Glaucoma Management Updates for Pharmacists

Primary open-angle glaucoma is a progressive eye disease that can lead to irreversible vision loss without timely treatment and ongoing monitoring. This course reviews practical approaches to glaucoma management, including treatment goals, common medication options, and factors that influence adherence and long-term disease control. You will be better prepared to support patients receiving glaucoma therapy through medication counseling, adherence support, and reinforcement of appropriate follow-up care.

HOST
Rachel Maynard, PharmD
GameChangers Podcast Host and Lead, Clinical & Partnership Education, CEimpact

GUEST
Stephanie Conway-Allen, PharmD
Associate Professor of Pharmacy Practice,
Massachusetts College of Pharmacy and Health Sciences -Worcester/Manchester 

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 CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Describe treatment goals and common management strategies for primary open-angle glaucoma.
2. Explain pharmacist-relevant considerations for counseling and supporting patients receiving glaucoma therapy. 

Rachel Maynard and Stephanie Conway-Allen have no relevant financial relationships to disclose.

0.075 CEU/0.75 Hr
UAN: 0107-0000-26-252-H01-P
Initial release date: 7/20/2026
Expiration date: 7/20/2029
Additional CPE details can be found here.

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Transcript

CE Credit And Welcome

SPEAKER_01 0:00

Here on Game Changers, we're all about helping you stay ahead of pharmacy practice. But why stop at listening? You can earn CE credit for this episode and hundreds more by visiting CEimpact.com and logging into your account or creating a new one. Get credit, get inspired, and make your learning count. Hey CE Impact subscribers. Welcome to the Game Changers Clinical Update podcast. I'm your host, Rachel Maynard. Today I'm excited to talk about a topic that can often feel a bit confusing, and that's the management of primary open angle glaucoma. Glaucoma is the leading cause of blindness worldwide, and primary open angle glaucoma is the most common form in the US, and prevalence is expected to go up dramatically as the population ages. There's no cure, but early detection and medications can help slow progression. And that's where we come in. So pharmacists can play a huge role in helping patients with adherence and long-term management. But I know for myself, I often have trouble keeping all the different eye products straight. Plus, we've had a few new medications come out in the last couple of years, and there are some updated guidelines that can help guide care. So to help us sort through how to manage all this and best support patients, I'm so pleased to welcome our guest, Dr. Stephanie Conway Allen. So welcome, Stephanie. So happy to have you. Thank you very much, Rachel. It's great to be here.

Meet The Guest And Focus

SPEAKER_01 1:12

Excellent. Well, thank you for your time and taking time out of your busy day. And to help our listeners learn a little bit about you, could you just share a little bit about your background, your current role, and why you're interested in this topic?

SPEAKER_00 1:21

Absolutely. So again, my name is Stephanie Conway Allen. I am an associate professor at Massachusetts College of Pharmacy and Health Sciences in Worcester, Massachusetts. I also teach within the UMass Medical School as well as the nursing school. I also teach in our PA program here, as well as our non-traditional PharmD program. So kind of my my you know hands in a few different, a few different areas. But uh, you know, areas of interest for me have always been uh a lot of community, a lot of non-prescription, a lot of uh really focusing on the the impact that the pharmacist can have being that frontline healthcare professional and being able to really talk to and take care of our patients in the best way possible because we do have such great relationships with them. And so that's sort of the uh the way that I'm gonna talk about things today is really sort of looking at what our pharmacists are are what types of glaucoma-related issues or questions might come up and where they might be able to really sort of help and guide their patients. So I know I kind of transitioned a little bit away from me and a little bit more into the topic at hand, but um I figure, you know, why wait?

SPEAKER_01 2:21

Yeah, no, that's great. And I I like I mentioned, I mean, I think this can be a very confusing topic because there are so many different eye products available and to help understand how they fit in and when they're used and to help patients use them properly is such an important thing as you alluded to. So I'm I'm right in line with that. Um definitely let's just go ahead and jump in. And I think to get us all on the same page, it would be good to start with a little refresher about what primary open angle glaucoma is and how how it's different than other forms of glaucoma. What are the key considerations with it, you know, prevalence, complications, all of those sort of background uh stage setting sort of questions.

