The evidence supporting earlier glaucoma intervention
Drs. Manjool Shah, Christine Funke, and Inder Paul Singh discuss the reasons to consider earlier treatment intervention for glaucoma.
Manjool Shah, MD:
Hey everybody. We’re here with Ophthalmology 360 and some of my great friends from around the country. My name is Manjool Shah. I’m coming at you from New York, New York, and I’m going to let my esteemed co-panelists introduce themselves as well.
Christine Funke, MD:
I’ll go next. Hey, Christine Funke, here from Phoenix, Arizona, enjoying yet another heatwave and getting to talk to you about glaucoma today.
Inder Paul Singh, MD:
All right, everybody, Paul Singh. I’m actually here in Madison, Wisconsin, right now, but I practice in Racine and Kenosha, Wisconsin. I live in Illinois, so figure that out. But it’s awesome to be here hanging out with 2 really good friends talking about glaucoma. It can’t get better than that, so looking forward to having some fun. Thanks.
Manjool Shah, MD:
Love it. Tonight, this is a topic I think we’re all really passionate about, which is the idea of promoting earlier intervention for glaucoma. We’re just doing so much better with our therapeutics and our diagnostics. The game has sort of changed and you guys are real leaders in the space and sort of thinking about this. Christine, talk to me about what we traditionally have done with glaucoma and how your practice has changed to embrace this earlier interventional strategy.
Christine Funke, MD:
Absolutely. I like to talk to people about when I started my fellowship, there were no minimally invasives. We’ve really come a really long way in I think a short time. Maybe I’m starting to age myself, but before traditionally what we learned were there was drops, there were trabs and there were tubes, and we usually threatened people with eye drops and then threatened them that if they didn’t do their drops, then we had to do something more invasive, like a trab or tube. That’s really shifted and the paradigm is kind of flipped. Instead of telling people, “If you don’t do your meds, I have to do surgery on you.” Now we get to clap our hands with excitement and say, “I have amazing surgical techniques and laser techniques that can help with your disease so that we can avoid drops.” Again, big change in terms of what we’re up to. I think it’s just better obviously for patients’ lifestyles as well as for this whole idea of keeping compliance, slowing down disease progression.
Manjool Shah, MD:
You make such a good point about putting the patient first. Paul’s like the oldest… I think he might be older than both of us combined actually.
Inder Paul Singh, MD:
Don’t go there, man. Don’t go there. I’ll grab the beard some more later on. Don’t worry.
Manjool Shah, MD:
There was that day when the diagnosis of glaucoma is bad enough, but the only thing worse is the treatment of glaucoma. It was very sort of punitive and we didn’t really get an opportunity to put patients first. Paul, how do you talk to your patients? How do you kind of introduce glaucoma and think about what they’re going through and their experience?
Inder Paul Singh, MD:
Yeah, I mean, I just want to dovetail off what Christine said. I just yesterday had to take a tube out. As much as we love our tubes and trabs, they do work, it is not a surgery that you can take light-hearted. There are complications that occur immediately or post-op and even later on. I think because of that, we really were afraid to do surgery. We had that middle ground between the patients who were early and the people who were advanced, what were we doing for those mild to moderate patients? I think what we realized is it’s not just about protecting you from getting worse over time, it’s also maintaining high quality of life. It was a choice. Do I want to actually maintain high quality of life or do I treat the glaucoma and be aggressive? Aggressive, meaning just IOP reduction.
We had to do one or the other. I think now what we’ve seen philosophically is that we can do both. We can maintain high quality of life and yet still, again, treat aggressively enough to protect them from getting worse. How I describe it to patients, I say, “Look, we’re lucky now.” I actually say that because I’ve been around for a long, long time, 20-plus years, and I can tell you that now we have so many opportunities to help our patients, get their pressures down in a high quality of life, and start now so they don’t have to worry about changing over time.
I tell patients, “Look, my job is to help prevent you from losing vision, keep you at the highest quality of life, and I’m going to use 1, 2, or 3 or many different type of treatments. We’ll start with something that’s very straightforward, a beam of light that rejuvenates the drain to help your eye function better naturally. If that doesn’t work, we have medications that we can deliver gently into the eyes. You don’t have to take drops. Or we could do minimally invasive procedures that are very quick and straightforward to again, help your conventional drain, the natural drain work better. We have drops if we need them and we can still use them if we need to, but to me, it’s going to take this or maybe multiple treatments over time. But I got you covered, don’t worry.”
