May 21, 2025 • 26 mins
With so may IOP-lowering drops on the market, it can be challenging to know which is the most appropriate drop to start a patient on for glaucoma. How does one choose between the variety of prostaglandin analogs, beta blockers, alpha agonists and carbonic anhydrase inhibitors that are available? When whould one choose monoterapy vs combination therapies? How do the drops' side effect profiles influence one's first choice on which drop to start? Glaucoma specialist Dr. Irfan Kherani joins the podcast.
This episode is sponsored by Thea Pharma Canada - https://www.theapharma.ca
Become a supporter of this podcast: https://www.spreaker.com/podcast/blind-spot-the-eye-doctor-s-podcast--5819306/support.
This episode is sponsored by Thea Pharma Canada - https://www.theapharma.ca
Become a supporter of this podcast: https://www.spreaker.com/podcast/blind-spot-the-eye-doctor-s-podcast--5819306/support.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:12):
Hey everybody, I'm zaeo Mednik and welcome to another episode
of blind Spot. This episode is sponsored by THEA Pharma Canada.
THEA Pharma Canada is the Canadian subsidiary of THEA, Europe's
leading pioneering and innovative eye health brand.
Speaker 2 (00:26):
Founded in nineteen ninety four by Henri Schibre.
Speaker 1 (00:28):
With five generations of history, the Schibret family has been
dedicated to I care for more than one hundred and
fifty years. Their commitment to improving lives is born of
their pioneering spirit. They continue to lead the worldwide preservative
free movement in eye care. They've created innovative delivery systems.
They've focused on making products accessible and cost effective for patients.
They live this mission every day because everyone should have
(00:51):
the same opportunities to see the world through healthy eyes.
So thank you THEO Pharmer Canada for supporting Blindspot. Glaucoma
obviously has an any treatments in the form of drops, lasers,
and surgical options. Traditionally, though and still very much true
in the present, drops are the main stay of treatment
in glaucoma. But how do you decide which drop to
(01:12):
put a patient on?
Speaker 2 (01:14):
On the surface.
Speaker 1 (01:15):
It might sound like a simple question, why not just
start with the most effective drop, such as a prostac
land and analog. But even if you decide to go
with a prostac land and analog, there's so many to
choose from and in which situations would you opt not
to go with the prostac land and analog. How do
you decide between prostac land and analogs, beta blockers, alpha agonists,
carbonic anhydrase inhibitors, preserved versus non preserved, and dual therapy
(01:39):
versus monotherapy options. To discuss this topic today, I'm joined
by doctor Irfan Karani. Doctor Cranny is an assistant professor
at the University of Toronto and offers the full gamut
of glaucoma and anterior segment medical, laser and incisional surgery.
Following his undergraduate degree at Princeton University in molecular biology,
he graduated from medical school at the University of Alberta. Thereafter,
(02:01):
he completed residency training and optomology at the University of Ottawa,
with fellowships afterwards in glaucoma and advanced anterior segment surgery
at the University of Toronto and vision Rehabilitation at the
University of British Columbia. His current research interests include the
quantitative effect of glaucoma, laser and surgery, comparing both traditional
and micro invasive on intraocular pressure, diurnal fluctuation, and corneal hystoresis.
(02:23):
Doctor Karani has a strong interest in medical education and
currently sits on the Ophthalmology Specialty Committee of the Royal
College of Physicians and Surgeons of Canada, as well as
leads the Glaucoma Education program at the University of Toronto.
All right, doctor Earfound Karani, Welcome to the podcast. Thank
you so much for joining me.
Speaker 3 (02:40):
You for having me Zail.
Speaker 1 (02:42):
So, I want to start this discussion by assuming someone
does not want SLT, because that obviously changes the nature
of this conversation. SLT, we know is in the algorithm,
and the question of when you start sltier drops is
a different conversation than maybe we'll have one day. Assuming
you're going to start DROP, we'll say the patient doesn't
want SLT for whatever reason, or they're not a good candidate.
(03:04):
The blind spot in many regards for me is that
it just makes sense to start from the most efficacious
DROP to the least efficacious drop, regardless how severe the
glaucoma is, even if it's early. In my mind, I
think I'm just going to kind of start with the
prostac lanes and analog unless there's ubitis there's some sort
of contraindication, because why not try and get the best
bang for our buck. If I'm going to ask this
(03:25):
patient to take one drop a day, I might as
well give them the most effective drop that we have
in our arsenal, so to speak. That's a loaded way
of opening the conversation saying, what's your general approach to
choosing a drop? Is it as simple as yeah, the
majority of my patients are going to start on a
prostac land and analog, a PGA or I know the answer.
Speaker 2 (03:45):
It's more nuanced than that.
Speaker 3 (03:48):
So you're totally right.
Speaker 4 (03:49):
I think the easy answer to your first line agent
is exactly what the Europeenian guidelines, the American guidelines, and
what were previously our Canadian guidelines. The answer that was
it's clearly a prostaglandin. And my response to you is
the answer is prostaglandin unless you can find a reason
for it not to be. And I think I would
(04:10):
focus more on that second part of the of my comment,
where we need to actively look for reasons not to
put a patient on a prostaglandin. And I would say
in I can't give you a percentage, but I can
say a large proportrait of my patients, I have a
reason not to put them on a prostaglandin, and I
start them off with something else.
Speaker 2 (04:30):
What would the majority of those reasons be?
Speaker 4 (04:32):
So I my first big reason is age, And for
you know, I have I wish I could say, and
this is a blind spot maybe for me, I don't
have you know, evidence to suggest why I use this
number that if a patient is a below the age
of sixty, prostact landins are not my first line agent.
And it has to do with the hyperreemia, the pigmentation
(04:55):
of the periocular skin tissue, their pigmentary changes on the iris,
and most notably, the orbital changes in the eyes after
being on profited landins for ten twenty thirty forty years
can be extremely pronounced. And if we're talking about you know,
difficulty for both patients and physician. For the patient standpoint,
(05:15):
it's it's pretty disfiguring when you've seen patients that have
been on crosted lands for you know, I'm not going
to say forty years, but I'm going to say, you.
Speaker 3 (05:21):
Know, the range of twenty to thirty years.
Speaker 4 (05:23):
In addition to that, for you know, my slight bias
to the guacoma surgeons doing filtering surgery on a patient
that's been on prostaglandins for many decades is very very challenging.
Speaker 1 (05:33):
You're talking about that fat atrophy which kind of gives
that sunken in appearance exactly.