Open Angle Vs Closed Angle

SPEAKER_00 2:56

Yeah, absolutely. So we hear the term glaucoma, right? Especially when we're, again, I'm sort of thinking about a lot of that community, sort of those medications where we've got caution and using these when we're looking at closed angle glaucoma is something that comes up a great deal. Closed angle glaucoma is a legitimate obstruction in regards to where the fluid in your eye, the aqueous humor, where it's supposed to drain from your eye. And because of that, we've an increase in pressure. That is actually something that could be an emergency. So closed angle glaucoma, we're not really going to touch on it all today because that is a bit outside of our scope of practice as the pharmacist, aside from acknowledging if someone presents with an immediate uh issue with vision or something drastically changed uh in addition to pain and whatnot, obviously refer them immediately. But we're talking now about open angle glaucoma, which is far more prevalent and as you mentioned, is the leading cause of blindness worldwide. And so essentially what happens in open angle glaucoma is kind of think of the eye sort of like a as a there's a drain, right? Or a sink, right? And you've got a drain where the the fluid that's in the eye needs to needs to drain out. So we've got this ciliary body creating this aqueous humor, which is this fluid that's just going to make sure that the eye stays moist and uh so that everything can move appropriately, right? No one wants a dry eye or a sticky eye. And so essentially you've got this aqueous humor, and the aqueous humor is going to leave the eye naturally. It it drains out as it normally does through what's called this trabecular meshwork. Well, what happens in close, excuse me, in open angle glaucoma is essentially you've got a blockage in that drain, not a full blockage, but you've got something that's sludging it up and it's not allowing for that aqueous humor to drain at the appropriate or effective rate or the rate that we would normally expect to happen. Why does this happen? Well, patients get older, things happen, protein deposits, different, you know, life. Most of the patients that are most patients that develop glaucoma, open angle glaucoma, do so, you know, a little bit later in life if there's family history, things like that. So essentially in glaucoma, you've got a slow blockage, not a full block, not a full obstruction, but you've got a slight blockage where that drain is not able to drain out that aqueous humor as effectively as it should. And so this then puts pressure on the eye, increases the pressure within the eye, which then can damage the optic nerve. Damage of the optic nerve is then what is going to cause those vision issues as well as blindness ultimately, you know, down the line. So what we're what we're talking about, we're thinking about this drainage mechanism and this aqueous humor, and what is it that we can do to better uh allow for that eye to drain that aqueous humor to decrease that intraocular pressure. With that said, is it possible for patients to have open angle glaucoma without elevated, technically elevated intraocular pressure or IOP? Yes, technically. We won't really get into that and how that happens in regards to the diagnostics and why that might happen, but that has something to do more with just the physical, uh, you know, the anatomical nature for individuals, where sometimes they may might be more likely to have, while the IOP is not uh increased, the actual ability to drain is still being affected, and therefore the optic nerve is still being affected. Another thing that's important to note about uh open angle glaucoma is there aren't really symptoms. So we have to acknowledge that most patients will not know that this is truly happening. So why that's important is they won't realize the optic nerve is actually being damaged until either it's identified via uh just screenings with uh with your with an eye doctor, or if it's found when uh actual vision is lost. So, what can happen even in one of the eyes, if you're slowly sort of starting to lose a little bit of that peripheral vision, the other eye will compensate for it, will correct for it. And so you don't even realize you're starting to lose a little bit of that peripheral vision in those early stages. And this is why glaucoma is not like a silent, but kind of a silent disease state. And patients don't realize that behind the scenes their eye could be actually being damaged, and their ability to see in the future might be slowly being compromised because of this uh silent uh uh drain issue uh with our eye being the sink.

SPEAKER_01 7:07

Yeah. So that's a fantastic summary. And um, I love how you described it as this drain, and then the if the drain is sludgy or you know, slowed for whatever reason, it can lead to that buildup and that increased intraocular pressure. And that's really what the goal for most patients, as you said. But that's really what the goal of managing glaucoma is is to help reduce that intraocular pressure. And it's sort of like blood pressure, helping to reduce pressure in a space to prevent damage. And you know, loose analogy, but that's sort of a similar concept. And then also same same concept in terms of being silent, people may not realize that they are at risk, or even if uh it's progressing. And so even with medications, patient, I think that ties into adherence, which we'll I know we'll talk about, but that really is an important factor because patients may not have symptoms, and so it can be difficult to think about the importance of taking the medicines, using the medicines if needed. So great summary there. Um and so I mentioned you know, lowering intraocular pressure is the goal of treatment and preventing progression. And so, what are the main strategies for for managing glaucoma that that we often see as pharmacists?

