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Patient compliance (and non-compliance, as the case may be) is nothing new when discussing glaucoma. Nor are the multiple devices and systems previously developed or under investigation with the hope of improving compliance, said Richard Lewis, MD, speaking here at Glaucoma Day at ASCRS 2016.
New Orleans-Patient compliance (and non-compliance, as the case may be) is nothing new when discussing glaucoma.
Nor are the multiple devices and systems previously developed or under investigation with the hope of improving compliance, said Richard Lewis, MD, speaking at Glaucoma Day at ASCRS 2016.
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âWeâve been talking about compliance for as long as I can remember,â Dr. Lewis said. âAnd weâve been trying to address the issue for just as long a time. Alternatives to eye drops were described as early as 1976, with the Ocusert implant.â
Ocusert was basically pilocarpine in a delivery system put into the lower cul-de-sac. The issue with the system was that it first delivered too much medication, which led to side effects, and then when the system delivered too little medication, there was little drug effect, he said.
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âThe problem was there were complications that sometimes couldnât be overcome and it wasnât a very successful product commercially,â he said. âBut the problem of patient compliance with traditional topical medications has not dissipated. We need better medications delivered for a longer duration.â
A potentially viable option to deliver drugs is through punctal plugs, but âthey have to be retained in the eye and thatâs been an obstacle,â Dr. Lewis said.
At issue are the higher retention rates needed to ensure punctal plugs remain commercially viable.
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âThe disadvantages beyond retention are directional flow and topical effect,â he said.
Too many earlier versions would end up in the nasal area instead of the eye, Dr. Lewis said.
Showing promise
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But two newer devices are showing promise, Dr. Lewis noted.
Mati Therapeutics is developing a punctal plug delivery system, as is Ocular Therapeutix. Mati purchased the delivery technology from QLT in 2013 and uses latanoprost.
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Ocular Therapeutixâs Dextenza is a sustained-release dexamethasone intracanalicular depot currently in phase III studies for allergic conjunctivitis, a phase II study for inflammatory dry eye disease, and is awaiting regulatory approval for the treatment of postoperative inflammation and pain. Dextenza has been developed to deliver a 4-week tapered release, the company has said, and once the therapy is complete, the hydrogel resorts and exits through the nasolacrimal system without need for physician removal.
âTheyâre currently working on using travoprost in a punctal plug,â Dr. Lewis said.
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Matiâs device is a solid core, while Dextenza conforms to the punctuation, âso there may be a higher retention rate,â Dr. Lewis said, noting both companies claim higher than 95% retention rates. Dextenza changes color if it falls out, which may also alert patients if the device has dislodged. And both companies claim drug duration effects of about 3 months.
Alternatives to punctal plugs are also being developed, including drug-eluting contact lenses.
âThese are non-invasive, have no preservatives, a steady elution rate,â he said.
According to the literature, a latanoprost-eluting contact lens has been developed by encapsulating latanoprost films in methafilcon by ultraviolet light polymerization.
âSo far, thereâs only animal data, but itâs a good idea and theyâre claiming increased compliance will be a reality. In vitro studies show thereâs about a 24-day duration,â Dr. Lewis said.
Gel drops
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Finally, there are gel eye drops, but this technology is âstill very investigational and also not yet in humans.â
The concept is that the drops form a stable gel that releases the medication over the course of a month, Dr. Lewis said.
In rabbit data, the gel appeared to be non-irritating, and was completely retained for the study duration (28 days).
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âThatâs got a lot of potential, and may be good for specific types of treatment, but it may not be an ideal vehicle in glaucoma,â he said.
Researchers are also evaluating the subconjunctival inserts.
âThese are non-biodegradable polymers that can be safely removed,â he said.
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Benefits include that theyâre preservative-free and are targeting a 12-month duration of effect.
âItâs still a work in progress and itâs unclear if these will be able to achieve adequate pressure reduction using a prostaglandin,â he said.
The ongoing challenge for all of these systems and device is zero order (rate of elimination is constant and does not depend on or vary with the drug intake or plasma concentration of the drug), and that not all the alternatives are ideal for all medication (prostaglandins in particular where it is unclear if prolonged exposure on the ocular surface is good or bad for pressure reduction).
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Finally, these types of studies are time consuming and typically last years. Theyâre also costly-even when investigating an already approved drug. And there may be unintended consequences-âthe Ocusert moved across the cornea,â Dr. Lewis said.
Most of the data available on the devices and drug delivery systems has been presented at ophthalmic meetings, but there is ânot a lot of data available in the peer-review journals yet,â he said.
Dr. Lewis is a consultant for Aerie Pharmaceuticals, Alcon Laboratories, Allergan, Carl Zeiss Meditec, Glaukos, Ivantis, Oculeve, and PolyActiva. He is also chief medical officer for Aerie Pharmaceuticals.
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