Speaker 4 (05:37):
So the sunken eye appearance, the tightening of the eyelids
makes not only everything, something as simple as taking a
tenometry measurement of a patient with very advanced orbit topathy
secondary to prostaglandins is very very difficult. And so you know,
it's not as though we don't have other options. We
do have other options. The question is when should we
(05:59):
be using. So I totally agree with you. I think
the easy answer is prostaglandin's first. However, my reasons, you know,
whether it's age is the big one that I've talked
about or interestingly, you know, we I've done reviews and
the idea of prostaglandins theoretically being pro inflammatory and therefore
being associated with macia assistic macular edema.
Speaker 3 (06:21):
The indist is actually very weak for that.
Speaker 4 (06:23):
A lot of patients that have hypertensive UV toit these
and you know, this is a really big area where
corneia and glaucoma overlap in the hsvvs at V world.
And you know what, I'm totally fine with using a
profite land and if it's going to get my pressure
lowering effect to where I need it and where we
can stave off doing blood based surgery. So I actually
don't use the udiis side of things, you know, necessarily
(06:44):
as pronounced, but age tolerance patients that are you know,
you know some people are very attached to their I
make up. For example, that's actually have of a reason
for me not to start off with the prostaglandin. And honestly,
I actually show a lot of my patients pictures of
prostaglandin associated orbitopathy, and if it scares them, I use
something cameras.
Speaker 2 (07:04):
So in general, patient under sixty was what.
Speaker 4 (07:07):
You said, patient under sixty, I'm typically starting off either
with you know what a large majority of the world
uses as a first line agent, which is actually team.
Speaker 1 (07:17):
Alol before we get to timolol, which is useful, This
is very practical already, I want to go back to
prostaglandin's if you are going to start a prostagland and analog,
my thought has been, why wouldn't I use something that's
been mad across based, like a Lumigan for example, where
(07:37):
we know that it is I don't know how much
more effective. You probably have a better idea than me.
We know that it's more effective than Latana prost. So
if I'm comparing Lumigan to Xalatan, why would I choose
Xalatan over Lumigan when I know Lumigan is a little
bit better. As I'm saying that, I guess I'm absorbing
what you just said about side effects. Maybe the hyperhemia
is a little bit less, maybe the fat atrophies of less.
(08:00):
But how would somebody make that call between Limigan and
just anything between the Mata prost and any of those
other PGAs.
Speaker 4 (08:09):
I'm going to complicate your questions slightly just because it
will give us a better answer. I don't think it's
necessarily the question of the matter prost versus latana prost.
That's one, you know, one part of the two by
two charts. The other two by portion of the two
by two chart is whether or not they're preserved or
preserved lucky to be in the world right now where
we have preservator free versions of both those medications. You
(08:32):
know that the mataprost versions and more recently on the market,
our latan a prost versions or monopast has been on
the market for quite a while now and typically actually,
you know, my first question when I'm starting off prostaglandins
is actually do you have truck coverage? And if you don't,
you know if there actually are some support mechanisms to
get preservativey drops. And the reason I say that is
(08:52):
prospect lendins can be very very bothersome you know, you
can get a pretty significant amount not you know, not
as bad as some of our other medications, but there's
still a good amount of injection and discomfort from them.
So we can get rid of the preservatives out of
them and be equally as effective.
Speaker 3 (09:05):
Why not? So to answer your question, even though we
know and.
Speaker 4 (09:11):
That the literature is very clear that at all time
periods during the day the matter cost at when it
was initially released as zero quin zero three percent was
superior to latanaprost.
Speaker 3 (09:24):
I can't say that.
Speaker 4 (09:25):
It's a big part of my practice to always choose
the mataprost over latin. Bigger thing for me is really
can I get them to use preservativey medications in a
cheap fashion? And we're lucky that a lot of our
preservative reversions are now available and there's actually companies support
to pay for preservative reversions of a lot of our
medications now. And so that's really a bigger conversation that
I have with my patients because I honestly think, you know,
(09:47):
for using a process gland to get twenty five thirty
percent iop lowering, you're probably going to get that little.
Speaker 1 (09:54):
That makes sense, and that is probably the same model
a lot of us using our own specialties and corny.
I know, when und debating between zydra sequel verstasis for casia,
a lot of those factors come into play. Technically, brocasy
is the strongest of all of those in terms of
its percentage of cyclosporin. I referenced zydra, which is lathidigrass
there which is not a cyclospor and it's it's lathidograss.
Speaker 2 (10:15):
But my point is there.
Speaker 1 (10:16):
I'm relating to that in that sometimes it just depends
on Okay, well what's your drug coverage, what's going to
be the most affordable for you? Maybe even what do
I have samples on that I can help kind of
absorb a little bit of that cost for you, so
that that then gets reassuring for people.
Speaker 4 (10:29):
And then you know, to make it's even a little
bit more fun Like now we have Latanda crossing buonat
In on the market here by by Zolta, which you
know has that same Latanas underlying mechanism, but we have
our igreab outside, you know, secondary secondary mechanism that's also
attached with which you know, depending on who you talk to,
can have a pretty significant effect.
Speaker 3 (10:49):
So I think the days.
Speaker 4 (10:50):
Where we were just looking at the matter prost or
Latana prost, I think those those states are kind of
they're kind of gone. And what you know, I actually
have one rep that talked to me once I said,
you know, there's enough prospect Glandits on the market and
the usage for prospect Landits on the market for everyone
to be a successful company. So I can honestly confidently
say that I think all of them work very very well.
(11:14):
I think generally speaking, if we can get patients under
preservative free prostaglandins from the very get go, I think
that's probably superior. Often there's you know, financial considerations there,
but that's generally my my big push.
Speaker 1 (11:26):
Yeah, always a balance between the theoretical and the practical.
So timoptic, that's what the next option would be. Talk
to me a little bit about timoptic and how that,
how that factors in your algorithm.
Speaker 4 (11:38):
So I think we often forget because we talk so
much about prostec lind ends as our first line treatment,
we often forget that, you know, for a large a
long period of time, and for large portions of the world,
timolol tym optic are the basics. It's cheap, it's well tolerated,
and so often we do want to use it as
our first line agent.
Speaker 3 (11:57):
So a good example.
Speaker 4 (11:58):
Where I often will use timolol or team optic as
my first line agent is a patient who's young and
has very, very mild their hypertension. And when I say mild,
I mean the pressures are not you know, thirty five,
they're you know, maybe in the twenty to twenty five range,
and the patients are a little bit anxious and they're like,
you know what, can I just do some treatment and
I'm not really interested in laser.
Speaker 3 (12:18):
Timolol's is very good medication.