Treatment Paths Drops And SLT

SPEAKER_00 8:14

Yeah, so you know, immediately when we think of glaucoma uh as a pharmacist, we think about a slew of of eye drops, probably many of which were you know, we're not ready to discuss as to how they work or what they're going to do. And that's okay. Uh, I'm gonna kind of talk about those sort of right now, if uh, you know, in regards to what we generally do. But just to sort of take a step back, when we identify a patient with glaucoma, what do we do with them? Well, for the most part, eye drops. It's which eye drop do we use? And we do have relatively hierarchy of which medication we would use first based off of, you know, its mechanism of action. Uh, we always consider cost, we consider ease of use, we consider all of those things. Um, so we do have eye drops that can be used. We also do have there are surgical treatments, there are laser treatments and the like, which there were some updates with some of the newer guidelines highlighting that um the role of, uh, and I always have to just make sure that I uh that I say the proper name, right? It's the selective laser trabeculoplasty. Selective laser trabeculoplasty or SLT. So, and again, pharmacists, I understand this is not something for you to be aware of, but an important update in the most recent uh guidelines that we're using when we're talking about glaucoma uh does highlight that we actually are able to use this uh SLT as an earlier therapy than we previously had. Previously was the eye drop first and foremost, and then eventually we would start looking at other options. But now they're sort of acknowledging that this SLT is can't is comparable to drops, is actually cost effective and may reduce progression. I'm not pushing for everyone to go and get laser treatment, but just acknowledging that we do now have additional options. I always think of cost, always at the top of my brain in regards to these types of things. And I did look up patients without without insurance, you're talking about one to two thousand dollars per eye in order to receive this uh selective laser trabeculoplasty with effects lasting for about 24 months up to five years. That's not saying it is going to completely uh, you know, uh provide the exact uh IOP level that you would like, right? But it is going to acknowledge that it might help clean out some of that sort of sludge that we had sort of identified before. Another thing just to note about uh the uh the the the this laser therapy again is because glaucoma is considered to be such a serious condition, even though it is that silent condition, it is often covered by insurance companies, this laser therapy. So we're gonna talk about the meds, but just acknowledging one new update is actually that this more, I don't want to it sounds invasive, but it truly is not truly invasive, right? It is a laser, but this is now something that they did sort of move as one of those more first line options. With that said, the medications that we typically use, our focus is going to be in one of two spaces for the most part. We either need to increase the outflow of said aqueous humor. So we've got to allow for that uh pressure to drop by decreasing the liquid in that manner, or we can opt to try to decrease the production of the aqueous humor and therefore preventing that, you know, decreasing that volume. And so do you want me to start talking? Go right into the colour. Yeah, let's go right into those classes.

SPEAKER_01 11:19

Yeah, because I think, yeah, it's gonna, like I said, that to me is always the most confusing part. And when I've learned about this in the past, you know, thinking about, as you said, these two mechanisms, either increasing outflow or decreasing production, that's a nice way to sort of bucket it. And yeah, let's get right into those classes where they fit in there.

Medication Classes And How They Work

SPEAKER_00 11:34

Yeah, absolutely. So our first line medications that we typically use are our prostaglandin analogs. So this is our Latanoprost, Bematoprost, uh Traviprost. And then we've got a series of other uh options within that class. Uh, that is the first line medication that we typically use because it does increase that aqueous outflow, but it also does so uh via a different means. So it doesn't go do this through the trabecular meshwork, which is the natural way in which the the aqueous humor usually drains. Instead, it pushes it through the uvulosclera. Oh boy, the uvul, the uveioscleral. Oh my gosh. Do we have to? Hey, these words are challenging. These are hard. Uvulosclerol uh meshwork. And so it actually drains in a different, in an alternative pathway.

SPEAKER_01 12:23

Okay, okay, okay.

SPEAKER_00 12:24

So our prostaglandin analogs essentially are increasing the outflow through this additional mechanism or through this additional pathway. Then you've got your beta blockers. These are going to be actually decreasing that aqueous humor. I can't say aqueous humor, though. I can't say uh we'll be decreasing the aqueous humor production in the ciliary body. Then you have your alpha 2 agonists. Uh, these also decrease aqueous uh humor, but they may also allow for that uh uvioscleral outflow just as the prostaglandin analog. So those kind of have a dual mechanism. And then you've got your topical carbonic anhydrase inhibitors, which also decrease that aqueous humor production. So again, beta blockers and your topical uh carbonic anhydrase inhibitors, those are gonna decrease the production. Prostiglandin analogs, those are going to allow for that outflow. And then you have your alpha agonists, which are going to essentially kind of do both, where they're gonna help with a decrease of that aqueous production and help with that additional pathway through the uvioscleral outflow versus the trabecular meshwork. There are other classes though, we've got a newer class of medications, which does actually push the aqueous humor out the meshwork. So it does go through that, that uh the the more standard, I don't want to say natural, right? But what the body typically does is it it does uh outflow or flow out in the uh via the trabecular meshwork. So those are our general classes, and that's generally what we're trying to do decrease the amount of liquid either by decreasing the production or by increasing its ability to be flushed out.

