BLOG: MicroPulse TLT for patients who struggle with drops

(Image Credit: AdobeStock/Michal Ludwiczak)

In my practice, I often see patients who have difficulty either applying or tolerating drops. In these cases, if the patient has already had previous selective laser trabeculoplasty (SLT) treatment, I often turn to MicroPulse transscleral laser treatment (TLT) for a solution that is neither topical nor incisional to avoid the practical challenges with drops and increased risk associated with incisional surgery.

A 90-year-old female presented with mild primary open-angle glaucoma in both eyes and was having trouble applying drops because she had arthritis and some tremor. She said the bottles were too small and that she needed to squeeze too hard to produce drops.

Her intraocular pressure (IOP) in both eyes was not under target on Xalatan. I initially tried escalating care to other once-daily treatment options, but they were either ineffective, or presented a financial difficulty for her. She had previously received SLT treatment many years ago with great effects. She elected to undergo MicroPulse TLT.

Her preop visual acuity was 20/40 OD and 20/25 OS, with IOP of 22 mmHg OD and 23 mmHg OS on the Xalatan. After the procedure, her vision remained stable OD and improved OS to 20/20-2. Her IOP one month after treatment had improved to 16 mmHg OD and 18 mmHg OS off topical drops and has remained at or below the target pressure of 18 mmHg without drops ever since.

It is not uncommon for glaucoma patients to have difficulty applying drops. A review of 15 observational studies found that between 18.2 and 80% of patients contaminate their eye drop bottle by touching their eye or face, 11.3–60.6% do not instill exactly one drop, and 6.8–37.3% miss the eye with the drop.¹ Problems applying drops often worsen as patients age, commonly due to joint problems and some amount of tremor. Increasing age and other medical difficulties also increase risks associated with incisional surgery.

Intolerance and Allergies

Patients may be intolerant or allergic to glaucoma drops. They may react at first exposure, or the problem can develop months or even years later.

A 90-year-old male patient had been experiencing a low-grade reaction to the Vyzulta he had been taking once a day before bed for years for ocular hypertension. Eventually, he felt he could no longer take the drops due to severe redness in his eyes.

He then had a reaction to other drops as well, suggesting the problem was likely caused by a common preservative. Preservative-free drops are often more expensive for patients because there are no generic substitutes and insurance companies tend not to include them in their preferred tiers. This was a concern for the patient, as was the fact that he sometimes dozed off in the evening without applying his drops.

Given these factors, he strongly preferred a non-topical treatment option. I initially performed SLT in both eyes with no significant IOP improvement after 3 months. I then performed MicroPulse TLT in both eyes. Before MicroPulse TLT treatment, the patient’s best corrected visual acuity was 20/30+2 in both eyes, and his IOP was 18 mmHg OD and 20 mmHg OS on Vyzulta.

Six months after MicroPulse TLT, the patient’s IOP was 16 mmHg OD and 18 mmHg OS off drops. His IOP currently remains at the goal of<21 mmHg, without drops, and his Humphrey visual field is stable.

My patients are extremely pleased when I can eliminate their need for drops. Even those who can tolerate drops and administer them properly deal with the challenge of remembering to use them every single day. A study using pharmacy claims data to measure adherence to regimes of IOP-lowering glaucoma medications reported a mean adherence rate of 76% on average for prostaglandin/prostamide medications.² Eliminating or reducing drops not only provides relief for my patients but also decreases my concerns about their compliance.

References:

1. Davis SA, Sleath B, Carpenter DM, Blalock SJ, Muir KW, Budenz DL. Drop instillation and glaucoma. Curr Opin Ophthalmol. 2018;29(2):171-177. doi:10.1097/ICU.0000000000000451

2. Wilensky J, Fiscella RG, Carlson AM, Morris LS, Walt J. Measurement of persistence and adherence to regimens of IOP-lowering glaucoma medications using pharmacy claims data. Am J Ophthalmol. 2006;141(1 Suppl):S28-S33. doi:10.1016/j.ajo.2005.09.011