Speaker 4 (12:19):
I do talk pretty directly about the side effects, though
admitedly the side effects can be I think we often
overstate them in a lot of our in a lot
of our assessments, because you know, there are all the
beta blocker side effects, but we get when we're when
we take them systemically. But you know, that's a that's
a good patient where you're not looking for a significant
lower you just want to get the edge off. You
just want to get that edge to maybe nineteen, and
(12:41):
you're happy with that. So I think we I think
we underutilize timolol and timoptic.
Speaker 1 (12:47):
We're the side effects of timolol. My impression and correct
me if I'm wrong, is that the ocular side effects
of timolol are probably lower than the side effects of
the other three classes we're discussing and better tolerated. And
then the systemic ones. Yeah, I guess sometimes I'm hesitant
to give it to people just because I'm not sure
what are the absolute contra indications you would have in
(13:10):
prescribing Timolaw.
Speaker 2 (13:11):
We know asthma as one.
Speaker 4 (13:13):
Asthma and CPD are really the big ones that I
talk about to all my patients before I'm starting them
on it. Interestingly, my patients that are very elderly, I'm
actually more inclined to use a prostact line at first
because I'm less inclined to use a beta blocker as
my first line agent. I wouldn't want to start my
eighty five or nine year old patient on a beta
blocker unless I really really had to, So that would
(13:34):
be a patient where I'd actually really want to use
a prostac landin as my first line agent. So that
would say that's probably my relative contraindication, but my absolute
contradications are really my asthmatic and COPD patients.
Speaker 1 (13:46):
Let's say you've tried the prostac landin, you've tried the
beta blocker not working. I mean, it's not a surprise.
We know that the other two are alphag and it's
some carbonic anhydrates and inhibitors. How do you decide between
from residency? I believe in my mind alphagonists or maybe
a little bit more effective than carbonic anhydro's inhibitors, but.
Speaker 4 (14:08):
Typically the side effect profile is much worse, and so
you have to balance the maybe slightly increased risk of
injection and discomfort from the outdo serface standpoint with using
an alphaagonist. However, it's a little bit better with you
know that the alpha gan P versions rather than the
alpha gan versions zero point two percent that we'd used
in the past, So you have to manage to kind
of balance that up with I think we underestimate how
(14:31):
much stinging is associated with some of our carbonic and
hydros inhibitors, and so, you know, I start a lot
of my patients on preservative free cosop for example. Granted,
yes it's a combination drop with the beta bucker, but
you know, is our cos opt they sting a lot
up in the side effects that people really get bothered
by these ones are you know, the small amought that
(14:52):
goes into the nasolacrimal system and causes that, you know,
a tickle in their throat that can I know, weird
metallic taste that we often talk about more or so
with the oral versions, my go to is more often
than not the carbonic and hydros inhibitors, and usually my
fourth class is the thigonist.
Speaker 1 (15:11):
So the carbonic anhydrase inhibitors, main side effect really is
that stinging, and the alpha agonists the main side effect
is a bit of that hyperaemia. And then if they're
having an allergy, which isn't uncommon that follicular reaction. Within
a class, how often practically do you actually switch between
agents if one agent isn't working. I know that we're
(15:31):
kind of told if one medication within the class isn't
working well, another medication in the class might not work.
On the other hand, realistically, if a prostaglandin didn't do anything,
I'm probably Realistically, if azop didn't do anything, I'm probably
not going to try to result just because I don't
want to kill time. And in my mind the mechanism
(15:53):
is similar enough that it's probably not gonna work practically,
From a Glauck Homo specialists to standpoint, how frequently are
you trying multiple medications within the same class.
Speaker 4 (16:03):
So I'm going to give you an answer that's actually
going to be specific to each of the different classes
and medications. So from the alpha egonist standpoint, really only
have one big player, which is the alphagain slash alphagaan p.
I mean, we do have iopadine on the system that
it's you know, more difficult to get access to. So
practically we're talking about bermondine and vermoditying P using them.
You know, there's some argument that vermoding P or the
(16:26):
zero percent version versus the original alphagain or alphagain or
vermodity at zero point two percent is you know, equal
effectiveness with a slightly you know, improved risk profile. I'm
not really going back and forth between those two. Alph
again didn't tolerate alphgain, probably not going to tolerate alf
again there from the carbonic and high based intimitter standpoint. Interestingly,
(16:47):
when true selt was brought into the market, it was
done as a non inferiority obviously relative to ass the
case in all of ours team a law, but you know,
specifically to azopt and it actually is not as effective
as ASoft, and so I'm really reserving true SOOFT. And
you know, primarily I use preservative free true soft for
often a lot of the patients that I share with
(17:08):
my Corniet colleagues. It's a very gentle medication, but it
also is not super effective, and so for that I
totally agree with you, though I'm pretty much going to
my my my as option, and I'm really unless they
don't tolerate other medications and I want an ultra and
gentle medication, that's when I'm switching to preservative free true Soft.
Speaker 2 (17:27):
And as the Cornea colleague appened, I'm a shamed.
Speaker 1 (17:30):
I haven't really used the gentler preservative free true Soft myself.
So okay, great, so nail nail, Let's go to the
next class.
Speaker 4 (17:38):
Let's go to the next liast so beta balkers again.
In this day and age, we primarily have Timolo on
the market. There is still big Top. I guess that's
that's available. It's not very commonly used practically speaking, someone's
on tiamolal or on timoloal. I'm you know, the only
real kind of question you have is whether or not
you're going to use zero point two five percent twice
a day, or whether or not you're going to jump
up to gel based versions as you're five percent and
(17:59):
use it once a day.
Speaker 3 (18:00):
That's really a big.
Speaker 4 (18:01):
Conversation you're having, not really switching medications per se. The
prospect glendin is totally different game. There's so much variety,
and you know, we spent a bit of time talking about,
you know, the big differences between mataprost and the tanna prost.
But when we throw in different concentrations of the mataprost available,
so you know, visit tent with the zero point three
percent versus the loom again, you know, reduced to zero
(18:22):
point one. When we talk about visolta with letanderprosta bunad,
if we're talking about you know, the preservative free versions
versus the non preserved free versions, I actually think you
can make a very reasonable argument switching in between the
different prost to glendits, just because there's so much variability there.
Speaker 1 (18:37):
That's a great answer, very specific, very practical, and as
per usual, it depends on which class. What is your
approach to dual agents? And first question here is once
I was speaking to a drug grap and they said
to me, would you ever consider starting somebody on this
dual agent? We know glaucoma is going to progress, et cetera.
(18:58):
And my initial reaction was kind of one.
