Video Roundtable: What’s Next in Glaucoma Management
Manjool Shah, MD:
My name’s Manjool Shah. I’m on faculty at NYU Langone Eye Center in New York, New York, and I’m joined by a couple of excellent colleagues from around the country and good friends, as well. We have coming at us from Atlanta, Georgia, Arkadiy Yadgarov, from Omni Eye Associates, and we have Morgan Micheletti from Houston, Texas, Berkeley Eye Center. Welcome, guys. Good to hang out. Let’s talk about glaucoma.
Arkadiy Yadgarov, MD:
Yeah, thanks for having us.
Morgan Micheletti, MD:
I’m excited. It’s going to be fun.
Manjool Shah, MD:
I know you guys are active in the next generation of glaucoma intervention. What’s your take on glaucoma today? How are we managing glaucoma? What are our unmet needs? Are we doing a good job?
Arkadiy Yadgarov, MD:
Yeah, I’ll just say a few comments here and then I’ll let Morgan talk, as well. But I think we’re doing a good job. I don’t think we’re doing a good enough job. Here we are in 2023, we’ve got lots of medicines that work and yet people still are getting worse. So we haven’t quite figured out glaucoma. And I think the current state of glaucoma is that our patient population is getting older, the prevalence of glaucoma is going to increase, and yet those that already have glaucoma are still getting worse.
So we’re really having more and more glaucoma in different stages that we’re having to treat. And I think one of the biggest unmet needs is what can we do better than the current status quo? And I think we’ll talk about that briefly, but that’s really where I think the unmet need is, is how do we go beyond what we’re doing now, which is medication, that’s the primary form of treatment. And is that better, the future, what we’re trying to get into, better than the current status quo?
Manjool Shah, MD:
Awesome. Yeah, I couldn’t agree more. What do you think, Morgan?
Morgan Micheletti, MD:
Yeah, I’m coming at this from a little different perspective, just as a cataract and refractive surgeon, but I think it’s twofold. I mean, we need to detect these patients early and get them in for treatment. That’s the first part. And how many times are we seeing patients where, I don’t want to say it’s too late, but their RNFL is already so thin, their GCL losses, and they have field cuts, and then we’re looking at intervening. But a lot of times, I almost wish I would’ve gotten the patient six, seven, eight years ago to get that SLT in, to look into adding MIGS to cataract surgery.
Because a lot of times they’ve already had cataract surgery, they’ve been on three, four drops, and now they’ve got a central island. And it’s like, “All right, well, you’re getting a tube or something at this point.” There’s so many things we can do with early intervention that I don’t think we’re doing yet. And I think that that’s really key is to detect and treat early. Because, we all know this, once you lose it gone, it’s gone. It’s gone.
Manjool Shah, MD:
Yeah. I mean, I think that’s really well said. And I think the lift, the barrier to entry to intervening earlier is lower than it was. I mean, I think if all you had was a trab or a tube, then you’re going to kick that can down the road as much as you can.
Morgan Micheletti, MD:
Right. Right, right, right.
Manjool Shah, MD:
But I think the environment has changed. So how do you guys integrate the newest technologies, from a 30,000-foot perspective? And then we’re going to get into the weeds, for sure. But how do you integrate the new technologies in identifying patients, as well as having that conversation about intervention?
Arkadiy Yadgarov, MD:
Sure. I think it comes from good data that guides our practice patterns. I think one of the biggest eye-opening moments at for a lot of us was the LiGHT trial out of the UK. And what was amazing to see was not only did SLT work as a first-line, but that after three years, head-to-head against the prostaglandin, both had similar pressure reduction. Three years later the glaucoma drop cohort did worse, from a secondary surgical intervention standpoint.
And I think that speaks loud, that I think we’re missing the point here, that medications probably are not the solution. That either it’s a compliance issue, maybe it’s a pharmacokinetic, diurnal/nocturnal issue that we’re missing, but that interventional approach may be better. I think that’s the biggest eyeopener. For example, for me, my practice pattern has changed. Everyone first-line now gets offered either a prostaglandin SLT. Typically, I nudge the patient and tell them the SLT may be better for them, long-term.
