EyeWorld Asia-Pacific June 2018 issue

Risk profile With safety concerns always at the forefront, risk profile is an im- portant consideration for patient selection. “Many of the MIGS procedures seem to be associ- ated with a higher risk of steroid response, so I would be more cau- tious in a known steroid responder and choose weaker steroids and shorter courses of therapy,” Dr. Wallace said. She is also cautious in patients under consideration for GATT who are on blood thinners that can’t be discontinued. “For a patient in whom I am planning a GATT, and to a lesser extent an ab externo canaloplasty, I discuss postop hyphema and the need for head up positioning so they have appropriate expectations for vision recovery after surgery,” she said. The risks or side effects associated with certain MIGS procedures are also part of the decision-making process. For example, the CyPass can be rarely associated with a myopic shift, choroidal effusions, and anterior chamber shallowing, Dr. Grover said. Angle-opening MIGS such as the KDB, Trabectome (NeoMedix, Tustin, California), and GATT have a slightly higher risk of transient hyphema but are still relatively safe, he added. Insurance Selecting the right medical option for a patient doesn’t always square with a patient’s insurance cover- age. “It gets to be challenging,” Dr. Brubaker said. The iStent is well covered through insurance, and the CyPass has some good coverage as well depending on the glaucoma severity, he added. If the best option is not covered by their insurance, Dr. Brubaker will let patients know that they would have to pay out of pocket and that the choice may be off-label. “Some patients are concerned about filter- ing devices, and they’re willing to try anything to avoid that step. In A GATT performed with a 5-0 prolene suture; the suture has passed nearly 360 degrees around Schlemm’s canal and the distal end of the suture can be retrieved prior to creat- ing a 360-degree trabeculectomy. Source: Davinder Grover, MD that case, it’s a good option. But not everyone can afford to pay for an off-label device,” he said. “Unfortunately, [insurance] is a harsh reality,” Dr. Grover said. “Without insurance coverage, it is hard for patients to afford the costs of surgery. This must be in one’s mind when discussing surgical options.” However, the availability of trabeculotomy and goniotomy reimbursement codes come in handy in those situations, he added. Lifestyle A patient’s work and hobbies also play a role in selecting MIGS op- tions. For example, if a patient is a scuba diver, Dr. Grover is concerned about the rare potential of blood reflux into the anterior chamber with the negative pres- sure induced by the scuba mask. “This could, theoretically, result in recurrent hyphemas, especially when diving,” he said. Addition- ally, if patients must hold their head in positions below the heart for prolonged time periods, Dr. Grover tries to avoid angle surgery because of the concern for blood reflux, a phenomenon he has seen in yoga instructors. “For these ac- tive patients, I may consider either a CyPass, XEN, or a traditional trab or tube shunt,” Dr. Grover said. Looking forward Although MIGS offers a multitude of treatment options, surgeons look forward to additional future uses for underserved patients. “I think the biggest under- served area is low tension glauco- ma,” Dr. Brubaker said. “There are no MIGS options right now that are designed to achieve an IOP in the high single digits.” The idea of using more than one MIGS device at a time—for instance, three iStents instead of one—and using certain MIGS as a standalone procedure without cataract surgery would open up treatment options for many pa- tients, Dr. Brubaker added. Dr. Wallace also sees a need for MIGS without cataract surgery. “In particular, it would be nice to offer the CyPass to patients who have had multiple retinal surgeries in the past and thus have signifi- cant scarring, which makes any filtering procedure quite difficult. Because many of these patients are pseudophakic, this device is cur- rently not available,” she said. Recently, Dr. Grover has been using Cypass in refractory glau- coma patients with prior tubes, secondary glaucoma patients with conjunctival scarring, and in patients who have failed angle sur- gery with relatively good results. “I think this will be a great potential use for Cypass although currently off-label,” he said. EWAP Editors’ note: The physicians have no financial interests related to their comments. Contact information Brubaker: jbrubaker@saceye.com Grover: dgrover@glaucomaassociates.com Sheybani: sheybaniar@wustl.edu Wallace: danajwallace@gmail.com June 2018 EWAP SECONDARY FEATURE 43