Dr. Nathan Klein, an Optometrist in South Florida, talks about Glaucoma and a new eye drop medication used to treat patients that is giving them even better pressure reduction.
Interview conducted by Ivanhoe Broadcast News in December 2017.
We hear a lot about glaucoma, tell us what is glaucoma and how prevalent is it? How many people does it affect?
Dr. Klein: Glaucoma is an eye disease. It’s typically when the pressure in the person’s eye gets too high for their own eye. When that pressure gets too high it kind of bangs away at the back nerve in the eye, the optic nerve, and causes it to degenerate and get damaged. Once it’s damaged, it causes peripheral vision loss first. It’s going to be on the outside so we might not notice it at first and then thereafter can cause blindness. It’s not reversible and it affects twenty to thirty million Americans.
Do people feel the symptoms coming on, any warning?
Dr. Klein: It’s painless and it slowly causes peripheral vision loss. It can go undiagnosed for a few years before we actually realize it because both eyes kind of play catch up with each other to cover the symptoms of the early vision loss.
So it does definitely affect both eyes?
Dr. Klein: Not always, it can just be in one eye but commonly will be in both eyes.
Can it affect anyone at any age?
Dr. Klein: It can. More commonly it’s going to affect the aging population over fifty. We do have some patients that might be born with glaucoma or get it as teenagers but most commonly it’s going to be the elder population.
Is it genetic, does it run in families?
Dr. Klein: It can. Having family with glaucoma is definitely one of the markers and one of the questions that we ask patients. Just because a family member has glaucoma does not mean that you will get glaucoma but it is one of the parts of the diagnosis.
So in other words if there are no symptoms that a person would notice until I guess it’s really affecting their vision peripherally, describe what it does, how it affects the vision.
Dr. Klein: It causes slow vision blindness with peripheral vision first. So a patient might be looking straight and see everything but they don’t realize they’re missing some of their vision out here or out here. It can get covered up because if my right eye is missing here my left eye might actually cover up and be able to see that part. That’s why it goes undiagnosed often for a lot longer than it should have.
It’s not reversible, but if you catch it early can you treat it earlier?
Dr. Klein: Correct. The point of treatment is to stop the progression. If it goes untreated then the vision loss will continue. We want to stop it where we find it. Early diagnosis is always key with glaucoma because if we start treatment early enough we won’t even get vision loss or minor vision loss at the most.
What you’re saying is if you treat it you can stop it where it is so it doesn’t get worse?
Dr. Klein: Correct.
How do you test for glaucoma and then we’ll talk treatment.
Dr. Klein: Testing for glaucoma always starts with a comprehensive eye exam. In a comprehensive eye exam, one thing we’re always going to measure is the eye pressure. If we see the eye pressure is a little bit elevated that might say ‘hey, what’s going on here’, this is a little bit different. We always look in the back of the eye at the optic nerve. That’s the part of the eye that is getting damaged with glaucoma. After that if we have any suspicions for glaucoma we’re going to do something called a visual field test. It’s going to test the peripheral vision. For those that have taken it they know what it is, you look straight ahead and you click the button when you see the lights. It’s a long test, it’s kind of boring. People don’t love it but it is a pinpoint measurement of if there was any vision loss.
Talk about the test for glaucoma.
Dr. Klein: There’re often two tests we do for glaucoma. The first one is a visual field test. It measures our peripheral vision to see if there is any loss. The second is called an OCT. It’s a laser scan of the optic nerve and the nerves around it and it sees if there’s any loss in the nerve fiber layer. If there is then we usually have the diagnosis of glaucoma.
And the higher the pressure the more damage to your optic nerve?
Dr. Klein: Not necessarily. Everyone has a different normal for their pressure. So just high pressure alone does not mean a person has glaucoma and just having good or lower pressure does not mean you do not have glaucoma. That’s why these other tests are extremely important to do and for us to look at in determining if somebody does have glaucoma.
How often should a person have that checked? Should you do it once a year every time you go for your vision exam? Or when should you be doing that?
Dr. Klein: We’re going to do an annual comprehensive exam. Everybody should have a comprehensive eye exam every year. If we see any indication to do any additional testing such as family history of glaucoma or suspicious looking optic nerves from a medical standpoint we’re going to go ahead and run the test. If we have a concern there might be glaucoma on the rise we might decide to see patients slightly more often to measure their pressure, to measure their visual field, and to measure the OCT scan.
So it’s definitely an important part of your annual comprehensive eye exam?
Dr. Klein: Exactly.
As far as treatments for glaucoma, what have they been up until recently?
Dr. Klein: Treatment all has the same idea. All treatment for glaucoma wants to lower the eye pressure. Even if the eye pressure is on the better side and kind of low but a patient still has glaucoma we still want to lower their eye pressure more. There’s different drops, typically we use eye drops to lower the eye pressure. Compliance is always key when it comes to eye drops. We want to get the most out of eye drops that we can. We want the patient to use as little or as few eye drops as we can prescribe and that usually has better outcome.
So up until now granted it has been eye drops and keeping the eye pressure low.
