The Window of Opportunity: Can We Intervene Earlier in Patients With Glaucoma?

Drs. Nathan Radcliffe and Ticiana De Francesco discuss the optimal time for standalone MIGS procedure for patients with glaucoma.

Nathan Radcliffe, MD:

Hello, and welcome to The Window of Opportunity Podcast. My name is Nate Radcliffe. I am a glaucoma specialist and cataract surgeon from New York City, and I’m thrilled to have with me here today Ticiana De Francesco. Introduce yourself for the listeners, Ticiana.

Ticiana De Francesco, MD:

Hello everyone. It’s a pleasure to be here. I’m a glaucoma specialist and anterior segment specialist here in Brazil, and I’m also an adjunct at University of Utah in Salt Lake City. I’m super happy to be here talking about a great topic that is glaucoma.

Nathan Radcliffe, MD:

Thank you for joining me. It’s a nice moment here to discuss a lot of changes that are happening in glaucoma. As we know, the key to addressing glaucoma is lowering the patient’s IOP, and how we approach that, it’s dependent upon what treatment option is best suited for the patient. We’re tailoring our therapies these days. The question is, with all these new classes of surgical procedures, notably the standalone MIGS devices, are we possibly missing an opportunity to intervene earlier with a procedure that is found to be faster, safer, and more effective? We’ll be discussing that in general, but perhaps we could just start with some of the background MIGS topics. How have standalone MIGS procedures addressed the unmet needs in glaucoma therapy for you and in your practice?

Ticiana De Francesco, MD:

It’s an interesting question, because even though we have so many studies already showing the efficacy and the safety of the standalone MIGS, but in reality, and actually the data shows, that standalone MIGS still represents only a small percentage of MIGS that is performed all over the world. Even though we know the benefit and the safety of the procedure, we still have a long way to go.

But in my practice, there’s a group of patients that I believe is a great fit for standalone MIGS. Those patients, I would say, is the patient that either needs an IOP reduction or even a medication reduction, and that those patients, they still don’t need a filtering procedure yet. I always like to say yet. For those, I believe the standalone MIGS came to fill a gap in the glaucoma treatment for those patients. They still don’t need the filtering procedure, but they can already benefit [from] having a glaucoma surgical procedure. When I mean about reducing IOP and reducing medications, we know when we lower medications, we improve patients’ compliance, and thus we improve the disease control and the patient’s quality of life as well.

Nathan Radcliffe, MD:

I love the way you put that in that little line, yet is so important, right? Because if we’ve waited until they need an incisional glaucoma surgery, and then we say those are risky, and then we try to do standalone MIGS, we didn’t get the timing right. The question we should ask ourselves is, could I see this person somewhere down the road needing a filtration procedure? Do I want to change that now? Do I want to decrease their future chances now? Some of the studies, including the LiGHT study, at 6 years, newly-diagnosed ocular hypertensives and early glaucoma patients in the drops group, 9% of them were going on to trabeculectomy in just 6 years. These rates of needing serious surgery aren’t as low as we might think. More people need these interventions.

Ticiana De Francesco, MD:

Even though, in my study, we’re dealing with patients with mild disease, we’re very surprised of this data for sure. I agree.

Nathan Radcliffe, MD:

Yeah. I tend to be of the position that most glaucoma progresses and that it’s not a benign disease overall. These patients where we kind of see time and time again, they’re borderline, they’re on the edge, they’re not tolerating their drops, they have compliance problems, but you also hit on something, is we don’t act as often as we should, and that’s the other gap. It’s the gap between what we probably feel is right for the patients, what we see in the data that we have in the literature, and then our own actions. I’ve spent some time calling myself out for maybe not acting in my office the way I would like to act in my mind. How do you motivate yourself to take action on these patients, rather than just move to the next room and let that borderline IOP go another few months?

Ticiana De Francesco, MD:

Yeah, I think it’s a very interesting question. Actually, when we have to offer a surgical procedure, a laser procedure, it requires more chair time with the patient. We need to spend more time with the patient, at least at that moment, so I think it’s a challenge. I think the biggest challenge here is changing the glaucoma specialist’s mindset, because I hear sometimes doctors say, “Oh, my patient doesn’t want it,” but then, did you offer your patient? Did you take the time and offer your patient and explain the risk and the benefits? I’ve been changing the way I approach my patients. I explain the surgical procedures to my patient, and I take time to explain to them. I’ve been very actually surprised how, for example, even SLT, how my patients, I have a really high percentage of patients now going for SLT as a first-line treatment for glaucoma. I think it all depends the way we approach patients.

