EyeWorld India September 2021 Issue

GLAUCOMA EWAP SEPTEMBER 2021 51 S ome MIGS options are approved (and thus insurance covered) only in conjunction with cataract surgery, while others are not limited in this way. Three ophthalmologists EyeWorld spoke with think there is a value in uncoupling some MIGS procedures from cataract surgery, yet two of the three do not perform off-label standalone MIGS, which we’re defining here as those approved without cataract surgery. “We should be able to find what is right for the patient— what is the best safety, efficacy, and cost,” said Larissa Camejo, MD. “What does the best balance look like for each particular patient? I can think of some patients where it might make sense to do an angle procedure or MIGS where you might want to do a standalone that is currently approved only with cataract surgery, and they might benefit from that vs. doing something more extensive.” What are the barriers? Robert Noecker, MD, said the barriers to standalone MIGS are multifaceted. One barrier is history. iStent (Glaukos) was approved in conjunction with cataract surgery, and as the first modern MIGS, as he described it, a lot of surgeons naturally began using it. This combination with cataract surgery continued with the approval of Hydrus (Ivantis) and CyPass (Alcon), prior to the latter being withdrawn from the market. In general, it makes sense to combine with cataract surgery because the procedure as a whole benefits glaucoma, Dr. Noecker said. “Studies have shown that cataract surgery alone is beneficial to glaucoma patients, but the combination of doing it with an angle procedure or a stent is incrementally helpful for IOP control. I think that’s part of why these procedures are tied to cataract surgery because it is a good thing to take out the lens in terms of opening the angle more and stabilizing it, preventing future peripheral anterior synechiae formation or intermittent angle closure as the lens grows,” he said. Another reason is the payer. “[The payer] sometimes allows a trabecular bypass stent as a standalone procedure, but more often they force the algorithm,” Dr. Noecker said. Performing the stent procedure in combination with cataract surgery is the only possible scenario for its use. Michael Pokabla, DO, said he thinks insurance is the biggest barrier. Patients in the MIGS age demographic are often on fixed incomes and unable to afford an out-of-pocket expense like this, he said. What’s more, there is always the risk of a complication, and then “you might not have a foot to stand on.” Finally, there is the data. The data for modern, angle- based MIGS is for the most part in conjunction with cataract surgery, while other options that are in the MIGS category but not combined with cataract surgery have long-term data without being a combination procedure. “Working against the standard of care and the lack of studies to support it is a very difficult barrier,» Dr. Pokabla said. WJo YoWld bePefit! When talking about situations for standalone MIGS, Dr. Camejo said we’re not really talking about mainstream cases. In managing glaucoma, there are so many minutiae, she said. There are cases where the patient is phakic without a cataract or already pseudophakic and you want to get them off one drop or offer better control, and an angle- based MIGS could achieve that, A frank discussion about standalone MIGS by Liz Hillman EyeWorld Editorial Co-Director Contact information Camejo: larissacamejo@mac.com Noecker: noeckerrj@gmail.com Pokabla: mjpokabla@yahoo.com This article originally appeared in the July 2021 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.