Implementing Standalone MIGS Patient Selection & Current Options
Dr. Sahar Bedrood:
Well hello, everyone. My name is Sahar Bedrood. I’m a glaucoma and cataract specialist based out of Los Angeles. I work at a practice called Advanced Vision Care. Today we are going to be talking about standalone MIGS. This is a podcast produced by Ophthalmology 360. We are going to be talking with Dr. Jacob Brubaker, who I will let him introduce himself shortly in a moment, and we’re going to have an amazing discussion and conversation about standalone MIGS and MIGS in general. Jacob, you want to introduce yourself?
Dr. Jacob Brubaker:
Yeah, sure. Thanks, Sahar. I am excited to be here. My name is Jacob Brubaker. I am basically kind of same thing, glaucoma, cataract surgeon just up the road from you. I can see you’re finally having a beautiful sunny day, unless that’s a background. We’re finally getting-
Dr. Sahar Bedrood:
No, no, it’s real. It’s real.
Dr. Jacob Brubaker:
Yeah. Finally in California we’re getting a sunny day. It’s been kind of nice. I’m up in Sacramento and I’ve been practicing for about 10 years. Yeah. My practice name is Sacramento Eye Consultants. I’m excited to be here. Thanks. It’ll be fun to talk about this.
Dr. Sahar Bedrood:
Awesome. Well, Jacob, I know that you do a lot of different types of glaucoma surgeries and I know you do MIGS. I wanted to kind of talk to you and really have a conversation about standalone specifically. What’s your experience with standalone MIGS? Which ones have you done by themselves? And just kind of take off the conversation with that.
Dr. Jacob Brubaker:
Yeah. I think it’s interesting to kind of look back at how much has changed in 10 years. I mean, you look at maybe our predecessors and you took 10 years of their lives in the glaucoma world and really wasn’t as much change. I think it was trabs and tubes and maybe eventually they got the Molteno or something like that, but it’s been pretty amazing to see how much has changed just in the 10 years since I’ve been in practice. When I first started, the old-school canaloplasty, ab externo canaloplasty, was kind of in vogue. iStent just barely came out. Even GATT was really something that kind of came out big probably a couple years after I was in practice. I feel like there’s been really a revolution on MIGS in general. Obviously in a lot of cases it’s been with cataract surgery just because a lot of the devices were initially approved for that purpose.
From the very beginning of my practice, I was involved with different clinical trials, with the Hydrus trial before it was approved, iStent and various different trials. It’s been interesting to see really the landscape and how things have changed. I would say that things that I’ve noticed for the most part as far as standalone, I think you kind of group them into maybe three areas. I think trabecular bypass has been one big area that has exploded. I think that really started off with GATT and doing a 360 type thing, and then that evolved into… We have the TRAB 360 and then the OMNI and then we have the Dual Blades and we have the Trabectomes and all those kind of things, however you want to do it, to try and do some kind of goniotomy.
Viscodilation, I kind of put those in a little bit of the same area, I guess, but then after that I would say that Xen or kind of micro and subconjunctival stents I think would be the next kind of area of microincision type devices that have come along that are standalone. I think for the most part, Xen is really something that I use almost 100% standalone. It’s pretty rare, honestly, that I use that in conjunction with cataract surgery. Then something that’s just really on the tip, I would say, at this point as far as things that are recently approved is microstenting, trabecular bypass type stents with the iStent Infinite just being FDA approved to be used as a standalone device. I think we’re just on the verge of microstenting the trabecular meshwork.
As far as experience, I think all of them. I was in the Infinite trial and did a handful of those cases in the trial. Then I’ve done… It hasn’t been too long, but I’ve done a handful of those since the trial has… Since it’s been commercially available. Then all the bypass, kind of excisional and incisional bypasses and then Xen, obviously.