Speaker 2 (18:59):
First of all, I.
Speaker 1 (19:00):
Want to see which agent is doing what, so I
want to know what's happening and which agent in that
dual agent is having the effect. And second of all,
they might not need both of them. Now I could
see the reason if somebody's got a pressure of thirty
five and they've got advanced glack homa, to start them
on a dual agent, what's your general approach? That's that's
my I'm answering the question from my perspective before I
(19:22):
get your before I get your more more expert take,
but what's your approach with dual medications?
Speaker 4 (19:27):
So I think there definitely is a role for dual
agents and for a lot of my patients that need
a significant lowering pressure, and you know, let's say, let's
say they're fifty or they're forty five, and I really
don't want to start them on across to landing. That's
the time period where I'm you know, very much considering
a combined beta blocker with either a carbonic and hydris
inhibitors that would be our post opd ASARCA options, or
(19:49):
directly putting them on a combined alpha iganis beta blockers,
so that would be our compagande options. So I think
there definitely is a role, and I'm gonna I'm gonna
venture maybe a little bit to the site saying this
is probably you know, the earfine Karani approach. I'm not
a huge fan of starting patients that you know, my
meximal tolerated medical therapy is not two combined agents. The
(20:13):
reason I the reason I say that a lot of
you know, I work with a lot of dreatees, and
you know that an easy go to is do CYMBRINSA
that's the classic go to, and some of the literature
has actually been quite clear that combined beta blocker with
a prostate land and ak do a traversalacom. You know,
the the effectiveness that you give up in the combined
agent relative to those two standard agents. It's actually pretty pronounced.
(20:36):
So we may not want to go to combined beta
blockers with prostaglandins and cymbers is an extremely good medication
for patients who tolerate it, But if you don't tolerate symburnsa,
which is a good proportion of our population, it can
be a very toxic you know, ocular surface big problem.
(20:57):
Like you see patients that get like red apple eyes
when they're on symburns as well. So my general approach
is actually one combined agent with the beta blocker, whether
that's a carbonic and hydros andhertor or an alphagonist and
a standalone prostaglandin as well as one of the obviously
the other one if I want to use my maximal
(21:18):
taller day medical therapy.
Speaker 1 (21:19):
And the idea there again is partially because of the
side effects, but more so because of the effectiveness is
diluted when you've got the dual agents. So even though
it is less convenient for the patient and maybe even
less convenient for the doctor in terms of giving instructions,
being on these solo medications are have been proven to
be more more efficacious and lowering the pressures than.
Speaker 2 (21:41):
These combined agents.
Speaker 4 (21:42):
I guess, and to be good, I'm not necessarily advocating
that we have you know, we're on four classes. We
did four separate medications. But I guess what I'm advocating
for is the idea that you know, three may be
superior to two and do attracts and Britain is a
really really easy go to, but that may not be
in the patient's best interest. And you know, I have again,
I have patients that are referred to me with pressures
(22:02):
of twenty three or twenty four on traps and brinza
and the next step is really surgery, and if I
can get them, you know, using I don't know cosop
toriy zarga and monoprost and alphagan p and their pressures
come down to seventeen. I've just put off surgery.
Speaker 1 (22:20):
Last question I have is a class that most non
glaucoma specialists do not use for treating glaucoma, including myself, pilocarping.
The only time I really use it is for pis
how does it factor into your treatment algorithm, if at all.
Speaker 4 (22:37):
So, pilocarping is extremely effective, extremely effective as a pressure
lowering drop, and particularly in our angle closure glockcoma patients,
it definitely has a role. Now, if I'm starting someone
on a pilocarping typically it's into one of two very
(22:57):
specific scenarios. Actually I should take three specific sceperios. One
really doesn't pertain to the non glauck homa surgeon, and
that's really in my post operative gap procedure patients where
I really want to constrict the people and pull the
iris OAY to reduce PAS.
Speaker 3 (23:11):
So taking that option out of it.
Speaker 4 (23:12):
Really two specific clinical situations that I would consider using pilocarpy.
One is the patient who needs a little bit of
extra pressure lowering and they are not a good candidate
for surgery. So again, we have an elderly patient multiple homorbidities,
going through surgery is probably not in their best interest,
but we really want to preserve their vision and we're
worried that we're not going to have enough vision left
(23:34):
for the duration of the time period that they need
their vision. Pilocarpan's a great, great option. Another area that
we would consider using it is really our ango closure mechanisms,
and so it kind of obviously makes sense that we're
pulling the iris away and hopefully opening up the angles
and it's particularly effective. Our big cautionary tale is, like
(23:55):
some of our other jobs, there's a lot of kind
of pro inflammatory nature associated with pilocarpi, and so we
want to make sure that patients are aware that they
can give them a bit of a headache and they
can cause some generalized discomfort intensitivity, but also doing a
good dilated exam to really make sure that you know
there's no weak spots that would benefit from a peripheral retinopexy,
just because the risk of retinal detachment is not insignificant, so.
Speaker 1 (24:18):
If it weren't for those side effects which are significant,
especially those risks of retinal pathology. Would pilocarbon do you
think be considered a much more used drug amongst those
other four.
Speaker 4 (24:29):
Yes, I absolutely pilocarpet is very very strong. We often
don't talk about how strong it is, like it's probably
in the same realm as our prostaglandin's, if not more
like it's a very strong medication.
Speaker 1 (24:42):
Here, Van, I've learned a ton from you again on
this podcast, really really practical combined with really good evidence
based research. One of the main takeaways for me, I
think is what you said. Many takeaways, but one of
the main takeaways is to really hesitate and think before
I put a sixty year old or somebody younger than
six yana prostic lands and analogue for likely twenty thirty
(25:04):
years the rest of their life. That's really valuable, a
lot of really interesting information. Do you have any final
thoughts for people considerations when they're choosing these drops, which
we're lucky now we have so many different options, but
can also make the situation a little bit more challenging
because they're more variables.
Speaker 4 (25:21):
My comment really no immedia at the end would actually
be straying away from drops, which is we have we're
fortunate to have a lot of drops, but we're also
in a large environment where we have a lot of
opportunities to take our patients either off drops or consider
other options. And so we're lucky that we have good options,
but we're also really lucky that we have SLT, and
we're really lucky that we have you know, earlier surgical
(25:42):
interventions as well, and so we want to be mindful
that you know, taking those five or seven drops a
day becomes it's my joke with my patients, and it's
the kind of full time job that they have, you know,
five or six alarms on their phone reminding them to
take their drops. And so we want to be mindful
that taking jobs is not easy, and it is it
is a good amount of effort on the patient's part.
