EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/1381991
126 | EYEWORLD | JULY 2021 G UCOMA About the physicians Larissa Camejo, MD Center for Medical and Surgical Eye Care Jupiter, Florida Robert Noecker, MD Ophthalmic Consultants of Connecticut Fairfield, Connecticut Michael Pokabla, DO Glaucoma Consultants of the Capital Region Slingerlands, New York References 1. Pillunat LE, et al. Micro-invasive glaucoma surgery (MIGS): a review of surgical procedures using stents. Clin Ophthalmol. 2017;11:1583–1600. 2. Silveira Seixas RC, et al. Mid- term evaluation of iStent inject trabecular micro-bypass stent implantation with or without phacoemulsification: A retro- spective study. Clin Ophthalmol. 2020;14:4403–4413. 3. Ivantis announces 3 year results of Australian SPECTRUM registry for Hydrus Microstent. www.ivantisinc.com/newsroom/ ivantis-announces-3-year-re- sults. Accessed Dec. 21, 2020. by Liz Hillman Editorial Co-Director S ome MIGS options are approved (and thus insurance covered) only in conjunction with cataract surgery, while others are not limited in this way. Three ophthalmologists EyeWorld spoke with think there is a value in uncoupling some MIGS procedures from cataract surgery, yet two of the three do not perform off-label standalone MIGS, which we're defining here as those approved without cataract surgery. "We should be able to find what is right for the patient—what is the best safety, efficacy, and cost," said Larissa Camejo, MD. "What does the best balance look like for each particular patient? I can think of some patients where it might make sense to do an angle procedure or MIGS where you might want to do a standalone that is currently approved only with cataract surgery, and they might benefit from that vs. doing something more extensive." What are the barriers? Robert Noecker, MD, said the barriers to stand- alone MIGS are multifaceted. One barrier is history. iStent (Glaukos) was approved in conjunction with cataract surgery, and as the first modern MIGS, as he described it, a lot of surgeons naturally began using it. This combination with cataract surgery contin- ued with the approval of Hydrus (Ivantis) and CyPass (Alcon), prior to the latter being with- drawn from the market. In general, it makes sense to combine with cataract surgery because the procedure as a whole benefits glaucoma, Dr. Noecker said. "Studies have shown that cataract surgery alone is beneficial to glaucoma patients, but the combination of doing it with an angle procedure or a stent is incrementally helpful for IOP con- trol. I think that's part of why these procedures are tied to cataract surgery because it is a good thing to take out the lens in terms of opening the angle more and stabilizing it, preventing future peripheral anterior synechiae formation or intermittent angle closure as the lens grows," he said. Another reason is the payer. "[The payer] sometimes allows a trabec- ular bypass stent as a standalone procedure, A frank discussion about standalone MIGS but more often they force the algorithm," Dr. Noecker said. Performing the stent procedure in combination with cataract surgery is the only possible scenario for its use. Michael Pokabla, DO, said he thinks insur- ance is the biggest barrier. Patients in the MIGS age demographic are often on fixed incomes and unable to afford an out-of-pocket expense like this, he said. What's more, there is always the risk of a complication, and then "you might not have a foot to stand on." Finally, there is the data. The data for mod- ern, angle-based MIGS is for the most part in conjunction with cataract surgery, while other options that are in the MIGS category but not combined with cataract surgery have long-term data without being a combination procedure. "Working against the standard of care and the lack of studies to support it is a very difficult barrier," Dr. Pokabla said. Who would benefit? When talking about situations for standalone MIGS, Dr. Camejo said we're not really talking about mainstream cases. In managing glauco- ma, there are so many minutiae, she said. There are cases where the patient is phakic without a cataract or already pseudophakic and you want to get them off one drop or offer better control, and an angle-based MIGS could continued on page 128 "We should be able to find what is right for the patient—what is the best safety, efficacy, and cost. What does the best balance look like for each particular patient?" —Larissa Camejo, MD