Dr. Sahar Bedrood:
That’s amazing. I mean, what’s interesting is when all of these combined procedures came out a few years ago, I would say 10, maybe 12 years ago, there was all this talk about, “Oh, does it work? Does it not?” Then it became such a big part and such a mainstay of if you’re a cataract surgeon and you have a glaucoma patient, you do MIGS with cataract. Now we’re evolving even more and we’re thinking even more about just being more minimally invasive. We don’t need the cataract done. We could actually just focus on the angle. I really wonder if just focusing and doing one angle procedure without anything else, it might be beneficial for the patient. Maybe there’s less inflammation, maybe there’s less chamber instability. I mean, there’s just so many questions and so many reasons to think about doing it standalone as far as angle-based goes.
I myself have tried Infinite as a standalone and I have done goniotomy standalone in certain patients and ECP and that’s still considered MIGS. I do a ton of Xen as well, and I think that’s for a little bit different population, but I do think that it’s really going to be fascinating as this takes off. I think one thing that I was thinking about is why is it that angle-based goniotomy… Goniotomy has been around for decades, and yet all of a sudden it is so popular. Can you speak as to what you think brought this on or… I have some thoughts. I think has a lot to do with innovation and technology, but do you think… What is it that brought this revival of goniotomy?
Dr. Jacob Brubaker:
Well, I think I remember… I’m sure maybe I’m older than you, I don’t know, but I do remember when I was in residency and fellowship even, I remember asking… You study and you learn about pediatric glaucoma and you learn about how goniotomy in a lot of cases is curative and that that’s the kind of therapy of choice, which obviously is still the case, and it’s easier, as you were kind of alluding to, to be able to do that. Now being able to do 360 goniotomy is so much easier now than it was even 15, 20 years ago. That’s opened up a lot with pediatric ophthalmology. But I do remember asking my predecessors and I’m like, “Well, if it works for kids, why doesn’t it work for adults?” They just all said, “Well, it just doesn’t.” [inaudible 00:07:23].
Dr. Sahar Bedrood:
Yeah. Yeah. Just accept it. Accept it.
Dr. Jacob Brubaker:
Just accept it. That’s dogma. I think that it had been dogma for so long, and then with Davinder and their kind of development of GATT and bringing that to pass… That paper I think was really kind of groundbreaking and really kind of changed the mindset of what responds to goniotomy. I think previously maybe people thought, “Okay, something that’s trabecular-based, maybe pigmentary, maybe some of those type of things.” But mostly I think really people felt it was like a dysgenesis, that anybody that had dysgenesis from birth, those people responded but not somebody that over time with age developed some kind of a dysfunction of the trabecular meshwork. I think that that probably started the revolution, I would say, and then it was just a matter of trying to figure out an easier way to do it, honestly.
Dr. Sahar Bedrood:
Yeah.
Dr. Jacob Brubaker:
I think that… GATT I think is not that crazy tricky, but it’s definitely more involved than a lot of other MIGS procedures, especially with a catheter or if you’re using a suture or something like that. You’ve got a lot of working parts, and especially somebody’s phakic, you’re worried about hitting the lens and all that kind of stuff. I think TRAB 360 and then subsequently OMNI obviously was trying to recreate a kind of 360 type situation, but without having to have multiple instrumentation in the eye. Then I think the other iteration was basically the Dual Blade and trying to say, “Hey, maybe incisional goniotomy is maybe not the best, but let’s try and do an excisional goniotomy type thing.” I think obviously Trabectome has been around for a long time and [inaudible 00:09:20] really took off. I think iStent got people back in the angle, I think, and got that popularized. I think that’s kind of some of the evolution just from a historical perspective, but I think it really started with that initial data that kind of opened our eyes that said, “Hey, actually we can go against that dogma that was always there.”
Dr. Sahar Bedrood:
Yeah. Honestly, you make such a great point with everything you said that… I think that GATT made a huge difference to look at goniotomy. I think iStent and iStent W got people really familiar and comfortable with turning the head, putting a prism on, looking at the angle, and then you started doing it so much that you started thinking about the angle and then thinking, “You know what? I could do more or I could do a goniotomy. Sure, why not.” Whereas when it wasn’t accessible and it wasn’t done in the operating room that much, you just strayed away from it. You didn’t want to do that. I also think obviously the innovation. I think goniotomy years ago was done with a bent needle in pediatric patients, and that is probably going to be a little bit different than having a more finessed device. Innovation helps us and we learn every single time about how to improve and how to improve each device.