I think establishing this idea that not one procedure, one technology is going to be enough for everybody and that we have to wait and see, and everyone’s anatomy is different, but don’t worry the patient. When it wears off, if it wears off, if it doesn’t work, we have other options. That conversation has allowed me not to be so scared about doing a standalone X, Y, and Z procedure. Because if it doesn’t work, the patient knows we’re not stuck there, we have other options, and to expect that we may have to do something else in the future. That conversation was not there 10, 15, 20 years ago. It was like drops, drops, drops, see you later. Here’s a trab or tube like Christine said. That conversation I think is exciting and something that’s really important to have if you want to have an interventional glaucoma mindset.
Manjool Shah, MD:
Yeah, no, that’s so well said, man, as always. But it’s interesting. We came into this game to be physicians first. Many of us didn’t go to med school knowing we wanted to be glaucoma specialists, but we came to take care of patients and we take care of them in any way we can. To be able to unburden the patient and to put that onus on us, that’s what we signed up for. That’s being a doctor. I see this sort of evolution as the key to enabling us to do that better.
Now we’re able to better serve our patients in the way that matters to them without compromising their long-term health and outcomes. Now we have 1.0 in this interventional glaucoma revolution was just having the technology, but now we actually have some data. We actually have some evidence to support it. I can’t tell you how many times I’ve reached for a piece of paper and write down LiGHT trial for my patients who are thinking about SLT. How do you guys talk to your patients about SLT? I know, Paul, you kind of talked about a gentle beam of light to rejuvenate the drain, which I love and it’s a line that I’ve stolen. Funke, how do you introduce SLT, the LiGHT trial, and all that stuff with your patients?
Christine Funke, MD:
First off, I’ve become SLT first and SLT often honestly. I tell patients with a lot of enthusiasm that we have something that is superior to drops and that if it was my own eye… Because I think everyone wants to know what we would do for ourselves because everyone always asks that, and the answer always is SLT first. I would never put a drop in first. It would always be SLT. Then from there, usually I go into a little bit about the LiGHT trial, which I think the most important things are, one, how effective it is to use SLT, how it’s longstanding, how it’s repeatable. I steal Paul’s line too of talking about how it’s a gentle rejuvenating beam of light without any discomfort. Then also talk about the fact that it slows down progression of disease and that they’re less likely to have visual field loss, which means less likely to go toward blindness.
As long as you say that, I don’t know how you say no to that. I think as long as you give the right expectations around why you’re doing that and showing that it’s because it’s better and best for them, it’s really never a conversation other than, “Okay, let’s go forward. When can I get that done?” Because I have heard other physicians say people will say no to the laser, and I think we all 3 are on the same wavelength of I don’t give a huge choice because we’ve all…
Manjool Shah, MD:
It’s better.
Christine Funke, MD:
Yeah, it’s better and we have a lot of evidence to support it’s better. I want to do what’s better for my patients. That’s why we all went to medical school and residency and all these things is because we want to help people in the right way.
Inder Paul Singh, MD:
Yeah. I just want to add to that. I think it’s so important to have confidence when you offer some technology or some procedure for the patient. I think to Christine’s point, I think so many doctors will say, “Yeah, yeah, SLT makes sense. I would do it for myself.” But then you look at all the data and all the different meetings we go to and you get the polling and half or less are offering it first line or consistently offering it first line. I think part of it’s the fear of rejection from the patient, the fear of being an outlier, fear of well, patients want drops first. Well, I’m just going to push back pretty hard on that because if you ask most patients, they don’t know what’s better. They’re actually coming to us to give them that kind of answer.
Number 2 is we always have data. Going back to what you just said Manjool and Christine, you have the data. It’s not like it’s a question that you have to defend. It’s like straight up, this is how it is. You go to a cardiologist, they’re going to put a stent because a stent is better for the valve when you have, let’s say, 90% blockage. It’s not a question. When we have data that said, this is better to protect you from getting worse and it’s safe. The other thing that’s really helpful is it addresses the cause.