Morgan Micheletti, MD:
Yeah, I kind of do the same thing. In patients, non-cataract patients, I’m primarily having the same conversation, SLT versus prostaglandin. Now, most of my patients are patients who have a cataract and so we are talking about MIGS. I mean, many of these patients, hopefully they’ve already had SLT. Unfortunately, many of them are coming to me and they’re on two, three drops with questionable compliance and a documented history of progression without any escalation in care. So for me it’s like, “All right, well, which MIGS are we doing?” And that’s, I think, where the conversation has really shifted now to it’s not, should I do MIGS, it’s which MIGS device or option or procedure should I do?
Arkadiy Yadgarov, MD:
I was just going to emphasize what you said, Morgan, because I think what you said, you hit it spot on. There’s too much stacking of medications going on. That’s how it used to be, right?
Manjool Shah, MD:
Right.
Morgan Micheletti, MD:
Right.
Arkadiy Yadgarov, MD:
Let’s add a second drop, let’s add a third drop, let’s add a fourth drop, now we need to do something. Or, more classically, and I know, Manjool, you’ve seen it in academic centers, and then I saw it in a residency fellowship. We wait until the fields progress. So the pressures are borderline. They’re maybe a little high, but we go, “Well, but we don’t want to do a tube or trab unnecessarily because of the risk.” So are the fields progressing? Let’s wait. And I think that mindset needs to stop now that we have MIGS. Exactly what Morgan said, which is it’s not about do we need to do a MIGS? It’s like no, we definitely need to do a MIGS. They’re saved. Now it’s which one, and probably the sooner, the better, before issues arise.
The other thing about stacking meds is the more medications, the more unhappy your patients are. I think doctors that go, “Here’s the second bottle, here’s a third bottle,” what they’re not realizing is now those patients have more dry eye, they have more ocular discomfort and they’re just unhappier. And we need to shift from that, from adding more medicines, to let’s talk about interventional glaucoma and MIGS.
Manjool Shah, MD:
So-
Morgan Micheletti, MD:
And we know-
Manjool Shah, MD:
Go ahead.
Morgan Micheletti, MD:
We know we know the medications work. We know the medications work when they take them. And I think that that’s the biggest problem in all of this is compliance. And when you look at data from doctors and surgeons that’s out there, compliance is the biggest issue. I always have a heart-to-heart with my patients. If it’s looking at adding drop three versus two, it’s like, “Okay, are you taking your medications? You have to tell me because you’re not doing yourself any favors.” And if they say, “No, I’m not, all right, we’re not doing drops. We’re looking into something interventional because adding more drops isn’t going to do anything if you’re not going to take them.
Arkadiy Yadgarov, MD:
Yeah, I was going to build on that because one of the big papers that kind of blew my mind, I think it was Newman Casey, I want to say, in 2020. It was a sub-analysis of the CIGTS study. And what blew my mind is that here is a big prospective study where patients were educated and medications were called in, there’s journals, there’s diaries, all of this. And when they looked at the sub-analysis of the medication group, if you had 100% adherence, fields were fully stable. But there was a good number of patients that had less than 80% adherence rate and a lot of them progressed.
And, to me, what that tells me is glaucoma is no longer a pressure problem, it’s a compliance problem. Just like you said, medications work. And so if you take your medications, you’ll stabilize. And yet plenty of patients progress. So we’re not really dealing with medications not working, we’re dealing with medications aren’t the solution. Patients don’t want to take them on a daily basis. That was the biggest eye-opener for me.
Manjool Shah, MD:
Such a good point. And I think what I’m hearing is our definitions of success or failure, controlled or uncontrolled, have evolved beyond millimeters of mercury. I mean, when I talk to patients, I bring up this concept of quantity of pressure reduction versus quality of pressure reduction. And I think we’re all on the same place here where, yeah, you can quantitatively get a pressure down with a drop, but how qualitatively good is that going to be?