You’ve been involved in trials, I’m sure you’ve been involved in some kind of device innovation. It’s really amazing how we can use that to propel the field forward and also help our patients. This is really important. One thing I think is important is data because there’s all… We can do things for fun all day long as surgeons, but if we don’t have good data we are… Then what are we doing it for? It’s interesting that you’re talking about mild… We think of so many different things. Is the patient mild, moderate, severe? Then you think about is the pressure high, mild, moderate or severe or low… It’s like all these different things, and it is really incredible that we have to sit there and make a quick decision within 15 seconds of figuring out someone’s diagnosis what we’re going to use.
Usually I think what happens is doctors have a go-to where they’re comfortable with. I always say to try to learn everything so that you can find what it is that’s your go-to.But I think what’s interesting… I wanted to touch upon the iStent Infinite data because that particular dataset were in patients that were advanced glaucoma patients who are refractory glaucoma who I think have had previous incisional surgery and failed. They put three iStents into the angle to see what the pressure lowering was. I believe the data on that was pretty good, and surprisingly good actually.
Dr. Jacob Brubaker:
Yeah, yeah.
Dr. Sahar Bedrood:
Because when you think iStent, you don’t really think advanced patient except when you see this data. In the Infinite that I’ve done standalone, what happened to be in a really advanced patient because she did have refractory glaucoma, she did have a scarred conj. She had really nothing else for me to do and I did not want to remove tissue in her angle, so I decided to do a bypass stent. What do you think about that data and does it change the way that you would do standalone in a more advanced patient?
Dr. Jacob Brubaker:
Yeah. I think… I mean, two things that I take home from that data. Just generally it was effective in about 78% of people with a 20% reduction. Again, I kind of… I mean, I was in the study and so I also was kind of pleasantly surprised by that. 50% of people got a 30% reduction in their eye pressure. Again, these are patients… All the patients that I had had had previous trabs, previous tubes, and the average patient I think had two incisional surgeries. It wasn’t just one. I mean, these were pretty advanced cases.
Dr. Sahar Bedrood:
Mm-hmm. I’m going to do something really fun. this is what I think is fun. I’m going to go through… I’m going to alternate between me and you so it’s not all on you, Jacob, but what I’m going to do is I’m going to have each of us share one short surgical pearl for each of the different MIGS as I go along the list, okay?
Dr. Jacob Brubaker:
Let’s do it.
Dr. Sahar Bedrood:
It can be rapid fire, first thing off your mind, you know?
Dr. Jacob Brubaker:
Okay. I’m ready.
Dr. Sahar Bedrood:
I’m going to go… Are you ready?
Dr. Jacob Brubaker:
Yeah.
Dr. Sahar Bedrood:
Okay. iStent and iStent W, what’s one pearl you would give?
Dr. Jacob Brubaker:
Be decisive. I think you got to pick your spot, put it in that spot and don’t wiggle around. Once you’re there in the spot, fire and let it go.
Dr. Sahar Bedrood:
Nice. Okay. It’s my turn. iStent Infinite, I haven’t done a ton of these, but I think the one I would say for that is that you need to come out of the eye completely after the two stents, turn your scope and then put the third one in, and try not to be a hero and do all three in one fell swoop. Actually adjust yourself.
Dr. Jacob Brubaker:
Well, I think one of the things with that also is recognizing how sometimes when you’re under the gonio prism you think you’re farther away from each other than you are, and then you realize later you’re like, “Oh, that was one clock hour apart.”
Dr. Sahar Bedrood:
Oh, totally.
Dr. Jacob Brubaker:
Yeah. So I think being cognizant of really trying to get some distance between those three iStents, which… With two it’s kind of easy because you got out of these two little spots there, but now, you’re right, you have to come out and really kind of move the microscope around, rearrange yourself and get a view of a completely different part of the angle.
Dr. Sahar Bedrood:
Exactly.
Dr. Jacob Brubaker:
Yeah.