I tell my patients, “All the drops do work to bring the pressure down, but they’re not really treating the actual cause of why your pressure is going off for majority of people. This beam of light treatment actually addresses that, what we call address the pathology.” All that combined in just a 30-second spiel, you can tell all that to patients in a very confident way to say, “This is what I do in my practice, and I use drops if needed. That doesn’t mean drops are bad; we don’t want to destroy it or say how bad they are, but it’s not something we have to do first line. It’s there if we need to as a bridge or as a backup.” I think that confidence is so important when you offer this or any of the technology.
Manjool Shah, MD:
Totally. I look at SLT… Again, we have this really robust data set. We have the LiGHT trial, and we even had 30 years ago the glaucoma Laser trial that obviously it was not using SLT, but it also showed that laser trabeculoplasty works. We’ve known this intrinsically for decades, and then we’ve just gotten better at it. For me, that not only is a tool to get the process going and provide good care, but it also introduces the whole concept of my job is to take care of your pressures and introduces this idea of using our minimally invasive surgical techniques as well. It’s sort of a nice segue. Do your patients ask you about the evidence for this stent or this whatever when I’m having my cataract surgery? Or has have people kind of already accepted that in your practices?
Inder Paul Singh, MD:
As a patient or for my colleagues?
Manjool Shah, MD:
Yeah, patient. Yeah.
Inder Paul Singh, MD:
Yeah. Luckily in Wisconsin, I mean, I really would say people are still very trusting of the doctors. I think they just want to know you have confidence that you believe in it, and that’s the number 1 thing. If you don’t believe in something, it comes through, they can hear you, they can feel it, and they lose the confidence. But I say, “Look, this is how we treat it. This is the standard of care in our practice.”
I say, “This is how we do it. We’re already there to take care of your cataract and now we’re going to help open the drain up, which if you look at the data, it shows no difference in safety between the 2.” I think to say that alone, and this is how we do it. For the most part, I haven’t really had people… I’ve had very rarely someone say, “Well, I don’t want to put a stent.” They ask about the stent, “Do you feel it? Do you see it? Is it going to cause a problem later on if it doesn’t work.” That’s extremely rare and I say, “Nope. It’s been shown to be very safe. We have data up to 5-plus years.” That alone I think is all you need, that confidence in how you present it to say, “It’s how we do it now in our practice.”
Manjool Shah, MD:
Yeah. Yeah, I think that’s a good…
Christine Funke, MD:
Yeah, I agree. Sorry, Manjool. I totally agree because I mean most patients I think are still very confident, especially if they’ve been with us for a while. I think they’re usually confident in how we practice and how we are evidence-based practitioners. They will always be an occasional person who comes in with the folder and then the pen and the sheet of paper with all the questions. That’s fine. I can respect that because that means they really care about what we’re doing and treating. Of course there’s always the backup discussion with more data points to talk about, but the majority of patients, I’m right with Paul, which is just saying, “This is what I do. I prefer this method because one, I’m already there. Two, we have evidence to show that this is going to slow down the progression of your disease better than meds, and we may be able to get you off some meds, which would be great for you anyway.”
Inder Paul Singh, MD:
I don’t know if we’re going to talk about this later on, but I would just say also when you think about the decision that we have to make as providers when we’re trying to tell someone they have to start treatment or let’s say change treatment. When someone is on a topical drop, 1, 2, or even 3 drops, let’s say, the decision becomes more complicated. Because in your mind when someone comes in, they’re progressing, their pressure is fluctuating without a target, now you think, “Is it because the drops aren’t working? Is it because they’re not compliant? Are they able to take them every day?” But when someone’s not on drops, they’re progressing still, the pressures are not controlled, the decision is very easy. I have to do something more now. I have found anecdotally, we don’t have any data on this, but anecdotally that our decision tree and the time it takes for me to make a decision far, far faster and far more clear when someone’s not on drops when making that decision.
Manjool Shah, MD:
That’s a really good point. Because not only do you have the variability of adherence or not, but you’re going to have variable responses to a pharmacotherapy, not to mention peaks and troughs of just when did you take the drop? How does it link up with your diurnal cycles and all that stuff, circadian rhythms, blah, blah, blah? We know all of these factors can affect aqueous humor dynamics and all of that. I think that’s a really good point.
