EyeWorld India December 2018 Issue

MIGS combinations expand surgical options for glaucoma patients by Vanessa Caceres EyeWorld Contributing Writer AT A GLANCE • The combination of MIGS procedures gives surgeons more options for treatment for many glaucoma patients. • There are a variety of MIGS combinations possible; one common approach is an iStent with cataract surgery and ECP. • Reimbursement issues in uence which combinations that surgeons choose. • In the near future, glaucoma specialists will get a better handle on which MIGS procedures are suitable for speci c types of glaucoma. Surgeons zero in on glaucoma severity, treatment goals, and reimbursement when selecting the right combination T he use of combined microinvasive glau- coma surgery (MIGS) procedures will con- tinue to expand the treatment op- tions available for most glaucoma patients. “Without question, the long- term and short-term safety ad- vantage over traditional filtration surgery is enormous,” said Won Kim, MD , Walter Reed National Military Medical Center, Bethesda, Maryland. “With my experience so far, I am satisfied with its ef- ficacy. The vast majority of my patients who have had combined MIGS are still on medical therapy, but most are achieving IOP in the low teens, which is typically the goal for those with severe field loss and certainly welcome for those with any level of disease.” With single and combined MIGS procedures available, only some glaucoma patients—such as those with neovascular glaucoma, angle closure, or iridocorneal endothelial syndrome—cannot be considered for MIGS, Dr. Kim said. What specific MIGS proce- dures are surgeons combining right now, and how effective are they? Common MIGS combinations Surgeons shared details and results on several of the MIGS combina- tions that they use, although this is not an exhaustive list. One common combination is the use of an iStent (Glaukos, Laguna Hills, California), cataract surgery, and endocyclophotocoag- ulation (ECP), said Nathan Rad- cliffe, MD , assistant professor of ophthalmology, Icahn School of Medicine at Mount Sinai, New York. He and several other sur- geons began to take this approach after the iStent was approved by the U.S. Food and Drug Adminis- tration (FDA) in 2012. “This was a nice procedure because it gave us a dual or even triple mechanism. The cataract surgery opens the angle a bit, the iStent bypasses the trabecular meshwork, and the ECP decreases aqueous produced,” Dr. Radcliffe said. Dr. Radcliffe has seen no long-term issues after following these patients for up to 6 years; many have maintained their IOP reductions. The approach described by Dr. Radcliffe, called ICE for short, also has benefited patients of Steven Sarkisian Jr., MD , clinical professor and glaucoma fellow- ship director, Dean McGee Eye Institute, University of Oklahoma, Oklahoma City. In fact, Drs. Sarki- sian, Radcliffe, and other surgeons continue to analyse a series of patients who have had the iStent with ECP. In Dr. Kim’s analysis of 56 of his patients who have had com- bined MIGS procedures in various forms, he has found safety compa- rable to isolated MIGS procedures. Only two patients had IOP spikes that were unresponsive to medi- cal therapy and required tradi- tional glaucoma filtration surgery. Among the 56 patients, there was one patient each with a transient wound leak, transient hypotony lasting 2 weeks, transient iri- tis, cystoid macular edema, and retinal detachment. Dr. Kim also said the patients have had solid ef- ficacy, with an average IOP of 12.2 mmHg on two medications at the last follow-up period. Brian Francis, MD , profes- sor of clinical ophthalmology, Doheny Eye Institute, David Gef- fen School of Medicine, UCLA, Los Angeles, has tried several MIGS combinations, including the Trabectome (NeoMedix, Tustin, California) with ECP and Micro- Pulse (Iridex, Mountain View, California). He now usually does MicroPulse along with the Trabec- tome. “I’ve gotten pressures in the lower teens versus in the mid- December 2018 30 EWAP SECONDARY FEATURE