This is an exciting time for glaucoma treatment in the ASC. With the availability of so many new products and protocols, there are more options than ever before to help lower IOP in safe and effective ways—while getting patients off of drops and enhancing their quality of life.

But glaucoma surgeons keeping up with what’s new is the key to making it all work.

“Glaucoma care is in a period of evolution,” says John Berdahl, MD, a leading international cataract and glaucoma surgeon with Vance Thompson Vision in Sioux Falls, SD. “Over the last decade, the new devices, drugs, and drug delivery systems that have been FDA approved have added tremendous value to the armamentarium available to the glaucoma specialist.”

New Treatment Pathways

In the ASC setting, access to more options in glaucoma care means more opportunity for interventional treatment at earlier stages of the condition, adds I. Paul Singh, MD, of Eye Centers of Racine & Kenosha, in Wisconsin. But Dr. Singh says there needs to be a shift in the collective mindset regarding traditional treatment pathways.

“When I have someone with glaucoma and a cataract at the same time, my philosophy is that glaucoma is the primary and the cataract is the secondary focus,” Dr. Singh explains. “With that mindset, having different mechanisms of action is important so that I can successfully treat both the glaucoma and the cataract with the product or modality best suited to that patient’s condition.”

Ultimately, the goal is to relieve patients of their medication burden, Dr. Singh adds. Quality of life must be a factor in treatment decision making.

“Many of the new products approved for use and coming to market are an opportunity to make glaucoma less onerous,” says Eva Liang, MD, FACS, founder and medical director of Center For Sight, Las Vegas. “The MIGS space has also incorporated user-friendliness for both doctors and patients—and most patients are grateful that these products can have a significant impact on their lives.”

Dr. Liang has experience using all the iStent iterations from Glaukos, and currently uses its Inject W, as well as the Hydrus Microstent from Ivantis in conjunction with cataract surgery for patients with mild-to-moderate glaucoma. Overall, Dr. Liang says that she has seen promising results with IOP reduction, medication reduction, and favorable safety. She is also looking forward to using the Glaukos Infinite, especially as a standalone device. Having all these options will ensure that one of them will be the right fit for the patient.

“With the iStent Inject W and with Infinite when it becomes available, the stents are spread out within the angle and increases the chance of success,” explains Dr. Liang. “With Hydrus, the device is larger, which can be intimidating, but I find the insertion very smooth and controlled. It also often leads to more medication reduction, so I lean toward the Hydrus when I need more bang for the buck.”

Dr. Liang says that medication compliance is a significant concern, and it can make a big difference in patients’ lives if they can get off of even just one of their medications.

“The overarching goal with glaucoma is lowering pressures and flattening the diurnal curve, and that’s exactly what these options allow us to do,” she says.

Drug Delivery Advances

Durysta (Allergan) is another new product having an impact on glaucoma treatment regimens. It is the first intracameral, sustained-release implant indicated to reduce IOP in patients with open-angle glaucoma or ocular hypertension. It consists of a small bio-degradable pellet that releases 10 mcg of bimatoprost into the eye over a period of approximately 4 months.

Nathan M. Radcliffe, MD, a cataract and glaucoma surgeon at the New York Eye Surgery Center in New York City, says he is using Durysta in patients who have severe hyperemia, dry eye related to the topical eye drops, or who are struggling with compliance. Overall, his results have been better than data seen in the clinical trial, with around 90% of patients making it to 6 months.

“The reason being is that I’m not injecting patients with outrageously high pressures,” Dr. Radcliffe surmises. “Instead, I’m using the product for those who are somewhat controlled but struggling with an issue, such as red eyes or medication compliance.”

Dr. Berdahl expected that the FDA label for single use would limit patient interest in Durysta, but he says it’s been much more adopted than anticipated.

“Patients have enjoyed the holiday from their prostaglandin eye drop—particularly if it was expensive and not tolerated well,” he says. “Even though we educate patients that they’ll likely only be able to receive one implant and go back on drops, they do appreciate that respite. I suspect once we have a label for multiple use, we will see an even better adoption rate.”

Earlier Intervention

If it could mean reducing medicine or even avoiding it altogether, Dr. Singh says there is a valid argument for using these types of procedures earlier.

“It goes back to the philosophy of what is considered ‘controlled glaucoma,’” he says. “If the pressure is stable, but we know there is a lack of compliance or discomfort with drops, is that truly controlled? My definition also includes quality of life. If the patient is on a long-term therapy and has perfect pressure but red eyes, that is not controlled in my opinion.”