Are we going to have sustained pressure control over 24 hours a day, seven days a week, 365 days a year? And so when you’re talking to your patients, how do you coach them as you set them up for surgery? You’re going to do this thing. How do you talk to them about what success looks like for you and for them?
Arkadiy Yadgarov, MD:
Morgan, you want to take this one?
Morgan Micheletti, MD:
Yeah, sure. When I’m talking to a patient about an intervention, primarily what we’re saying is, in comparison to drops, a lot of these patients are on drops and they’re used to taking their drops. Hopefully they’re used to taking their drops, but many times they’re not. And so I can say, “Look, you are progressing. We need to do something. You can continue taking a drop intermittently and have incomplete pressure control. Or even if you do take it completely, you’re treating and you’re not stabilizing.”
Like you said, Manjool, I mean, really, what we want to see is this 24/7 effect. And with interventions we can actually get that, with SLT, with MIGS, we’re going to get 24/7 around-the-clock consistent pressure reduction. Sure, there’re going to be some spikes and stuff here and there that we may need to manage, but for the most part we’re getting this, separate from what the patient’s doing in their day-to-day life and not having to add different medications to the ocular surface that they’re complaining about, the burning, the stinging, all these other things. And I think that, from a lifestyle standpoint, like you said, the quality of the pressure reduction, it doesn’t just go to just that 24/7 control, but quality of life.
Manjool Shah, MD:
Yeah.
Arkadiy Yadgarov, MD:
Yeah, I think quality of life actually is number one here in terms of MIGS, and I’ll explain. Patients want to be comfortable, and some of my happiest patients are those that I’ve been able to get off glaucoma medicines during cataract MIGS. And that includes standalone MIGS now. When they’re off their medicine, I mean, they’re just like, “Wow, my eyes feel better.” And that finally feels good. As glaucoma docs especially, we’re not used to that. We’re used to unhappy patients. “My eyes don’t feel good. I forget my medications. I forgot my refill.”
And so to finally go, “I got this. As a surgeon, I’ll take care of you. Let me treat the glaucoma. Let’s do this procedure.” We’ve never really been able to do that safely, though. Blebs come with risk, tubes come with major risk. We’ve really never had this kind of limelight feeling of, “Hey, I got this,” until standalone MIGS came onto the market. And now we can finally have a device or a tool that I’m comfortable using for patients.
And so, Manjool, the way I talk to my patients is, “I now have a safe, effective, efficient procedure where we’re in and out in a convenient timeframe and that the patients are back to normal within a day.” And I’d love to hear your experience with, for example, the iStent Infinite, but the next day I barely see cell. We’re not stripping meshwork, we’re not manipulating much. And that’s the quality of life that I’m talking about is you’re taking the patient off their medication, but they’re also back on their feet the same day, if not the next day.
Manjool Shah, MD:
Yeah. I think standalone MIGS have really come into their own here in the last few months with products like iStent Infinite. We’ve had some tools already in the toolkit. Canaloplasty, incisional goniotomy of what sort. Morgan, how have the sub-branch of MIGS, that standalone MIGS, affected your patient profile? And I mean, take me through a prototypical patient on the last time you were in the OR, that conversation from diagnosis, monitoring them, pulling the trigger on surgery and how they’ve done. Take me through that patient journey.
Morgan Micheletti, MD:
Yeah. If I see a patient, let’s say, that is pseudophakic, they’re progressing on their glaucoma, they’ve had SLT perhaps before, so some sort of surgical intervention. I’ll talk to them, “Hey, look, I can send you off to the straight-up glaucoma guys who are incredible and they can do a tube and all these other things, but before we get there, there are some other options and they’re really good options. In particular, the iStent Infinite, because we can go in and put three stents.”
