Eyeworld

continued from page 117 118 | EYEWORLD | DECEMBER 2020 G UCOMA Contact An: anja@health.missouri.edu Brubaker: jbrubaker@saceye.com Herndon: leon.herndon@duke.edu Provencher: LProvencher@cvphealth.com Dr. Brubaker thinks are suited for these stand- alone angle procedures. Given cost constraints and lack of coverage as standalone procedures, he said he has a hard time recommending treat- ment with Hydrus or iStent outside of cataract surgery. Dr. An said if a patient is already pseu- dophakic, there needs to be a good reason to proceed with incisional surgery, especially in the COVID-19 era. Reasons include intolerance or incapacity to use medications. In these cases, she said she would choose XEN over an angle surgery. Dr. Provencher expressed a similar senti- ment regarding the need to consider the situa- tion driving toward incisional surgery. "It takes a strong patient-doctor relation- ship to abandon a 'stable' situation, where drops are controlling the glaucoma, and to proceed with incisional surgery," she said. "You never want to talk a patient into surgery, and unless they come in miserable from ocular surface disease, side effects, cost, etc., it may take a few visits before a surgical discussion is appropriate or welcome. "My approach is to empower patients to initiate the discussion and to feel comfort- able discussing their options," Dr. Provencher continued. "I want them to know I care about their quality of life and that I pay attention to compliance." Dr. An said with injectable and sustained-re- lease medications and wider use of SLT as a first-line therapy, there is a good chance of re- placing typical drop regimens in many patients if these interventional options are offered early. "I truly hope that's the case," Dr. Herndon said of the envisioned future where drops are less relied upon to control IOP. "I would love to be 10 years from now and say the great major- ity of my patients' glaucoma is well controlled without topical medication, be it they had a MIGS procedure or they had an injectable. There are other delivery systems coming out soon." There are several other sustained-release options still in the pipeline, including iDose (Glaukos), a bimatoprost-eluting ring (Al- lergan), the Evolute intracanalicular insert (Mati Therapeutics), the intracameral implant ENV515 (Envisia Therapeutics), and the intra- cameral implant OTX-TIC (Ocular Therapeutix). Durysta and the status of these pipeline product was in "Sustained-release making inroads in glaucoma" in the May 2020 issue of EyeWorld. Standalone MIGS The physicians EyeWorld spoke with said they currently perform MIGS as indicated in FDA la- beling. iStent (Glaukos) and Hydrus Microstent (Ivantis) are approved in combination with cataract surgery, and none of the physicians interviewed use them regularly as a standalone. There are, however, a number of MIGS ap- proved as standalone procedures that can serve a range of glaucoma severity. "What we're trying to do is find the right procedure for the right patient," Dr. Herndon said. "There are some patient characteristics that I look for when I try to decide which of these angle procedures to recommend. It depends on the age of the patient, the type of glaucoma, the pressure goal that I have, the pig- mentation of the angle. There are a lot of things that I'm putting into the equation when I tell the patient what I think will be the best option for them." Dr. Brubaker said there is a sweet spot for standalone ab interno canaloplasty, OMNI Surgi- cal System (Sight Sciences), Kahook Dual Blade (New World Medical), and gonioscopy-assisted transluminal trabeculotomy (GATT). Patients who have mild glaucoma have the options of drops, SLT, and Durysta, while those with more severe disease and high pressures are better suited for tubes and XEN Gel Stent (Allergan), he said. For those in the middle with fair visual fields where medications and SLT have been tried but who you're not quite comfortable mov- ing toward a tube or XEN, these are the patients

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