Dr. Sahar Bedrood:
I don’t know if you’ve done Trabectome. I have not.
Dr. Jacob Brubaker:
I have not done Trabectome ever. I’m sorry.
Dr. Sahar Bedrood:
Okay. So we’ll skip that one. I don’t know a lot of people who have, but it was a great initial innovation. Okay. For KDB, I can give that one. I think one thing I do is I actually… You make that initial nick to slide across, but one advice I was given and I do is I make the nick on the end where I am planning on finishing it so that… And I kind of carve it in a little bit. It’s backhanded at that point. Then when I go in to slide across the TM, then I can get the filament to be taken off because I’ve already kind of disconnected it at the end. If that doesn’t happen, I remove it, but I thought that was a little fun one.
Dr. Jacob Brubaker:
Yeah. That’s really good.
Dr. Sahar Bedrood:
Then, let’s see, GATT. I don’t do GATT much, but do you? If not, we can skip that one.
Dr. Jacob Brubaker:
Not so much anymore, but definitely I think… Yeah. I would say personally I really liked the iScience catheter just because I kind of liked the light. I did a ton of canaloplasty so I did nice a bunch of ab externo canaloplasties back 10 years ago. I did a ton in residency and… Sorry, a ton in fellowship, and so I was kind of used to the blinking light and kind of liking that.
Dr. Sahar Bedrood:
Yeah.
Dr. Jacob Brubaker:
I think the trick is really cord management. It’s really making sure that you’re putting the catheter through the right hole, that you have the angle of the side-port incision that’s angled right towards the angle, getting everything all lined up, ready to go, making sure that you… Usually you have the cords of the catheter kind of taped down, so you need to make sure you’re not taped too close. Sometimes what will happens is you’re going around and you’re like, “Why is it not moving anymore?” You’re underneath the scope and you can’t see anything else and it’s because it was tethered by your tape and you have to come out and untape it. You need to make sure you have enough kind of slack, I guess, to get around, and then it’s just a matter of… It’s actually pretty simple once you have it in there and get around.
Dr. Sahar Bedrood:
Good.
Dr. Jacob Brubaker:
Usually a pretty satisfying, fun surgery, but it’s definitely not something… I kind of got away from it mostly because I felt like 180 is about as good as 360, I would say, as goniotomies are concerned, and we can get that with other devices without having to… I felt like really a 360, you almost have to do 360. You can do 180 with it, but it’s not quite as easy, I would say.
Dr. Sahar Bedrood:
Yeah. Yeah, that makes sense.
Dr. Jacob Brubaker:
Yeah.
Dr. Sahar Bedrood:
Okay. The next and almost the last one is Xen. We both do a lot of those. For me, I think the one pearl… There’s so many I can give for that one. I do it ab externo and I open the conj up, but the one thing that I never leave the case without doing is making sure I see a droplet come out of the stent before I close. For whatever reason, anytime I haven’t done that [inaudible 00:18:28] superstition or what. Anytime I haven’t seen that drop come out, I feel like it doesn’t work as well. I wait. I’ll inflate the eye if I have to, I push on the eye. I just want to make sure that it is open and patent. If I see that drop come out, then I close up, but-
Dr. Jacob Brubaker:
Yeah. I think definitely you can have peritubular flow without intraluminal flow.
Dr. Sahar Bedrood:
Exactly. Exactly.
Dr. Jacob Brubaker:
Occasionally you can have a blockage inside the Xen and so you want to make sure that it’s… That’s one of the nice things as doing it open. Obviously when you’re doing ab interno you really… I mean, you may see the blood rise but you don’t know if it’s rising because of transluminal flow or intraluminal flow. I think that’s a really good pearl.
Dr. Sahar Bedrood:
Yeah. Exactly. Good. Then an oldie but goody, I still use this. Our last one is ECP. A pearl for ECP, I mean, for me is in order to control the inflammation that can be associated with it, I don’t… You can do one quadrant, you don’t have to do it 180 degrees. I think that’s my pearl. Sometimes I’ll just do a touch of ECP on patients to just get a little bit lower pressure and not have so much inflammation. How about you? Do you have a pearl for that?
