Proactive strategies and sustained delivery advance glaucoma care

Proactive strategies in glaucoma care, including minimally invasive glaucoma surgery (MIGS) and physician decision-making, were the focus of a recent Ophthalmology Times Case-Based Roundtable, moderated by Sahar Bedrood, MD, PhD, a glaucoma specialist at Advanced Vision Care in Los Angeles, California.

The participants discussed the treatment algorithms used in their practices and how these treatments have evolved over the past decade. Previously, physicians were reactive, ie, they treated patients medically with 3 sets of glaucoma eye drops and then waited for disease progression. Over time, they applied more proactive treatment approaches aimed at getting ahead of the disease, reducing reliance on glaucoma eye drops, and minimizing visual loss rather than having patients instill numerous eye drops, she noted.

The participants also discussed the varying levels of aggressiveness in their treatment approaches (ie, first-line surgery, laser, or medication drops).

“There was the realization that physicians do not have to wait until all the drops are unsuccessful, and there can be different thresholds for a procedural intervention,” she said.

A case of mild open-angle glaucoma

Bedrood described a 70-year-old woman with high myopia of –9 and –8 diopters (D) with mild open-angle glaucoma and cataracts. The left eye had more severe retinal nerve fiber layer (RNFL) thinning than the right eye. The patient had a history of a disc hemorrhage. The highest IOP was 22 mm Hg, and the goal was 16 mm Hg.

The patient had previously undergone selective laser trabeculoplasty and was on 1 anti-glaucoma eye drop. No significant visual loss occurred, and the status of the visual field was good. The patient expressed a desire to be independent of both spectacles and eye drops.

Bedrood opted to implant a Light Adjustable Lens (LAL; RxSight) with monovision to satisfy the distance and near visual needs. “It’s a perfect lens for high myopes whose measurements do not fit perfectly into our normal algorithms,” she said. “In this patient with early glaucoma or potential for future field loss, the LAL will not reduce the contrast sensitivity or add any diffractive issues.”

She also implanted a travoprost sustained-release implant (iDose; Glaukos) because the glaucoma was well controlled at the pressure target.

Pearls from the case

A pearl for implanting the LAL is to create the opening incision slightly larger than the original, because the injector is slightly bigger. With this 3-piece lens, she overinflates the posterior capsule to create sufficient room for the LAL when it leaves the injector.

She also advised that when implanting the iDose, the angle should be carefully identified. She indents the trabecular meshwork, creates stria, and then releases the implant, taking care to confirm that it is embedded securely in the trabecular meshwork.

The patient underwent the first LAL adjustment at postoperative month 3. The visual acuity (VA) was 20/20 for distance and J1+ for near without glaucoma eye drops.

Considerations of glaucoma treatments

When considering different options, the suggestions included MIGS, canaloplasty, or a bypass stent, and other lens choices, all based on the surgeon’s preference.

Bedrood explained that for patients who cannot tolerate 1 or 2 anti-glaucoma drops, she opts for an iDose implant or a procedural pharmaceutical administered in the OR to replace a glaucoma eye drop.

The topic of patient selection for sustained-release IOP implants was discussed. Since the implant contains a prostaglandin, patients must be able to tolerate this drug.

Another consideration when placing an implant is the absence of a corneal transplant, Fuchs dystrophy, or any condition that would cause corneal edema or issues.

Generally, Bedrood has had good experience with IOP and medication burden following iDose implantation. “The device has replaced at least 1 drop for the patient,” she said.

A case of more advanced glaucoma

This patient was a 59-year-old woman with high IOP and angle closure. The left eye VA was 20/60 and blurry, and the IOP was 33 mm Hg with almost complete angle closure. The right eye was 20/30 with an IOP of 17 mm Hg. Both eyes were cataractous. The RNFL was significantly thinned bilaterally. The left eye had a superior arcuate defect consistent with moderate-to-severe glaucoma.

The right and left eye refractions were –12 and –13 D, respectively, which was unusual in the presence of angle closure. “In this case, the axial length was high, the anterior chamber depth was shallow, and her angle was extremely tight,” Bedrood said. “This differs anatomically from what is predicted for a patient with angle closure.”

Immediate instillation of drops and the resulting response eliminated the need for an emergent laser peripheral iridotomy.

Discussing treatment options led to placing a toric IOL (Tecnis Eyhance; Johnson and Johnson Vision) combined with femtosecond-assisted cataract surgery. Bedrood ultimately performed iTrack canaloplasty (Nova Eye), which dispenses and flushes viscoelastic, along with endocyclophotocoagulation (ECP).

On day 1 postoperatively, the VA was 20/50, and by week 1, the IOP was 15 mm Hg with stable VA. The refraction was a –1 D myopic surprise.

Useful pearls

Bedrood shared some pearls that are useful in this patient scenario. Mannitol decompresses the vitreous in a patient with angle closure and allows the anterior chamber to open, making surgery easier.

She also performs a Koch calculation for patients with myopia exceeding 25 to 25.5 D, aiming to prevent a hyperopic surprise.

She pointed out that with ECP, the surgeon can use the photocoagulation tip to burn and shrink the ciliary body. This shrinkage helps to facilitate the opening of the angle.

“Koch calculation is useful for long axial lengths but not for short anterior chamber depths, as in this patient,” she said. “Rethinking this, I used a Barrett calculation as I normally would for a normal eye, for the fellow eye. She ended up with a little bit of monovision, which she liked.”

Bedrood noted that not all angle closure is equal. “We have to look at the mechanism and age, repeat the gonioscopy, look at the response to the original treatment, and see what we can do,” she said. “Not all angle closure requires cataract surgery, but this patient was a high myope and already had vision loss. We want something definitive that also helps her refractively.”

During cataract surgery, surgeons have several options to open the angle, including goniosynechialysis, canaloplasty, or ECP.

Bedrood also likes more traditional surgical approaches, such as tube shunts and trabeculectomies, but typically does not use them as first-line treatments. She prefers less invasive methods, especially in cases of early disease.

Success in glaucoma management can ultimately be defined by the answers to the following questions: Has the visual loss been stabilized? Has an appropriate target IOP been achieved? Has the patient’s reliance on eye drops been minimized?

“If I can answer them positively, the patient has really benefited,” Bedrood concluded.