Eyeworld

EW FEATURE 46 Glaucoma's armamentarium • August 2018 Dr. Lewis said prior to ICD-10, glaucoma surgeons were able to perform surgery on patients with glaucoma independent of what type they had. ICD-10 is more specific in terms of stage and type of glaucoma. "Ever since then, the insurance companies have become very strict about staying on-label in terms of allowing them to do surgery. For a lot of things in the MIGS world, it's for mild to moderate glaucoma but that doesn't always fit what is best and safest for the patient, and that's where it becomes frustrating be- cause the usual advantage of MIGS is safety," he said. "We're locked into doing this in only mild to moderate when the more advanced have just as many safety needs as the mild to moderate, and that becomes a problem because they're denying care. Either we have to come to some agreement with the insurance companies or we're going to have to broadly label by doing more studies." All three doctors said they think the labeling of MIGS procedures that require them to be done in con- junction with cataract surgery needs to change. In some cases, studies that could potentially change or ex- pand this labeling are in the works. There is a clinical trial evaluating the 5-year results of standalone Cy- Pass implantation. Dr. Okeke noted the iStent inject has been in studies as a standalone procedure as well, with results showing safety and IOP-lowering ability. Research to expand labeling can be expensive though, Dr. Lewis noted. Independent of the labeling of these devices and procedures is the challenge of understanding what's the best choice for the patient, Dr. Lewis said. "Forget advanced, mild, mod- erate. Is pseudoexfoliation best suited for a canal-based procedure or is it not? If we as clinicians could sort through this and begin to give advice to our colleagues, that would be a huge benefit. It comes up all the time in meetings, the problem is getting data," he said, explain- ing that he thinks the American Academy of Ophthalmology's IRIS Registry could contribute on that front in terms of looking at how these patients fare with different procedures and what factors led to their success or failure. There are also questions of timing and combination with newer procedures. "How long we keep people on medications is an issue. I think the newer medications [and] what role they're going to be playing with regard to the meshwork is an interesting question," Dr. Lewis said. "Can we benefit from combining the newer medications and MIGS? There are a lot of questions, but we have to make decisions each day we see patients, we can't wait for these studies to come out, so we need to collect more information and begin to get a better handle on the data we've got so far." Dr. Teymoorian also thinks that more needs to happen from an edu- cation standpoint both for patients and physicians. "Patients need to be more educated in that there are surgi- cal options in glaucoma that are relatively safe to do," he said. "On the physician side, as we're becom- ing more and more aware of MIGS, there are some people who are further along, but there are still a lot of doctors out there, it's not first in mind, they don't even look for how this can be used in their cataract pa- tient or standalone patient. So there is still some physician education that needs to be done." The paradigm is shifting from glaucoma treatment being reactive to proactive, Dr. Teymoorian con- tinued. "We used to allow the optic nerve to get worse … then we would react to it and we would hope by giving some kind of medication that would be enough," Dr. Teymoorian said, adding that this is because the only alternatives at that time were more medication or trabeculecto- mies and tube shunts. "Now, we're trying to play to win, we're trying to be proactive, and the reason that we can do that is we have good play- ers in the game and we have other options." EW Editors' note: Dr. Lewis has financial interests with Alcon, Allergan, Glaukos, New World Medical, Sight Sciences, Ivantis (Irvine, California), and Aerie Pharmaceuticals (Durham, North Carolina). Dr. Okeke has financial in- terests with Alcon, Allergan, NeoMedix, Glaukos, and Ellex. Dr. Teymoorian has financial interests with Glaukos, Alcon, and New World Medical. Contact information Lewis: rlewiseyemd@yahoo.com Okeke: iglaucoma@gmail.com Teymoorian: steymoorian@harvardeye.com with no or only little response, and they need more therapy to reduce pressure. Maybe they're on the maximum medical therapy they can tolerate, Dr. Okeke said. "Now you have surgery, where this patient is pseudophakic or pha- kic, but I don't want to take out the cataract because it's not part of the issue because [the lens] is clear and it's not stretching the angle in any- way, so I don't want to do a com- bined procedure. Here I am needing to get their pressure down, and if my options are just the traditional glaucoma surgeries—if this is a mild to moderate glaucoma—I'd like to try to avoid doing a trabeculectomy or avoid doing a tube shunt," Dr. Okeke said, adding that she thinks those with more advanced glaucoma can be candidates for MIGS as well, even while they might only be indi- cated for mild to moderate disease. In terms of a discussion with the patient when the MIGS procedure is considered off-label, Dr. Okeke said she emphasizes the patient's need for further pressure reduction and the efficacy of these procedures that are FDA approved with cataract surgery. She tells patients her expe- rience with these devices without cataract surgery is good and that she thinks it could offer the patient the pressure reduction they need, adding, however, that it would likely be an out-of-pocket expense. "For many people, the expense can be the limiting factor. If they don't have the money, they can't do the procedure, but some of them are willing to pay for the option of hav- ing something that has the potential to work in a less invasive way," she said. Zooming continued from page 44 XEN is indicated for use as a standalone procedure or with concomitant cataract surgery. Source: Joseph Panarelli, MD Standalone MIGS Steven Sarkisian, MD, discusses standalone MIGS procedures. EWrePlay.org

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