Patient-reported behavior and problems in using glaucoma medications

Association of Psychosocial Factors with Activation Among Patients with Glaucoma

OBJECTIVE

To investigate the association of psychosocial factors with health self-management behaviors and beliefs among patients with primary open-angle glaucoma (POAG).

DESIGN

Prospective cross-sectional cohort study.

PARTICIPANTS

Patients (n = 202) with mild, moderate, or advanced bilateral POAG.

METHODS

Patients (N = 1164) were identified from electronic medical records at a single academic medical center. Letters soliciting participation were mailed to 591 randomly selected potential participants. Psychometric measures and a social determinants of health questionnaire were administered by phone to 202 study participants.

MAIN OUTCOME MEASURES

The National Eye Institute Visual Function Questionnaire-8 (NEI-VFQ), the Multidimensional Health Locus of Control (MHLC), the Perceived Medical Condition Self-Management Scale-4, the Patient Health Questionnaire-9 (PHQ), the Patient Activation Measure-13 (PAM), a health literacy question, and a social determinants of health questionnaire.

RESULTS

For each increase in level of POAG severity, there was a decrease in mean NEI-VFQ score (P < 0.001). For each unit increase in NEI-VFQ item 1, self-rated vision, mean PAM score increased (R2 = 5.3%; P = 0.001; 95% confidence interval [CI], 0.077-0.276). For each unit increase in "Internal" on the MHLC, mean PAM score increased (R2 = 19.3%; 95% CI, 0.649-1.166; P < 0.001). For each unit increase in "Doctors" on the MHLC, mean PAM score increased (R2 = 11.0%; 95% CI, 1.555-3.606; P < 0.001). For each unit increase in "Chance" on the MHLC, mean PAM score decreased (R2 = 2.6%; 95% CI, -0.664 to -0.051; P = 0.023). On multivariate analysis, adjusting for age, sex and race, for each unit increase in PHQ, mean PAM score decreased (95% CI, 0.061-1.35; P = 0.032); for each unit increase in MHLC "Doctors", mean PAM score increased (95% CI, -1.448 to 3.453; P < 0.001); for each unit increase in MHLC "Internal", mean PAM score increased (95% CI, 0.639-1.137; P < 0.001); for each unit increase in MHLC "Chance", mean PAM score decreased (95% CI, -0.685 to -0.098; P = 0.009).

CONCLUSIONS

We identified modifiable behavioral factors that could increase patients' self-perceived ability and confidence to manage their own eye care. Locus of control (MHLC), level of depression (PHQ), and self-rated functional vision (NEI-VFQ) were each associated with patient behaviors, attitudes, and beliefs needed for health self-management (activation, assessed by the PAM) and may be important determinants of adherence behaviors. Targeting change in patients' care beliefs and behaviors may improve activation and treatment outcomes.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Patient-Reported Dry Eye Treatment and Burden of Care

OBJECTIVES

Dry eye is a common condition that can decrease the quality of life. This survey-based study of persons with dry eye investigated self-reported treatments (initial, current), out-of-pocket expenses, time spent on self-management, sources of care, and sources of information about their condition.

METHODS

Online dry eye newsletters and support groups were emailed a link to an electronic survey asking members to participate. Survey respondents were not required to answer every question.

RESULTS

In total, 639 persons with self-reported dry eye responded (86% women, 14% men [n=623]; mean ± SD age, 55 ± 14 years [n=595]). Artificial tears were the most reported intervention (76% initially, 71% currently). The median (interquartile range) out-of-pocket treatment cost annually was $500 ($200-$1,320 [n=506]). In addition, 55% (n=544) estimated 5 to 20 min daily on self-management; 22% spent an hour or more. Ophthalmologists provided most dry eye care (67%, n=520). Only 48% (n=524) reported that their primary source of dry eye information came from their eye care clinician.

CONCLUSIONS

Artificial tears are the primary treatment for dry eye. Ophthalmologists provide most dry eye care, but half of patients report that their eye care provider is not their primary source of information. Almost one fourth of patients spend an hour or more daily on treatments.

Predictors and long-term patterns of medication adherence to glaucoma treatment in Denmark-an observational registry study of 30 100 Danish patients with glaucoma

BACKGROUND

Self-treatment with glaucoma medication (eye drops) has been associated with adherence challenges. Poor adherence results in worse outcomes in terms of visual field loss.

OBJECTIVE

To investigate patterns in medication adherence among Danish patients with glaucoma in relation to selected predictors of adherence, long-term adherence patterns, and long-term societal economic consequences of poor adherence.

METHODS AND ANALYSIS

This register-based study included 30 100 glaucoma patients followed for 10 years between 2000 and 2018. Glaucoma was identified from the Danish national registers by diagnosis of Open Angle Glaucoma and/or by redeemed prescriptions of glaucoma medication. Logistic regression models were applied to estimate patient characteristics related to medical adherence. Diagnosis-related group fees were applied to estimate healthcare costs.

RESULTS

High adherence in the first year(s) of treatment was less likely among men (ORfirst year: 0.78, 95% CI: 0.75 to 0.82), younger individuals and among those with a positive Charlson Comorbidity Index (CCI) score (ORfirst year/CCI≥3: 0.71, 95% CI: 0.63 to 0.80). Adherence in the first year and in the first two years was associated with adherence in the fifth (ORfirst year: 4.55, 95% CI: 4.30 to 4.82/ORfirst two years: 6.47, 95% CI: 6.10 to 6.86) as with adherence in the 10th year with slightly lower estimates. Being medical adherent was related to higher costs related to glaucoma medication after 5 and 10 years comparing with poor adherence, whereas poor adherence was associated with a marked increase in long-term costs for hospital contacts.

CONCLUSION

Increasing age, female sex and low comorbidity score are correlated with better adherence to glaucoma treatment. Adherence in the first years of treatment may be a good predictor for future adherence. In the long term, patients with poor adherence are overall more expensive to society in terms of hospital contacts.

Improved Glaucoma Medication Access Through Pharmacy Partnership: A Single Institution Experience

Purpose

A major barrier to glaucoma medication adherence is the patient's out-of-pocket costs. At the University of Chicago Medical Center (UCMC), the institutional pharmacy piloted a program to query out-of-pocket costs for each patient's medication list based on their insurance coverage. This study aims to describe the impact of this collaboration between the glaucoma service and the outpatient pharmacy service.

Methods

This study is a single institution, retrospective chart review of glaucoma patients with a formulary inquiry placed by a single glaucoma specialist between 4/1/2020 and 2/28/2022. Main outcome measures included medications before and after formulary inquiries, additional steps required to access the medications (ie, formulary exceptions, prior authorizations, tier exceptions), and out-of-pocket costs.

Results

A total of 343 formulary inquiries, representing 568 individual medication inquiries, were conducted. Out of the 568 medication inquiries, only 78 could be filled for an affordable price without any additional steps. For 45 inquiries, additional steps were required for the medication to become covered at an affordable price. The remaining 445 inquires required additional steps with subsequent denial or prohibitive out-of-pocket costs.

Conclusion

The UCMC workflow provided transparent out-of-pocket costs for patients to access glaucoma medications. This workflow may be cost-effective as it minimizes the burden on the overall system by reducing the number of patients who are unable to fill a prescription at the pharmacy due to issues with coverage or affordability. This model of physician-pharmacy collaboration can guide other institutions to implement similar workflows which directly mitigate costs and improve quality of care.

FAST® questionnaire for identifying glaucoma patients at risk for ocular surface disease

OBJECTIVES

To evaluate the validity and reliability of the new Fast Assessment of the Ocular Surface Trouble (FAST®) questionnaire for identifying glaucoma or ocular hypertension (OHT) patients at risk of ocular surface disease (OSD).

METHODS

A multicenter, international, cross-sectional, epidemiological survey evaluated the most accurate interview items and ocular signs on the initial 14-item version of FAST® to develop a shorter version for routine, quick clinical use. Rasch analysis and least absolute shrinkage and selection operator (LASSO) method was used to reduce the number of items on the questionnaire. Sensitivity and specificity of FAST® were assessed with receiver operating characteristic (ROC) curves for the detection of OSD with the questionnaire and ophthalmic assessment.

RESULTS

A total of 2308 eyes (1154 patients) were analyzed in this study by 92 ophthalmologists. The initial version of the FAST® indicated 60% of the subjects had OSD. Rasch analysis allowed removal of some clinical signs. The LASSO method allowed elimination of some items from the original questionnaire for a 9-item and a 6-item version of FAST®. For the 6-item questionnaire, the sensitivity and specificity were 71.9% and 74.3% respectively and the area under the curve was 0.815.

CONCLUSIONS

The FAST® questionnaire is a valid and reliable tool for use in routine clinical practice and in clinical trials. The short versions of the questionnaire allow quick detection of the majority of patients with OHT or glaucoma at risk of dry eye.