SPEAKER_01 14:00

Okay, okay, so great summary. And I like how you call that, I like how you call that those four classes and recognizing that the prostaglandin analogues are first line generally for most patients. Although I know in practice we've all seen beta blockers like Timolol, carbonic anhydrase inhibitors like dersolamide, brinzolamide, alpha agnes like bromonidine, apriclonidine. So those are also available, but have now that we have generics for the prostaglandin analogs, we've that I think is part of the reason why, right? And also in terms of efficacy and I think once daily dosing generally, so it has some other factors that make them first line. Anything else you want to put perspective on there in terms of why they are sort of the recommended class?

Prostaglandin Pearls And Side Effects

SPEAKER_00 14:40

Absolutely. So even just the amount of reduction that we can expect from from our prostaglandin analogs, you're looking at you know 25 to 30 or some or so percentage of a reduction when you're looking at 25 to 33 percent, actually, is the expected IOP reduction for our prostaglandin analogs. And so again, when we're looking at that IOP, right, we've got a range, we typically want it to be 10 to 21 or whatever that number is. And then if we're elevated above that, we're looking for a decrease of 25 to 33 percent or 25 to 30 percent just in general. And so these prostaglandin analogues are often able to deliver that. Um, and so they are first line and often can be um, you know, the mainstay of treatment and the monotherapy for a decent amount of time in individuals, but this is also where the adherence and uh make sure that patients are able to do to prevent the worsening and the the the further progression of their illness. Because again, just want to remind everyone the patients can't feel their optic nerve necessarily being damaged. The patient can't even necessarily feel the pressure in their eye necessarily. So the this is also why the importance of adherence is there because these patients don't necessarily feel the impact of them using their medication properly. They won't you have to explain and outline to them that we're using now so that ultimately in the future, hopefully we can prevent worsening. So, even more a little bit in regards to the prostaglandin analogs. They are super effective, they are also generally very well tolerated. Again, you can expect that IOP to drop pretty substantially. These are refrigerated, excuse me, uh one or two of these are refrigerated, but Tana Prost and the TravProst are refrigerated prior to opening. Once opening, they can remain out of the refrigerator. They're generically available, they're relatively inexpensive, they're covered by insurance companies. They may have a couple of additional pearls though that folks might not love quite so much. These can contribute to things like iris color change. And so uh eye growth, uh, excuse me, eye Latin eye growth, wouldn't you imagine? Eyelash growth, yeah. Eyelash growth. We know what you meant. Eyelash growth, which is actually something that this has been reformulated, and so we have our uh different products available and different strengths to uh for different reasons. And we actually do use uh some of these prostaglandin analogs for things other than glaucoma because of said side effects. Right. Uh but again, these are things to consider when you're talking to your patients and helping them select a drug or counseling them. I mean, how scared would your patient be if they didn't know that their eye iris was going to turn a little bit more brown? Uh it does take a bit of time, does take years, you know, it does it's it's not something that's necessarily instant. Um, but uh, you know, obviously you want to make sure that your patients are fully aware of uh of what can happen. Absolutely.

SPEAKER_01 17:21

And uh in terms of thinking about uh proseclinate analogs first, and then uh we are thinking about adding sort of like again, managing high blood pressure, where you might think about adding on or combining options. And we do know that there are fixed combination products available too, and so that also provides additional options for patients. And when we think about administration, I can see that there might be benefit there if it's affordable just the same way as having the two separate products, because obviously administration uh giving two eye drops is is more difficult than a fixed combo product. But anyway, yeah, so there's there's lots of options to consider there, but I think we have a good framework of the different classes and considerations. Um are there any other updates from the guidelines that we need to be thinking about that are going to affect us in practice, do you think, or anything else to be aware of? Or is that sort of the yeah?

