EyeWorld Asia-Pacific June 2018 issue

continued on page 42 Matching glaucoma patients with MIGS treatment options G laucoma surgeons and comprehensive ophthalmologists continue to better un- derstand how to effectively match patients with microinvasive glauco- ma surgery (MIGS) options. “We are still trying to figure out which MIGS is best for which patient and determine the best way to tailor the surgery to the patient,” said Davinder Grover, MD, attending surgeon and clini- cian, Glaucoma Associates of Texas, Dallas. The explosive growth within MIGS creates more options, but it also involves further analysis of the factors needed to match MIGS procedures with each patient. Here are the factors that several surgeons currently use to help with their decision and where they think the need for MIGS is still underserved. Glaucoma severity, IOP goals A great starting point is to think about glaucoma severity and whether the MIGS in question uses or bypasses trabecular outflow, said Arsham Sheybani, MD, assis- tant professor of ophthalmology and visual science, Washington University School of Medicine, St. Louis. “In general, in patients with advanced disease who need lower pressures than where they are at or who need to reduce medications, we typically won’t start with the trabecular outflow pathway,” Dr. Sheybani said. “I think traditionally, most types of MIGS procedures are better for patients with mild or moderate primary open angle glaucoma [POAG],” Dr. Grover said. “The advanced stages of POAG likely need a new drainage either with the XEN [Allergan, Dublin, Ireland], InnFocus MicroShunt [not yet approved in the U.S.; Santen, Osaka, Japan], or a trab or tube.” Like many surgeons, for Jacob Brubaker, MD , Sacramento Eye Consultants, Sacramento, Califor- nia, there’s a constant evaluation of a patient’s glaucoma sever- ity, current IOP and IOP goal, and medication use. He shared a typical example and how that has changed. “Until recently when there was only the iStent [Glaukos, San Clemente, California], it was a mat- ter of what their IOP is right now. If someone came in with an IOP of 15 on three medications and they had a cataract, even with severe glaucoma, I’d feel comfortable us- ing the iStent to get a little lower IOP,” he said. “Now, with the CyPass [Al- con, Fort Worth, Texas], the XEN, and goniotomy, that opens up the spectrum. My algorithm is that patients who are ideal for the iSt- ent are on one or two medications, have mild glaucoma, their IOP is well controlled, and I am confident that I can get them off one drop and get their IOP down to 15,” Dr. Brubaker explained. However, if Dr. Brubaker has a patient with a cataract, an IOP in the upper teens or low 20s, and who is on many drops, he will lean toward the CyPass. “There’s a higher likelihood of getting them off their medications and getting their pressure a little lower than with the iStent, but there’s a higher risk for myopic shifts and hypo- tony,” he said. The level of IOP change needed or the need to come off a certain number of drops can affect what MIGS choice can be used—or if it can be used at all, Dr. Sheybani said. He is also cautious about not getting the IOP too low. “We can always get pressure lower, but it’s hard to go low and come back up,” he said. For advanced glaucoma, there may not be sufficient IOP lowering or medication reduction with an iStent, as U.S. surgeons are limited to implanting one iStent at a time, said Dana Wallace, MD, Thomas Eye Group, Atlanta. She will let pa- tients know this in advance to keep their expectations in check. Another consideration is whether the patient has a cata- ract. The iStent and CyPass can be performed only at the time of cataract surgery, so that affects procedure and device choices, Dr. Wallace said. Although that can be limiting, she cited several stan- dalone MIGS procedures such as gonioscopy-assisted transluminal trabeculectomy (GATT), ab interno canaloplasty, and the Kahook Dual Blade (KDB, New World Medical, Rancho Cucamonga, California) as possible choices. June 2018 40 EWAP SECONDARY FEATURE Making MIGS choices by Vanessa Caceres EyeWorld Contributing Writer AT A GLANCE • The growth of MIGS means more treatment options for patients and a careful consideration of the best match for each individual patient. • Factors that surgeons consider when selecting MIGS include glaucoma severity, IOP goals, medication use, the presence of a cataract, risk profile, insurance, and lifestyle. • In the future, surgeons would like to see certain MIGS options available without concurrent cataract surgery and better choices for low tension glaucoma.