Rapid and efficient generation of a transplantable population of functional retinal ganglion cells from fibroblasts

Glaucoma and other optic neuropathies lead to progressive and irreversible vision loss by damaging retinal ganglion cells (RGCs) and their axons. Cell replacement therapy is a potential promising treatment. However, current methods to obtain RGCs have inherent limitations, including time-consuming procedures, inefficient yields and complex protocols, which hinder their practical application. Here, we have developed a straightforward, rapid and efficient approach for directly inducing RGCs from mouse embryonic fibroblasts (MEFs) using a combination of triple transcription factors (TFs): ASCL1, BRN3B and PAX6 (ABP). We showed that on the 6th day following ABP induction, neurons with molecular characteristics of RGCs were observed, and more than 60% of induced neurons became iRGCs (induced retinal ganglion cells) in the end. Transplanted iRGCs had the ability to survive and appropriately integrate into the RGC layer of mouse retinal explants and N-methyl-D-aspartic acid (NMDA)-damaged retinas. Moreover, they exhibited electrophysiological properties typical of RGCs, and were able to regrow dendrites and axons and form synaptic connections with host retinal cells. Together, we have established a rapid and efficient approach to acquire functional RGCs for potential cell replacement therapy to treat glaucoma and other optic neuropathies.

Qualitative Development of the Allergan Satisfaction with Treatment Experience Questionnaire (ASTEQ) Instrument, a Patient-Reported Outcome Measure in Glaucoma and Ocular Hypertension

INTRODUCTION

Sustained-release intraocular implants provide a therapeutic option for open-angle glaucoma (OAG) and ocular hypertension (OHT) patients who are non-compliant with eyedrops. Currently, there are no published patient-reported outcome (PRO) measures that assess treatment satisfaction with intraocular implants. To address this gap, a new PRO instrument, the Allergan Satisfaction with Treatment Experience Questionnaire (ASTEQ), has been developed in accordance with Food and Drug Administration guidance.

METHODS

Qualitative research interviews were conducted among patients with OAG/OHT who had received three intraocular injections of a sustained-release bimatoprost (10 or 15 µg) implant within the clinical trial setting. A preliminary conceptual framework capturing treatment satisfaction concepts in glaucoma, as identified from the literature, was used to develop a semi-structured interview guide. A concept elicitation (CE) interview to identify aspects of the glaucoma treatment experience pertinent to intraocular implants provided content for a draft instrument. A cognitive debriefing (CD) interview to test the instrument's interpretability, relevance, and validity informed its subsequent refinement. Interview analysis followed a grounded theory approach to identify data patterns and relationships.

RESULTS

CE interviews (n = 19) indicated that participants' main considerations in rating satisfaction with implant treatment were physical comfort during preparation for the implant and implant administration, anxiety about the procedure, frequency of implant administration, possible side effects, convenience and accessibility of the implant, relationship with the clinician, and lifestyle fit. Draft ASTEQ revision based on CD interviews (n = 20) and readability tests yielded a nine-item ASTEQ instrument comprising satisfaction with overall implant experience and frequency of administration, occurrence/bother of immediate and long-term side effects, worry about implant administration and possible risks/side effects, and physical discomfort during preparation for the implant and implant administration.

CONCLUSION

The ASTEQ instrument has demonstrated content validity in patients with OAG/OHT treated with a sustained-release bimatoprost implant. Further research is necessary to evaluate its psychometric properties.

Barriers and enablers to medication adherence in glaucoma: A systematic review of modifiable factors using the Theoretical Domains Framework

PURPOSE

Nonadherence to medication reduces treatment effectiveness, and in chronic conditions it can significantly reduce health outcomes. In glaucoma, suboptimal adherence can lead to sight loss, which places a greater financial burden on society and reduces patients' quality of life. Interventions to improve adherence have so far had limited success and lack robust theoretical underpinnings. A better understanding of the determinants of medication adherence behaviour is needed in order to develop interventions that can target these factors more effectively. This systematic review aims to identify modifiable barriers and enablers to glaucoma medication adherence and identify factors most likely to influence adherence behaviour.

RECENT FINDINGS

We searched CINAHL, MEDLINE, PsycINFO, EMBASE, the Cochrane Library and sources of grey literature up to August 2022 for studies reporting determinants of glaucoma medication adherence. Data describing modifiable barriers/enablers to adherence were extracted and analysed using the Theoretical Domains Framework (TDF), a behavioural framework consisting of 14 domains representing theoretical factors that most likely influence behaviour. Data were deductively coded into one of the TDF domains and inductively analysed to generate themes. Key behavioural domains influencing medication adherence were identified by frequency of study coding, level of elaboration and expressed importance. Eighty-three studies were included in the final synthesis. Four key domains influencing glaucoma medication adherence were identified: 'Environmental Context and Resources', 'Knowledge', 'Skills' and 'Memory, Attention and decision processes'. Frequently reported barriers included complex eyedrop regimens, lack of patient understanding of their condition, forgetfulness and difficulties administering eyedrops. Whereas simplified treatments, knowledgeable educated patients and good patient-practitioner relationships were enablers to adherence.

SUMMARY

We identified multiple barriers and enablers affecting glaucoma medication adherence. Four theoretical domains were found to be key in influencing adherence behaviour. These findings can be used to underpin the development of behaviour change interventions that aim to improve medication adherence.

Novel tactile bottle neck adaptor facilitates eye drop adherence in visually impaired patients

PURPOSE

To test the use of Ring-IT, a novel 3D tactile bottle neck adaptor in topical eye drop adherence in visually impaired patients.

METHODS

Bottle neck ring adaptors with either one, two or three protrusions with cube or sphere endings were designed. In phase 1, low vision was simulated in healthy subjects (n=20) with a 20/200 vision simulator; while in phase 2, visually impaired patients (n=26; 20/70 or worse) were recruited. Subjects were randomised to six combinations of varying protrusions and shapes on medication bottles and asked to identify these traits at different presentations. Responses and time to identify were recorded.

RESULTS

Phase 1: 98.3% of subjects correctly identified the number of protrusions. Mean time to identify was 4.5±6.1 s. Identification success for cube and sphere end pieces were 91.7% and 73.3%, with average time for identification of 9.9±7.6 and 10.9±9.0 s. In phase 2, 92.3% of subjects correctly identified the number of protrusions. Mean time to identify was 6.0±3.0 s. Identification success for cube and sphere end pieces were 78.2% and 74.4%; with average time for identification of 7.5±4.8 and 8.5±5.6 s, respectively.

CONCLUSIONS

Ring-IT was identified with accuracy and speed by both low vision simulated subjects, and by patients with true limited visual capabilities. These tactile bottle neck ring adaptors can be used as an assistive low vision aid device and may increase eye drop regimen adherence in visually impaired patients.

Factors Affecting Glaucoma Medication Adherence and Interventions to Improve Adherence: A Narrative Review

Glaucoma is a leading cause of vision loss. First line therapy for primary open angle glaucoma (POAG) are topical ocular hypotensive drops. Patient adherence with topical therapy for glaucoma is a significant challenge with a reported adherence of 60%. The purpose of this review is to discuss factors associated with glaucoma adherence (including demographic factors, cost, patient education, health beliefs, treatment burden and regimen, and physical limitations) and to explore potential interventions to improve medication adherence. Articles included in this review were found by searching PubMed and Google Scholar using the key words "Glaucoma Treatment Adherence" and "Glaucoma Treatment Compliance." Data from this review demonstrates that higher medication cost, lower patient education/literacy levels, and being of African and Hispanic descent are associated with lower medication adherence rates. The data is inconclusive on whether medication regimen complexity lowers patient medication adherence rates. Interventions that have successfully improved medication adherence rates for minority patients have focused on building trust and addressing fears and false beliefs. For cost, explicit physician communication to patients regarding medication cost is important and can help the physician determine any patient concerns about cost. Outside the USA, adherence has been improved through adherence-contingent rebate systems and government subsidies. Most interventions that aim to increase adherence target patient education and literacy with the following interventions demonstrating efficacy: written instructions targeting glaucoma-specific health literacy, literacy level appropriate glaucoma education videos, and interactive and personalized educational programs. More clinic infrastructure and programs that utilize patient reminder tools and patient educators could help physicians and patients in support of these personalized action plans.

Usability of an Eye Drop Delivery Aid for Single-Dose Instillation: Results from a Market Research Study

Background

One of the challenges of treating chronic ocular diseases like vernal keratoconjunctivitis (VKC), glaucoma, and ocular surface disease is patient adherence to topical medication. To support correct eye drop instillation, a variety of delivery aids have been developed for both single-dose and conventional multi-dose containers.

Methods

To evaluate Dropaid™ Single-dose, an eye drop delivery aid designed for single-dose containers, a usability study was conducted on 30 parents and caregivers of patients with VKC. After assessing the ability to squeeze a single eye drop from the single-dose container onto the eye of a pediatric medical dummy, the delivery aid was evaluated using an 11-point Likert scale on a variety of characteristics: from "very difficult" (-5) to "very easy" (+5).

Results

The majority of participants rated the task of opening the single-dose units (SDUs), preparing, and positioning the Dropaid™ Single-dose device as "very easy". When providing a single eye drop from the container, 87% of participants rated the Dropaid™ Single-dose device as either "very easy" or "easy", with a median rating score of +5.0 (interquartile range [IQR], 4.0-5.0). For general ease of use, 84% considered the delivery aid as either "very easy" or "easy", with a median score of +4.0 (IQR, 3.0-5.0). Most participants (93%) rated Dropaid™ Single-dose as either "very comfortable" or "comfortable" to hold, with a median score of +5.0 (IQR, 4.0-5.0).

