EyeWorld Asia-Pacific March 2021 Issue

52 EWAP MAR C H 2021 GLAUCOMA Dr. Huang gave a quick update on what’s in the pipeline for glaucoma that she’s looking forward to. PRESERFLO (Santen, formerly the InnFocus Microshunt), an ab externo subconjunctival MIGS similar to the XEN Gel Stent (Allergan), is anticipated. The iStent infinite (Glaukos), which Dr. Huang said will have three stents in a standalone procedure for severe and refractory glaucoma, is also expected. Additionally, there are some drug- eluting implantable devices that may benefit glaucoma patients in the future, she said. Glaucoma pipeline update are only single-use, single- packs, Dr. Zhang said, while others require a unit to be purchased for multiple uses. Some MIGS are also less likely to be covered by insurance compared to traditional glaucoma surgery, according to Dr. Huang. Dr. Zhang said she doesn’t think patient perception is too much of a barrier to MIGS. In her practice, if she recommends a MIGS procedure, patients are usually on board. She said she sets honest expectations for them, explaining that they might not take the patient completely off medications but could reduce the medication burden. In addition to potentially lowering the amount of drops needed, Dr. Zhang said the visual outcomes of phaco combined with a MIGS procedure are better than phaco combined with trabeculectomy. What’s more, cataract surgery causes inflammation and can cause a trabeculectomy to fail when done in combination. “When you do MIGS with cataract surgery, it tends to have a better outcome visual outcome than phaco plus trabeculectomy,” Dr. Zhang said. EWAP Editors’ note: Dr. Huang is in practice at the Glaucoma Institute of Northern New Jersey, Rochelle Park, New Jersey, and has relevant interests with Sight Sciences. Dr. Patrianakos is in practice at Cook County Health, Northwest Chicago Eye Specialists, Chicago, Illinois. Dr. Zhang is Assistant Professor of Ophthalmology, Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan. Dr. Patrianakos and Dr. Zhang declared no relevant financial interests. 4. The data All three doctors said when new devices and procedures are introduced, there are always safety and efficacy concerns until long-term data shows otherwise. “Certain MIGS devices have been approved for some time and have had longer follow-up times. It is always important to continue to monitor and assess patients for safety and efficacy of a device,” Dr. Huang said. Dr. Zhang said she thinks many physicians don’t think they have adequate long-term data for more modern MIGS. “Someone opposed to MIGS might say ‘Look at CyPass,’” Dr. Zhang said, referencing the recall of Alcon’s suprachoroidal stent in August 2018. A 5-year post-surgery data study found the potential for endothelial cell density loss if too much of the device extended into the anterior chamber. Dr. Patrianakos brought up another data concern. There are different study designs, different definitions of success, some use washout periods and some don’t, different years of follow-up, and different experience levels by the surgeons involved in the studies. “One of the things we need to do to solidify MIGS as a procedure is plan for these future studies to be more standardized and make comparisons between studies easier and also compare to traditional glaucoma therapies,” Dr. Patrianakos said. 5. Intraoperative gonioscopy Learning intraoperative gonioscopy is essential for most MIGS procedures. “It’s important if you’re going to do any of this that you’re comfortable with intraoperative gonioscopy,” Dr. Patrianakos said. Dr. Zhang advised ophthalmologists to start practicing visualization of the angle through intraoperative gonioscopy on all of their standard cataract surgeries. 6. Financial hesitations Equipment concerns could be a barrier to some physicians bringing certain MIGS options into their practice. Some MIGS