And I tell them, “Look, we normally put two stents in during cataract surgery. This is approved for three. And we had a great pressure reduction there. The study for the iStent Infinite was remarkable. And it’s a standalone procedure that is very similar to cataract surgery in terms of the patient experience.” And most patients have had a really good experience with cataract surgery and so they say, “Oh, okay. I remember that day. It wasn’t too bad at all.”
And I let them know that it’s not going to change their vision. This is a protection, it’s a protective program. So we’re going into the OR to do a straightforward procedure that is going to be painless and hopefully help not only lower the pressure, reduce the number of drops they’re taking, hopefully improving their quality of life and reducing visual field loss and progression of their glaucoma. And most of the time patients are just really excited about that. They’re like, “When can we do it?”
And talking about outcomes, it was kind of funny. One of my optometrists actually just literally texted me this morning, and I don’t know if you can see that, but it’s a three-week post-op of an iStent Infinite. Vision’s 20/25, which is the pre-op vision, off all meds, pressure’s 13.
Manjool Shah, MD:
It’s amazing.
Morgan Micheletti, MD:
It’s amazing. It’s awesome. Yeah. It’s like that’s amazing. Awesome. And the patient is thrilled, so that’s the kind of stuff. And that’s anecdotal. That’s one patient. But I can tell you, in my experience, every single patient that I’ve used iStent Infinite on so far, for [inaudible 00:15:42] case, I’ve gotten them off all of their medications and their pressure has come down tremendously, which tells me they probably weren’t taking their medications, potentially, which is one of the reasons we did it, was compliance, and now we’re actually getting that effect.
So I’m really excited about this technology, especially in bridging the gap between, “Okay, now you’re on three, four meds and now we’ve got to send you for a large incisional surgery.” And I think that’s so great about this, especially for the anterior segment surgeon, the cataract and refractive surgeon, is this can help bridge the gap and also get more hands involved as we intervene early, because you guys are amazing, but there are so many glaucoma patients out there, you guys need some help, too, so I think those-
Manjool Shah, MD:
I think that’s such a good point. I think the MIGS revolution has kind of democratized glaucoma surgery and that’s a good thing, and there’s still plenty for everyone. So any glaucoma surgeon who says, “Oh, I don’t want to share the love” is living in a bubble because we all need the help. Arkadiy, you, again, having done a glaucoma fellowship and seeing the whole spectrum, where do all of these, in the standalone space, of all the tools we have, where do things fit for you?
Arkadiy Yadgarov, MD:
Well, I’ll tell you what I really like about standalone iStent Infinite is just some of the data we got out of the pivotal trial. I mean, those are our patients, those are the glaucoma specialist patients, those are the failed previous glaucoma procedures. And to see how well it worked in that cohort has given me a lot of confidence. For example, some of my patients are a little bit more refractory in nature, so they’re on multiple medications. They might’ve had SLTs, they might’ve had a micropulse, they might’ve even had a tube shunt, or a failed trab from 10 years ago, trabeculectomy.
And now all of those patients technically, based on that pivotal trial, as long as they’ve got an open drain, are iStent Infinite candidates. I think that has guided me now, is giving that an option to these patients. I’ll tell you, from a glaucoma standpoint, and I had Grover’s GATT study guide me that way, I do look at mean deviation. If I see mean deviation that’s way in the big minus, I’ll still move on to transscleral. But if the mean deviation is maybe better than 18 decibels or something like that, why wouldn’t you try this first?
This is minimally invasive. If it works, you just saved this person from another major surgery. So this is something now that I offer all my refractory glaucoma patients. “Here’s this option.” And I’ll tell you another cool thing. Morgan mentioned about how, with these pseudophakic patients, it’s kind of an easy sell because they’ve already had cataract surgery and they remember what it was like. iStent Infinite is actually a great tool in the phakic patients. Phakic patients are very scared of surgery.
Imagine me trying to convince them to do a trabeculectomy and they never had eye surgery in the first place. Now, how much simpler it is to convince them to do an iStent Infinite. So I think the iStent Infinite has made my life easier because it’s allowed me now to finally bring in that interventional sooner, to patients that are weary. And if it works in that cohort or that subset of patients, we’re all thankful. But if it doesn’t, the patient’s already kind of been primed, to some degree.
