Q&A: Personalizing Microinvasive Glaucoma Surgery in a Complex Treatment Landscape

Introduction:

Personalizing Microinvasive Glaucoma Surgery in a Complex Treatment Landscape: Q&A featuring Dr. Brad Sutton, Dr. Nathan Radcliffe, and Dr. Constance Okeke.

Brad Sutton, OD:

So most MIGS procedures focus on increasing outflow via the trabecular meshwork pathway, but there’s been interest in growing other procedures to target the uveoscleral outflow in the suprachoroidal space. Do you think there’s a particular benefit to targeting those particular pathways as opposed to the traditional more TM based angle pathway? How about Constance, you start us off, and then Nate, you can pipe in too.

Constance Okeke, MD:

Yes, I definitely think that there’s some benefit. As I mentioned before, I believe that multiple mechanisms of action can be beneficial and we use them to tailor to our specific patients. Prior to the device, the CyPass that was on the market, it’s now off, having that mechanism of action, it was very beneficial to a lot of my patients who I did use it in. We just have to figure out a way in order to make it safe for the patients. But I know that there is a number of different devices that are in trial phases, so I do believe it’s something that we’re going to be able to have access to in the future. But I do believe that it is a great area for us to be able to target, just like we know our PGAs that have the same pathway are very effective, one of the most common drops that we use in glaucoma. So I do think it’s a pathway that we eventually will have and when we get access to it, I’ll be excited to use it for my patients.

Brad Sutton, OD:

Great.

Nathan Radcliffe, MD:

I would agree because we know that not all trabecular procedures work in terms of getting the patient off drops or lowering the I O P to the target. And on the other side of the glaucoma spectrum, I have a lot of patients who’ve had a few different conjunctival surgeries and where do we go with them? And the supraciliary or suprachoroidal space is just another great target. We know glaucoma kind of fights us and scars things and we need to be agile and nimble and use our other options as well.

Brad Sutton, OD:

Wonderful. So right now we mainly recommend glaucoma surgery for patients that can’t be controlled with topical medication or maybe post SLT. Would you consider recommending these MIGS procedures earlier in the management due to higher success rate, convenience to the patient, less risk, et cetera, than traditional incisional type surgeries? How about you start us Nate on this one?

Nathan Radcliffe, MD:

Sure. I think we have this concept that using drops first is sort of the most benign thing. We are a pharmacologic culture and I think that’s a big problem with our thinking. We’ve seen very strong evidence now with laser that starting with the trabecular meshwork treatment is not just as good as drops, it is unquestionably better and by that I say no one in their right mind would really choose to start glaucoma therapy with eyedrops rather than laser based on the data. And I believe that as we accrue more data on these micro incisional trabecular procedures that they would and should move up.

Keep in mind that S L T laser works better if you’ve never been on therapy than if you’ve been on a drop than if you’ve been on two drops. So it’s not just that it doesn’t matter when you start it. So that may be the case with stents. It may be that some of our stent failures are people who just, we didn’t get to soon enough. We let the disease spread past the trabecular meshwork into the canal collector channels and so on. So be watching for a paradigm shift here. We’re not quite there yet, but I think we’re headed in that direction.

Constance Okeke, MD:

And I agree with Nate In regards to patients who are initially diagnosed with glaucoma, if they’re a candidate with their angles being open, I always strongly recommend SLT first.

Now in terms of MIGS kind of trumping or coming before SLT, there are some scenarios where that does happen for me, say for example, the patient has come in as a cataract referral and I diagnose glaucoma at that moment, I’m going to start them on a drop in interim between now and the time of surgery. But I likely will recommend that they consider a MIGS option at that time, regardless if they’re early stage because it’s an ability at the time of cataract surgery to also have now access to your natural drainage system and help modulate it so that it can function better.

So there are some instances where I might be considering a surgical procedure over doing a SLT first, but typically just because of the more benign nature of SLT and it is a surgery, unless there’s, I usually would start with SLT first over just a straight alone MIGS procedure just to see also when you do SLT, you can get a sense of how their trabecular meshwork outflow system reacts to the SLT if it’s some type of a complete, I’m not getting any type of reaction here or if I’m getting some level of some robust reduction, that might at least be a starting point, and then from there, I might consider doing a MIG soon after, depending on the stage of their glaucoma, where their eye pressure is.

So usually in that setting, like I mentioned of a cataract MIGS evaluation, those are sometimes when I do MIGS first before SLT.

Brad Sutton, OD:

Terrific. Great. I think this other question that came in here, you both just answered that there are certain times where maybe a standalone MIGS procedure or a MIGS procedure with cataract surgery makes sense actually as your initial therapy. Nate, a little follow-up question from me here. You had mentioned that SLT works better when maybe you haven’t been on drops for a while first. Do you find that to be the case with some of the MIGS procedures as well? Do you find that there are certain MIGs procedures that are better suited to be done before a patient has been on drops for an extended period of time?

Nathan Radcliffe, MD:

Yeah, and let’s take the opposite scenario is I noticed most of my MIGS failures in patients who maybe got glaucoma in their fifties or sixties and they’re having cataract surgery 20 years later. They’ve been on three drops now for the past 15 years and I’m coming in and putting a stent in. Those are cases where I feel like it might not work as well. And so that sort of leads me to believe the converse is likely to be true, that the earlier we can bypass the meshwork, that’s where glaucoma starts, the bigger of the impact we can have. And of course it’s all about restoring that outflow.