That has led Dr. Singh to offer procedures to patients with mild-to-moderate cases rather than waiting for advanced stages.

Dr. Radcliffe adds that may also mean bringing glaucoma patients who don’t need cataract surgery into the ASC to get pressure under control.

The Xen Gel Stent (Allergan) is a standalone option that does not have to be combined with cataract surgery. While it does not require cutting into the eye, Dr. Radcliffe says that this procedure can be performed in the ASC for a highly sterile environment and to ensure high-quality anesthetization of the eye and sedation of the patient.

Novel Combinations

As these advances are made, it’s becoming increasingly common that surgeons are also looking at ways to combine MIGS procedures.

“With the abundance of treatments, especially in the surgical space, we’re seeing more MIGS combinations,” Dr. Berdahl says. “I suspect surgeons are doing this because of the enhanced safety profile and to avoid the risk that can accompany sub-conjunctival and transscleral procedures.”

According to Dr. Singh, combining traditional standalone procedures can help to further reduce pressure while also avoiding the risks that come with more invasive surgeries.

“What’s exciting is that the combination of mechanisms and products allows us to maximize the outcome,” Dr. Singh says.

“For instance, we can combine a trabecular meshwork bypass stent with cataract surgery while also incorporating an Omni (Sight Sciences) goniotomy with visocodilation or a Kahook Dual Blade (KDB, New World Medical) goniotomy,” he adds. “We are maintaining a high level of safety, but getting enhanced results in innovative ways.”

Overcoming the Learning Curve

“Though new is always intimidating, I do feel that the MIGS space is an easy one for most doctors to step into,” says Dr. Liang. “These are also procedures that are well-received by patients. Most of the procedures are covered by insurance, which means that most patients want them when they learn about them. It’s an approachable conversation with the patient, and most are happy to have the option of something that will ultimately make their life easier.”

However, the abundance of choice comes with its own set of challenges.

“While the emergence of so many options in this category, the flip side to having so much choice is that it’s impossible for us to be able to use everything,” Dr. Liang says. “My best advice is to focus on what you feel comfortable with and what you find gives you the best results.”

Dr. Berdahl agrees.

“While the abundance of new tools is helping surgeons to have more options to take better care of patients, it also makes it impossible to have an algorithmic approach to determining which technology is best for each individual patient,” he says.

“Combine that with the fact that big studies like the LiGHT trial have suggested the benefits of early SLT—and I think it’s fair to say we’re in a reorganization of the right systematic approach to treating glaucoma.”

Dr. Singh says to keep in mind that the skill set of many of these procedures is quite similar. There is a learning curve for stenting, canal dilation, or cutting—but within each category, the skill set is similar.

“In other words, if you have experience in one MIGS device, you can transfer those skills to another with much less of a learning curve than the first time,” he continues.

Dr. Singh also notes that the more options you can offer, the more you can tailor your treatment to the patient’s specific needs.

Incorporating New Products in the ASC

Although there has been an “explosion of safe glaucoma surgical options in the last 10 years,” Dr. Radcliffe says there is still a way to go for more comprehensive adoption in the ASC.

“I think it is commonly accepted that most patients with ocular hypertension or glaucoma who are using a topical therapy would benefit from an additional glaucoma procedure at the time of a cataract extraction,” Dr. Radcliffe continues. “In fact, it could be argued that it is a missed opportunity for the patient—and the doctor treating them—not to add these additional surgical options into the ASC.”

Dr. Radcliffe says that if an ASC has glaucoma surgeons who perform straight cataract procedures with no MIGS options, it is worth exploring how adding these procedures to the OR can better serve patients—as well as the ASC.

“It is both healthy and helpful for ASCs to employ surgeons who are performing MIGS procedures,” Dr. Radcliffe says.

“In many cases, these surgeons are performing two surgeries in one, which contributes positively to the finances of the ASC while also ensuring improved patient satisfaction,” he explains. “The second procedure reimburses at 50%, so it is also more cost effective for insurers to have these glaucoma procedures combined with cataract procedures.

“Because insurance covers these procedures, it’s wise for the ASC to have glaucoma specialists who use MIGS,” Dr. Radcliffe adds. “They are quick and safe procedures that historically have little to no complications.” ■