SPEAKER_00 18:14

So I can kind of just talk a little bit about uh, you know, some of the items from the

Individualized Care And Technique Counseling

SPEAKER_00 18:18

guidelines. So one of the most important things from the guidelines truly was was acknowledging that, you know, it's not simply as straightforward as asking like which drop should we use, right? It's it's it's far more involved in regards to patient education, it's far more involved in regards to, you know, follow-up and the like. And so really one of the biggest uh, you know, uh key points that was highlighted within these guidelines is that it's less drop only and it is more individualized. That sort of theme kept up, kept coming up quite a bit. So what that means is we're not just looking at, well, first line is prostaglands, let's go for it. It we are having different conversations, we are considering other conditions, we are considering those things in a in addition to making sure that we provide said counseling. So I'll I'll give a little bit of, I suppose, an example, right? So, you know, we've got our prostagland analogs. I just gave examples of why we may or may not want to use those, right? Side effects that individuals may experience, right? For example, and so if we're thinking about some of our other agents, say we then go to, all right, well, let's try a beta blocker. There's a lot of things to consider in regards to the beta blocker. Yes, this is an eye drop, but one of the most important concerns we've got is of course systemic side effects or systemic absorption. This is where the counseling of your patient is so, so important in regards to, yeah, in regards to their uh, you know, administration technique. And I feel like why not talk about that now as we're here? So, one of the reasons why this is so important, that administration uh and technique is so important, I will use the beta blocker as the example because systemic effects of a beta blocker in a patient that does not require or is not prescribed a beta blocker, obviously not necessarily ideal. And no one is prescribing the beta blocker for the eye as a just in case they get systemic absorption, it won't hurt them, right? That's not where we are. So if we're using a beta blocker in the eye, we really want to make sure that the it does stay local to the eye. And so when we're counseling our patients in regards to the importance of that, beta blockers, we know we can either be beta one specific, beta two specific. Beta one specific, we're looking at cardiovascular concerns, beta two, we're looking at lung concerns, right? But when we're using these medications, what's going to happen is we if we get systemic absorption and for a patient that has asthma, right? A patient has asthma, and then we get systemic absorption of their beta blocker through poor administration technique, resulting in it going down into their nasal passages and then getting direct absorption. And now they're having systemic effects of a beta blocker and they're an asthmatic. Obviously, that could trigger bronchospasms, that could be cautious, that could be dangerous. If the patient has an asthma attack and they need to use their beta blocker, now we've got beta agonists on board. And that might sound like it's not truly a concern because we're thinking about eye drops, but again, when we're thinking about administration, it is so important to acknowledge how directly it all ties in together, right? The eyes are directly connected. And so when you're and so when your patients are using these eye drops, you know, the the some of the things they might, you know, maybe they use one drop, maybe they decide that, oh, I didn't get that all in, I want to use two drops. Maybe they start blinking like this, like crazy. As they start blinking, their lacrimal pump starts pumping. And now actually, what they just dropped into their eye is leaking down through their nasal passages. And guess what absorbs super well in your nasal passages? A solution. And now that is getting to be systemic absorption. And so when we're having our patients use the product, we need to let them know you're only using one drop. Usually that one drop is actually greater than the the actual amount that would be absorbed either way, but that's okay. After giving the after uh using said drop, the las uh the nasolacromil occlusion or putting your finger. Over that duct so that you're not allowing for that medication to leave the eye to potentially start that blinking, whether it's uh intentional or not. Uh perhaps if you start blinking, now you're actually pumping that medication uh down into your nasal passages and then absorbing it, and that can be dangerous. So, again, just sort of highlighting, we also mentioned an alpha agonist, right? We've got an alpha agonist on board, which also has cardiovascular implications and the like. And so we put down another sappathomimetic and we're letting that get absorbed through the nasal passages. Now we've got a patient that has significant fatigue and sedation, maybe dry mouth, and they don't understand why. And it happened to have been just that one drop in their eye that perhaps they were, you know, they didn't use the proper absorption, uh, excuse me, the proper technique, and then not doing that nasolacrimal uh occlusion, which is really just putting your finger and holding in the to the uh you know the corner of the eye, sort of occluding that and doing that for one to two minutes, super important.

Prevent Systemic Absorption With Occlusion

SPEAKER_00 22:57

Yeah. Another, another thing just very quickly to acknowledge here, too, because we're just thinking about this administration technique. I mentioned before that the size of the drop can be a little bit different as well, either causing patients to think that they should use more or whatever. But that really, you know, the systemic implications are pretty terrible. But then we also have to always think about that cost implication. You've got patients that are wasting drops potentially. If you've got patients using multiple drops and they use them too quickly back and back back to back, now they're washing out one drop with another drop. And so we really need to make sure that that counseling is so super important. And again, just thinking about the impact or the potential implications of the beta blocker or the alpha agonist being absorbed systemically, you can see that while it might not be truly you know alarming for all patients. Number one, they're not getting it the medication, the effectiveness in their eye. But for some patients, that could be quite substantial because remember, we're talking about older patients typically with glaucoma either way. They could be on a whole series of other medications, lots of things to consider.