Conclusion

The Dropaid™ Single-dose delivery aid demonstrated rapid learning and ease of use across all stages of application, including opening the container, eye drop administration, and handling comfort. Although designed for use with single-dose containers to help eye drop instillation in patients with VKC, Dropaid™ Single-dose may provide a wider utility across a range of other ocular diseases such as glaucoma and dry eye.

Polymer-Based Self-Assembled Drug Delivery Systems for Glaucoma Treatment: Design Strategies and Recent Advances

Glaucoma has become the world's leading cause of irreversible blindness, and one of its main characteristics is high intraocular pressure. Currently, the non-surgical drug treatment scheme to reduce intraocular pressure is a priority method for glaucoma treatment. However, the complex and special structure of the eye poses significant challenges to the treatment effect and safety adherence of this drug treatment approach. To address these challenges, the application of polymer-based self-assembled drug delivery systems in glaucoma treatment has emerged. This review focuses on the utilization of polymer-based self-assembled structures or materials as important functional and intelligent carriers for drug delivery in glaucoma treatment. Various drug delivery systems, such as eye drops, hydrogels, and contact lenses, are discussed. Additionally, the review primarily summarizes the design strategies and methods used to enhance the treatment effect and safety compliance of these polymer-based drug delivery systems. Finally, the discussion delves into the new challenges and prospects of employing polymer-based self-assembled drug delivery systems for the treatment of glaucoma.

Disparities in Eye Care Access and Utilization: A Narrative Review

This narrative review summarizes the literature on factors related to eye care access and utilization in the United States. Using the Healthy People 2030 framework, this review investigates social determinants of health associated with general and follow-up engagement, screenings, diagnostic visits, treatment, technology, and teleophthalmology. We provide hypotheses for these documented eye care disparities, featuring qualitative, patient-centered research. Lastly, we provide recommendations in the hopes of appropriately eliminating these disparities and reimagining eye care.

Technological Advances in a Therapy of Primary Open-Angle Glaucoma: Insights into Current Nanotechnologies

Glaucoma is a leading cause of irreversible blindness and is characterized by increased intraocular pressure (IOP) and progressive optic nerve damage. The current therapeutic approaches for glaucoma management, such as eye drops and oral medications, face challenges including poor bioavailability, low patient compliance, and limited efficacy. In recent years, nanotechnology has emerged as a promising approach to overcome these limitations and revolutionize glaucoma treatment. In this narrative review, we present an overview of the novel nanotechnologies employed in the treatment of primary open-angle glaucoma. Various nanosystems, including liposomes, niosomes, nanoparticles, and other nanostructured carriers, have been developed to enhance the delivery and bioavailability of antiglaucoma drugs. They offer advantages such as a high drug loading capacity, sustained release, improved corneal permeability, and targeted drug delivery to the ocular tissues. The application of nanotechnologies in glaucoma treatment represents a transformative approach that addresses the limitations of conventional therapies. However, further research is needed to optimize the formulations, evaluate long-term safety, and implement these nanotechnologies into clinical practice. With continued advancements in nanotechnology, the future holds great potential for improving the management and outcomes of glaucoma, ultimately preserving vision and improving the lives of millions affected by this debilitating disease.

Cost-Utility Analysis of a Medication Adherence-Enhancing Educational Intervention for Glaucoma

OBJECTIVE

To evaluate the cost utility of a glaucoma medication-enhancing intervention compared to standard of care over a lifetime from the United States Department of Veterans Affairs (VA) payer perspective.

DESIGN

Model-based cost-utility analysis of a glaucoma medication-enhancing intervention from a randomized clinical trial.

SUBJECTS

Veterans with glaucoma, or suspected glaucoma who were prescribed topical glaucoma medications, had their visual field assessed within the last 9 months, and endorsed poor glaucoma medication adherence.

METHODS

Veterans were randomized either to a behavioral intervention to promote adherence or to a standard of care (control) session about general eye health. A decision analytic model was developed to simulate lifelong costs and quality-adjusted life years (QALYs) for an intervention tested in a randomized clinical trial at a single VA eye clinic. Costs included direct medical costs that the VA payer would incur, as informed initially by the clinical trial and then by published estimates. Health-state quality of life was based on published utility values. Scenario analyses included addition of booster interventions, a 3% decline in chance of staying medication adherent annually, and the combination of the two. Analyses were also conducted in the following subgroups: those with companion versus not, and those with once-daily versus more than once-daily dosing frequency.

MAIN OUTCOME MEASURES

Incremental cost-effectiveness ratio (ICER).

RESULTS

Compared to standard of care, the intervention dominated resulting in lower costs ($23 339.28 versus $23 504.02) and higher QALYs (11.62 versus 11.58). Among the 4 subgroups, the intervention dominated for 3 of them. In the fourth subgroup, those with more than once-daily dosing, the ICER was $2625/QALY. Compared to standard of care, an intervention with booster interventions led to an ICER of $3278/QALY. Assuming both a 3% annual loss in chance of continuing to be adherent and addition of booster interventions, the ICER increased to $71 371/QALY.

CONCLUSIONS

From a VA payer perspective over a lifetime, the glaucoma medication-enhancing behavioral intervention dominated standard of care in terms of generating cost savings and greater QALYs.

FINANCIAL DISCLOSURES

Proprietary or commercial disclosure may be found after the references.

Fixed versus Unfixed Combination of Topical Latanoprost/Timolol for Glaucoma: An Observational Study Investigating the Level of Adherence and Ocular Surface Health

PURPOSE

To investigate the effect of fixed combination versus concomitant unfixed topical glaucoma treatment on patients' adherence and ocular surface health.

PATIENTS AND METHODS

This is a 6-month, prospective, parallel-group, observational study in patients with ocular hypertension (OHT), primary open-angle glaucoma (POAG), or exfoliation glaucoma (XFG). A total of 142 patients with similar baseline characteristics were enrolled in this study. Seventy-one patients received a Latanoprost 0.005%/Timolol 0.5% fixed combination in the evening, whereas seventy-one patients received the unfixed treatment with Latanoprost 0.005% in the evening and Timolol 0.5% twice daily. The primary outcome was the adherence rate at baseline, and at the 3- and 6-month follow-up visits. The secondary outcomes included the signs of ocular surface disease (OSD) and intraocular pressure (IOP).

RESULTS

The adherence of patients treated with the fixed combination was higher than the unfixed treatment at the 3-month (78.0% vs. 63.0%, p < 0.001) and at the 6-month visits (73.0% vs. 58.5%, p < 0.01). The Break-up Time, Schirmer test, and Van Bijsterveld score were worse in the unfixed group at baseline and all subsequent examinations (p < 0.05 for all comparisons). There were no differences in the mean IOP between groups at baseline, 1-, and 3-month visits. IOP appears higher in the unfixed group at 6 months (16.7 vs. 15.0 mmHg, p < 0.01).

CONCLUSION

The patients with ocular hypertension and primary open-angle glaucoma treated with a fixed combination are significantly more adherent and show a healthier ocular surface than those treated with an unfixed combination. The study provides significant evidence of the benefits of fixed combination treatment.

Reduction of Eyedrop Volume for Topical Ophthalmic Medications with the Nanodropper Bottle Adaptor

Purpose

To determine the drop volume and total number of dispensed drops using the Nanodropper eyedrop bottle adaptor (Nanodropper, Inc.) compared to drops dispensed from stock bottles to potentially limit ocular toxicity of these eyedrops and prolong bottle use.

Patients and Methods

Six topical ocular hypotensive medications (5 solutions, 1 suspension), one steroid (suspension) and two artificial tears emulsions were selected for this study. An analytical balance was used to determine the mass per 10 drops with and without the volume-reducing adaptor and repeated until the bottles were completely emptied. The density of each product was determined using the calculated density. The average drop volume and number of drops per bottle for the nine medications were compared with and without the adaptor with paired t-testing.

Results

When all medications were assessed, the drops delivered with the adaptor were 62.1% smaller than eyedrops administered from standard bottles. Compared to stock bottle eyedrops, which had a mean volume of 39.8 ± 2.1 μL, the adaptor resulted in drops with a mean volume of 15.1 ± 1.0 μL, p<0.0001. The adaptor delivered 2.6x the number of drops dispensed from a standard 2.5 mL bottle (184.1 ± 15.1 drops with adaptor and 69.8 ± 4.9 drops from stock bottle, p<0.0001).

Conclusion

The Nanodropper eyedrop bottle adaptor can significantly reduce drop volume and increase the overall number of drops dispensed compared with stock eyedrop bottles. Further studies are needed to elucidate the clinical impact of utilizing decreased drop volume with direct comparison to current standards of care.

