David S. Friedman, MD, PhD, MPH, is director of the glaucoma service and medical director of clinical research at Massachusetts Eye and Ear (MEE), Harvard Medical School (HMS) professor of ophthalmology, and co-director of the HMS Ophthalmology Glaucoma Center of Excellence. He received one of our Sight & Science 2020 awards for his pilot project, “Latanoprost-Eluting Contact Lens for Treating Glaucoma and Ocular Hypertension.”
How much of a problem is medication adherence in glaucoma treatment? How did you get the idea for the contact lens approach and what progress have you made?
Only about 70% of doses of daily eye drops are taken. People struggle to take their drops, and both younger and older individuals appear to be less adherent. Also, as people age, conditions like arthritis or Parkinson’s can make manipulating a small bottle and getting drops in their eyes even more difficult. I’ve conducted two clinical trials to try to improve adherence. We’ve used alarms and called people to review drop taking with them. Those combined interventions increased adherence by about 20 percent over a short time period. SMS reminders also have worked. There are ways to improve patient adherence, but they require systems and investments of time and effort. Widespread use has not occurred.
“Only about 70% of doses of daily eye drops are taken. People struggle to take their drops, and both younger and older individuals appear to be less adherent.”
I joined the Harvard faculty in May 2019. At a faculty retreat I met Joe Ciolino, MD, an associate professor of ophthalmology and the inventor of this contact lens technology that I am now studying. We talked about the promising ways he’s using it to deliver drugs. That approach, which involves a slow release of the medication, really appealed to me. There’s primate data indicating that it lowers intraocular pressure more than conventional drug delivery using drops.
That meeting was the beginning of a great partnership. The Harvard Catalyst grant came up just as we were discussing how we would proceed and we were fortunate to be selected for the award. To date, we’ve submitted and been approved by the Internal Review Board (IRB) both the funded smaller safety pilot with five participants, and also a larger double-blind phase II/III study to compare contact lens delivery to drops. Initially, we’ll have patients wear the lens for a week, even during the night. We plan to submit for Investigational New Drugs (IND) approval from the FDA in the near future. It’s considered a new drug because the latanoprost is being delivered in a totally different way.
You’re known for your international collaborations and contributions, particularly on angle-closure glaucoma. What’s the biggest change that’s happened in treatment and how did you contribute?
Angle-closure glaucoma represents probably about a third of all of glaucoma, but it causes about half the blindness, I’ve done much research with collaborators in Asia and China, where angle closure is even more common. I also collaborated with the group that did a lens extraction study in the United Kingdom. That study has led to important changes in managing angle closure glaucoma; simply taking out the lens helps reduces eye pressure and prevents vision loss from angle-closure glaucoma.
What happened to Glaucoma Service patients during the lockdown and do you still think telemedicine can work as you’ve envisioned?
During the lockdown elective care was not allowed, but since glaucoma can lead to blindness, many patient visits could not be deferred. We triaged and limited who came in. One of the major reasons I came to MEE was to try to grow telehealth. The COVID pandemic has created a different world where there’s now reimbursement for virtual visits. Virtual visits have worked well for problems with the front of the eye, which you can see with a camera. For glaucoma, it’s a little more difficult. We need to be more creative.
There are two ways for this to happen, I believe. We have to develop virtual testing sites in outlying, less populous locations where patients can safely get the testing needed to monitor glaucoma. Then we can follow up with a virtual encounter. We’re about to start offering Saturday virtual visits to patients. We also have to think about new technologies that might make monitoring glaucoma remotely even more possible. For example, I’ve submitted a grant to the National Institutes of Health to look at home testing of visual fields, using tablets or virtual reality devices.
You lead a CDC-funded program to identify new approaches to screening underserved populations for glaucoma and other eye diseases. What kind of approaches are you using?
“In a time of crisis, you have to innovate and do things differently, better, and safer. And we all are.”
Much of my understanding of how to do this has been gained from my experiences working overseas. There’s a tremendous amount of outreach that goes on, for example, in South India and Africa to identify patients with problems and bring them in. Aravind Eye Hospitals in South India has vision centers where ancillary personnel do a video of the eye for a doctor to remotely review. These ideas are not mine, but we need to figure out how to implement them here.
Then there’s the whole artificial intelligence piece. We have within the Schepens Eye Research Institute a strong group of visual physiology experts who do computational analysis of visual fields and optic nerve head imaging. I’m hoping that by enlisting them, we’ll be able to identify glaucoma and whether or not it’s getting worse by applying AI to data we already collect, which will help remote care tremendously.
How have you and your family fared through these challenging times and how do you stay centered?
I have two grown children and an infant at home. My older children were working remotely, so they came and got to know my daughter and I got to spend a lot of time with them, which is a real joy. I do a lot of walking in the Fells, which is a great place to wander. If I am busy, I can still make work calls from the woods, walk my dog, and stay sane. I feel like I work all the time in the COVID era. But it an exciting time. In a time of crisis, you have to innovate and do things differently, better, and safer. And we all are.