Dr. Jacob Brubaker:
I haven’t done ECP since fellowship.
Dr. Sahar Bedrood:
Oh my gosh.
Dr. Jacob Brubaker:
I loved it. I loved doing it. I think it’s the funnest thing in the world. At that time, obviously, again, there’s capital expense with ECP.
Dr. Sahar Bedrood:
Yes.
Dr. Jacob Brubaker:
Honestly, personally I felt like just the other things that we have I felt like are at least as successful, and I was maybe biased. We had a good number of people to end up with CME and chronic uveitis and stuff like that so I kind of shied away from it. That being said, I do think that something that’s becoming MIGS-like is really MicroPulse transscleral laser. I think that, to tell you the truth… CPC, kind of traditional continuous wave, is kind of its own animal, right, for really advanced glaucoma.
Dr. Sahar Bedrood:
Right.
Dr. Jacob Brubaker:
But I really feel like… In my mind, I’m thinking that MicroPulse is really kind of somewhere between SLT and transscleral, right?
Dr. Sahar Bedrood:
Mm-hmm.
Dr. Jacob Brubaker:
It’s something that’s repeatable, it’s something that I feel like has fairly mild vision loss from it. I don’t know if I’ve ever had that. I think that that’s becoming MIGS-ish, I guess you could say, in some… If patients are… I won’t always use it in all, but it’s definitely the right patient that wouldn’t necessarily benefit from internal MIGS. Maybe they’ve already had them, maybe they’re older and they don’t want to do a Xen or a tube or something like that or they’ve already had a lot of those other things. I feel like it actually gives really good success and I’m not that worried about the side effects like I was with traditional CPC.
Dr. Sahar Bedrood:
Yeah. Okay. Good point. Well, we’re going to wrap it up. This has been a really great conversation. I think that-
Dr. Jacob Brubaker:
Actually, one question before you wrap it up.
Dr. Sahar Bedrood:
Yeah. Yeah, yeah. Go ahead.
Dr. Jacob Brubaker:
This is maybe not a wishlist, but if reimbursement was taken out of it and you had what you think is the data… Obviously we don’t have the perfect data, but if you kind of like what your hunch is and what you think is reality, what would be your algorithm as far as how you would take… Say somebody has mild glaucoma. I think we can probably all agree that SLT is maybe the other MIGS that we didn’t really talk about, but that’s… The LiGHT trial has really given us the strength to be able to say, “Hey, we don’t need to do meds first.” We have really good evidence that we can say, “Hey, we can convincingly say this is what you should do first and let’s do SLT first.” Let’s just say that that’s starting the paradigm.
Dr. Sahar Bedrood:
Mm-hmm.
Dr. Jacob Brubaker:
As you’re walking through the paradigm, what do you feel like would be kind of the next steps in an ideal world, assuming that reimbursement was out of it and assuming that what your hunch is for glaucoma you actually also had data for?
Dr. Sahar Bedrood:
Okay. Well, I’m going to say my next step would probably be some kind of sustained release, which is not a MIGS. It could be. iDose is coming out in the future and we have Durysta right now, but sustained release that doesn’t need to be replenished very often would be great.
Dr. Jacob Brubaker:
Yeah, of course.
Dr. Sahar Bedrood:
But after that, and let’s say cataract is not there, okay?
Dr. Jacob Brubaker:
Yeah, yeah.
Dr. Sahar Bedrood:
I would-
Dr. Jacob Brubaker:
So they’ve already had cataract surgery.
Dr. Sahar Bedrood:
Honestly, I-
Dr. Jacob Brubaker:
They had cataract surgery 10 years ago, but they didn’t get MIGS.
Dr. Sahar Bedrood:
Yeah. I would do a canaloplasty to try to revive that area of some sort, either with OMNI, and I would do a bypass stent. I would do an iStent. That would be, in my world, what I would do. Or you put Hydrus. That’s also a great idea. Goniotomy is great. I have to consider the type of patient, usually younger, uveitic, pigmentary or pseudoex.
Dr. Jacob Brubaker:
Yeah, sure.