[Ocular surface disease in glaucoma patients: Expert opinion and management algorithm in Algeria]

INTRODUCTION

The main goal of treatment for any glaucoma patient is to reduce the intraocular pressure. Unfortunately, the long-term use of glaucoma medications causes deleterious effects on the ocular surface, leading to impaired quality of life and failed glaucoma surgery. In addition, adverse effects of medications are a barrier to adherence and compliance, and this directly affects efficacy. It is therefore essential to regularly assess the ocular surface of glaucoma patients in order to detect any signs of damage early and act accordingly. Although the TFOS DEWS 2 now offers a strategy for diagnosing ocular surface pathologies, some examinations are unfortunately not feasible in Algeria due to lack of time and/or knowledge on the part of some ophthalmologists or are simply inaccessible to others.

METHODS

Algerian experts (members of the ACOS club) met for the purpose of proposing an algorithm for the management of Algerian glaucoma patients, based on the recommendations of the DEWS, their own practice and the results of a preliminary national survey of ophthalmologists.

RESULTS

The proposed algorithm allows evaluation of the ocular surface of the glaucoma patient in current practice by any Algerian ophthalmologist.

CONCLUSION

Management of glaucoma patients should include a systematic examination of the ocular surface. The choice of treatment should be determined by the ocular surface condition of the glaucoma patient.

Review of glaucoma medication adherence monitoring in the digital health era

Current glaucoma treatments aim to lower intraocular pressure, often with topical ocular hypotensive medications. Unfortunately, the effectiveness of these medications depends on sustained patient adherence to regimens which may involve instilling multiple medications several times daily. Patient adherence to glaucoma medications is often low. Recent innovations in digital sensor technologies have been leveraged to confirm eyedrop medication usage in real-time and relay this information back to providers. Some sensors have also been designed to deliver medication reminders and notifications as well as assist with correct eyedrop administration technique. Here, we review recent innovations targeted at improving glaucoma medication adherence and discuss their limitations.

Interventions for Glaucoma Medication Adherence Improvement: A Network Meta-analysis of Randomized Controlled Trials

TOPIC

Comparative effectiveness of interventions to improve glaucoma medication adherence.

CLINICAL RELEVANCE

High adherence to ocular hypotensive therapy is essential for prevention of visual impairment in glaucoma patients. Various types of intervention for adherence enhancement have been proposed, although there is still no firm evidence of their relative efficacies.

METHODS

We searched PubMed, EMBASE, Scopus, the Cochrane Central Register of Controlled Trials, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov on November 30, 2021. Randomized controlled trials (RCTs) entailing interventions for improved adherence to ocular hypotensive therapy were identified. A network meta-analysis (NMA) was performed, and the following 11 interventions (single category or combinations of categories) were compared: (1) standard of care ([SOC] control), (2) short message service, (3) telephone call, (4) device reminder, (5) motivational interview, (6) multimedia education, (7) physician education, (8) provision of own medical records, (9) incentives, (10) tailored care, and (11) enhanced SOC. The primary outcome was the postintervention mean adherence score. The standardized mean differences (SMDs) were analyzed, and the effectiveness was ranked by P-score (probability of being best treatment). We appraised trials using the Cochrane risk-of-bias tool for RCTs. Confidence of results was assessed by Confidence in Network Meta-analysis.

RESULTS

We obtained data for 19 RCTs (4981 participants). Tailored care, as inclusive of face-to-face needs assessment and a personalized care plan, was superior to SOC in improving adherence (SMD, 1.28; 95% confidence interval [CI], 0.08-2.48; P-score, 0.810). Multifaceted interventions that included tailored care showed further adherence improvement: tailored care + multimedia education (SMD, 1.44; 95% CI, 0.20-2.67; 0.850) and tailored care + multimedia education + device reminder (SMD, 1.61; 95% CI, 0.75-2.47; 0.914). The ranking of the remaining interventions by P-scores was as follows: incentives (0.606), short message service (0.535), enhanced SOC (0.458), multimedia education (0.430), device reminder (0.429), telephone call (0.401), provision of own medical records (0.391), physician education (0.281), SOC (0.230), and motivational interview (0.165).

CONCLUSIONS

The NMA indicated that tailored care can improve adherence to glaucoma medication compared with SOC. A multifaceted approach might yield additional improvements.

Iontophoretic ocular delivery of latanoprost-loaded nanoparticles via skin-attached electrodes

Prolonged drug efficacy to reduce the number of administrations is a key factor in the successful treatment of glaucoma through topical drug delivery to the eye. Therefore, we propose a new strategy for iontophoretic ocular delivery of drug-loaded nanoparticles. Considering safety and convenience, our strategy is involved with topical administration of the drug-loaded nanoparticles followed by their permeation into the eye tissues via noninvasive iontophoresis, using the skin-attached electrodes. Thus, those nanoparticles stayed longer in the eye, and during this period, the drug was released in a sustained manner, thereby prolonging drug exposure even with one-time treatment. The nanoparticles were made of poly(lactic-co-glycolic acid) (PLGA), which were loaded with a glaucoma drug, latanoprost. We varied the size of the nanoparticles at 100, 200, 300, and 500 nm and sought to find the optimum size under the fixed conditions for iontophoresis proposed in this work (4 mA; 30 min). Even with iontophoresis through the skin-attached electrodes, the nanoparticles were indeed deposited in the eye tissues, where with an increase in particle size, drug release was more sustained, but fewer particles could permeate into the eye tissues. Because of these two competing factors, iontophoretic delivery of the 300-nm particles exhibited the most prolonged drug efficacy in vivo for more than 7 days, and showed an approximately 23-fold increase in drug efficacy compared with that of Xalatan®, a commercially available eye drop of latanoprost developed for once-a-day administration every day. STATEMENT OF SIGNIFICANCE: To treat glaucoma, conventional eye drops are often prescribed; however, they often require multiple daily administrations due to rapid preocular clearance. To resolve this, we suggest a noninvasive iontophoretic ocular delivery of latanoprost-loaded PLGA nanoparticles using the skin-attached electrodes. Even with iontophoresis via the skin-attached electrodes, the nanoparticles can indeed be deposited into the eye tissues. However, with an increase in particle size, fewer particles can permeate into the eye tissues, although drug release is more sustained. Therefore, the particles with a size of 300 nm show the optimal in vivo delivery profile in this work, where the drug efficacy can be extended for more than 7 days with a single administration.

Real-world data from selective laser trabeculoplasty in Brazil

Evaluate real-world data of outcomes from selective laser trabeculoplasty (SLT) performed in different regions of Brazil and investigate potential predictors of success associated with treatment. Multicenter retrospective case series with patients who underwent a primary SLT procedure. A total of 835 eyes from 835 patients were included. The mean follow-up was 916.8 ± 563.0 days. The mean age was 64.5 ± 14.9 years and 56.6% were women. We observed an intraocular pressure reduction comparing baseline to post-SLT measurements (18.4 ± 3.8 mmHg versus 14.8 ± 3.5 mmHg; P < 0.001) and mean number of glaucoma medications (1.8 ± 1.3 versus 1.4 ± 1.4; P < 0.001). We observed visual acuity loss over time (0.1 ± 0.3 versus 0.2 ± 0.3 logMAR, baseline and post-SLT, respectively, P = 0.009) and decrease in visual field mean deviation values (- 5.4 ± 5.9 versus - 5.7 ± 6.0 dB; P = 0.054) The Kaplan-Meier survival analysis showed an estimated probability of treatment success of 88% at 12 months, declining to 70% at 24 months and 54% at 36 months post-SLT. In the multivariable model, we found that a denser angle pigmentation (HR 0.69; 95% CI 0.57-0.85, P = 0.001) and corticosteroid treatment following SLT (HR 0.59; 95% CI 0.39-0.91, P = 0.018) were significantly associated with a lower risk for failure. Primary SLT achieved relatively high success rates without sight-threating complications in this real-world study with a large sample of Brazilian patients. These findings corroborate previous studies regarding SLT outcomes and may help clinicians to identify the best candidates for laser treatment.

Comparing the effectiveness of different postoperative counseling methods for post-keratoplasty patients

PURPOSE

To compare various counseling methods for improving patient education, compliance, and administration of eye drops prescribed for post-optical keratoplasty patients and assess the most efficient counseling method.

METHODS

A prospective, questionnaire-based pilot study was conducted among 60 post-optical keratoplasty patients who were randomly assigned into three groups for postoperative eye drop counseling, namely group 1 (video counseling), group 2 (chart counseling), and group 3 (verbal counseling at Cornea department). The questionnaire was answered by the patients/attendants applying the eye drops on the first 3 consecutive visits. McNemar-Bowker test was used to compare responses in each group and the Kruskal-Wallis test was used to compare responses among the three groups. The Institutional Ethics Committee of Aravind Eye Hospital, Tirunelveli (Registration number ECR 816/Inst/Tn/2016) approved this study.

RESULTS

Results demonstrated improvement in various categories assessed regarding drop administration in all three groups, which assessed patients' knowledge, attitude, and hygiene. Although all three groups showed improvements during subsequent follow-up visits, the video-counseling method was found to be an effective means of communication.

CONCLUSION

Our study emphasizes that the nonverbal and noncontact means of communication by video demonstration would be an effective way of counseling. It can be considered in the present scenario of the pandemic as well.

