Until new innovations began transforming the field a decade ago, ophthalmologists had a limited toolbox. This option allows ophthalmologists to provide positive outcomes for their patients.
Nothing will cue exasperated expressions and tales of woe from glaucoma specialists faster than asking us to share our challenges in helping patients correctly and adherently administer their drops. Of course, we know the stakes are high: Achieving and maintaining healthy eye pressure in patients with glaucoma preserves their vision.
Until new innovations began transforming the field a decade ago, ophthalmologists had a limited toolbox. Many of us have tried every innovation in the book—and written our own chapters—to ensure the right amount of medicine reaches its intended target at the correct intervals. Yet every eureka approach comes with a litany of cautionary tales.
I have seen careful, detailed explanations on drop administration fail to achieve adherence, because patients are on 2 or 3 different drops that must be dispensed in the right quantity at correct intervals multiple times a day.
I have done tactile primers on bottle “squeezability,” because how hard you squeeze determines how fast the drops come out. The right squeeze gets the right dose, but patients on multiple drops may have to contend with bottles of varying firmness, not to mention arthritis and other physical challenges that can impact the consistency of their squeeze. To add to the challenge, patients who oversqueeze can also run out of drops before they can refill their prescription.
I’ve sent patients home with detailed, written instructions and color-coded bottle caps only to see their pressure precipitously drop, despite their insistence that they were doing everything right. So, I had them bring me their bottles to demonstrate only to discover they had switched the colored caps and were taking the wrong dosage.
Of all the studies I have seen chronicling rampant nonadherence in glaucoma care, what’s most interesting is the strikingly low adherence rates of patients for their medications, including just a single prostaglandin analogue.1,2 Patients routinely tell me, “Doc, I’d rather to die than go blind.” The entire subspecialty of interventional glaucoma care was founded to end-run nonadherence and prevent that calamity from coming to pass.
The emergence of laser procedures and minimally invasive glaucoma surgery has transformed my practice. It has allowed us to shift focus away from treating the symptoms related to eye pressure and instead focus on the core issue. We know poor eye drop adherence often has long-term consequences.
We want to give patients different choices and provide them with our best treatment recommendations, but there’s a substantial cohort of patients who look at interventional procedures as a last resort, as many are viscerally squeamish about contact with their eyes.
There has long been a need for a middle option between eyedrop roulette and surgery. Finally, in the summer of 2020, that’s exactly what the FDA gave us.
The Bimatoprost implant (Durysta; AbbVie) is the first FDA-approved, dissolvable implant for patients with open angle glaucoma or high eye pressure (ocular hypertension), and it has been shown to lower eye pressure for patients for 15 weeks in clinical studies. As the implant dissolves, it automatically releases to help reduce high pressure inside the eye without the need for eye drops.
I’ve now treated 800 eyes with the bimatoprost implant. Approximately 75% of my patients on 2 different drops saw their IOP go to target pressure when the ocular implant replaced both drops. To me, these kinds of results not only demonstrate its efficacy, but they also starkly illustrate that nonadherence on drops is every bit the problem we feared and more.
Most of my patients are happily surprised when I share an illustration of the implant size, which is just 1 mm in length, and explain that the insertion feels just like the sensation of checking their eye pressure. The ability to stop using drops for the treatment duration is another selling point.
It’s important to be up front about adverse effects, but I’ve found this is also an easy pitch. The primary adverse effects are redness, irritation, or possibly some light sensitivity for a couple days. These are also common adverse effects of eye drops. I tell patients that adverse effects of eye drops can last forever, whereas the implant’s adverse effects generally resolve over time.
At present, the bimatoprost implant is approved for a 1-time use, lasting 15 weeks. However, new data are coming in every day, and my findings will soon be published, showing more durable and long-lasting effects in most of my patients. Regardless, the bimatoprost implant is an entryway for patients with glaucoma who’ve had reservations about interventional procedures writ large.
As ophthalmologists, nothing beats the joy of seeing sudden improvement. I have now treated enough patients to understand the immediate impact this treatment can make. In my view, the bimatoprost implantis a consequential innovation in glaucoma care, and the benefits are increasingly appreciated by providers and patients. Ocular implants demystify interventional glaucoma care and serve as a bridge to better health and vision.
Savak Teymoorian, MD
Dr Teymoorian specializes in cataracts and glaucoma at Harvard Eye Associates, a large, multisubspeciality ophthalmology practice in Orange County, California.
1. Schwartz GF, Quigley HA. Adherence and persistence with glaucoma therapy. Surv Ophthalmol. 2008;53(suppl 1):S57-S68. doi:10.1016/j.survophthal.2008.08.002
2. Yeaw J, Benner JS, Walt JG, Sian S, Smith DB. Comparing adherence and persistence across 6 chronic medication classes. J Manag Care Pharm. 2009;15(9):728-740. doi:10.18553/jmcp.2009.15.9.728