Nathan Radcliffe, MD:

Yeah, I agree with that. Sometimes just sharing what you think may be obvious, their pressure is 20, they’re on 3 drops, and we all like to give our patients good news, be uplifting, give them hope, but sometimes just saying, “Hey, I do think you’re going to get worse if we leave you like this,” and just almost like a stream of consciousness. Then when you approach it with them, they’re more amenable to doing something. Maybe we held too much close to the vest and then the patient doesn’t understand why we think we should do something. What we’re talking about, also, is interventional glaucoma, the new proactive, patient-focused approach, early predictive diagnostics whenever we have them, active and advanced monitoring, early and more aggressive intervention. Obviously, standalone MIGS fits well into this paradigm. How do you see things along the spectrum now? We start with laser, we have drug delivery, we have standalone MIGS. Where does it all fit? Is it the same for every patient?

Ticiana De Francesco, MD:

Yeah, I think this has been changing a lot in these last years. Right now in my practice, as I mentioned, if my patient is diagnosed with open-angle glaucoma and is not going for cataract surgery, this patient probably is going to go for SLT as the first option of treatment. Then if this doesn’t work, then I think we need to start thinking about either adding a medication or thinking about standalone MIGS.

Here’s a situation that I think is very interesting when it comes to interventional glaucoma and standalone MIGS. For example, sometimes we have a patient that is not controlled, the pressure is high, the patient is on 3 medications, that I suppose is a patient with a mild glaucoma, and then it’s very often we see a doctor prescribing a fourth medication. Even I do that sometimes, but we know that the data shows that the third or the fourth medication doesn’t change much in the pressure, but even though we know that, we still prescribe. We’re kind of postponing the surgical treatment that the patient needs, and we’re delaying to give the patient the best treatment. This is the kind of situation that I think that we need to use standalone MIGS to apply the interventional glaucoma concept.

Nathan Radcliffe, MD:

Yeah, I agree. Yeah, we do all sorts of things, and we do all sorts of off-label things, which is sort of a buzzword here, but sometimes question ourselves in other areas. You made just a comment about SLT. I really think you’re probably not going to be doing much interventional glaucoma if you don’t start with SLT, at least whenever you can, whenever your patient’s agreeable to it. I don’t think there’s going to be a new doctor law that says everyone has to do SLT or they go to jail, but I do think we’re in an era where it’s wise to offer this, and even recommend it with a vote of confidence, to the patient first, because that gets all of us in that interventional mindset.

Ticiana De Francesco, MD:

One thing I tell my patients is, “Glaucoma, it’s only young once,” so it’s only young once. If you wait and do your SLT 5 years later, probably you’re not going to have the best result. [The] same applies, probably, for standalone MIGS. It’s important to let a patient knows about the probability of having success with those procedures depending on the time of the glaucoma journey that they’re going to do these procedures.

Nathan Radcliffe, MD:

It’s such a great phrase that you used about glaucoma only being young once, and it is part of this window of opportunity. SLT works its best when it is used as a very first therapy. Even if you start a patient on meds and then go for SLT, you’re just slightly cheating SLT out of its best opportunity. Also, the funny thing is, there’s never been a study where medications did better than a stent, than a laser, than any other IOP-lowering therapy. We talk about how meds are the first-line therapy. They’ve never earned that through any type of progression, data review, outcomes-type study. It’s funny because people feel like if I recommend an intervention here, am I doing something that hasn’t been proven? It’s like meds haven’t been proven either. We do have good data for some of these things. We’ll talk about iStent infinite® in a little bit.

We have all these different approaches, we’re intervening earlier, we’re questioning the role of medications, viewing them a little bit more as this kind of bridge therapy, ideally between interventions that are going to be long lasting. We know all the compliance data. This isn’t a 6-hour podcast, so we can’t review all the problems meds, but what do you see happening when we intervene early? Let’s say we have a patient who gets their SLT, they try a few meds, they have some side effects, they have some compliance problems, and then get moved to a standalone MIGS procedure. What do we know about those patients, how they’ll do? What’s your feeling there?

Ticiana De Francesco, MD:

I think when you’re thinking about the benefits of the standalone MIGS, the first thing that came to my mind, of course, is safety, second thing, IOP control, and third thing is a medication reduction. When we talk about medication reduction, then we’re going to talk about disease control and the patient’s compliance and everything. As you mentioned, unfortunately, we know that patients’ compliance is still very poor in a disease that is chronic as glaucoma. When we’re reducing the medications, actually, we have many studies showing that, even the LiGHT study, other studies comparing phaco versus phaco-stent, showing that when we control the disease with laser or with procedure, those patients usually they progress less than patients that are being controlled with medications. When we’re performing the standalone MIGS and when we’re reducing the number of medications, we’re also providing a better disease control. It’s not just IOP, but also compliance in the disease and overall, and lowering the risk of progression, improving patients’ quality of life.