Facilitators and Barriers to Glaucoma Medication Adherence

PRCIS

Patient education and dosing self-efficacy are important factors related to ongoing adherence to glaucoma topical treatment, and patients view their disease management as a shared effort with their provider.

PURPOSE

Glaucoma affects nearly 3 million Americans, and medication adherence has been reported to be as low as 20% in this patient population; however, key limitations to our understanding of this behavior in adults with glaucoma exist.

PATIENTS AND METHODS

This research used an electronic survey including validated concepts related to topical medication use and an in-person interview to investigate the influencers of and solutions for challenges to medication adherence in adults with glaucoma. Patient eligibility was determined upon arrival to a regularly-scheduled visit to the Vanderbilt Eye Institute, during which they were asked for consent to complete the survey. Responses were captured by tablet and assessed using descriptive and inferential statistics. The primary focus was instrument correlations with the Adherence to Refills and Medications Scale score and were run between Adherence to Refills and Medications Scale, and the totaled score for each individual questionnaire as well as individual items. Recorded interviews were thematically assessed by multiple study team members.

RESULTS

Survey results of adults with glaucoma suggested that self-efficacy, forgetfulness, fear of side effects, and dosing ability were all related to self-reported medication adherence. Despite most having glaucoma for several years, discrepancies in disease knowledge were observed. Patient interviews uncovered 3 overall themes related to glaucoma treatment: (1) glaucoma management as a shared responsibility; (2) the importance of patient education; and (3) specific adherence facilitators and barriers.

CONCLUSION

Glaucoma medication adherence interventions may benefit from focusing on developing patient medication-taking self-efficacy, disease-related education, and engagement with their provider.

Comparison of Medication Adherence Assessment Tools to Identify Glaucoma Medication Nonadherence

PURPOSE

To assess the accuracy of 5 subjective self-assessment tools (3 adherence measures and 2 psychometric scales) and pharmacy refill data in predicting objective electronically monitored nonadherence.

DESIGN

Prospective cohort study.

PARTICIPANTS

Glaucoma patients (> 40 years old, >1 medication with poor self-reported adherence) were recruited from University of Michigan Kellogg Eye Center for a study assessing the impact of a personalized glaucoma coaching program on medication adherence.

METHODS

Participants completed an initial assessment including 5 self-assessment tools and a 3-month period of electronic monitoring of glaucoma medication adherence (AdhereTech); pharmacy refill data were obtained. Electronically monitored adherence was calculated monthly as the percentage of doses taken on time. The median of these adherence rates was designated as baseline adherence. Patients with adherence of ≤80% by electronic monitoring were considered nonadherent. Self-assessment tools were scored, and pharmacy refill data were summarized as the proportion of days covered. Correlation between measures of adherence was estimated with Pearson and Spearman correlation coefficients. Receiver operating characteristic curves, including estimation of area under the curve (AUC), sensitivity, specificity, and accuracy were used to compare measures of adherence with respect to predicting electronically monitored nonadherence.

MAIN OUTCOME MEASURES

Accuracy of self-reported and pharmacy refill data adherence measures in predicting electronically monitored nonadherence.

RESULTS

Ninety-five patients completed 3 months of electronic monitoring with a median monthly adherence of 74 (± 21%); 53 patients (56%) were nonadherent. Pharmacy refill data were not correlated significantly with electronically monitored medication adherence (r = 0.12; P = 0.2). Of all the measures, a single-item adherence question ("Over the past month, what percentage of your drops do you think you took correctly?") showed the largest correlation with median electronically monitored adherence (r = 0.47; P < 0.0001), largest AUC for predicting nonadherence (AUC = 0.76 [95% confidence interval [CI], 0.66-0.87]), best accuracy (71% [95% CI, 61%-82%]), and good sensitivity (84% [95% CI, 73%-96%]).

CONCLUSIONS

The single-item question was the most accurate in predicting electronically monitored nonadherence among participants with poor self-reported adherence. In clinical practice, where alternatives are too resource intensive, this free single-item screening question can help to identify glaucoma patients at risk of poor medication adherence with reasonable accuracy.

Topical Medication Adherence and Visual Field Progression in Open-angle Glaucoma: Analysis of a Large US Health Care System

PRCIS

Modeling of visual field and pharmacy data (Kaiser Permanente, 2001 to 2014) from open-angle/pseudoexfoliation glaucoma patients in clinical practice indicated a significant inverse association between the level of medication adherence and rate of visual field progression.

PURPOSE

The aim was to quantify the effect of nonadherence to topical hypotensive medication on glaucomatous visual field progression in clinical practice.

METHODS

Retrospective analysis of combined visual field and pharmacy data from Kaiser Permanente Southern California's HealthConnect electronic health record database. Patients with a diagnosis of primary open-angle glaucoma or pseudoexfoliation glaucoma (2001 to 2011) and ≥3 subsequent visual field tests of the same Swedish Interactive Threshold Algorithm type were followed up from first medication fill to final visual field test. Medication adherence (proportion of days covered) was estimated from pharmacy refill data. A conditional growth model was used to estimate the effect of adherence level in modifying the progression of mean deviation over time after adjusting for potential confounders, including age, sex, race/ethnicity, baseline glaucoma severity, and comorbidity.

RESULTS

In total, 6343 eligible patients were included in the study and followed for (mean) 5.8 years; average treatment adherence during follow-up was 73%. After controlling for confounders and the interaction between time and baseline disease severity, the model indicated that mean deviation progression was significantly (P=0.006) reduced by 0.006 dB per year for each 10% (absolute) increase in adherence. Model estimates of time to glaucoma progression (mean deviation change -3 dB from baseline) were 8.3 and 9.3 years for patients with adherence levels of 20% and 80%, respectively.

CONCLUSIONS

Improving patient adherence to topical glaucoma medication may result in slower deterioration in visual function over time.

Design, development, and characterization of an idebenone-loaded poly-ε-caprolactone intravitreal implant as a new therapeutic approach for LHON treatment

Leber's Hereditary Optic Neuropathy (LHON) is a hereditary mitochondrial neurodegenerative disease of unclear etiology and lack of available therapeutic alternatives. The main goal of the current pilot study was based on the evaluation of the feasibility and characteristics of prolonged and controlled idebenone release from a PCL intravitreal implant. The design, development, and characterization of idebenone-loaded PCL implants prepared by an homogenization/extrusion/solvent evaporation method allowed the obtention of high PY, EE and LC values. In vitro characterization was completed by the assessment of mechanical and instrumental properties. The in vitro release of idebenone from the PCL implants was assessed and the implant erosion was monitored by the mass loss and surface morphology changes. DSC was used to estimate stability and interaction among implant's components. The present work demonstrated the controlled and prolonged idebenone delivery from the PCL implants in an in vitro model. A consistent preclinical base was established, supporting the idea of idebenone-loaded PCL implants as a new strategy of long-term sustained intraocular delivery for the LHON treatment.

Assessment of Corneal Epithelium Thickness in Glaucomatous Patients Undergoing Medical Treatment

PRECIS

Patients with glaucoma have reduced and irregular corneal epithelial thickness (CET) even if they do not report symptoms of dry eyes. The reduction of corneal epithelium affects equally the superior and inferior areas of the cornea.

PURPOSE

To evaluate CET parameters by means of anterior segment optical coherence tomography in glaucomatous patients undergoing medical treatment and compare them with CET parameters of controls.

METHODS

This was a cross-sectional study of 62 patients with primary open-angle or pseudoexfoliative glaucoma (study group) and 62 age-matched controls. Fourier-domain optical coherence tomography (RTVue) with a corneal adaptor module was used in the present study. Τhe pachymetry scan pattern was used to map the cornea and the software generated corneal thickness parameters were recorded. Simple comparisons between groups were performed and the correlations of CET parameters with parameters associated with medication use (treatment duration, number of medications and number of instillations) were assessed.

RESULTS

Mean age of the patients was 68±11.9 years in the glaucoma group and 65.5±8.5, years in the control group (P=0.17). Median number of instillations of medication was 2 (range, 1 to 6) for the glaucoma group. Central corneal thickness was 537.6±33.3 in the glaucoma group and 550.8±33.7 in the control group, respectively (P=0.028). The central CET was 48.8.±3.7 μm in the glaucoma group and 53.5±3.7 μm in the control group (P<0.001). Similarly, the average superior (2 to 7 mm) CET and the average inferior (2 to 7 mm) CET were almost equally reduced in the glaucoma group (45±4 vs. 49.6±3.3 μm, P<0.001 and 49±3.9 vs 53.5±3.7, P<0.001, respectively). No CET parameter was correlated with any of the treatment parameters.

CONCLUSIONS

Patients treated for glaucoma have uniformly reduced corneal epithelial thickness.

Comparison of BAK-preserved latanoprost and polyquad-preserved travoprost on ocular surface parameters in patients with glaucoma and ocular hypertension

BACKGROUND

To compare the effect of two different prostaglandin analogues (Travatan® vs. Xalatan®) on ocular surface parameters.