Dr. Klein: Correct, low pressure.
Now, what has recently been approved and is on the market and why is it a game changer for people with glaucoma?
Dr. Klein: This new drop just got FDA approved called the Vyzulta. Vyzulta is a game changer when it comes to glaucoma. Up until now when we use a drop called a prostaglandin, an evening drop used once a day in both eyes, we’ve been seeing somewhere between twenty and thirty percent reduction in the pressure. Often that’s not enough. With Vyzulta we’re getting much better results, thirty to forty percent even, with the same single drop, both eyes in the evening. It’s just one drop and we’re getting thirty to forty percent pressure reduction on a lot of patients. Whereas other drops we might think it’s not enough by itself and have to add a different brand or a different type of eye drop, for this we’re getting the same results with just maintaining the one drop in the evening. The eyes have two different mechanisms for outflow of the liquid in the eye called the aqueous. Most other drops work on one of those two. So there’re two drains, it goes out of one of the two drains and increases one of the two drains. With the Vyzulta they’re actually working on both the drains and increasing the outflow with both drains. This is causing that pressure to come way down and stay way down.
That is what you have seen with your patients and in the studies?
Dr. Klein: Yes. The studies have proven that Vyzulta is decreasing pressure more. We’ve been prescribing it and switched a lot of our patients over before we change their meds and add a lot more medication. We’ve switched them with great success and great outcomes.
What are you hearing from your patients? Do they like it?
Dr. Klein: Patients love it. They’re using fewer drops, having better pressure, more confidence in their treatment and they’re just ecstatic about it.
So the idea behind this is they use this drop once a day in both eyes at night, one drop at night and this keeps their pressure low or lowers their pressure and that maintains their level of vision. It doesn’t mean their vision is going to get better?
Dr. Klein: Their vision won’t get better but it maintains their vision where it is, it stops additional loss of peripheral vision and avoids blindness. That is what we want to do; we always want to stop the vision loss. We can’t get it back but we want to avoid extra vision loss or more vision loss.
And this is FDA approved, how recent?
Dr. Klein: Within the last few months.
How would you describe it, is it the newest glaucoma medication?
Dr. Klein: It’s the newest glaucoma breakthrough in about twenty years. There hasn’t been a new eye drop in about twenty years that’s going to change the mechanisms and decrease the amount of pressure. This is the first one that’s come out in about twenty years and the results are amazing. We’re able to do less eye drops with better pressure reduction, avoiding surgeries when needed. It’s been excellent.
When do you know when is surgery needed?
Dr. Klein: Typically we will use a few different drops first. We will use a certain mechanism, so drop A sometimes, a drop B, and a drop C. After a patient is using two or three different types of eye drops and we’re still not getting the pressure that we want or need the patient to have then we’ll have to refer them out for a different type of surgery to reduce the pressure that way.
The hope is to avoid the surgery.
Dr. Klein: Definitely want to avoid surgery when possible especially if it’s as simple as just putting one eye drop in both of your eyes one time a day.
So then patients like Ryan and Michael who are young, certainly on the younger side, the hope would be if they continue to use Vyzulta that they’ll keep the vision they have now correct?
Dr. Klein: Yes. We definitely want that, especially for our younger patients. We definitely want everybody to maintain their vision and not have additional vision loss when possible.
How much does the medication cost? Is it covered by insurance? We know it just came out.
Dr. Klein: It’s a brand new medication. It is a little bit more difficult to get the meds that have been around for twenty years. They have this excellent program that’s available through Walgreens. You go to their website vyzulta.com. There’s a card that you can call and activate, and it comes in two month supplies. If you have a commercial plan it’s only thirty dollars for every two months. If you don’t have any insurance, it’s about seventy dollars for every two months. That makes it very affordable. This is often much cheaper than doing it other ways where a patient might have to fill two or three medications, this is just one. That’s done through Walgreens only at this time. I’m sure they have plans to roll out more nationally but for now since its new they’re probably just having rollout.
You guys are very excited.
Dr. Klein: We’re super excited about a new medication and we’re super excited about all of the results we’ve been seeing. Our patients couldn’t be happier, they’re having better results than they’ve had in years and we’re doing our best to avoid blindness.
How fast does this work in patients?
Dr. Klein: After we switched some of these patients over we saw about an additional twenty percent decrease in pressure after a week and a half. That’s a dramatic decrease in pressure and that’s a very fast time for that to be working that fast. And it’s maintained.
You expect it to maintain?
Dr. Klein: We expect it to maintain in the future. We’ll keep checking them, making sure it maintains.
Does glaucoma come on like you’re saying it happens? It’s a process that happens over years but for patients it may just be one day they have blurry vision?
Dr. Klein: Typically glaucoma is a slow process and the vision loss will be slow and gradual over time. There are some cases of glaucoma that the damage can happen fast. There are some cases that it can be somewhat painful. But the common types are going to be slow and progressive.
And nothing we can do to prevent it?
Dr. Klein: Nothing we can do to prevent it except early diagnosis and proper treatment.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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