A little more than a decade ago, glaucoma was defined as a disease of “pressure in the eye higher than the statistical norm” and treatment consisted of burdensome ocular drops or complicated surgeries, including trabeculectomy and tube shunts. Patients and physicians were dissatisfied. As a result, glaucoma fellowships were left unfilled as ophthalmology residents raced toward higher-paying, more exciting cataract and retina subspecialties. But baby boomers kept aging, creating an ever-increasing number of glaucoma patients, which led to innovation in the market. We now know that glaucoma is probably similar to other degenerative nerve diseases, such as Alzheimer’s or Parkinson’s Disease. The American Academy of Ophthalmology (AAO) has modified the definition of glaucoma to a ‘disease that damages your eye’s optic nerve.” While the only modifiable risk factor remains IOP, the ophthalmic industry has invested heavily in improved options for treating patients safely and more efficiently.

When I was surveying specialties 7 years ago, I noted all of the devices and products in development for glaucoma, and the anticipated progress enticed me to apply for a glaucoma fellowship. I wasn’t the only person; glaucoma is now rumored be the most-enrolled specialty in ophthalmology.

Why Glaucoma?

There are many reasons that glaucoma has become a very attractive specialty. First, diagnostic advances have changed outcome potential. Previously, glaucoma specialists were treating patients with such severe disease that irreparable vision loss was often inevitable. Now that OCT is used for diagnosis, detection of disease happens earlier, so risky surgeries are less likely and vision loss often can be prevented. It’s a much more satisfying experience for a physician when he or she has the ability to make a significant impact on a patient’s quality of life.

The development of the iStent Trabecular Micro-Bypass (Glaukos) marked the birth of micro-invasive glaucoma surgery. Since then, other minimally invasive glaucoma (MIGS) treatments have emerged. MIGS is recognized as minimally invasive treatments that restore the eye’s natural outflow system, thereby reducing IOP and protecting the optic nerve. Collectively, these new treatments and procedures led to a tremendous change — glaucoma care shifted from pharmaceutical management to surgical management. Furthermore, these new procedures are very elegant and offer lower pressures with few side effects or adverse events.

A straightforward procedure with fewer side effects also means that surgeons can perform them more frequently. Although reimbursement for glaucoma procedures has not increased, this is offset by our ability to perform more surgeries in less time. The improved safety profile means that follow-up visits are minimal as well. This is combined with an ever-growing patient population. The result is that new glaucoma specialists can set up shop just about anywhere in the U.S. and have enough patients to fill their schedule within a couple of months. The physicians can also combine glaucoma with general ophthalmology or cataract services, developing a wide spectrum of patients and cases.

I was looking for a surgical field that involved complex surgery under the microscope, but I also wanted to have the opportunity to develop relationships with my patients. For me, glaucoma fits the bill. I have a large variety of disease management options, and I see patients on an ongoing basis, so I get to know them much as a primary care doctor would.

MIGS Training

I completed my residency training at the University of California-Davis, an institution known for being on the brink of innovation. There, the focus is on early diagnosis and early adoption of MIGS procedures. I was very fortunate to be able to perform iStent, endocyclophotocoagulation, Kahook Dual Blade, and other procedures during my residency. I completed my fellowship at the Stein Eye Institute at the University of California-Los Angeles. There, I gained experience working in private practice as well as in public service with an underserved population.

Experiencing the whole range of disease and patients was excellent training for establishing how I wanted to approach treatment in my practice. Now that I work with the University of Southern California (USC), I see both underserved as well as private insurance patients in the same clinic. This is rewarding because, in most cases, I believe that the earlier we can intervene surgically for glaucoma, the better. Surgical solutions remove the risk of patients being noncompliant with topical medication regimens, which could lead to vision loss.

Not all ophthalmology students have the option to practice MIGS surgery during their residency or fellowship, and some ophthalmologists completed their training prior to the emergence of the MIGS devices. Luckily, there are other ways to get exposure and training. Companies, such as Alcon (maker of the CyPass Micro-Stent) and Glaukos provide excellent training programs for new physicians. The Glaukos training includes a wet lab, for which they supply artificial eyes and all tools needed to complete formal training. Training also includes online modules and an expert who is present in the OR to guide trainees through several cases. The expert is also present for the first post-op visit and to assist throughout follow up.

Glaukos has also taken the progressive step of creating a training course specifically for residents and fellows. It begins at their headquarters, with a deep dive on MIGS, an overview covering existing and emerging devices, and hands-on training and video reviews. It continues with highly experienced speakers who share their knowledge in a very interactive way. I send all of my residents and fellows who are interested in glaucoma to that course.

In addition to company-specific training courses, ophthalmology conferences are an excellent opportunity to gain information and experience. The American Glaucoma Society’s annual meeting is devoted to glaucoma, but the American Society of Cataract and Refractive Surgery and the AAO also have good sub-specialty days in which talented young surgeons present on all of the latest treatments, including videos of techniques and complications. In my third year of medical school, I attended multiple meetings and saw how the leaders in the field were managing glaucoma. It was infectious to hear them talk about the future, and was an important factor in my decision to focus on glaucoma for my fellowship.

Individual glaucoma surgeons in your local community are another excellent resource. Find someone who is willing to take you into the OR several times over a few weeks so you can see the full spectrum of techniques available.

The Future of Glaucoma Management

Working in a training institution, we have a responsibility to the continued growth of the field. At USC, we participate in a wide variety of clinical trials and hold CME courses that are open to everyone. Our approach to education is to be very open to investigating new technologies. I recently performed my initial implants of the Xen Gel Stent (Allergan) and invited several surgeons to be present in the OR to see how we managed. Large universities are the first to participate in studies, publish the outcomes, and work out side effects and techniques. Thus, I believe they should share those experiences with private community physicians. Our responsibility is to spread knowledge for the benefit of our patients.

I look forward to innovations still in the pipeline for glaucoma. We know that IOP is an inconsistent diagnostic, so there are attempts to diagnose the mechanics of the optic nerve head. Here at USC, we are participating in a study evaluating blood flow and the mechanics of the lamina fibrosa, as well as diurnal fluctuations in IOP to see how we can predict glaucoma progression. It’s a race to diagnose early, then provide effective treatments without side effects to prevent the loss of vision. We are also working on strategies to validate the mechanics of the optic nerve rather than just the structure, so we can be sure to treat the patients who are most likely to progress.

Soon, we will have devices that slowly release medications inside of the eyes, relieving patients of the burden of topical drops. Farther into the future, it would be great to have a stent that can gauge pressure and automatically dilate to maintain pressure where it needs to be.

In Demand

The demand for glaucoma treatment is large — and growing. It will take both glaucoma specialists and comprehensive ophthalmologists to treat this vast number of patients. Training all residents, regardless of future specialty, in the management of glaucoma is essential in my view, as almost all ophthalmologists will be performing some kind of glaucoma surgery in the future. GP

Dr. Reznik is an assistant professor of clinical ophthalmology and the co-director of the Glaucoma Fellowship Program at the University of Southern California, Roski Eye Institute in Los Angeles. Her research focuses on the development of novel surgical techniques and new approaches for patients with early glaucoma. She can be reached via email at aklimava@gmail.com.