METHODS

This study includes 44 eyes of 44 patients with newly diagnosed primary open-angle glaucoma (POAG) or ocular hypertension (OHT). Patients were randomly divided into two groups and treated with either benzalkonium chloride (BAK)-preserved latanoprost and polyquad-preserved travoprost. Changes in intraocular pressure (IOP) levels and ocular surface parameters including ocular surface disease index (OSDI) questionnaire, tear breakup time (TBUT), ocular surface staining scores, and Schirmer test scores of patients were performed at baseline, 1, 3, 6, and 12 months of treatment and compared.

RESULTS

The age, sex ratio, visual acuity, central corneal thickness, and cup/disc ratio were similar between the groups. A decrease in IOP levels (23.3 ± 2.5 to 15.5 ± 2.3), TBUT (5.5 ± 2.3 to 4.1 ± 1.7 s), Schirmer test values (11.3 ± 5.9 to 8.6 ± 4.7 s), and a worsening in OSDI scores (44.6 ± 15.2 to 55.1 ± 13.1) and staining scores (1.7 ± 1.6 to 2.3 ± 1.8) were observed in all patients in the first month of treatment (p < 0.05, for all). No further worsening was detected during the 1-year follow-up. There was no difference between the groups in terms of alterations in IOP levels and ocular surface parameters.

CONCLUSION

Travatan® and Xalatan® have a similar effect on IOP levels and ocular surface parameters in patients with POAG and OHT.

Impact of pharmacist-led interventions in improving adherence to glaucoma medications in the geriatric population

OBJECTIVES

Geriatric patients can be non-adherent to ophthalmic glaucoma medications because of complex eye drops instillation techniques and forgetfulness, so pharmacists can play their part in improving the clinical outcomes of patients by acting as care providers. The purpose of the current study was to implement various pharmacist-led interventions to improve adherence to glaucoma medications and to evaluate the outcomes of interventions in the geriatric population.

METHODS

The Morisky Green Levine (MGL) adherence scale was used for analysis because it measures the extent of non-adherence and analyses the reasons for it. The interview-based sessions were conducted with control and interventional groups followed by educational interventions, including techniques for eye drop instillation, graphical images, precautionary measures, and individual patient counselling for the interventional group. Patients were asked to complete the adherence scale after the conclusion of every follow-up session for a duration of 6 months.

RESULTS

After 6 months of pharmacist-led interventions, a significant shift was found in the interventional group from low to high adherence according to MGL scale evaluation. Moreover, the number of patients in the interventional group whose intraocular pressure was in the safe range significantly increased and follow-up sessions significantly improved the patient's knowledge about glaucoma.

CONCLUSION

The results of this pharmacist-led educational interventional study showed it was effective in improving adherence to glaucoma medications in the geriatric patients, who showed better adherence scores and improved intraocular pressure.

Retinal Ganglion Cell Transplantation: Approaches for Overcoming Challenges to Functional Integration

As part of the central nervous system, mammalian retinal ganglion cells (RGCs) lack significant regenerative capacity. Glaucoma causes progressive and irreversible vision loss by damaging RGCs and their axons, which compose the optic nerve. To functionally restore vision, lost RGCs must be replaced. Despite tremendous advancements in experimental models of optic neuropathy that have elucidated pathways to induce endogenous RGC neuroprotection and axon regeneration, obstacles to achieving functional visual recovery through exogenous RGC transplantation remain. Key challenges include poor graft survival, low donor neuron localization to the host retina, and inadequate dendritogenesis and synaptogenesis with afferent amacrine and bipolar cells. In this review, we summarize the current state of experimental RGC transplantation, and we propose a set of standard approaches to quantifying and reporting experimental outcomes in order to guide a collective effort to advance the field toward functional RGC replacement and optic nerve regeneration.

Educational intervention to adopt selective laser trabeculoplasty as first-line glaucoma treatment: Randomized controlled trial: Educational intervention on selective laser trabeculoplasty

PURPOSE

To determine the efficacy of an educational intervention on patient adoption and attitudes toward selective laser trabeculoplasty (SLT) as first-line treatment for glaucoma.

METHODS

This study is a randomized controlled trial. Subjects include 33 patients within 1-year diagnosis of either primary open-angle glaucoma, ocular hypertension, or pseudoexfoliation syndrome. After informed consent, subjects were randomly assigned to a Usual Care or Educational Intervention group. All subjects completed a pre-intervention questionnaire. The Educational Intervention group was shown a slideshow presentation and a 3-min video and given a post-intervention questionnaire. Follow-up examinations were reviewed for 6 months to determine subject completion of SLT, the primary outcome. Secondary outcomes include assessment of attitude toward SLT before and after intervention.

RESULTS

Age, gender, and baseline characteristics between the groups did not differ. The Usual Care group had a higher proportion of African Americans (77% vs 31%, p = 0.04). At 6 months following the intervention, 63% of subjects underwent SLT compared to 35% of Usual Care subjects (p = 0.12). Older age was associated with decreased SLT uptake (OR 0.90, 95% CI 0.82-0.99, p = 0.03). Prior to the intervention, there were no differences in attitudes of both groups regarding SLT therapy. Nineteen percent of Educational Intervention subjects changed positively toward SLT (p = 0.08) and 50% scheduled an SLT appointment after intervention (p = 0.005).

CONCLUSIONS

A slideshow and video-based educational intervention may positively enhance patient adoption of SLT.Clinical trial registration name, number, URL: Educational Intervention to Adopt SLT as First-Line Glaucoma Treatment, NCT03365778, https://clinicaltrials.gov/ct2/show/NCT03365778.

Patients’ adherence to topical antiglaucoma medications in a tertiary care hospital

Objectives

Adherence to glaucoma medications is a central factor to control intraocular pressure and manage glaucoma effectively. This study aims to assess the level of adherence of glaucoma patients to ocular hypotensive agents and determine factors contributing to non-adherence in the Aseer region.

Methods

This was a single-centre, prospective cross-sectional study carried out in Aseer Hospital, Saudi Arabia. Data were collected through a customized questionnaire adapted from the Morisky, Green and Levine Medication Adherence Questionnaire (MGLS).

Key findings

Of the 102 glaucoma patients, 63 (61.8%) were non-adherent to their glaucoma medications. About 48 (76.2%) of them reported that they have no background information about glaucoma. Older participants (37, 58.7%; &gt;50 years) showed a low adherence level compared with the younger individuals. Contributing factors to non-adherence include forgetting the dose time (32, 50.8%), illiteracy (31, 49.2%; P = 0.313), economic problems (26, 41.3%; P = 0.286) and lack of information about prescribed medications (15, 23.8%; P = 0.188).

Conclusions

No significant relationship was found between medication adherence and patient’s demographic data or their background knowledge about glaucoma. Despite the need for improving the glaucoma patient’s knowledge of their disease and the importance of medication adherence, an additional strategy as alerts by smartwatches should be encouraged to improve the adherence level.

Safety and efficacy of microinvasive glaucoma surgery with cataract extraction in patients with normal-tension glaucoma

This study assesses the safety and efficacy of microinvasive glaucoma surgery (MIGS) with cataract extraction in patients with normal-tension glaucoma (NTG). In our sample of 45 NTG patients, mean intraocular pressure (IOP) decreased from 13.7 to 12.3 mmHg at 2.5 years, and mean medication burden decreased from 2.0 to 1.1 at 1.5 years. For success defined as IOP reduction ≥ 30% from baseline IOP with medication burden reduction from preoperative levels, success probability was 5.4% at 1.5 years. For success defined as medication burden reduction with an IOP reaching goal IOP as determined by the glaucoma specialist, success probabilities were 67.2% at 1.5 years and 29.4% at 2.5 years. At the last follow-up visit, eyes with two MIGS procedures with different mechanisms of action achieved successful medication reduction 68.8% of the time versus 35.7% achieved by a single MIGS procedure (p = 0.052). At their last visit, visual acuity was unchanged or improved in all eyes (100%). MIGS with cataract surgery results in modest reductions in IOP and medication burden in NTG patients, which may lead to lower costs and better therapeutic compliance. A combination of two MIGS procedures with different mechanisms of action may potentially be more effective in reducing medication burden than a single MIGS procedure in NTG patients. Further research is necessary to ascertain whether MIGS for NTG patients may help decrease medication burden while helping achieve goal IOP.

Predicting Adherence With the Glaucoma Treatment Compliance Assessment Tool

PRéCIS:: Univariate and multivariable models using the Glaucoma Treatment Compliance Assessment Tool (GTCAT) statements identified multiple, patient-specific factors associated with adherence that could be used to inform personalized interventions to optimize glaucoma adherence.

PURPOSE

The purpose of this study was to determine the health behavior factors related to glaucoma adherence in patients with self-reported poor adherence.

METHODS

A research coordinator used the Chang Adherence Measure and the Morisky Medication Adherence Scale to identify subjects with poor self-reported glaucoma medication adherence and enrolled them in a 3-month study to electronically monitor medication adherence. At enrollment, the coordinator administered the GTCAT. We calculated the percentage of prescribed doses taken over a 3-month period using an electronic dose monitor (AdhereTech). We used Rasch analysis, and univariate and multivariable regression to determine the GTCAT statements that predicted electronically monitored adherence.

