Eyeworld

7 Supported by Aerie Pharmaceuticals, Alcon Laboratories, Allergan, and Bausch + Lomb 7 Panel discussion Reay Brown, MD: Dr. Ahmed, in an average cataract case, when a patient is using 2 drops for glaucoma but the intraocular pressure (IOP) is not very high, what is your typical microinvasive glaucoma surgery (MIGS) combi- nation? Ike Ahmed, MD: When we combine glaucoma surgery with cataract surgery, safety is para- mount because refractive out- comes and recovery are critical to patient satisfaction and outcomes. I think the canal space is the ideal place for safety and for a modest IOP reduction. Dr. Brown: Dr. Radcliffe, what types of combinations do you use? Nathan Radcliffe, MD: I com- bine endocyclophotocoagulation with a variety of outflow proce- dures, such as the micro-stent (iStent) or a goniotomy. Dr. Brown: Do any of you recommend cataract surgery a bit earlier to take advantage of IOP reduction? Richard Lewis, MD: Cataract surgery is probably our single best glaucoma therapy. It's valuable in angle closure. It tends to be cu- rative and changes the dynamic. Even in open-angle glaucoma, it reduces pressure but it also presents other opportunities, such as a MIGS procedure or other options. Dr. Radcliffe: I do but I also try to avoid the temptation. If it is urgent to remove the cataract because we need to reduce IOP, that does not sound like a MIGS patient to me, so I am very careful about that. If I'm counting on significant pressure reduction, I use a trabeculectomy or tube. Dr. Brown: Regarding medica- tions, if you're adding a second Dr. Ahmed: I teach my residents and fellows that 13 is the new 21. If patients truly have glaucoma, with damage to their optic nerve, I think they need to significantly reduce IOP. The longer we follow our patients, we often wish we were more aggressive because we see visual field progression. Patients who have lower targets tend to be stable for a longer period of time, even if they have moderate disease. Therefore, the problem is how to achieve that safely. That is why I think combinations—medications, MIGS, drug delivery—allow us to get there. Therefore, I tend to be more aggressive than I may have been early in my career. Dr. Lewis: As a point-counter- point, I received a phone call from a patient in whom I per- formed trabeculectomy in both eyes 18 years previously because of very high IOPs. He had been in his 30s. He complained that his eye was "not feeling right." We found that he had endophthal- mitis. Therefore, as aggressively as we want to reduce pressure, we have to balance it against the long-term risk of complications from our procedures. Dr. Ahmed: You're absolutely right. That's why I think we were not eager to get there with our OLD therapies, but I think our new therapies will allow us to get there and stay there. Dr. Brown: As I have practiced longer, I am much less aggressive with trabs and tubes, but we need aggression in innovation because we need to try things and find out what works. MIGS is so excit- ing because it is safe, and new longer-acting medications are also exciting. eye drop, when do you consider a combination eye drop as your second choice as opposed to a single medication? Dr. Lewis: The second med- ication once again raises the question of compliance and whether we will have enough additivity. None of the secondary medications, at least timolol and a prostaglandin, were sufficiently additive to achieve approval by the Food and Drug Administra- tion, but 50% of ophthalmolo- gists use timolol as their second medication. It's inconsistent. Dr. Brown: Yes, we all want to help the patient, but we don't want to cause problems that they did not have before. There is so much in the pipeline. What are you most excited about as we enter the golden age of glaucoma treatment? " As I have practiced longer, I am much less aggressive with trabs and tubes, but we need aggression in innovation because we need to try things and find out what works. MIGS is so exciting because it is safe, and new longer-acting medications are also exciting. " –Reay Brown, MD

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