SPEAKER_01 24:05

Right. Yeah, and I I think it's one of those things that people don't think about an eye drop having systemic effects potentially. And so the and the fact that it is such a simple technique of just uh closing off that tear duct and and allowing, you know, preventing that from being absorbed that way, ensuring patients wash their hands is obviously a good uh recommendation also in terms of eye drops generally, but before they put their hand on their eye, obviously that's uh another point to reinforce. But yeah, such a simple strategy that can help improve tolerability and efficacy, as you say. And so just a good reminder for for all of us to be talking about that with patients is there's there's a lot to think about, I think, when you when you're counseling a patient on eye product administration generally, because it can be difficult and people aren't necessarily it, you know, it's it's a it's it takes some practice. And so maybe, you know, introducing this, but I would also say with refills, people are gonna be on these medications long term. So with refills continuing to reinforce some of these points because maybe there was a lot of information given at the first fill, and now, oh, did you remember close off that tear duct before you're you know, after you administer the drop so it's not being absorbed, those sorts of things, as you say, are gonna just I think continue to be important to be reinforced.

Adherence Clues Refills And Follow Up

SPEAKER_00 25:18

Absolutely. And even throughout the guidelines, it it kind of uh, you know, really highlighted that asking your patient to go through how they use their eye drops, because it is not just the the physical act of how they're dropping it in. It's also in regards to does it require any sort of uh uh a shake or an inversion at all? Was it supposed to be refrigerated in any capacity? You know, uh just acknowledging the timing between drops again. Do they have contact lenses because they need to wait a certain amount of time? Usually it's about 15 minutes prior to putting those in after using then drop said drops. Do they want something that's preservative free for a different reason? We've got a whole slew of these products are available preservative free, but then you're dealing with cost and dealing with other things as well. But again, um, just it's so many different pieces uh, you know, of the puzzle. But if we're asking our patient how are you using your drops, then we are best suited to identify those, you know. I put this drop in and then I put the next drop in. Oh, hold on a second. How much time did you wait? Or I put this drop in and then I blink a bunch of times. Oh, let's pause for a second, right? So being able to reinforce that is super duper important, absolutely. And looking at those refills and the timing of the refills, are they getting them on time? Are they getting them too soon? Are they getting them too late? For any of us in the community pharmacy world, we know with insurance companies, is it 20 drops per ml? Is it 15? Is it 17? What are we doing here? But the actual size of the drop might be different. The physical volume could technically be different. We know we go by whatever those numbers are if the insurance company or our employer dictates and whatnot. But again, think about it. They accidentally miss a drop, they get a drop uh outside of their eye. They do that, that happens multiple times, you know, over the course of the month. What does that look like? What happens there? And again, if they're actually doing something that is preventing them from you having the best, you know, efficacy and safety for their meds, let's acknowledge it and identify it right there. Because what is the point of our patients putting eye drops in their eye to prevent something from happening way down the line if we're not actually making sure they're using it and doing it? If this were something that had a direct result to them using it, right? They take the medication, we can see the result. We know that that would be so much easier to follow and track and counsel our patients on. But because this is silent and whatnot, it is so, so important uh to make sure that we're really asking our patients to describe and talk about how they're using those drops.

SPEAKER_01 27:41

Absolutely. And that teach back method, encouraging them to walk through that process and then you can pick up on what they might be missing. Absolutely. And also, uh, you know, the you mentioned the refills, either too soon or too early. Sorry, too soon or too late can be uh a big cue as to okay, maybe they're not using it properly, or maybe they are using if they don't think it's gone in. And there's all kinds of issues you can then investigate once you see that. And so those early or late refills can be a good cue. I do want to mention too that the follow-up and encouraging that they're getting those regular eye exams is also important. So, you know, that is something, as you mentioned at the beginning, how people are not going to know necessarily how this is progressing or how it's being managed. And so those regular eye visits are going to be another key counseling point, I think, to just ensure that they're getting those and not just getting the refills and thinking it's sort of a one and done situation.

SPEAKER_00 28:35

Absolutely.