Nathan Radcliffe, MD:

Yeah, I agree. It really does kind of open up this analogy of medications being palliative, and these therapies that address the meshwork, the outflow system, being more disease modifying, restoring the normal physiology, and just kind of restoring the eye to its state.

Let’s talk a little bit about iStent infinite®, which does have approval as a standalone MIGS procedure. Just a few things that kind of come to my mind, you can treat a lot of different types of patients with infinite®, including patients who have failed medical or surgical intervention, who have failed laser intervention, so you can kind of work backwards if you have someone who maybe had a tube or a trab. They’re candidates and were studied in the data that was submitted to the FDA for their approval. There are 3 stents, so you have a lot of the area of the meshwork and canal that you can address, and you can get multiple pathways of outflow.

When you look at the iStent®, of course, overall, hundreds of studies that show generally exceptional results, sustained efficacy, good long-term results, and again, as you mentioned, incredible safety, and definitely something that is going to address not just non-compliance, which is rampant, but also the fact that most patients don’t tolerate their medications; half of our glaucoma patients get dry eye, all those things. Then to me, there’s always that nocturnal component, where we know that these procedures that lower the IOP tend to have better 24-hour control than a drop, which has its peak 2 hours after administration and wears off throughout the day.

Ticiana De Francesco, MD:

Yeah. I think another important point is that it does not manipulate conjunctiva. We know when we are dealing with glaucoma patients, there’s always a possibility of needing a secondary glaucoma surgery in the future. It leaves the conjunctiva intact, does not interfere with possible future glaucoma surgeries. I think this also makes us comfortable intervening early with those kind of procedures.

Nathan Radcliffe, MD:

Yeah. It’s interesting. I always like saying glaucoma sometimes likes to stay a few steps ahead, so and sometimes even in my note I’ll say, if this doesn’t work, we’ll do this, and if that doesn’t work, we’ll do this. Just thinking about this, it’s almost like if one of your future steps is this patient might need surgery someday, you know?

Don’t let yourself put 2 steps of adding more drops in. You’re sort of trying to change the algorithm. I’ve realized now that the traditional meds, then laser, then surgery algorithm is just falling apart from a million different directions. Look at the role laser’s going to take. It’ll probably surpass meds as primary therapy. We have drug delivery, which we aren’t going to get to talk about today, but that’s changing the paradigm. Then standalone MIGS, again, gives us opportunity to bring surgery way earlier in the pathway. What are your thoughts, overall, about what’s happening to the paradigm?

Ticiana De Francesco, MD:

I actually compare when I was in residency, that was not too long ago, maybe 7 years ago, and it was a completely different kind of treating glaucoma. Now I see my residents even changing their mindset. They’re [like], “Why don’t you offer SLT? Why don’t we do a standalone MIGS?” I see this on my residents. Actually, it’s been very rewarding. We’ve seen actually now in meetings talking about interventional glaucoma. I think 3 years ago we didn’t even hear about that. I think I’m having a very positive feeling about this whole changing in the mindset of treating glaucoma, and I’m happy that I’m here watching all this to happen and being part of this.

Nathan Radcliffe, MD:

What advice do you give to maybe a surgeon who’s younger and hasn’t adopted standalone MIGS yet into their practice?

Ticiana De Francesco, MD:

I would say focus on patient selection, because if we’re starting in the standalone MIGS procedures with cases who are with advanced glaucoma, you probably won’t have the better results, and you probably won’t feel so comfortable repeating those procedures again. I would say choose the patients that probably will have the best results, that those are the patients with mild to moderate disease. Those are the patients that we know that the distal outflow is still not that impacted by the disease. I think it’s all about patient selection to have better outcomes.

Nathan Radcliffe, MD:

Yeah, I couldn’t have said it better myself. I think that you just encapsulated the window of opportunity. It’s earlier than we think. Glaucoma sneaks up on all of us, and the sooner we address it with a meaningful and safe intervention, the better off our patients will be, and the doctors will be too, and then will be happy that they took such good care of their patients. Ticiana, thank you so much for joining me today. I really enjoyed speaking with you, and I look forward to chatting more in the future.

Ticiana De Francesco, MD:

Thank you so much. It was a pleasure to be part of this.