And if it’s the meshwork that’s holding you up and you open that up now you should be restoring outflow to the canal, the collector channels episcleral system. And so I do think of it as a use it or lose it scenario. I know Connie and I have talked about this is a reason why we like the trabecular outflow drugs, whether it’s a Latanoprostene bunod or netarsudil because we want to exercise that outflow system stenting and laser may be another way of doing it in addition to certain medications.

Brad Sutton, OD:

Great. And then another questions coming in here. Do you have any guidance on how to learn and master new MIGS procedures when you’re no longer in part of your training? Constance, you want to start us on that one?

Constance Okeke, MD:

Yeah, I mean there’s a number of different methods that we use in order to get access to adopting a new MIGS procedure. I mean, there’s working with the company of the device that you’ve chosen to do next, the surgical reps, allowing them to assist you with wet labs and the other videos and things like that. Utilizing access to KOLs who may utilize a lot of that particular device so that they can give some advice, real world advice that might be helpful. Also going to conferences. There’s a number of conferences where you can get wet labs and training that way using YouTube channels videos. I’m a proud sponsor of the eye glaucoma YouTube channel where there’s a lot of educational surgical videos that one can watch in order to gain visual access to procedures in the way that they’re done or challenges and how to overcome them.

So there’s a number of different resources to be able to use and then things that are coming out in the future and that I’m working on strategies to help with courses for adopting new mixed procedures, again through my eye glaucoma YouTube channel. But those are some of the resources that I would mention.

Brad Sutton, OD:

Nate, you have anything to add?

Nathan Radcliffe, MD:

Just that Connie’s videos, MIGS University eye glaucoma on YouTube. They’re great. She really puts a lot of time into getting great surgeons to give inputs and tell interesting stories, show interesting cases. So if you haven’t checked that out, I highly recommend that you do so.

And I think one of the keys to this whole concept is that there was no real MIGS when I was finishing my training and I’ve had to learn it all on the fly. And that the sooner we all make that a regular part of our career, the better we can all do keeping up because it’s just going to keep changing and changing and there’s no viable scenario where you stop learning when your training’s done, so the only alternative is to get online and learn that way and it works.

Brad Sutton, OD:

Perfect. Another good question here, one that I kind of consider a lot clinically when I’m caring for my glaucoma patients. How do you feel the durysta bimatoprost implant may or may not currently fit in our treatment continuum with say SLT, MIGS and drops? Nate, you want to start us?

Nathan Radcliffe, MD:

Sure. It absolutely fits in. It, first of all, it works longer than four months, so keep that in mind. I just saw someone yesterday is on month 18 and I’ll see her in four months. So you want to pick open angles and patients who are having some problem with drop tolerability or compliance. And in those two scenarios, I’d rather have the durysta than a patient who’s just doing their best but not doing good enough with drops. So absolutely has a place and these options will only get better and better over time.

Constance Okeke, MD:

Yeah, I agree with Nate. I will admit that I was someone who was a late adopter for durysta, and one of the things was because I was getting hung up on this concept of it just works for about four months. The first patient that I did the durysta on lasted over a year and a half. And one thing a comment a colleague had gave to me that really helped me kind of grasp the concept of durysta. Durysta is a great implant to use in a lot of different scenarios like Nate was mentioning. But the idea of think of glaucoma like you’re a patient, it’s like they’re in the desert and they’re going through day by day, sometimes struggling at the heat, but they need to keep going on and it’s a chronic disease, so it’s ongoing.

But imagine you’re in the desert and someone wants to offer you a drink of water, some level of relief, even if that period of time is not the whole duration, even if it’s a seemingly somewhat short-lived four months, six months, a year, a year and a half, you’re going to take it. You’re not going to walk past that relief.

And so when I grasp that concept with durysta, if a patient is having difficulty keeping up with all their medications and they need the relief, even if one medication is less, it’s a relief. If their medication is causing them irritation in their eyes that they struggle with on a daily basis and you remove that medication or lessen it and now their eyes feel better, now they have to use artificial tears less often, that’s less activity. That’s quality of life that’s improved. So there’s a lot of different scenarios. Let’s say a person is active life, they had S L T didn’t work all the way to your target, but you still need to have a little bit more pressure lowering. Using durysta after that and now not having to use that one drop a day, even if it’s just one drop a day can make a difference. So durysta, I found, has a lot of benefit for my patients and it’s a very simple procedure to do in the office. And so yes, I think it has a great place and space in our armamentarium and something that should be used.

Brad Sutton, OD:

Great. I’m so glad to hear you both say that because my experience on my patients that I’ve had it put in is exactly matching what you’re talking about. You both mentioned 18 months, and that’s typically what I see. Most everyone that I’ve had it used for gets about 18 months of excellent pressure control out of it, which is far longer than the published data and or the claims from the company will say. And I think if we ever get to the point where the ongoing trials allow for repeat installation, it will definitely have a big role.

Constance, I love the way you said the drink of water. That was an outstanding analogy. I tell my patients, even if you just get a little drop holiday, a little vacation from having to buy your drops and put your drops in every day, and all this ocular surface irritation that you get from taking your drops, if we get you a one year to 18 month vacation from that, there’s benefit in that, even if we can’t ever go back and put that implant in. And I hope at some point we will be able to do that.

But I’m glad you both said that because I’ve been really impressed with the longevity and the safety of it, and even patients who are taking a prostaglandin successfully, I anyway seem to find that when they get the durysta, not only does it take the place of their prostaglandin and do well, actually their pressure is usually lower because there’s constant application of the drop. You don’t have periods of time where you’ve been a while from the drop. So I personally find them to be really effective.