Speaker 1 (26:04):
You're a fan, Karenni from the University of Toronto. Thank
you so much for joining me. You've been a fantastic
guest and it's such a delight to have you on
the podcast.
Speaker 3 (26:12):
Thanks so much. Oh you guys, have an awesome, awesome.
Speaker 1 (26:14):
Day, and thank you everybody for listening to another episode
of blind Spot. Have a great day.
Hey everybody, I'm zaeo Mednik and welcome to another episode
of blind Spot. This episode is sponsored by THEA Pharma Canada.
THEA Pharma Canada is the Canadian subsidiary of THEA, Europe's
leading pioneering and innovative eye health brand.
Speaker 2 (00:26):
Founded in nineteen ninety four by Henri Schibre.
Speaker 1 (00:28):
With five generations of history, the Schibret family has been
dedicated to I care for more than one hundred and
fifty years. Their commitment to improving lives is born of
their pioneering spirit. They continue to lead the worldwide preservative
free movement in eye care. They've created innovative delivery systems.
They've focused on making products accessible and cost effective for patients.
They live this mission every day because everyone should have
(00:51):
the same opportunities to see the world through healthy eyes.
So thank you THEO Pharmer Canada for supporting Blindspot. Glaucoma
obviously has an any treatments in the form of drops, lasers,
and surgical options. Traditionally, though and still very much true
in the present, drops are the main stay of treatment
in glaucoma. But how do you decide which drop to
(01:12):
put a patient on?
Speaker 2 (01:14):
On the surface.
Speaker 1 (01:15):
It might sound like a simple question, why not just
start with the most effective drop, such as a prostac
land and analog. But even if you decide to go
with a prostac land and analog, there's so many to
choose from and in which situations would you opt not
to go with the prostac land and analog. How do
you decide between prostac land and analogs, beta blockers, alpha agonists,
carbonic anhydrase inhibitors, preserved versus non preserved, and dual therapy
(01:39):
versus monotherapy options. To discuss this topic today, I'm joined
by doctor Irfan Karani. Doctor Cranny is an assistant professor
at the University of Toronto and offers the full gamut
of glaucoma and anterior segment medical, laser and incisional surgery.
Following his undergraduate degree at Princeton University in molecular biology,
he graduated from medical school at the University of Alberta. Thereafter,
(02:01):
he completed residency training and optomology at the University of Ottawa,
with fellowships afterwards in glaucoma and advanced anterior segment surgery
at the University of Toronto and vision Rehabilitation at the
University of British Columbia. His current research interests include the
quantitative effect of glaucoma, laser and surgery, comparing both traditional
and micro invasive on intraocular pressure, diurnal fluctuation, and corneal hystoresis.
(02:23):
Doctor Karani has a strong interest in medical education and
currently sits on the Ophthalmology Specialty Committee of the Royal
College of Physicians and Surgeons of Canada, as well as
leads the Glaucoma Education program at the University of Toronto.
All right, doctor Earfound Karani, Welcome to the podcast. Thank
you so much for joining me.
Speaker 3 (02:40):
You for having me Zail.
Speaker 1 (02:42):
So, I want to start this discussion by assuming someone
does not want SLT, because that obviously changes the nature
of this conversation. SLT, we know is in the algorithm,
and the question of when you start sltier drops is
a different conversation than maybe we'll have one day. Assuming
you're going to start DROP, we'll say the patient doesn't
want SLT for whatever reason, or they're not a good candidate.
(03:04):
The blind spot in many regards for me is that
it just makes sense to start from the most efficacious
DROP to the least efficacious drop, regardless how severe the
glaucoma is, even if it's early. In my mind, I
think I'm just going to kind of start with the
prostac lanes and analog unless there's ubitis there's some sort
of contraindication, because why not try and get the best
bang for our buck. If I'm going to ask this
(03:25):
patient to take one drop a day, I might as
well give them the most effective drop that we have
in our arsenal, so to speak. That's a loaded way
of opening the conversation saying, what's your general approach to
choosing a drop? Is it as simple as yeah, the
majority of my patients are going to start on a
prostac land and analog, a PGA or I know the answer.
Speaker 2 (03:45):
It's more nuanced than that.
Speaker 3 (03:48):
So you're totally right.
Speaker 4 (03:49):
I think the easy answer to your first line agent
is exactly what the Europeenian guidelines, the American guidelines, and
what were previously our Canadian guidelines. The answer that was
it's clearly a prostaglandin. And my response to you is
the answer is prostaglandin unless you can find a reason
for it not to be. And I think I would
(04:10):
focus more on that second part of the of my comment,
where we need to actively look for reasons not to
put a patient on a prostaglandin. And I would say
in I can't give you a percentage, but I can
say a large proportrait of my patients, I have a
reason not to put them on a prostaglandin, and I
start them off with something else.
Speaker 2 (04:30):
What would the majority of those reasons be?
Speaker 4 (04:32):
So I my first big reason is age, And for
you know, I have I wish I could say, and
this is a blind spot maybe for me, I don't
have you know, evidence to suggest why I use this
number that if a patient is a below the age
of sixty, prostact landins are not my first line agent.
And it has to do with the hyperreemia, the pigmentation
(04:55):
of the periocular skin tissue, their pigmentary changes on the iris,
and most notably, the orbital changes in the eyes after
being on profited landins for ten twenty thirty forty years
can be extremely pronounced. And if we're talking about you know,
difficulty for both patients and physician. For the patient standpoint,
(05:15):
it's it's pretty disfiguring when you've seen patients that have
been on crosted lands for you know, I'm not going
to say forty years, but I'm going to say, you.
Speaker 3 (05:21):
Know, the range of twenty to thirty years.
Speaker 4 (05:23):
In addition to that, for you know, my slight bias
to the guacoma surgeons doing filtering surgery on a patient
that's been on prostaglandins for many decades is very very challenging.
Speaker 1 (05:33):
You're talking about that fat atrophy which kind of gives
that sunken in appearance exactly.
Speaker 4 (05:37):
So the sunken eye appearance, the tightening of the eyelids
makes not only everything, something as simple as taking a
tenometry measurement of a patient with very advanced orbit topathy
secondary to prostaglandins is very very difficult. And so you know,
it's not as though we don't have other options. We
do have other options. The question is when should we
(05:59):
be using. So I totally agree with you. I think
the easy answer is prostaglandin's first. However, my reasons, you know,
whether it's age is the big one that I've talked
about or interestingly, you know, we I've done reviews and
the idea of prostaglandins theoretically being pro inflammatory and therefore
being associated with macia assistic macular edema.
