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EW FEATURE 44 Glaucoma's armamentarium • August 2018 AT A GLANCE • There are several surgical glaucoma procedures that could be considered microinvasive that are approved without concomitant cataract surgery, but others must be performed with cataract surgery to be considered on-label. • There's a growing call from glau- coma specialists for standalone MIGS as some patients don't need cataract surgery but could benefit from pressure-lowering procedures. • Discussions with patients regard- ing standalone MIGS involve the risk-benefit profile of MIGS vs. more invasive procedures as well as financial considerations. by Liz Hillman EyeWorld Senior Staff Writer a gold standard trabeculectomy or tube shunt surgery because although they're good at reducing pressure, there's a lot of risk involved." The only standalone MIGS stenting device approved without the concomitant cataract surgery is the XEN Gel Stent (Allergan, Dublin, Ireland), which is for more advanced stages of disease, but oth- ers are in the works. From a safety perspective, Dr. Teymoorian said he's not concerned about performing standalone MIGS off-label, but it often comes down to if the patient is willing to pay. There are procedures that could be considered MIGS, such as gonioto- my and trabeculotomy, which don't have labeling restrictions limiting them to combination with cataract surgery. The catch here, Dr. Teymoo- rian said, is they do come with a little more risk compared to stenting procedures. "Although there's a little more risk in those procedures compared to traditional trabecular bypass, like an iStent, these would be covered as a standalone," he said, explaining that he would use them if the pa- tient didn't want the out-of-pocket expense with an off-label stenting procedure. Richard Lewis, MD, Sacramen- to Eye Consultants, Sacramento, California, performs MIGS proce- dures that don't have labeling re- strictions as standalone procedures, but he's also implanting MIGS devices (iStent and CyPass) off-label when the situation calls for it. "The bottom line is I'm the one who is responsible for the safety of these surgeries," he said. "Patients have read a lot about this and they come in demanding a safer and a better surgery. One of the problems with trabeculectomy is the long- term risk of infection and endoph- thalmitis. Patients don't want that; they're concerned about long-term risks and they may be willing to pay cash or go off-label and we hope that [insurance will] approve it. Sometimes they do, sometimes they don't. The driver has to be what's best and safest for the patient." Sometimes Dr. Lewis initiates the conversation about the poten- tial for an off-label MIGS procedure with patients, while other times, the patients are broaching the topic with him. On-label options that stand alone and making the decision to go off- label in some cases S avak Teymoorian, MD, Harvard Eye Associates, Laguna Hills, California, has a significant number of glaucoma patients who come into his practice in need of further IOP reduction to protect their optic nerve. While they might be good candidates for a microin- vasive glaucoma surgery (MIGS), a sticking point for many of these patients can be that they're already pseudophakic. They don't need con- comitant cataract surgery that some of the MIGS options are approved in conjunction with under the labeling by the U.S. Food and Drug Adminis- tration (FDA). iStent (Glaukos, San Clemente, California), the iStent inject (Glau- kos), and the CyPass Micro-Stent (Alcon, Fort Worth, Texas) are approved for patients with mild to moderate primary open angle glau- coma as a combination procedure with cataract surgery, but the call for these—and other options—in the standalone MIGS market is growing. "There's definitely a market and a need for it," Dr. Teymoorian said. "For instance, we have a lot of patients who are referred. They're al- ready pseudophakic, and they need some kind of advancement in their therapy, but I don't want to resort to Zooming in on standalone MIGS continued on page 46 The iTrack illuminated catheter can be used to perform ABiC or GATT. Source: Ellex Trabectome handpiece unroofing Schlemm's canal in trabecular meshwork removal Source: NeoMedix "The patients are much more informed than they used to be, and they know this is a lifelong disease," he said. "They're not just thinking acutely how to get the pressure down, they're thinking how do you keep them seeing for the rest of their life. That's where it gets so conflicted here." Constance Okeke, MD, Virgin- ia Eye Consultants, Norfolk, Vir- ginia, said she takes a conservative, stepwise approach in her glaucoma management. "Would I go from a standalone medication straight to surgery and bypass laser?" Dr. Okeke asked. "No. … But when the laser treatment hasn't worked or it's not an option, the MIGS procedures can play a role for these patients." As standalone MIGS proce- dures, Dr. Okeke said she currently uses or has used the Trabectome (NeoMedix, Tustin, California), ab interno canaloplasty (ABiC) with the iTrack (Ellex, Adelaide, Austra- lia), the Kahook Dual Blade (New World Medical, Rancho Cucamonga, California), gonioscopy-assisted transluminal trabeculotomy (GATT), and the Visco360 and Trab360 (Sight Sciences, Menlo Park, Califor- nia). She has implanted CyPass as a standalone procedure in pseu- dophakic patients, off-label, with good results, but it's not something she offers at this time. Dr. Okeke said she is slated to add XEN as a standalone procedure in her practice later this year. For Dr. Okeke, patients who might benefit from a standalone MIGS procedure are those who are on drops, have had a laser treatment

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