RESULTS

The mean adherence was 73.8% (SD=21.04%, range: 13% to 100%). Rasch analysis showed that the GTCAT had a good overall fit and no differential bias (Anderson likelihood ratio test >0.05). Multiple GTCAT statements were associated with adherence, which represented increased knowledge, increased cues-to-action, decreased barriers, less depression, and increased self-efficacy (P<0.09 for each). The full GTCAT or a subset of statements had a high association with adherence (R range: 0.44 to 0.51, P<0.005 for all). The GTCAT identified >50% of patients who wanted more education about glaucoma; >68% who did not use reminders; and >40% who reported having difficulty using the eye drops.

CONCLUSIONS

The GTCAT identified multiple factors associated with adherence. Clinicians and researchers could use this tool to identify specific barriers to adherence and develop potential interventions to improve adherence.

[Glaucoma surgery today]

BACKGROUND

The main goals of glaucoma treatment are to preserve the visual function and maintain as high a quality of life as possible at a cost acceptable to society. Therefore, it is crucial to carefully observe each individual patient in order to determine an individual and personalized treatment approach.

MATERIAL AND METHODS

This article summarizes the advantages and disadvantages of medicinal glaucoma treatment as well as traditional methods of glaucoma surgery, based on the current state of knowledge. The article explains the various mechanisms of action of new minimally invasive procedures, introduces the methods mostly commonly used in Germany and gives recommendations for preoperative care and postoperative follow-up.

RESULTS/CONCLUSION

In addition to the plethora of medicinal glaucoma treatments and classical surgical procedures, new minimally invasive treatment alternatives have become available in the past few years. The latter are an option for an earlier surgical intervention, especially in naïve or previously treated patients who appear to be unsuitable for medicinal treatment.

Factors Associated With Favorable Laser Trabeculoplasty Response: IRIS Registry Analysis

PURPOSE

We examined patients in a large clinical registry to assess factors associated with laser trabeculoplasty (LTP) responses.

DESIGN

Retrospective cohort study.

METHODS

StudyPopulation: LTP patients in the Intelligent Research in Sight (IRIS) Registry, 2013-2018.

OBSERVATION

IRIS Registry data were extracted if the eye had a procedural code for LTP and a glaucoma diagnosis. Eyes were excluded if LTP laterality or baseline intraocular pressure (IOP) could not be determined. Following LTP, "nonresponders" were those with <20% IOP reduction after 8 weeks, while "responders" were those with ≥20% IOP reduction. MainOutcomeMeasures: Proportion of responders, odds ratios (OR) of pre-LTP factors associated with being a nonresponder.

RESULTS

A total of 263,480 eyes were included, with mean age 71.4 ± 11.7 years. Mean baseline IOP was 19.1 ± 5.0 mm Hg, mean number of pre-LTP medications was 2.1 ± 1.5. Response rate was 36.9% overall and 68.8% for those with baseline IOP >24 mm Hg. Higher baseline IOP was associated with reduced odds of nonresponse (OR = 0.60, P < .0001 for a 3 mm Hg increase). Angle recession, uveitis, and aphakia increased the odds of a nonresponse (ORs 2.46, 1.50 (both P < .0001), and 1.55 (P = .0259), respectively). In nonresponders with at least 1 medication at baseline, 76.3% of eyes had fewer medications postoperatively.

CONCLUSIONS

Lower baseline IOP, angle recession, uveitis, and aphakia were associated with increased odds of nonresponse. Future studies that analyze LTP responder survival and implementation lag would facilitate resource optimization in glaucoma therapy.

Sustained-release drug delivery systems for the treatment of glaucoma

Glaucoma, a leading cause of irreversible blindness, affects more than 64 million people worldwide and is expected to grow in number due to the aging global population and enhanced methods of detection. Although topical therapies are often effective when used as prescribed, the drawbacks of current medical management methods include poor patient adherence, local and systemic side effects, and in some cases, limited therapeutic efficacy. Novel ocular drug delivery platforms promise to deliver differentiated drug formulations with targeted delivery leveraging patient-independent administration. Several platforms are in various stages of development with promising pre-clinical and clinical data. The Bimatoprost Sustained Release (SR) intracameral implant was approved in the United States in March of 2020, making it the first long-term injectable therapy available for the treatment of glaucoma. This review aims to provide an update on novel sustained release drug delivery systems that are available today as well as those that might be commercialized in coming years.

<p>Decreasing Avoidable Vision Loss: Identifying Antecedents of Adherence</p>

Adherence to medication treatment protocols and active participation by individuals in their medical care are important for all patients, but especially for those with chronic conditions such as vision loss. Adherence is crucial for decreasing avoidable vision loss. Failure to take medications as prescribed and keep scheduled appointments reduces treatment effectiveness, increases complications and results in poorer outcomes. Reasons for nonadherence vary by diagnosis and include not understanding the importance of adherence, low health literacy, lack of adequate self-efficacy, low level of activation and behavioral issues including depression. Patients may lack information about their condition and its prognosis, available treatment alternatives, and other essential information such as how to monitor their eye condition, what to do if vision deteriorates and how to get needed community-based help. Each of these factors impedes patients’ ability to engage with their physician and participate in their own care. The ability of individuals with vision loss to actively and effectively manage their health care, ie, activation, has been understudied. When patients are involved with their own care, their care experience, and most importantly, their outcomes, are improved. Identifying antecedents of adherence may help provide disease- and patient-specific pathways to reduce avoidable vision loss.

Signs and Symptoms of Ocular Surface Disease: The Reasons for Patient Dissatisfaction with Glaucoma Treatments

Ocular Surface Disease (OSD) and hyperemia are the most common adverse events of topical ocular medications. While active compounds may cause allergic reactions or irritation, preservatives, which are intended to prevent bacterial growth, are toxic as well. Therefore, the most recent glaucoma medications no longer contain preservatives. Despite this, local tolerability may still impact treatment compliance and patient quality of life. We conducted an observational, multi-center, international, cross-sectional study in 793 treated and stabilized glaucoma patients to assess patient satisfaction and local tolerability of their treatment. The vast majority (93.7%) of patients was satisfied or very satisfied with their treatment in terms of tolerability and only 6.3% were dissatisfied. However, ophthalmological examination showed a high frequency of ocular signs: conjunctival hyperemia (32%), OSD (42.5%) and positive conjunctival fluorescein staining (10.3%). Additionally, patients reported symptoms upon instillation (31.4%) and between instillations (57.3%); 25.1% of patients were using tear substitutes. All signs and symptoms were significantly (p<0.001) associated with patient dissatisfaction. A logistic regression model indicated that dissatisfaction was higher in patients with symptoms upon instillation and in those using tear substitutes (OR: 3.03 and 4.63, respectively). The mean patient tolerability score to treatment was 82.7±16.1 on a 100-point visual analogue scale. In conclusion, even if patients may be highly satisfied with their current treatment, most of them present ocular signs and symptoms. A treatment change should be considered in case of clinical signs or patient-reported symptoms.

Reasons for the Underutilization of Generic Drugs by US Ophthalmologists: A Survey

Introduction

Cross-sectional survey of 92 board-certified practicing Midwestern ophthalmologists to determine why prescribing habits favor brand-name drugs over generics and to identify approaches for increasing generic drug utilization.

Methods

A survey was sent to members of state ophthalmology societies, private practice groups, and individual ophthalmologists to evaluate basic demographic/practice information, knowledge and opinions on generic drugs, frequency of drug representative visits, understanding of the Food and Drug Administration’s process of evaluating generics, knowledge of patients’ financial status and preferences, and action items that would increase generic utilization.

Results

Three factors increase the likelihood of ophthalmologists switching patients to generic drugs: increased knowledge of (1) generic options, (2) price differences between brand-names and generics, and ((3) patient preference for generics. The following four factors decrease the likelihood of ophthalmologists switching patients to generic drugs: (1) increased disease severity, (2) feeling that patient outcomes may be affected by choice of brand-name versus generic, (3) personal preference for taking a brand-name drug over a generic for their own hypothetical eye disease even if both were free, and (4) increased personal preference for taking a brand-name drug for their hypothetical eye disease.

Conclusion

Ophthalmologists should continue to update themselves on generic medication options, become familiar with the price difference of generics versus brand-name drugs for commonly prescribed medications, and seek patients’ opinions on generics and correct them when possible to increase generic utilization. In addition, studies evaluating the clinical equivalence of generic drugs relative to brand-name drugs should be performed and may help increase generic utilization.

Current and new pharmacotherapeutic approaches for glaucoma

INTRODUCTION

Glaucoma is the leading cause of irreversible blindness worldwide. Medical therapy is the main line of treatment of open-angle glaucoma (OAG) and ocular hypertension. Despite the expansion of the glaucoma lineup with the newly approved medication classes, many barriers and issues still exist with topical therapy. Novel non-topical drug delivery may address such issues, adding more options to glaucoma pharmacotherapy.

AREAS COVERED

This review outlines current topical therapies for glaucoma, in addition to new medications under trials. The issues with topical therapy, in general, are discussed, as well as the new non-topical drug delivery systems. The authors performed a comprehensive search for published studies on glaucoma medical therapy using the electronic database of PubMed and manual search for each medication and non-topical delivery options. The extra- and intraocular delivery methods and the new topical glaucoma medications under research are covered.

