EyeWorld Asia-Pacific December 2018 Issue

Reimbursement issues In the U.S., the ability to com- bine MIGS procedures is limited by private insurance or Medicare reimbursement. “The first thing to think of is if the patient has a cataract. If the answer is yes, then the op- tions are open,” Dr. Francis said. “If the answer is no, then we can’t do suprachoroidal procedures.” In the latter, surgeons must consider procedures like the Trabectome, Kahook Dual Blade (New World Medical (Rancho Cucamonga, California), goniotomy-assisted transluminal trabeculectomy, and ab interno canaloplasty, Dr. Francis said. Some glaucoma specialists may be hesitant to combine pro- cedures because of concerns about cost, but Dr. Radcliffe thinks oth- erwise. “Treating glaucoma aggres- sively is always cost effective,” he said. He explained that when you combine MIGS procedures, you typically get reimbursed 50% for the second procedure and 25% for a third procedure, if used. “There’s some additional expense, but it’s not a triple expense.” The use of procedures like go- niotomy and ECP do not involve a stent, so that can help lower costs, Dr. Radcliffe said. Recently, Dr. Sarkisian has had trouble getting reimburse- ment for the use of ECP with another procedure. However, he sees the bundling of many MIGS procedures with cataract surgery as a drawback. “Just because the FDA approved these devices with phaco … it doesn’t mean it’s the right way in all circumstances. It’s just because that’s the way the studies were done,” he said. “Un- fortunately, the insurance com- panies have decided that’s when they should be paid for.” Once there are FDA indica- tions for standalone procedures without phaco, the bundling needs to end, Dr. Sarkisian thinks. He likens bundling reimburse- ment for combining MIGS to Medicare theoretically not cover- ing a topical prostaglandin in a patient who also uses a topical beta blocker or carbonic anhy- dride inhibitor. “The system would save more money in the long run if we could use stents appropriately and com- bine them when a surgeon thinks it is warranted,” he said. “We also should not be limited by severity of disease or lens status.” Looking ahead When MIGS came along, it revo- lutionized glaucoma treatment. The refinements that will occur with these surgeries in the near future and their combinations won’t be revolutionary, but they will be remarkable. “I don’t foresee a revolution, but definitely an evolution over the next 5 years,” Dr. Francis said. Dr. Francis thinks the path- ways via MIGS to treat glaucoma will remain the same, but phy- sicians will get a better idea of which combinations work best with different glaucoma types. There also will be new procedures that will come out, and enhance- ments will take place with exist- ing procedures. Stents also will continue to improve. In the stent realm, one ad- dition to the market likely will be the iStent Supra (Glaukos), which is a suprachoroidal stent. “I haven’t had the opportunity to try it, but I think it’s promis- ing,” Dr. Radcliffe said. He cited the results of a study published this year, sponsored by Glaukos, which found that in patients with refractory glaucoma followed for 4 years, the use of two iStent trabecular stents, the iStent Supra, and a prostaglandin led to a mean IOP below 13.7 mmHg compared with 22 mmHg preop. 1 He thinks these results may lead to a useful future surgical approach. The use of sustained release medication also will likely benefit patients using combined stent types in the future, Dr. Sarkisian said. EWAP Reference 1. Myers JS, et al. Prospective evalua- tion of two iStent trabecular stents, one iStent Supra suprachoroidal stent, and postoperative prostaglandin in refractory glaucoma: 4-year outcomes. Adv Ther. 2018;35:395–407. Editors’ note: Dr. Radcliffe has financial interests with Glaukos, Alcon, Allergan, Ellex, Sight Sci- ences, New World Medical, and Iridex. Dr. Sarkisian has financial interests with Alcon, Glaukos, and New World Medical. Drs. Francis and Kim have no financial interests related to their comments. Contact information Francis: bfrancis@doheny.org Kim: wonkim74@hotmail.com Radcliffe: drradcliffe@gmail.com Sarkisian: steve-sarkisian@dmei.org MIGS combinations – from page 31 32 EWAP SECONDARY FEATURE December 2018