Eyeworld

AUG 2018

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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49 EW FEATURE August 2018 • Glaucoma's armamentarium Once there are FDA indications for standalone procedures without phaco, the bundling needs to end, Dr. Sarkisian thinks. He likens bun- dling reimbursement for combining MIGS to Medicare theoretically not covering a topical prostaglandin in a patient who also uses a topical beta blocker or carbonic anhydride inhibitor. "The system would save more money in the long run if we could use stents appropriately and com- bine them when a surgeon thinks it is warranted," he said. "We also should not be limited by severity of disease or lens status." Looking ahead When MIGS came along, it revolu- tionized glaucoma treatment. The refinements that will occur with these surgeries in the near future and their combinations won't be revolutionary, but they will be remarkable. "I don't foresee a revolution, but definitely an evolution over the next 5 years," Dr. Francis said. Dr. Francis thinks the pathways via MIGS to treat glaucoma will remain the same, but physicians will get a better idea of which combi- nations work best with different glaucoma types. There also will be new procedures that will come out, and enhancements will take place with existing procedures. Stents also will continue to improve. In the stent realm, one addi- tion to the market likely will be the iStent Supra (Glaukos), which is a suprachoroidal stent. "I haven't had the opportunity to try it, but I think it's promising," Dr. Radcliffe said. He cited the results of a study published this year, sponsored by Glaukos, which found that in patients with refractory glaucoma followed for 4 years, the use of two iStent trabec- ular stents, the iStent Supra, and a prostaglandin led to a mean IOP below 13.7 mm Hg compared with 22 mm Hg preop. 1 He thinks these results may lead to a useful future surgical approach. The use of sustained release medication also will likely benefit patients using combined stent types in the future, Dr. Sarkisian said. EW Reference 1. Myers JS, et al. Prospective evaluation of two iStent trabecular stents, one iStent once, and you have separate paths for outflow," he said. Dr. Kim has combined two trabecular microbypass stents with a supraciliary stent and has even further combined these with other procedures among nearly half of the 56 patients he has followed. "If I had my druthers, I'd use the CyPass and the iStent in the same eye," Dr. Sarkisian said. "For now, Medicare is bundling them, and the surgeon only gets paid for one." Reimbursement issues In the U.S., the ability to combine MIGS procedures is limited by pri- vate insurance or Medicare reim- bursement. "The first thing to think of is if the patient has a cataract. If the answer is yes, then the options are open," Dr. Francis said. "If the answer is no, then we can't do suprachoroidal procedures." In the latter, surgeons must consider proce- dures like the Trabectome, Kahook Dual Blade (New World Medical (Rancho Cucamonga, California), goniotomy-assisted transluminal trabeculectomy, and ab interno canaloplasty, Dr. Francis said. Some glaucoma specialists may be hesitant to combine procedures because of concerns about cost, but Dr. Radcliffe thinks otherwise. "Treating glaucoma aggressively is always cost effective," he said. He explained that when you combine MIGS procedures, you typically get reimbursed 50% for the sec- ond procedure and 25% for a third procedure, if used. "There's some additional expense, but it's not a triple expense." The use of procedures like goniotomy and ECP do not involve a stent, so that can help lower costs, Dr. Radcliffe said. Recently, Dr. Sarkisian has had trouble getting reimbursement for the use of ECP with another proce- dure. However, he sees the bundling of many MIGS procedures with cataract surgery as a drawback. "Just because the FDA approved these devices with phaco … it doesn't mean it's the right way in all cir- cumstances. It's just because that's the way the studies were done," he said. "Unfortunately, the insurance companies have decided that's when they should be paid for." Figure 2a. CyPass is placed in the supraciliary space. Figure 2b. An iStent-L is placed, followed by an iStent-R facing in the opposite direction. Figure 2c. At completion, two iStents and a CyPass allow for outflow of aqueous into multiple pathways. Source (all): Won Kim, MD Supra suprachoroidal stent, and postoperative prostaglandin in refractory glaucoma: 4-year outcomes. Adv Ther. 2018;35:395–407. Editors' note: Dr. Radcliffe has finan- cial interests with Glaukos, Alcon, Allergan, Ellex, Sight Sciences, New World Medical, and Iridex. Dr. Sarki- sian has financial interests with Alcon, Glaukos, and New World Medical. Drs. Francis and Kim have no financial interests related to their comments. Contact information Francis: bfrancis@doheny.org Kim: wonkim74@hotmail.com Radcliffe: drradcliffe@gmail.com Sarkisian: steve-sarkisian@dmei.org

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