So I think the iStent Infinite is very versatile in that manner, the phakic, pseudophakic, as well as refractory or, like you said, Morgan, earlier stage. And I do think, personally, that that’s really the window of opportunity. As much as we see the refractory and more the moderate to advance, you have to get them sooner. I do believe that. I think, again, based on that data out of Grover that showed that angle-based surgeries don’t seem to work well, the more advanced, that mean deviation. That tells me we really have a window of opportunity in that earlier cohort, that earlier group. We have to get them then because there’s a possibility that we may be modulating their outcomes.
Manjool Shah, MD:
Such a good point. And again, I know I’m talking to two cutting-edge dudes. I think there’s two barriers that I see getting in our way. One is on the patient side, one is on our peers’ side. I think on the patient side, I think you made a really great point, Arkadiy, that making that fear factor of surgery, surgery’s kind of a scary word, but you take them through a really efficient procedure, a very safe procedure, like iStent Infinite, and they come out the other side and say, “Oh, that wasn’t so bad. That wasn’t so bad.”
And so I think that, introducing SLT, introducing sustained release, there’s a number of ways we can get patients into the interventional paradigm without disrupting their lives. And so we’re always able to be ahead of the game. You guys spend a lot of time talking to peers around the country, around the world. That’s the barrier that I still also have a hard time with, with my colleagues and peers. What’s the one takeaway you would give, I’ll go with you Morgan, first, in terms of that plug for interventional glaucoma for taking control in your own hands, that you would give to a doc who’s a little nervous about getting into this mindset?
Morgan Micheletti, MD:
Yeah, I think it’s actually pretty straightforward. I mean, if it were me, it’s what I would want. And that’s exactly what I tell them. Like, “Look, if you don’t do it, it’s a missed opportunity.” I mean, it really is. Like both of you guys have touched on, there’s the window and when you’re talking about interventional glaucoma, the earlier that we intercede, the better the patient is going to do. And we’ve seen that. We have plenty of evidence to back that up.
And it’s during this opportunity that we can actually intervene to do it. And to say that, “Hey, if it were me, first, I’d probably do SLT. And if I’m down the road, yeah, I’m going to go with some sort of angle-based surgery to help treat my glaucoma before I’m going to start looking at other things.” And honestly, personally, before I started looking into certain drops, just because I’ve seen so much of the quality of life issues that come with drops.
Arkadiy Yadgarov, MD:
Yeah. I think the answer, in my mind, to that question, Manjool, is you have to get the patient involved. A lot of doctors, they just unilaterally make decisions for patients. “Well, I think we’re okay here. Keep doing the medications.” But educate the patient. “You can continue your medications. You’re barely tolerating your medications or you’re forgetful. You could get worse. Or we could do this procedure, this iStent Infinite procedure.” Describe it and let the patient decide.
And I think you will be surprised, or these surgeons who haven’t really jumped on board yet, will be surprised just how interested patients will be. I feel like one of the biggest resistance to new surgeries is doctors go, “Well, I don’t know who the right patient is.” They ask that question a lot. I think just educating the patient. “Here are your options.” And let the patient discuss it with you. That would be an easier way for surgeons to go, “Okay. Well, let’s do the iStent Infinite.” Versus, “Hey, I’m going to find the right patient and tell them ‘You need an Infinite.'”
Morgan Micheletti, MD:
Yeah, and I think we owe it to our patients to educate them, exactly like you said. I mean, when we talk to a patient on any procedure, any intervention, any drop, we’re supposed to go over risk, benefits and alternatives. And so to actually review all the alternatives. And again, if you’re talking to a patient about MIGS or standalone MIGS, you’ve got to talk about the alternatives, which means drops, SLT, everything else. Most of the time you’ve probably already had that discussion, because now you’re talking about the next step. But again, I think we owe it to our patients to educate them. And I think you hit the nail on the head, Arkadiy, is let them decide. Educate the patients and let them play a role in their decision making.