EXPERT OPINION

Medical management of glaucoma represents a challenge for both patients and clinicians. Noncompliance (e.g. difficulty with administering the eye drops), cost, side effects, and intraocular pressure fluctuation are the major problems with topical therapy. To overcome such barriers, research should continue in developing new medications and innovation of non-topical drug delivery systems.

Current Medical Therapy and Future Trends in the Management of Glaucoma Treatment

Glaucoma is a neurodegenerative disease characterized by progressive loss of retinal ganglion cells and their axons. Lowering of intraocular pressure (IOP) is currently the only proven treatment strategy for glaucoma. However, some patients show progressive loss of visual field and quality of life despite controlled IOP which indicates that other factors are implicated in glaucoma. Therefore, approaches that could prevent or decrease the rate of progression and do not rely on IOP lowering have gained much attention. Effective neuroprotection has been reported in animal models of glaucoma, but till now, no neuroprotective agents have been clinically approved. The present update provides an overview of currently available IOP-lowering medications. Moreover, potential new treatment targets for IOP-lowering and neuroprotective therapy are discussed. Finally, future trends in glaucoma therapy are addressed, including sustained drug delivery systems and progress toward personalized medicine.

Matrix Metalloproteinases and Glaucoma Treatment

Matrix metalloproteinases (MMPs) are a family of proteolytic enzymes that degrade extracellular matrix (ECM) components such as collagen and have important roles in multiple biological processes, including development and tissue remodeling, both in health and disease. The activity of MMPs is influenced by the expression of MMPs and tissue inhibitors of metalloproteinase (TIMPs). In the eye, MMP-mediated ECM turnover in the juxtacanalicular region of the trabecular meshwork (TM) reduces outflow resistance in the conventional outflow pathway and helps maintain intraocular pressure (IOP) homeostasis. An imbalance in the MMP/TIMP ratio may be involved in the elevated IOP often associated with glaucoma. The prostaglandin analog/prostamide (PGA) class of topical ocular hypotensive medications used in glaucoma treatment reduces IOP by increasing outflow through both conventional and unconventional (uveoscleral) outflow pathways. Evidence from in vivo and in vitro studies using animal models and anterior segment explant and cell cultures indicates that the mechanism of IOP lowering by PGAs involves increased MMP expression in the TM and ciliary body, leading to tissue remodeling that enhances conventional and unconventional outflow. PGA effects on MMP expression are dependent on the identity and concentration of the PGA. An intracameral sustained-release PGA implant (Bimatoprost SR) in development for glaucoma treatment can reduce IOP for many months after expected intraocular drug bioavailability. We hypothesize that the higher concentrations of bimatoprost achieved in ocular outflow tissues with the implant produce greater MMP upregulation and more extensive, sustained MMP-mediated target tissue remodeling, providing an extended duration of effect.

The Use of Generic Medications for Glaucoma

The use of generic medicines has grown considerably in recent years providing considerable cost savings. In England, generic items represented 11.7% of prescriptions for glaucoma and ocular hypertension in 2009, increasing to 55.2% of prescriptions in 2018. Generics can be brought to the market quickly and at low cost as manufacturers are not required to repeat animal or clinical research on active ingredients already approved for safety and efficacy. Although there is no regulatory requirement for studies comparing branded and generic eye drops, several randomised crossover studies have been performed comparing branded and generic prostaglandin analogues. While most have shown similar intraocular pressure lowering, studies are of short duration and have not evaluated visual field endpoints. Furthermore, differences in inactive ingredients, pH, viscosity, levels of particulate matter, and degradation over time have been reported. Other potential problems with generic eye drops include differences in bottle design affecting adherence, problems with supply, and the possibility that reduced revenue for innovator companies will lead to reduced investment in new drug development. This article reviews the potential advantages and disadvantages of generic antiglaucoma medications.

Comparison of the Intraocular Pressure-Lowering Efficacy and Safety of the Brinzolamide/Brimonidine Fixed-Dose Combination versus Concomitant Use of Brinzolamide and Brimonidine for Management of Open-Angle Glaucoma or Ocular Hypertension

Objective

To demonstrate that the intraocular pressure (IOP)-lowering efficacy of a twice-daily brinzolamide 10 mg/mL (BRINZ)/brimonidine 2 mg/mL (BRIM) fixed-dose combination (BBFC) was non-inferior to its individual components (BRINZ+BRIM) dosed concomitantly in patients with open-angle glaucoma (OAG) or ocular hypertension (OHT). Safety was also evaluated.

Methods and Analysis

This was a Phase III, multicenter, observer-masked study in patients from China, Russia and Taiwan. Patients aged ≥18 years with a mean IOP ≥21 mmHg and ≤36 mmHg in the same eye after washout of other IOP-lowering medications were included. Eligible patients were randomized (1:1) to receive BBFC or BRIZ+BRIM eye drops twice daily for 3 months. The primary endpoint was the mean change in diurnal IOP (averaged over 09:00, +2 h, and +7 h) from baseline to Month 3. Adverse events (AEs) were recorded throughout the study.

Results

The per-protocol set included 349 patients (BBFC, n=172; BRINZ+BRIM, n=177). The mean±standard deviation diurnal IOP at baseline was 24.6±2.66 mmHg in both groups. At Month 3, the least square mean±standard error change in diurnal IOP from baseline was −7.2±0.34 mmHg and −7.3±0.34 mmHg with BBFC and BRINZ+BRIM, respectively (between-group difference: 0.1 mmHg [95% CI −0.5, 0.7]). In the BBFC and BRINZ+BRIM groups, 53.3% and 55.0% of patients achieved a diurnal IOP <18 mmHg, and 43.2% and 37.4% of patients, respectively, achieved a mean diurnal IOP reduction >30% from baseline at Month 3. Ocular AEs were reported in 28.7% (BBFC) and 22.5% (BRINZ+BRIM) of patients; conjunctival hyperemia was the most frequent ocular AE (BBFC, 6.4%; BRINZ+BRIM, 6.8%). Non-ocular AEs were reported in 32.4% (BBFC) and 30.4% (BRINZ+BRIM) of patients.

Conclusion

The study findings demonstrate that the efficacy of twice-daily BBFC was non-inferior to BRINZ+BRIM in patients with OAG/OHT. The safety profile of BBFC was similar to that of BRINZ+BRIM.

Impact of Ocular Surface Disease Treatment in Patients with Glaucoma

Purpose

Chronic topical treatment for glaucoma may lead to Ocular Surface Disease (OSD). This study aimed to evaluate: (1) the prevalence of OSD in glaucoma patients under topical treatment, quantifying symptoms and objective ocular surface parameters and (2) the impact of ocular surface treatment on OSD and IOP control.

Methods

Patients with primary open angle or primary angle closure glaucoma under topical treatment for at least 6 months were enrolled in the study. Patients underwent symptom screening with the ocular surface disease index (OSDI) questionnaire, assessment of objective ocular surface parameters, ocular surface staining and Schirmer test. A treatment for OSD with eyelid hygiene, fluorometholone acetate 0.1%, preservative-free lubricants, free-acid supplementation and oral tetracyclin derivate was started, and the same evaluation was performed.

Results

In our sample (n=19), 73.68% of the patients reported severe symptoms of dry eye disease, with OSDI scores higher than 33 at baseline. Tear film instability was found in 50% of patients, while 23.53% had severe meibomian gland abnormalities. Fluorescein and lissamine green stainings were abnormal in 88.24% and 82.35% of patients, respectively. After ocular surface treatment, statistically significant improvement was found in best-corrected visual acuity (p=0.0003), OSDI score (p<0.0001), bulbar redness (p=0.0196) and fluorescein staining (p<0.0001.) Mean IOP following OSD treatment reduced −1.59 mmHg from baseline in the left eye (p=0.0510).

Conclusion

The prevalence of OSD signs and symptoms was high in glaucoma patients under medical treatment. Short-term OSD treatment may improve ocular surface disease and IOP control, with no need to discontinue glaucoma medications.

Nanotechnology for Medical and Surgical Glaucoma Therapy-A Review

Glaucoma is the second leading cause of blindness worldwide. Even though significant advances have been made in its management, currently available antiglaucoma therapies suffer from considerable drawbacks. Typically, the success and efficacy of glaucoma medications are undermined by their limited bioavailability to target tissues and the inadequate adherence demonstrated by patients with glaucoma. The latter is due to a gradual decrease in tolerability of lifelong topical therapies and the significant burden to patients of prescribed stepwise antiglaucoma regimens with frequent dosing which impact quality of life. On the other hand, glaucoma surgery is restricted by the inability of antifibrotic agents to efficiently control the wound healing process without causing severe collateral damage and long-term complications. Evolution of the treatment paradigm for patients with glaucoma will ideally include prevention of retinal ganglion cell degeneration by the successful delivery of neurotrophic factors, anti-inflammatory drugs, and gene therapies. Nanotechnology-based treatments may surpass the limitations of currently available glaucoma therapies through optimized targeted drug delivery, increased bioavailability, and controlled release. This review addresses the recent advances in glaucoma treatment strategies employing nanotechnology, including medical and surgical management, neuroregeneration, and neuroprotection.