Speaker 3 (06:21):
The indist is actually very weak for that.
Speaker 4 (06:23):
A lot of patients that have hypertensive UV toit these
and you know, this is a really big area where
corneia and glaucoma overlap in the hsvvs at V world.
And you know what, I'm totally fine with using a
profite land and if it's going to get my pressure
lowering effect to where I need it and where we
can stave off doing blood based surgery. So I actually
don't use the udiis side of things, you know, necessarily
(06:44):
as pronounced, but age tolerance patients that are you know,
you know some people are very attached to their I
make up. For example, that's actually have of a reason
for me not to start off with the prostaglandin. And honestly,
I actually show a lot of my patients pictures of
prostaglandin associated orbitopathy, and if it scares them, I use
something cameras.
Speaker 2 (07:04):
So in general, patient under sixty was what.
Speaker 4 (07:07):
You said, patient under sixty, I'm typically starting off either
with you know what a large majority of the world
uses as a first line agent, which is actually team.
Speaker 1 (07:17):
Alol before we get to timolol, which is useful, This
is very practical already, I want to go back to
prostaglandin's if you are going to start a prostagland and analog,
my thought has been, why wouldn't I use something that's
been mad across based, like a Lumigan for example, where
(07:37):
we know that it is I don't know how much
more effective. You probably have a better idea than me.
We know that it's more effective than Latana prost. So
if I'm comparing Lumigan to Xalatan, why would I choose
Xalatan over Lumigan when I know Lumigan is a little
bit better. As I'm saying that, I guess I'm absorbing
what you just said about side effects. Maybe the hyperhemia
is a little bit less, maybe the fat atrophies of less.
(08:00):
But how would somebody make that call between Limigan and
just anything between the Mata prost and any of those
other PGAs.
Speaker 4 (08:09):
I'm going to complicate your questions slightly just because it
will give us a better answer. I don't think it's
necessarily the question of the matter prost versus latana prost.
That's one, you know, one part of the two by
two charts. The other two by portion of the two
by two chart is whether or not they're preserved or
preserved lucky to be in the world right now where
we have preservator free versions of both those medications. You
(08:32):
know that the mataprost versions and more recently on the market,
our latan a prost versions or monopast has been on
the market for quite a while now and typically actually,
you know, my first question when I'm starting off prostaglandins
is actually do you have truck coverage? And if you don't,
you know if there actually are some support mechanisms to
get preservativey drops. And the reason I say that is
(08:52):
prospect lendins can be very very bothersome you know, you
can get a pretty significant amount not you know, not
as bad as some of our other medications, but there's
still a good amount of injection and discomfort from them.
So we can get rid of the preservatives out of
them and be equally as effective.
Speaker 3 (09:05):
Why not? So to answer your question, even though we
know and.
Speaker 4 (09:11):
That the literature is very clear that at all time
periods during the day the matter cost at when it
was initially released as zero quin zero three percent was
superior to latanaprost.
Speaker 3 (09:24):
I can't say that.
Speaker 4 (09:25):
It's a big part of my practice to always choose
the mataprost over latin. Bigger thing for me is really
can I get them to use preservativey medications in a
cheap fashion? And we're lucky that a lot of our
preservative reversions are now available and there's actually companies support
to pay for preservative reversions of a lot of our
medications now. And so that's really a bigger conversation that
I have with my patients because I honestly think, you know,
(09:47):
for using a process gland to get twenty five thirty
percent iop lowering, you're probably going to get that little.
Speaker 1 (09:54):
That makes sense, and that is probably the same model
a lot of us using our own specialties and corny.
I know, when und debating between zydra sequel verstasis for casia,
a lot of those factors come into play. Technically, brocasy
is the strongest of all of those in terms of
its percentage of cyclosporin. I referenced zydra, which is lathidigrass
there which is not a cyclospor and it's it's lathidograss.
Speaker 2 (10:15):
But my point is there.
Speaker 1 (10:16):
I'm relating to that in that sometimes it just depends
on Okay, well what's your drug coverage, what's going to
be the most affordable for you? Maybe even what do
I have samples on that I can help kind of
absorb a little bit of that cost for you, so
that that then gets reassuring for people.
Speaker 4 (10:29):
And then you know, to make it's even a little
bit more fun Like now we have Latanda crossing buonat
In on the market here by by Zolta, which you
know has that same Latanas underlying mechanism, but we have
our igreab outside, you know, secondary secondary mechanism that's also
attached with which you know, depending on who you talk to,
can have a pretty significant effect.
Speaker 3 (10:49):
So I think the days.
Speaker 4 (10:50):
Where we were just looking at the matter prost or
Latana prost, I think those those states are kind of
they're kind of gone. And what you know, I actually
have one rep that talked to me once I said,
you know, there's enough prospect Glandits on the market and
the usage for prospect Landits on the market for everyone
to be a successful company. So I can honestly confidently
say that I think all of them work very very well.
(11:14):
I think generally speaking, if we can get patients under
preservative free prostaglandins from the very get go, I think
that's probably superior. Often there's you know, financial considerations there,
but that's generally my my big push.
Speaker 1 (11:26):
Yeah, always a balance between the theoretical and the practical.
So timoptic, that's what the next option would be. Talk
to me a little bit about timoptic and how that,
how that factors in your algorithm.
Speaker 4 (11:38):
So I think we often forget because we talk so
much about prostec lind ends as our first line treatment,
we often forget that, you know, for a large a
long period of time, and for large portions of the world,
timolol tym optic are the basics. It's cheap, it's well tolerated,
and so often we do want to use it as
our first line agent.
Speaker 3 (11:57):
So a good example.
Speaker 4 (11:58):
Where I often will use timolol or team optic as
my first line agent is a patient who's young and
has very, very mild their hypertension. And when I say mild,
I mean the pressures are not you know, thirty five,
they're you know, maybe in the twenty to twenty five range,
and the patients are a little bit anxious and they're like,
you know what, can I just do some treatment and
I'm not really interested in laser.
Speaker 3 (12:18):
Timolol's is very good medication.
Speaker 4 (12:19):
I do talk pretty directly about the side effects, though
admitedly the side effects can be I think we often
overstate them in a lot of our in a lot
of our assessments, because you know, there are all the
beta blocker side effects, but we get when we're when
we take them systemically. But you know, that's a that's
a good patient where you're not looking for a significant
lower you just want to get the edge off. You
just want to get that edge to maybe nineteen, and
(12:41):
you're happy with that. So I think we I think
we underutilize timolol and timoptic.