Manjool Shah, MD:
I think that’s great.
Arkadiy Yadgarov, MD:
I’ll build on-
Manjool Shah, MD:
Yeah, go for it. Yeah.
Arkadiy Yadgarov, MD:
With SLT, I’ll build on that, Morgan, because sometimes you get patients that are just like, “No, I’m good. I’m good. I’m good.” And so then, as a practice, to some degree, or like an experiment, I just say, “You know what? I’m going to spend an extra five minutes.” I’m like, “What’s the holdup? Why no?” So I’m like, “Why?” I literally ask the patient, “Why?” And they’ll go, “Well, it’s interventional.” And then I go, “Okay.” And then we go down how the process is, how there’s really minimal downsides.
And most times than not, if I just spend an extra five minutes educating, converted. Patient goes, “Oh, really? Why wouldn’t I do that right? Then I can stop my medication.” So patient education is key here. And side effect profile. You make a good point. We don’t always talk about medication side effects. A lot of patients think that their [inaudible 00:25:17] is benign.
Manjool Shah, MD:
That’s free. Yeah, the drops are a freebie. Everything else carries risks, but the medications don’t somehow, right?
Morgan Micheletti, MD:
Exactly.
Manjool Shah, MD:
I think a lot of that makes a ton of sense. I like setting the stage from the first consult. I tell them there’s four ways to treat glaucoma, drops, lasers, surgery, and sustained release. That’s what we have. And we have more and more data that points to one versus the other. Of course, tailoring that directionality to their minus 20 mean deviation with a pressure of 50. We’re not talking about SLT today, but you have a little bit of an agenda-setting moment where you’re taking the time with the patient. But, Arkadiy, such a good point, man. Just a couple extra minutes and folks are able to get past inertia and start to actually open their minds to what actually might be best.
And this is probably something that we all do as humans. You’ve been doing it this way forever, so why wouldn’t you just keep doing it, even when a better solution is offered to you? But taking five minutes to mindfully think about why I’m doing what I’ve been doing and what my real goals are. My goal is to preserve vision. My goal is to have an active life. My goal is to not be encumbered by the therapy for the disease that I don’t even feel I have. All of a sudden these are in line with some of the interventional tenants that you guys have raised as opposed to the drug-based first kind of modality.
Arkadiy Yadgarov, MD:
Well said.
Morgan Micheletti, MD:
And the other question that patients ask is how much is this going to cost?
Manjool Shah, MD:
Oh, good point. Good point. Yeah, yeah.
Morgan Micheletti, MD:
And a lot of times, I mean, it’s covered by insurance. Most of our MIGS are covered by insurance. SLT, a lot of these things are covered by insurance. And so when you look at, not only the quality of life, but also probably the overall cost over the care of the glaucoma patient’s lifetime, from an insurance-covered procedure, to drops every month, plus the time it takes to either order them, reorder them, call, go pick them up at the pharmacy or whatever else it may be, if you add up that time compared to a laser or one visit to the OR, and the overall risk is, as we’ve talked about with drops and stuff. I mean, it’s something that would be really interesting to look at. I’m sure someone’s probably already looked at that already, but it’s-
Manjool Shah, MD:
Well, the jury’s still out on a lot of our procedures, but one of the outcome measures in the LiGHT trial that you brought up, Arkadiy, was exactly that, cost-effectiveness. And there was a sense, at least in the UK, that it was cost-effective. So I think you’re absolutely right, Morgan. There’s many ways to look at the potential benefits of this interventional mindset. Yeah. Awesome. Guys, Arkadiy, Morgan, it’s been a pleasure. Thank you all so much for hanging out and we’ll look forward to chatting again next time.
Arkadiy Yadgarov, MD:
Sounds good.
Morgan Micheletti, MD:
Awesome. Thank you so much. Always a pleasure, guys.
Arkadiy Yadgarov, MD:
Thank you.
