normal-to-low range. They can be ideal for patients who have difficulty using medications with multiple doses to simplify the regimen and for those patients with cardiovascular disease who cannot tolerate the systemic side effects of other classes like beta blockers or alpha agonists.
Netarsudil, in contrast, would be ideal for those patients who are concerned about iris color change that can be seen with prostaglandin analogs, as well as patients with uveitis, with macular edema, or for whom prostaglandin analogs are not effective.
Treatment paradigm shifts have also been occurring in determining when to introduce SLT therapy. Instead of waiting to introduce this SLT therapy as a second, third, or even fourth-line form of treatment, many eye doctors are introducing SLT as a first-line therapy.
The many benefits of introducing SLT as first-line therapy include avoiding the side effects of topical medications, removing the difficulty of adherence to medication eye drops, simplifying the treatment regimen, and improved SLT efficacy when used as first-line therapy.
Article by Constance Okeke, MD, MSCE. Dr. Okeke is an assistant professor of ophthalmology at Eastern Virginia Medical School in Norfolk, VA., and a glaucoma specialist and cataract surgeon at Virginia Eye Consultants.
Last reviewed on February 14, 2020