EyeWorld India March 2021 Issue

FEATURE EWAP MAR C H 2021 49 GLAUCOMA Standalone MIGS The physicians EyeWorld spoke with said they currently perform MIGS as indicated in FDA labeling. iStent (Glaukos) and Hydrus Microstent (Ivantis) are approved in combination with cataract surgery, and none of the physicians interviewed use them regularly as a standalone. There are, however, a number of MIGS approved as standalone procedures that can serve a range of glaucoma severity. “What we’re trying to do is find the right procedure for the right patient,” Dr. Herndon said. “There are some patient characteristics that I look for when I try to decide which of these angle procedures to recommend. It depends on the age of the patient, the type of glaucoma, the pressure goal that I have, the pigmentation of the angle. There are a lot of things that I’m putting into the equation when I tell the patient what I think will be the best option for them.” Dr. Brubaker said there is a sweet spot for standalone ab interno canaloplasty, OMNI Surgical System (Sight Sciences), Kahook Dual Blade (New World Medical), and gonioscopy-assisted transluminal trabeculotomy (GATT). Patients who have mild glaucoma have the options of drops, SLT, and Durysta, while those with more severe disease and high pressures are better suited for tubes and XEN Gel Stent (Allergan), he said. For those in the middle with fair visual fields where medications and SLT have been tried but who you’re not quite comfortable moving toward a tube or XEN, these are the patients Dr. Brubaker thinks are suited for these standalone angle procedures. Given cost constraints and lack of coverage as standalone procedures, he said he has a hard time recommending treatment with Hydrus or iStent outside of cataract surgery. Dr. An said if a patient is already pseudophakic, there needs to be a good reason to proceed with incisional surgery, especially in the COVID-19 era. Reasons include intolerance or incapacity to use medications. In these cases, she said she would choose XEN over an angle surgery. Dr. Provencher expressed a similar sentiment regarding the need to consider the situation driving toward incisional surgery. “It takes a strong patient- doctor relationship to abandon a ‘stable’ situation, where drops are controlling the glaucoma, and to proceed with incisional surgery,” she said. “You never want to talk a patient into surgery, and unless they come in miserable from ocular surface disease, side effects, cost, etc., it may take a few visits before a surgical discussion is appropriate or welcome. “My approach is to empower patients to initiate the discussion and to feel comfortable discussing their options,” Dr. Provencher continued. “I want them to know I care about their quality of life and that I pay attention to compliance.” Dr. An said with injectable and sustained-release medications and wider use of SLT as a first-line therapy, there is a good chance of replacing typical drop regimens in many patients if these interventional options are offered early. “I truly hope that’s the case,” Dr. Herndon said of the envisioned future where drops are less relied upon to control IOP. “I would love to be 10 years from now and say the great majority of my patients’ glaucoma is well controlled without topical medication, be it they had a MIGS procedure or they had an injectable. There are other delivery systems coming out soon.” EWAP References 1. Gazzard G, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet. 2019;393:1505–1516. 2. Hirabayashi M, et al. Predictive factors for outcomes of selective laser trabeculoplasty. Sci Rep. 2020;10;9428. Editors’ note: Dr. An is Medical Director, Mason Eye Institute East, University of Missouri, Columbia, Missouri, and has relevant interests with Aerie Pharmaceuticals, Allergan, Iridex, Ivantis, and New World Medical. Dr. Brubaker is in practice with Sacramento Eye Consultants, Sacramento, California, and has relevant interests with Aerie Pharmaceuticals, Allergan, Glaukos, Ivantis, and New World Medical. Dr. Herndon is Chief of Glaucoma, Duke Eye Center, Duke University, Durham, North Carolina, and has relevant interests with Alcon, Allergan, Glaukos, Aerie, Sight Sciences, Ocular Therapeutix, New World Medical, and Santen. Dr. Provencher practices at Cincinnati Eye Institute, Cincinnati, Ohio, and declared no relevant financial interests.