SPEAKER_01 28:36

Yep. Yeah. So we've talked about a lot of information. And I think we've got a good overview of the goal of primary open angle glaucoma. You nicely differentiated that from closed open angle glaucoma and the goal of lowering intraocular pressure. We've got our classes of meds, we've got uh, you know, prostaclandin and analogs is sort of the first line, but there are other options available depending on patient-specific factors, as you said, and all of those important counseling points, um, the importance of adherence, technique matters, all of those. And this is why I think pharmacists are such a pivotal care provider in in this space, because this is such a it's right when when they're thinking about using a medicine, that's us, and and we can give so many so much advice to to use it properly. So I think you just really summarized it well. And I guess is there anything uh that we didn't touch on that you want to be sure we address?

Implants Newer Agents And OTC Pitfalls

SPEAKER_00 29:29

I mean, I do have a couple more things if we, yeah, a couple more updates, absolutely, that uh that I do think are important. So there are some there are some newer products that came out, which your patients might actually ask about. Uh, and they include things like implants. And so they uh, you know, we've got now these sustained released uh prostaglandin implants. We've got the Pematoprost as well as the Traviprost implant. And these are obviously done in an office, but just acknowledging that when we see this adherence and we see these issues, you know, uh maybe perhaps I'm I'm sort of again going right to that community piece, but that's where we have the first, you know, opportunity to identify patients that appear to be uh non-adherent or to appear to perhaps be struggling uh with the use of their drops. And so perhaps an implant or a reservoir is something that could be used for those folks. And again, this is outside of our space uh specifically, but if we do have a patient that gets a prostaglandin implant, they're not going to be getting their prescriptions from us any longer, right? Because, excuse me, they're not gonna be getting their their latanoprost, right? Uh or the bamatoprost, excuse me, implant, they're not gonna be necessarily getting those drops. So that is an important thing to also not accuse them of not being inherent if we uh if they say they actually use some they're using something different. With those, with that being said, however, the the Bematoprost implant right now is only really used as a bridge. It can be in there for four to six months, and we only do one implant for that one because it actually can cause some damage to the cornea because of other means and other mechanisms and other pumps and other things going on. And so right now, this is a sort of a bridge therapy. I don't know exactly what we're bridging here, conversation, uh discussion, uh plans for the future, or maybe what if our patient is about to disappear for several months on end and they're not going to be able to have eye drops with them and be able to sort of do that? Um, you know, uh, so is there something like this that can be helpful? And so these implants that hold the reservoir of these prostaglandin analogs, you know, is one option. Uh, we also have, I mentioned, I alluded to before, one of the newer agents, the rho kinase inhibitor. The this has been around since 2017, since 2019, it's available in a combination with the Latanoprost as well. But again, this is just another mechanism. So when we're thinking about taking care of our patient, we like to be able to have different mechanisms so that we're not, you know, so we're maximizing, you know, trying to be as efficacious and safe as possible, sure, but also acknowledging that some things may need to change, might need to adjust. And so if we can hit something from multiple different angles, you know, obviously uh, you know, we're happy to do that if we can. We're not gonna duplicate therapy, we're not gonna use two prostaglandin analogs, right? We don't even necessarily want to use two medications that work similarly. Like we don't want to, if both medications are going to decrease the aqueous humor, that may or may not be necessary or appropriate. So if we've got someone already that's on, say, uh the latanoprost or one of the prostaglandin analogs, and they're not reaching their their goal, we believe that we want them to have another agent. We're not gonna add another, we probably wouldn't add the bromonidine, for example, that is also going to increase the the uh outflow, right? Instead, we might go with something that's gonna decrease the aqueous humor so that we were attacking from two different mechanisms. And so that typically is what we will do, sure. We've got some of these long-acting medications, sure. These rokinase inhibitors, as I mentioned, are looking are are using the trabecular mesh work as an outflow option. So that can be used with the Latanoprost that is also increasing aqueous outflow, right? Uh the aqueous humor outflow, uh, because they are technically doing so in via different mechanisms. With that being said, a couple other important counseling points, I think, um, is we have to remember the non-prescription piece of eye drops. Okay. So what I mean by that is what if you've got a patient, they're using something like the the netoseridal and so uh the rochinase inhibitor, right? So they're using that and it causes a significant redness of the eyes. You know what else causes significant redness of the eyes is bromonidine, right? So that's another one of our medications that we use for glaucoma. So if they cause significant redness of the eye, they go to their pharmacy, they go to the counter, and now they want to purchase a product to help with the redness of the eye. One of those products is bromonidine. And so they actually could then be using duplicate therapy, thinking they're treating treating one product, one uh issue with another. And in reality, they're just wasting money, adding to, you know, increasing the risk of systemic absorption and systemic effects. And and again, they're, you know, not explaining that or highlighting that when you've got over-the-counter or non-prescription products as well as prescription products can be troublesome. Patients also have a tendency to say, well, I was on something once before. Maybe I can use that. I had to use an uh anti-infective once before, or an NSAID once for my eye, or an antihistamine for my eye. I wonder if that might help because you know, sometimes, you know, the eye, it kind of feels elusive, right? Like you know what, no one knows, right? It's yeah, and aside from directly seeing a spot or it being red or it hurting or something physical on the eye, it is difficult for patients to sort of acknowledge the importance of making sure that they're uh, you know, not just putting anything in their eye, including medications and drops, right? The tendency to put more than you need or to do it more often than you should is obviously there. And so again, just acknowledging that we as, and I will say again to those community pharmacists out there, when you see those folks in the aisle and they're looking at drops, right? Go out there and talk to them and make sure that they're gonna do the right thing. Because if not, they will definitely feel like it's not that important. It's just a drop. Um and so just acknowledge just acknowledging that, especially if it's something like, you know, they're having discomfort from using the drop, which could be expected. Maybe, you know, it's a red, it might sting a little bit, and then they go, you know what helped with me last time when I used my antihistamine eye drop, that helped when my eyes were itchy. Maybe I should use that. And then in reality, we're you know, we're we're gonna have some drug interactions potentially within the eye. We're gonna have uh, you know, we're not gonna necessarily be getting to the true uh, you know, mechanism and uh and whatnot that we're we're looking for uh with our glaucoma eye drop. So again, just acknowledging uh to take a step back and to ask those questions of your patients because because you never know. And they think they might think they're doing the right thing, and we appreciate that so very much. But um, you know, let them, you want to make sure that they know that they can talk to you about these things and that you can be well versed. And if you're not, that's okay. Look it up and get back to them. Please don't leave them hanging because again, the eye, it just it feels it just feels a little bit different, I feel like whenever we're dealing with the eye or the ear, it just feels a little bit different in regards to patients and their self-care of those, of any of them.