Dr. Sahar Bedrood:
Then I have to be prepared for the hyphemas that come up on post-op day one. I think that that’s probably what I would do. I mean, I… Yeah, I would do Infinite with either goniotomy or canaloplasty.
Dr. Jacob Brubaker:
Yeah. I mean, I think we’re on the same page. I think that honestly, if I had maybe not my wishlist, but what I think would be best for our patients as far as a mind shift and change is really that we start with SLT, which I think it’s taken a while to get there, but I think we’re finally there and I think hopefully people are coming to that acceptance. I think it’s been maybe a long time coming, but definitely SLT. When I was in residency and fellowship, I felt like SLT never worked, but using it after they’d already tried three drops or something like that.
Dr. Sahar Bedrood:
Yes. Yeah.
Dr. Jacob Brubaker:
I feel like-
Dr. Sahar Bedrood:
Also the machine.
Dr. Jacob Brubaker:
That’s probably true, yes.
Dr. Sahar Bedrood:
The machine was probably not up to par.
Dr. Jacob Brubaker:
Yeah. Right.
Dr. Sahar Bedrood:
Then now the new ones are just so great. [inaudible 00:24:52].
Dr. Jacob Brubaker:
Right. I honestly feel like standalone… No, sorry, kind of patients that are naive do great with SLT so I think SLT first, and then I think the next step is some kind of a prostaglandin, whether it’s a Durysta or iDose down the road or a topical prostaglandin. I think that makes a lot of sense. It’s once a day, it’s very effective, and I think that… I don’t know if we can completely get rid of medications, but I do think that I would like to see the days of torturing eyes with four or five medications, making them feel miserable when they have mild to moderate glaucoma, I would like to see those days leave us and have a cultural shift where once we do one drop, maybe two max, but then we’re kind of saying, “Hey, for your betterment here’s the data that shows that you’re less likely to progress, you’re less likely… You’re going to do better from a compliance standpoint and all that kind of stuff.”
If we then move on to whether it’s an iStent Infinite, a Hydrus, some kind of a canaloplasty, som surgery at that point that’s going to hopefully work and be the next step and then kind of moving on from there. I really think that that is kind of… The Infinite data kind of convinced me that those max medical therapy patients are the ones that we should be targeting. Those are the patients that are in that mild to moderate category that are going to have I think the best response, just the same way that SLT now is early and we now see, “Oh, hey, it works.” I think it’s kind of the same thing. If we’re doing stenting and we’re treating the TM in early to moderate glaucoma, I think we’re going to see much better results than if we’re waiting till the very end of the road.
Dr. Sahar Bedrood:
Yes. 100%.
Dr. Jacob Brubaker:
I hope that that’s kind of where we’re going. And I agree. I mean, we have data, I just think we need probably more of it to really sway that pendulum, just like the LiGHT study did with SLT. I think we need more data that’s going to be compelling and hopefully convince us that that’s the best thing for our patients.
Dr. Sahar Bedrood:
Yeah, and talk about it and discuss it and bring it up at conferences because the more you discuss, the more you educate each other. There’s still things that I learn at every conference or even in podcasts or even in discussions or ad boards or whatever that I’m like, “Wow, okay. I haven’t thought of it that way.” And I feel like I’m in the thick of this stuff, right?
Dr. Jacob Brubaker:
Yeah.
Dr. Sahar Bedrood:
It’s great. I mean, I think having these kinds of discussions are so great and so valuable. I thank you for your time.
Dr. Jacob Brubaker:
Yeah. Thank you. Yeah, it’s been great.
Dr. Sahar Bedrood:
This was really great. We should do this more often.
Dr. Jacob Brubaker:
Nice to catch up. I’m glad you have sun. I’m glad I have sun. Hopefully everybody else has sun. It’s been nice.
Dr. Sahar Bedrood:
Yeah. Absolutely. Okay, awesome. This was great. Thank you again, and look forward to the next time we do a podcast together.
Dr. Jacob Brubaker:
Yeah. Thanks for having me.
Dr. Sahar Bedrood:
Awesome. Thank you.