You actually get to be a more precise clinician when you eliminate some of the extraneous factors there. Not only are we providing better care from the patient side, but we’re also helping ourselves do a better job for them too. The newest sort of game in the minimally invasive space is in standalone surgery. Now take your early patients who may have had SLT, they’re still phakic it, they’re still young, they’re still active. Again, drops are not really going to fit with their lifestyle and their quality of life goals. Have you seen that sort of segment of the patient population kind of growing and how do you address those folks?
Christine Funke, MD:
Yeah, I was just going to say, I think standalone generally is just becoming a bigger part of my practice. I mean, slowly but surely. I think especially for me, I have a practice where I get fed a lot from external and internal ODs. I think the more that they get comfortable with seeing the results from the cataract-MIGS combos, I think they’re starting to say, “Oh, well now we should also be doing this more standalone available.”
Today, when I was in the operating room, I had half my cases were cataracts with MIGS, and then the other half were just standalones, which is a huge shift even just within the last couple of years. I think I’m starting to talk about it a lot more. I’m starting to think about it as the next step if SLT didn’t work or if I need a little bit more of a pressure push than I may think I might get with laser or for a whole myriad of different reasons. But I think that this is going to become something where, in the end, I hope that we’re seeing just as many cases as a standalone as we do with cataract surgery.
Inder Paul Singh, MD:
Yeah, I think it’s one segment of this whole new interventional glaucoma world that we’re living in. It’s still a little slower to increase. I think it makes sense because a lot of doctors and I understand are concerned about delivering on the promise of the patient. Is it going to work? You can put a stent and you can now have dilation and cutting, whatever you do, you’re always like in the back of your mind, “Is it going to work or not? Am I going to get the patient off of drops or am I going to reduce the pressure? If it doesn’t work, they’re going to blame me.” I think this is kind of where I came back to once I started having that conversation with a patient right away, saying, “Look, everyone’s anatomy is different. Glaucoma is not the same for every patient, but I’m going to do something that I think is very safe for you that addresses the problem directly.”
We’re going to go and do our best to open the drain up, or you put a stent, whatever we decide. If it doesn’t work, that’s okay. We have other options. Let’s try this first. I think that calmness, that conversation you have with the patient to expect that this may or may not work and we have other options, has allowed me to feel comfortable going into surgery as a standalone in a phakic. I just did recently… an [iStent] infinite and iDose combination in a patient who was phakic. I also had a patient yesterday who was a canal dilation, canalplasty. I do all of them in different segments in really phakic patients early on for different reasons. I think that conversation is so important to have to manage that expectation. Not to be afraid if it doesn’t work.
Manjool Shah, MD:
Again, this is another emerging space where we are starting to have some evidence. I for one was certainly shocked, happily shocked with some of the data coming out of the standalone pivotal trial. What did you guys think of that? Were you as blown away as I was?
Inder Paul Singh, MD:
I was in the trial, man. I remember when Glaukos was like, “Hey.” They came to me and said, “Do you want to be part of this trial as an investigator?” Because I part of the phase 3 trials for [iStent] inject the original iStent as well. They were like, “What do you think?” I’m like, “You want me to put a stent in a post-trab, post-tube, post-cyclodestructive procedure patient? Are you kidding me? You guys are crazy.”
Because I always thought you can’t open up the conventional pathway once you divert fluid away from it. That was what we were taught and we were drilled on. I will say I was surprised. Granted these patients were sick because they weren’t off of meds. The goal was not really a reduction of meds. It was let’s get the pressures down, but to get 70% of people at 20% IOP reduction on the same or less meds, that was something that was really shocking. We did see those patients, of course, some of them of course not, but a majority of them had a response. That was really, really shocking to me because I really thought we couldn’t open up the conventional pathway. It was shocking to be honest with you.
Manjool Shah, MD:
When you see that kind of outcome in that sort of patient, man, that sort of really opens up the options for patients who are not post-trab, post-tube, post-cyclodestruction, all of the above times 3, the end stage of the end stage. Now if it works in them…
Inder Paul Singh, MD:
In the study, there was the MTMT groups, so about 20 patients I believe or 19 patients I believe were in total were MTMT, maximum tolerable medical therapy. The FDA allowed a small group of those. If you did a subgroup analysis of those, 90% of patients got 20% reduction. I think 70% or 80% got 30% reduction, like 40% got 40% reduction, relatively, I think. A good amount of patients got to the middle to lower teens, and many of those patients were on less medications. You got up to 30% to 40% reduction of IOP and some reduction of medications in the MTMT groups. Your point is a mild to moderate patient where they’re not fibrosis, the conventional path is not scarred down. You may have an opportunity to really help them early on versus waiting until they’re more advanced. Absolutely right.