SPEAKER_01 36:07

So that's a great call out. Um, thank you for mentioning the implants too. We didn't touch on that before, but that is another option where again could come into play uh based on what what is appropriate for the patient and may affect whether or not they are using eye drops or not for glaucoma. So great call out there. And then, yes, the importance of remembering that OTC eye drops are available in a variety of different ingredients, products, and that there may be duplicate or potentially other interaction considerations that we need to be thinking about with those. So great call

The Game Changer Takeaway And Close

SPEAKER_01 36:36

out. Stephanie, this has been an amazing uh discussion. We covered a lot of ground. And um, to wrap up, it is our game changers podcast. So we always wrap up with what is the game changer and uh what do you want our listeners to walk away with?

SPEAKER_00 36:48

I mean, I think our game changer is uh is really if you've got a patient in front of you that's that has glaucoma, if you've got a patient in front of you that is is requiring glaucoma treatment, uh the game changer really is is oh my gosh, what's the game changer? Uh the game changer is really is is is having that conversation essentially. The game changer is is adherence and actual administration tech technique could truly be that game changer. If you've got patients that are aware of the importance now and aware of the technique now, you can hopefully prevent years from now that optic nerve being as damaged as quickly. And so, game changer here is that adherence as well as the the technique is so super important. And the pharmacists have such an awesome ability or or opportunity to really make an impact on their patient's eye health and that nasolacrimal uh occlusion, you know, maybe that's the game changer.

SPEAKER_01 37:43

Yeah, I think I think the game changer, as you said, is sort of the the pharmacist's role in educating patients, and whether that's with adherence or technique or use with other products in the eye, all of those factors, the pharmacist role in the educating of patients. I think, yeah. 100%, yeah, absolutely. And that's why this is such an interesting topic because it is, it can be a little bit murky, but um I think we clarified a lot of really important points and did we can now walk away with reminders of some of those key takeaways that uh we need to think about when working with patients. So, Stephanie, thank you so much for your time. Really appreciate you uh chatting with us and uh yeah, look forward to having you again. This was a great discussion.

SPEAKER_00 38:22

Thank you very much, Rachel.

SPEAKER_01 38:24

All right. Well, we talked about a lot of great practical tips today. These will all be summarized in the practice resource that goes along with this podcast and is included in the CE subscription. And if you want to claim your CE credit for this episode of Game Changers, you can log in at CEimpact.com. And as always, have a great week and keep learning. I can't wait to dig into another game changing topic with you all next week.