Speaker 1 (12:47):
We're the side effects of timolol. My impression and correct
me if I'm wrong, is that the ocular side effects
of timolol are probably lower than the side effects of
the other three classes we're discussing and better tolerated. And
then the systemic ones. Yeah, I guess sometimes I'm hesitant
to give it to people just because I'm not sure
what are the absolute contra indications you would have in
(13:10):
prescribing Timolaw.
Speaker 2 (13:11):
We know asthma as one.
Speaker 4 (13:13):
Asthma and CPD are really the big ones that I
talk about to all my patients before I'm starting them
on it. Interestingly, my patients that are very elderly, I'm
actually more inclined to use a prostact line at first
because I'm less inclined to use a beta blocker as
my first line agent. I wouldn't want to start my
eighty five or nine year old patient on a beta
blocker unless I really really had to, So that would
(13:34):
be a patient where I'd actually really want to use
a prostac landin as my first line agent. So that
would say that's probably my relative contraindication, but my absolute
contradications are really my asthmatic and COPD patients.
Speaker 1 (13:46):
Let's say you've tried the prostac landin, you've tried the
beta blocker not working. I mean, it's not a surprise.
We know that the other two are alphag and it's
some carbonic anhydrates and inhibitors. How do you decide between
from residency? I believe in my mind alphagonists or maybe
a little bit more effective than carbonic anhydro's inhibitors, but.
Speaker 4 (14:08):
Typically the side effect profile is much worse, and so
you have to balance the maybe slightly increased risk of
injection and discomfort from the outdo serface standpoint with using
an alphaagonist. However, it's a little bit better with you
know that the alpha gan P versions rather than the
alpha gan versions zero point two percent that we'd used
in the past, So you have to manage to kind
of balance that up with I think we underestimate how
(14:31):
much stinging is associated with some of our carbonic and
hydros inhibitors, and so, you know, I start a lot
of my patients on preservative free cosop for example. Granted,
yes it's a combination drop with the beta bucker, but
you know, is our cos opt they sting a lot
up in the side effects that people really get bothered
by these ones are you know, the small amought that
(14:52):
goes into the nasolacrimal system and causes that, you know,
a tickle in their throat that can I know, weird
metallic taste that we often talk about more or so
with the oral versions, my go to is more often
than not the carbonic and hydros inhibitors, and usually my
fourth class is the thigonist.
Speaker 1 (15:11):
So the carbonic anhydrase inhibitors, main side effect really is
that stinging, and the alpha agonists the main side effect
is a bit of that hyperaemia. And then if they're
having an allergy, which isn't uncommon that follicular reaction. Within
a class, how often practically do you actually switch between
agents if one agent isn't working. I know that we're
(15:31):
kind of told if one medication within the class isn't
working well, another medication in the class might not work.
On the other hand, realistically, if a prostaglandin didn't do anything,
I'm probably Realistically, if azop didn't do anything, I'm probably
not going to try to result just because I don't
want to kill time. And in my mind the mechanism
(15:53):
is similar enough that it's probably not gonna work practically,
From a Glauck Homo specialists to standpoint, how frequently are
you trying multiple medications within the same class.
Speaker 4 (16:03):
So I'm going to give you an answer that's actually
going to be specific to each of the different classes
and medications. So from the alpha egonist standpoint, really only
have one big player, which is the alphagain slash alphagaan p.
I mean, we do have iopadine on the system that
it's you know, more difficult to get access to. So
practically we're talking about bermondine and vermoditying P using them.
You know, there's some argument that vermoding P or the
(16:26):
zero percent version versus the original alphagain or alphagain or
vermodity at zero point two percent is you know, equal
effectiveness with a slightly you know, improved risk profile. I'm
not really going back and forth between those two. Alph
again didn't tolerate alphgain, probably not going to tolerate alf
again there from the carbonic and high based intimitter standpoint. Interestingly,
(16:47):
when true selt was brought into the market, it was
done as a non inferiority obviously relative to ass the
case in all of ours team a law, but you know,
specifically to azopt and it actually is not as effective
as ASoft, and so I'm really reserving true SOOFT. And
you know, primarily I use preservative free true soft for
often a lot of the patients that I share with
(17:08):
my Corniet colleagues. It's a very gentle medication, but it
also is not super effective, and so for that I
totally agree with you, though I'm pretty much going to
my my my as option, and I'm really unless they
don't tolerate other medications and I want an ultra and
gentle medication, that's when I'm switching to preservative free true Soft.
Speaker 2 (17:27):
And as the Cornea colleague appened, I'm a shamed.
Speaker 1 (17:30):
I haven't really used the gentler preservative free true Soft myself.
So okay, great, so nail nail, Let's go to the
next class.
Speaker 4 (17:38):
Let's go to the next liast so beta balkers again.
In this day and age, we primarily have Timolo on
the market. There is still big Top. I guess that's
that's available. It's not very commonly used practically speaking, someone's
on tiamolal or on timoloal. I'm you know, the only
real kind of question you have is whether or not
you're going to use zero point two five percent twice
a day, or whether or not you're going to jump
up to gel based versions as you're five percent and
(17:59):
use it once a day.
Speaker 3 (18:00):
That's really a big.
Speaker 4 (18:01):
Conversation you're having, not really switching medications per se. The
prospect glendin is totally different game. There's so much variety,
and you know, we spent a bit of time talking about,
you know, the big differences between mataprost and the tanna prost.
But when we throw in different concentrations of the mataprost available,
so you know, visit tent with the zero point three
percent versus the loom again, you know, reduced to zero
(18:22):
point one. When we talk about visolta with letanderprosta bunad,
if we're talking about you know, the preservative free versions
versus the non preserved free versions, I actually think you
can make a very reasonable argument switching in between the
different prost to glendits, just because there's so much variability there.
Speaker 1 (18:37):
That's a great answer, very specific, very practical, and as
per usual, it depends on which class. What is your
approach to dual agents? And first question here is once
I was speaking to a drug grap and they said
to me, would you ever consider starting somebody on this
dual agent? We know glaucoma is going to progress, et cetera.
(18:58):
And my initial reaction was kind of one.
Speaker 2 (18:59):
First of all, I.
Speaker 1 (19:00):
Want to see which agent is doing what, so I
want to know what's happening and which agent in that
dual agent is having the effect. And second of all,
they might not need both of them. Now I could
see the reason if somebody's got a pressure of thirty
five and they've got advanced glack homa, to start them
on a dual agent, what's your general approach? That's that's
my I'm answering the question from my perspective before I
(19:22):
get your before I get your more more expert take,
but what's your approach with dual medications?