Christine Funke, MD:
I agree. They really give themselves a big hurdle to jump over. I was super surprised too with the results, but I think it’s saying just that. One, it’s reminding us exactly what we’re saying, which is the younger the disease when we’re intervening, the more successful generally it is. But even when you’ve got something more advanced, it’s still worth a try to use these less invasive techniques, which is what I tell patients as well, which is, “Hey, this is almost no risk compared to what else we’d be talking about. Then we have a very large chunk of patients who do well with this, so let’s give it a go. If you don’t fall into that bucket and unfortunately fall into the other, then we still have other options. But at least we’ve tried the less invasive thing first.”
Manjool Shah, MD:
To your point, you know who the patients who do worse with trabs and tubes are? Younger patients. They heal, they scar, they lead active lives, they bend over to pick up their kid. I mean these eyes that we’re catching earlier because we’re just doing a better job, they’re screening for this sort of early microinvasive strategy that really tries to harness their physiology as opposed to bypass it all together. Again, it’s such a remarkable time to be treating glaucoma. One wonders if we really augment conventional outflow in these patients, what are they going to look like in 10 years and 20 years? We don’t even know the full magnitude. We’re starting to see that with some of the 5-year data and whatnot. But man, what’s the world going to be like when we’re Paul’s age? I’m just kidding.
Inder Paul Singh, MD:
No, I’ll tell you, man, I’m finally feeling my age because I actually did have a little exercise looking at some of the patients I did earlier SLT on like 15, 20 years ago and the ones who didn’t and there’s no doubt and I can’t… It’s not published. There is no doubt a difference in the regression rates of these patients and the overall ocular surface disease that we talk about those other things, it is real. I’ll tell you, those younger ophthalmologists out there who are just starting out treating glaucoma, whether they’re comprehensive or glaucoma specialist, don’t get fooled.
These patients who look pre-parametric, they look like they have a small nasal step and they’re like, “Ah, we’re fine. We have time.” You wait 5 or 6 years and bam, they come back with a big arcuate defect. They’re like, “Where did that come from? I don’t know what happened.” You’re like, “Yeah, it was there all along. It just got worse and I just couldn’t tell.” It could happen overnight in some of these patients. Be aggressive early on in the safest way possible. I think that’s what we’re learning more now. You’re absolutely right about the studies.
Manjool Shah, MD:
Yeah, amazing. Guys, always great to hang out. Any final thoughts before we call it a night?
Christine Funke, MD:
I think that we’ve skipped one of the biggest things, which is what interventional glaucoma is all about, which is we are getting rid of one of the biggest problems that we have dealt with in glaucoma for decades, which is compliance. We finally have the opportunity to skip that and bypass it. Meaning just like Manjool said, we can take the ownership of this disease and we can bypass the whole, are they or are they not taking their meds? Which so many people are not taking their meds.
Manjool Shah, MD:
They’re not.
Inder Paul Singh, MD:
Don’t be afraid to do what’s best for the patient. I’m saying that and I know that sounds cheesy and I know it sounds kind of obvious, but we sometimes hesitate when we know the data’s out there. We know it’s best for patients to get them off the meds, from costs, side effects, forgetfulness, all the other compliance issues that Christine alluded to as well. We have the data out there. Although there’s a fear, you got to get out of that box. You got to step away and take a chance because once you start treating these patients and you see them come back, you can have happy glaucoma patients. I could not say that 20 years ago, but I can tell you now, it is one of the best feelings in the world, especially to take someone off a medication. They’ll trust you and they’ll be your patient forever and they’ll love you for that. Don’t be afraid. Try it.
Manjool Shah, MD:
It was so great to hang out and see you guys. Wishing you all the best and looking forward to the next time we get to do this.
Christine Funke, MD:
Awesome.
Inder Paul Singh, MD:
Thank you guys. That was awesome.
Christine Funke, MD:
Thank you.
Inder Paul Singh, MD:
That was great discussion. Thanks, Manjool. Thanks, Christine.
