We are, without question, in the midst of a glaucoma treatment and management renaissance.

It’s been a long time coming. From the early 2000s until 2012, when the first minimally invasive glaucoma surgery (MIGS) arrived, the glaucoma specialist had little that was new to offer patients.

Not that the current generation of specialists hasn’t anything to offer. To be sure, our group is standing on the shoulders of the glaucoma giants who helped determine the treatment rationale and paradigm for glaucoma care, such as the Ocular Hypertension Treatment study (2002), Collaborative Normal-Tension Glaucoma study (1998) and the Advanced Glaucoma Intervention study (2000).

We are also indebted to those who pitted traditional glaucoma surgeries head-to-head, comparing shunts like the Ahmed Glaucoma Valve (New World Medical) and Baerveldt glaucoma implant (Johnson&Johnson Vision) and tube shunt surgery to trabeculectomy with mitomycin C (MMC) in those with previous eye surgery (Tube Versus Trabeculectomy study).

But those dates clarify the story.

A NEW CHAPTER

Late last year, for the first time since Xalatan (latanoprost, Pfizer) was first introduced 22 years ago, not one but two glaucoma medications received FDA approval. Glaucoma specialists, and their patients, now have more viable treatment choices to make.

These two medications are a welcome addition to our options for treating glaucoma. The first, netarsudil (Rhopressa) is a Rho kinase inhibitor approved for the treatment of open-angle glaucoma and ocular hypertension. The exact mechanism of action is unknown; however, it is thought to reduce IOP by increasing the outflow of aqueous through the trabecular meshwork. The other medication, latanoprostene bunod ophthalmic solution (Vyzulta), has two components: the latanoprost acid, a prostaglandin analog that is thought to act via the uveoscleral pathway, and butanediol mononitrate, which is thought to improve outflow through the trabecular meshwork. Both medications are very promising, and the glaucoma community awaits their availability. Then, we can help determine which patients are the best candidates for each medication, and how these medications work when treating other types of glaucoma as well as in patients with prior glaucoma surgery.

OUR ROLE

While it is an exciting time to be a glaucoma specialist and care for glaucoma patients, it is now on our generation to put all these MIGS surgeries in perspective and to carry the field further. We need to determine which MIGS surgeries will persist, which ones will/should go away and when to use each surgery. We need to better understand Schlemm’s canal and the collector channels of the eye. More importantly, we need to understand how collector channels and outflow capacity change following specific MIGS surgeries.

Lastly, we need to have a frank discussion about the cost implications of our surgical choices on the medical system as a whole. These challenges require carefully designed studies directly comparing various MIGS procedures to evaluate safety, efficacy and the economic impact of our surgical choices.

This is a tall task for the MIGS Millennial generation, but we owe it to our patients, our colleagues and our glaucoma mentors to continue to move the field forward. OM

Davinder S. Grover, MD, MPH, is an attending surgeon and clinician at Glaucoma Associates of Texas, in Dallas. His interests include innovative glaucoma surgeries, complex glaucoma, cataract and anterior segment surgeries and clinical research outcomes in medical and surgical glaucoma. Contact him at dgrover@glaucomaassociates.com.