Speaker 4 (19:27):
So I think there definitely is a role for dual
agents and for a lot of my patients that need
a significant lowering pressure, and you know, let's say, let's
say they're fifty or they're forty five, and I really
don't want to start them on across to landing. That's
the time period where I'm you know, very much considering
a combined beta blocker with either a carbonic and hydris
inhibitors that would be our post opd ASARCA options, or
(19:49):
directly putting them on a combined alpha iganis beta blockers,
so that would be our compagande options. So I think
there definitely is a role, and I'm gonna I'm gonna
venture maybe a little bit to the site saying this
is probably you know, the earfine Karani approach. I'm not
a huge fan of starting patients that you know, my
meximal tolerated medical therapy is not two combined agents. The
(20:13):
reason I the reason I say that a lot of
you know, I work with a lot of dreatees, and
you know that an easy go to is do CYMBRINSA
that's the classic go to, and some of the literature
has actually been quite clear that combined beta blocker with
a prostate land and ak do a traversalacom. You know,
the the effectiveness that you give up in the combined
agent relative to those two standard agents. It's actually pretty pronounced.
(20:36):
So we may not want to go to combined beta
blockers with prostaglandins and cymbers is an extremely good medication
for patients who tolerate it, But if you don't tolerate symburnsa,
which is a good proportion of our population, it can
be a very toxic you know, ocular surface big problem.
(20:57):
Like you see patients that get like red apple eyes
when they're on symburns as well. So my general approach
is actually one combined agent with the beta blocker, whether
that's a carbonic and hydros andhertor or an alphagonist and
a standalone prostaglandin as well as one of the obviously
the other one if I want to use my maximal
(21:18):
taller day medical therapy.
Speaker 1 (21:19):
And the idea there again is partially because of the
side effects, but more so because of the effectiveness is
diluted when you've got the dual agents. So even though
it is less convenient for the patient and maybe even
less convenient for the doctor in terms of giving instructions,
being on these solo medications are have been proven to
be more more efficacious and lowering the pressures than.
Speaker 2 (21:41):
These combined agents.
Speaker 4 (21:42):
I guess, and to be good, I'm not necessarily advocating
that we have you know, we're on four classes. We
did four separate medications. But I guess what I'm advocating
for is the idea that you know, three may be
superior to two and do attracts and Britain is a
really really easy go to, but that may not be
in the patient's best interest. And you know, I have again,
I have patients that are referred to me with pressures
(22:02):
of twenty three or twenty four on traps and brinza
and the next step is really surgery, and if I
can get them, you know, using I don't know cosop
toriy zarga and monoprost and alphagan p and their pressures
come down to seventeen. I've just put off surgery.
Speaker 1 (22:20):
Last question I have is a class that most non
glaucoma specialists do not use for treating glaucoma, including myself, pilocarping.
The only time I really use it is for pis
how does it factor into your treatment algorithm, if at all.
Speaker 4 (22:37):
So, pilocarping is extremely effective, extremely effective as a pressure
lowering drop, and particularly in our angle closure glockcoma patients,
it definitely has a role. Now, if I'm starting someone
on a pilocarping typically it's into one of two very
(22:57):
specific scenarios. Actually I should take three specific sceperios. One
really doesn't pertain to the non glauck homa surgeon, and
that's really in my post operative gap procedure patients where
I really want to constrict the people and pull the
iris OAY to reduce PAS.
Speaker 3 (23:11):
So taking that option out of it.
Speaker 4 (23:12):
Really two specific clinical situations that I would consider using pilocarpy.
One is the patient who needs a little bit of
extra pressure lowering and they are not a good candidate
for surgery. So again, we have an elderly patient multiple homorbidities,
going through surgery is probably not in their best interest,
but we really want to preserve their vision and we're
worried that we're not going to have enough vision left
(23:34):
for the duration of the time period that they need
their vision. Pilocarpan's a great, great option. Another area that
we would consider using it is really our ango closure mechanisms,
and so it kind of obviously makes sense that we're
pulling the iris away and hopefully opening up the angles
and it's particularly effective. Our big cautionary tale is, like
(23:55):
some of our other jobs, there's a lot of kind
of pro inflammatory nature associated with pilocarpi, and so we
want to make sure that patients are aware that they
can give them a bit of a headache and they
can cause some generalized discomfort intensitivity, but also doing a
good dilated exam to really make sure that you know
there's no weak spots that would benefit from a peripheral retinopexy,
just because the risk of retinal detachment is not insignificant, so.
Speaker 1 (24:18):
If it weren't for those side effects which are significant,
especially those risks of retinal pathology. Would pilocarbon do you
think be considered a much more used drug amongst those
other four.
Speaker 4 (24:29):
Yes, I absolutely pilocarpet is very very strong. We often
don't talk about how strong it is, like it's probably
in the same realm as our prostaglandin's, if not more
like it's a very strong medication.
Speaker 1 (24:42):
Here, Van, I've learned a ton from you again on
this podcast, really really practical combined with really good evidence
based research. One of the main takeaways for me, I
think is what you said. Many takeaways, but one of
the main takeaways is to really hesitate and think before
I put a sixty year old or somebody younger than
six yana prostic lands and analogue for likely twenty thirty
(25:04):
years the rest of their life. That's really valuable, a
lot of really interesting information. Do you have any final
thoughts for people considerations when they're choosing these drops, which
we're lucky now we have so many different options, but
can also make the situation a little bit more challenging
because they're more variables.
Speaker 4 (25:21):
My comment really no immedia at the end would actually
be straying away from drops, which is we have we're
fortunate to have a lot of drops, but we're also
in a large environment where we have a lot of
opportunities to take our patients either off drops or consider
other options. And so we're lucky that we have good options,
but we're also really lucky that we have SLT, and
we're really lucky that we have you know, earlier surgical
(25:42):
interventions as well, and so we want to be mindful
that you know, taking those five or seven drops a
day becomes it's my joke with my patients, and it's
the kind of full time job that they have, you know,
five or six alarms on their phone reminding them to
take their drops. And so we want to be mindful
that taking jobs is not easy, and it is it
is a good amount of effort on the patient's part.
Speaker 1 (26:04):
You're a fan, Karenni from the University of Toronto. Thank
you so much for joining me. You've been a fantastic
guest and it's such a delight to have you on
the podcast.
Speaker 3 (26:12):
Thanks so much. Oh you guys, have an awesome, awesome.
Speaker 1 (26:14):
Day, and thank you everybody for listening to another episode
of blind Spot. Have a great day.
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