On June 10-11, eyecare practitioners from all over the world gathered online for Eyes On Glaucoma 2022, a two-day educational event all about glaucoma disease diagnosis, treatment, and management.
With so much fantastic education happening at once, we knew that people had to choose which sessions to attend. So over the next few months, we'll be releasing much of the excellent content from Eyes On Glaucoma for you to watch at your leisure—whether for the first time or to review important learnings!
Enjoy this presentation from Dr. John Berdahl and Dr. Nathan Radcliffe's lecture on surgical advancements in glaucoma, and don't forget to check out our list of future events!
Please note that these videos are provided for review only.
The decision-making process of glaucoma treatment is becoming a more collaborative progress between the ophthalmologist, the optometrist, and their patient. Dr. John Berdahl and Dr. Nathan Radcliffe sat down to discuss advances in glaucoma surgical treatments.
Durysta implant
Currently, the only FDA-approved glaucoma drug delivery device is a 10 mcg bimatoprost implant. Durysta provides patients with at least four months of IOP-lowering medication. At this time, however, repeat use is an off label indication. Dr. Radcliffe still recommends requesting a prior authorization before readministration, as there are times when insurance will cover repeat use.
The ideal candidate for this procedure is a patient with a well-controlled IOP on a prostaglandin and either not tolerating their glaucoma drops, unable to apply their drops, or their medication is cost-prohibitive.
This procedure is typically done at a slit lamp, but can also be performed in an operating room or laser suite. The eye is prepped with betadine and a numbing agent. The pellet is usually ejected into the anterior chamber or sometimes the sulcus. It is a short procedure that can be done the same day in office. The best effect on the eye will occur a month after insertion of the Durysta implant.
Follow-up times vary from next day to four months, depending on how high their IOP was previously and the severity of their glaucoma. If the IOP is still controlled at 4 months, monitor the patient until further treatment is needed. The effect of Durysta doesn’t wear off immediately. Dr. Radcliffe finds that Durysta is remarkedly predictable in a one millimeter per one to two months rate of ascending IOP. The implant will erode slowly over several years.
Selective Laser Trabeculoplasty (SLT)
Dr. Berdahl and Dr. Radcliffe both agree that considering SLT as a first-line treatment is best practice. Dr. Radcliffe has seen 85% to 90% of patients reach their target IOP at 1 month to 6 weeks SLT follow-up. There is a disconnect between doctors believing this safe procedure should be the primary therapy and what actually occurs. Insurance companies now pay for it as primary therapy. SLT has been proven to be a better therapy, as fewer patients go on to get surgery and fewer are rapid progressors compared to latanoprost.
The LiGHT study suggests that if you have a non responder, you can go ahead and retreat after 3 months.1 However, some like to get IOPs under control for 2 years and then repeat SLT. If the patient doesn’t get the IOP they or their doctor are hoping for, Dr. Radcliffe says to start with whatever “the most efficacious therapy is, usually will be prostaglandin analog (PGA). Rho kinase inhibitors would still be additive because they’re decreasing episcopal venus pressure.
Microinvasive Glaucoma Surgery (MIGS)
When considering the right MIGS for a patient, there is much more that makes these procedures similar then differentiates them. Since MIGS devices are all designed to lower IOPs, most times surgeon comfort and approach play a dominant role in selection. It is also important to have high-quality data. For instance, Hydrus (Schlemm canal microstent) has five years of data showing that, compared to cataract surgery alone, it can slow the rate of visual field loss progression.
Another example is the iStent which has a multitude of peer-reviewed data. iStent Inject W (trabecular microbypass stent) is the second generation with a wider flange.
During goniotomy, a surgeon opens or excises a piece of trabecular meshwork tissue under gonioscopic visualization. A Kahook Dual Blade is used to excise the trabecular meshwork during an excisional goniotomy. Micro Goniotomy (iAccess) is a newer procedure where the trabecular meshwork is micro punctured instead.
In an OMNI procedure (Ab-interno trabeculotomy + Canaloplasty), the device allows for catheterization and vasodilation of Schlemm’s canal. Streamline is a newer device that is a micro goniotomy and micro canaloplasty instrument.
Note: Practitioners should ask themselves: Am I sure I'm not over treating this MIGS glaucoma patient? Have I at least tried to get this patient off of some of their drops?
Conclusions
We don't have to go from drops to trabs and tubes anymore. There are a lot of other options in between that are available. Practitioners can now not only focus on controlling their patients' glaucoma but also discuss with them which treatment will improve the patient's quality of life the most. In the profession of eyecare, ophthalmologists and optometrists are on the same team. They have the same goal of taking care of the patients in our communities.
References
- Gazzard, G., Konstantakopoulou, E., Garway-Heath, D., Garg, A., Vickerstaff, V., Hunter, R., Ambler, G., Bunce, C., Wormald, R., Nathwani, N., Barton, K., Rubin, G., Buszewicz, M., & LiGHT Trial Study Group (2019). Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet (London, England), 393(10180), 1505–1516. https://doi.org/10.1016/S0140-6736(18)32213-X
