Leaders in glaucoma care discuss the transformative impact of minimally invasive glaucoma surgery and point to the benefits of an early intervention mindset.
Nathan M. Radcliffe, MD
Assistant Clinical Professor of Ophthalmology, Mount Sinai School of Medicine, New York
drradcliffe@gmail.com;
Twitter @n8radcliffe
Financial disclosure: Consultant (AbbVie/Allergan, Alcon, Bausch + Lomb, BVI Medical, Belkin Laser, Elios Vision, Nova Eye, Glaukos, Iantreck, Iridex, Lumenis Vision, New World Medical, Sight Sciences, ViaLase)
Private practice, Advanced Vision Care, Los Angeles
saharbedrood@gmail.com
Financial disclosure: Consultant (Abbvie/Allergan, Alcon, Glaukos, Theá Laboratories, Nova-Eye, BVI Medical, Elios Vision)
Cornea, glaucoma, cataract, and refractive surgery specialist, Vance Thompson Vision, Sioux Falls, South Dakota
justin.schweitzer@vancethompsonvision.com
Financial disclosure: Consultant (Abbvie/Allergan, Alcon, Glaukos, Sight Sciences, Theá)
Introduction
Glaucoma is a chronic and progressive ocular pathology. Over the course of the disease, elevated intraocular pressure (IOP) slowly damages the optic nerve and causes visual field defects and irreversible vision loss.1 Since its introduction in 2012, MIGS has transformed glaucoma care and uncovered the benefits of early surgical intervention over conventional treatment modalities.
This discussion highlights the benefits of collaborative care between optometrists and glaucoma specialists and points to MIGS adoption strategies and the critical role of patient safety. The future of glaucoma management, these experts explain, must include early intervention, proven MIGS procedures, and embracing new technologies.
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Nathan M. Radcliffe, MD: It’s hard to fathom that MIGS has been around for more than a decade. One of the first MIGS procedures, the iStent (Glaukos), was introduced about 12 years ago and has impacted our field in myriad ways. Dr. Schweitzer, you have been involved in numerous clinical studies with this technology. Looking back over the history of the iStent, what has been its impact on glaucoma care?
Justin Schweitzer, OD, FAAO: To be frank, I don’t know if I would be able to manage glaucoma without MIGS. It’s the revolution that glaucoma care needed. It filled a critical gap needed for the care of our glaucoma patients.
Sahar Bedrood, MD: The iStent became available just as I started my fellowship at Wilmer Eye Institute. Being a more risk-averse setting that focused on classical glaucoma surgery, the practice waited for data before adopting it. When I finally got the opportunity to use the iStent, it was revolutionary. It changed the way I thought about glaucoma care. I went from doing the traditional ‘tubes and trabs’ to thinking about incorporating glaucoma surgery into cataract surgery, understanding that any amount of reduction in pressure or reduction in drops is important.
Dr. Radcliffe: I was at Cornell when the iStent was approved. About the same time, I started feeling that the glaucoma surgeries I’d learned in fellowship were too risky for my patients. I love how the iStent changed the trajectory of glaucoma care toward early and safe intervention that could help spare some patients from more serious surgeries.
Given our options to approach the trabecular meshwork, what do recommend for patients who meet the criteria for a traditional tube but never had anything done to the trabecular meshwork beyond selective laser trabeculoplasty (SLT)? Do we need to approach the meshwork first?
Dr. Bedrood: I think the meshwork should be approached at some point, whether it’s first or last. It is a huge part of the disease process, and you must revive that area, especially in eyes that don’t have filters or further surgery.
Instead of performing an implant surgery or a procedure with large incisions or holes in the eye, why not start with something small to see if we can revive the trabecular meshwork? Then, if we can’t, we move to more invasive procedures. But the reverse is also true. You can place an iStent infinite (Glaukos) in a refractory glaucoma patient who has had other glaucoma surgery previously and now do it as a standalone procedure and obtain promising results.2
Dr. Radcliffe: I agree, it’s not a linear algorithm. For patients with a tube who now need cataract surgery, maybe it’s time to target the trabecular meshwork. Dr. Schweitzer, what does your algorithm look like for patients who could go either way but haven’t had anything done to their angle?
Dr. Schweitzer: Safety is the key factor. Generally, angle-based procedures are safer than filtering procedures, so I usually start there, especially if SLT and/or medications are not controlling the condition.3 Before we proceed with surgery, however, I take time to educate patients and remind them that although no glaucoma treatment lasts forever, but they can get years of benefit from an angle-based procedure.
Dr. Radcliffe: Given your experience working closely with surgical colleagues, how do you encourage other optometrists to get patients with glaucoma to the right doctor and the right procedure?
