Medical therapy remains initial choice for glaucoma

Stanford, CA-"Medical therapy for glaucoma remains the preferred first option for most patients in developed countries," said Kuldev Singh, MD, MPH, as he described the status and future of glaucoma therapy.

"[Although] one would expect that this will result in price reductions for medications, the actual cost savings to patients remain unknown," said Dr. Singh, professor of ophthalmology and director, Glaucoma Service, Stanford University School of Medicine, Stanford, CA.

The increase in the prevalence of glaucoma in the United States has been exponential over the past century, with aging an important risk factor. By the year 2050, there will be substantially more Americans over the age of 40 relative to under 40, and this demographic shift will result in glaucoma being a much greater burden on our society, both in terms of morbidity as well as cost of providing care, Dr. Singh said.

Preferred over laser, surgery

Despite the historically high cost of glaucoma medications, there is a reason why physicians prefer medicines over laser or surgery as initial therapy, according to Dr. Singh. The Collaborative Initial Glaucoma Treatment Study (CIGTS), which compared medical treatment with trabeculectomy for 607 patients with newly diagnosed glaucoma, showed that the IOP was slightly lower after surgery compared with medical therapy. At the 5-year time point, however, there was no difference between the two treatment groups with regard to visual preservation.

Patients opt for medical therapy initially when offered the two treatments because of the adverse events associated with glaucoma surgery, he said. Although a good case can be made for initial laser trabeculoplasty, Dr. Singh said that initial medical therapy, when available and affordable, will continue to be the preferred first-choice treatment in the United States and other developed countries for a variety of reasons.

"Medical therapy is effective but expensive, especially given the circumstance that many of our patients need more than one medication," Dr. Singh said. CIGTS showed that 75% of patients in the study needed two or more glaucoma medications to meet the study goals. The Ocular Hypertension Treatment Study, in which the treatment goal was a modest 20% reduction from baseline IOP, reported that 49% of those enrolled needed two or more medications to meet that study goal.

"It is not uncommon for such patients who are taking more than two medications to spend $2,000 or more annually to treat glaucoma," he said.

Why is it then that effective surgical options are not chosen first? Fewer than 100,000 glaucoma surgeries are performed annually in the United States in a population where there are more than 1 million patients with the disease.

"There still is no ideal glaucoma surgery for early disease," he said. "The risk-benefit profile for our current operations, while tolerable for refractory cases, is not acceptable for such procedures to be initial therapeutic options in most circumstances. Glaucomatous disease is common but fortunately only results in blindness in a modest percentage of all those under treatment."