Dr. Schweitzer: I try to emphasize an interventional mindset. I remind other optometrists that we have a variety of options now that allow us to intervene earlier in the disease process. I encourage them to work with surgeons who do a variety of procedures, including MIGS, SLT, and sustained release drug delivery, to help reduce the medication burden. For some patients, glaucoma medications can be hard on the ocular surface,4-7 especially when multiple medications are being used.
Another thing that can be overwhelming for optometrists is understanding what MIGS procedure is best for patients. Communication with the surgeon they work with is critical so the same preoperative message is being delivered. I think, however, it is more important for them to be comfortable providing postoperative care—such as looking in the angle utilizing gonioscopy to see if a stent is open or the goniotomy is still functional—and educating patients on what to expect after a MIGS procedure. It may take 3 months before their IOP is better, and guiding patients through that process is important.
Dr. Radcliffe: Dr. Bedrood, what advice do you have for surgeons who want to get more involved in interventional glaucoma?
Dr. Bedrood: We are still amid the paradigm shift toward an interventional mindset. In my opinion, it is a disservice to patients not to learn the skills and techniques that help you intervene earlier in the disease state. I think a good place to gain an understanding about MIGS is by watching videos and learning about them from colleagues at society meetings. Both resources can help you learn about perfect cases but also complications. I think approaching it slowly, being part of discussions, and going to advisory board meetings, can be informative. I also think you can learn a lot from the company reps. Pick your favorite MIGS device and ask a rep to come to your OR.
Dr. Radcliffe: Coming back to you, Dr. Schweitzer, what advice do you give young optometrists and ophthalmologists in your practice about glaucoma care?
Dr. Schweitzer: We walk our residents and fellows through our stepwise approach to glaucoma management and try to get them thinking from an interventional mindset. For us, this includes SLT, topical medications, and sustained release drug delivery as first-line treatments followed by MIGS. By the time they finish their year with us, our hope is that they are very comfortable with a variety of glaucoma procedures and know how they would manage patients considering not only disease progression but also patient quality of life.
Dr. Radcliffe: Now that we have permanent J codes for sustained release drug delivery devices like Durysta (bimatoprost intracameral implant 10 mcg; AbbVie) and iDose TR (travoprost intracameral implant 75 mcg; Glaukos), how do you approach these procedures in your practice?
Dr. Bedrood: The first sustained release implant I did was for a patient who had borderline ocular hypertension primary open-angle glaucoma. She had a trabeculectomy in the other eye years ago, and she was noncompliant with her drop regimen. Although she didn’t have severe glaucoma in that eye, I saw the trajectory and offered her a sustained release option. She was so happy with the outcome.
The beauty of these treatments is that there isn’t one specific type of patient who will benefit. It is a good option for patients with bronchial hypertension, open angle glaucoma, and those who need 24-hour control without a drop regimen.
Dr. Schweitzer: For our practice, patients who had MIGS with a stent procedure several years ago but now have added one or two medications back are ideal candidates for sustained release drug delivery technology.
Dr. Radcliffe: Dr. Bedrood, for patients with borderline glaucoma control, how do you make the distinction between a standalone MIGS procedure versus incisional glaucoma surgery?
Dr. Bedrood: It’s important to take a step back and consider the less-invasive option first. Discuss the options with patients because it will help reveal the best course. Most patients don’t want something invasive or incisional.
Dr. Radcliffe: I agree with that approach. I get referred a lot of patients for standalone MIGS who frankly I feel are too late in the disease state for this approach. I tell them that a standalone procedure will provide a 60% chance of success whereas a more aggressive procedure will provide about an 85% chance of success. I’ve found that many patients are okay with a stepwise approach where we do a safer procedure first. The conversation is documented in their patient chart. I feel more confident pushing patients with early disease toward a standalone MIGS approach, but I agree it’s important to get patients involved in the decision.
Dr. Bedrood: If you tell patients, “Let me do a less-invasive procedure first and then I might need to take you back for a more invasive procedure later down the line,” they will most likely say yes to that approach.
Dr. Radcliffe: Dr. Schweitzer, what do you think the future looks like?
Dr. Schweitzer: Even more minimally invasive procedures. Some of the different procedures in the pipeline don’t even require incisions. In the future, I think we’ll see femtosecond lasers and other laser technology used to create perfect channels in the trabecular meshwork to lower IOP.
My goal is to continue educating the optometric community around managing patients with glaucoma. The perfect patient care model, in my opinion, is having talented surgeons in the operating room doing cutting-edge glaucoma surgery and optometrists handling the clinical care. That’s hard to do if my optometric colleagues aren’t embracing these procedures, educating patients, and providing pre- and postoperative care around them.
Dr. Bedrood: The introduction of the iStent 12 years ago was just the beginning of the revolution interventional glaucoma. I think that we’re going to have a lot of options, and that’s a good thing, but there will be a learning curve.
Dr. Radcliffe: As we evolve and get more comfortable with treatment algorithms, we’ll also better use the tools we have. I think our mindsets will evolve just as much, if not more, than the technology.
