Eyeworld

128 | EYEWORLD | JULY 2021 G UCOMA achieve that, Dr. Camejo said. On the flip side, there are more advanced glaucoma cases where they might already have a tube or a trab but they need more control and they have an angle that could accommodate a Hydrus or iStent. What if it's not just about pressure but about reducing a patient's drops due to ocular surface issues? "Intolerance to what you have to keep them on should be equally important. This is some- thing they have to deal with for the rest of their life. That needs to be prioritized much more than what is being done nowadays," she said. Despite seeing a benefit of a standalone MIGS in cases like these, Dr. Camejo said she isn't using them off-label. She said she is often using the XEN Gel Stent (Allergan) and the Omni Surgical System (Sight Sciences) for these cases. Another type of patient who might benefit from a standalone MIGS is one who lives far from the physician, Dr. Pokabla said. "Where I live, we see patients from 3 hours away, so to have some of these [more invasive] procedures, it's very difficult for them to do the tedious follow-up required," he said. Another example is a one-eyed patient, Dr. Pokabla said, explaining that more invasive pro- cedures can make vision blurry at first, which is a barrier if a patient only has one eye. Will angle procedures ever be approved for standalone use? Dr. Noecker said that XEN leapfrogged to the front of the treatment algorithm for patients who need lower pressures than could be achieved by angle procedures but don't need or already had cataract surgery. XEN is approved for use without concomitant cataract surgery. He does use iStent and Hydrus off-label in some cases and said on a practical level, there is data coming out that he thinks will favor doing these as standalones. Dr. Pokabla said he doesn't think insurance companies will budge in their coverage for standalone MIGS without hard data to support patient safety and efficacy. continued from page 126 "I think they're smart and watching over the patients, and they want the best things for the patients as well," he said. Studies are being published discussing standalone MIGS. A review article several years ago discussed several studies that looked at standalone stent procedures. 1 Last year a retrospective study found iStent inject with and without cataract surgery decreased IOP and drops needed 6 months postop. 2 Last year, Ivantis released data from its SPECTRUM trial that found standalone Hydrus, which is ap- proved outside of the U.S., resulted in a 30% IOP drop and medication reduction. 3 Dr. Pokabla emphasized the importance of physicians tracking and communicating their data for the benefit of their patients. Who will do standalone MIGS? If standalone MIGS were to become approved for mainstream use, who would perform the procedures? Dr. Noecker said a majority of MIGS currently are not being done by glauco- ma specialists. Cataract specialists often get the "first crack" and see milder glaucoma cases where it's appropriate to do these kinds of pro- cedures. On the other hand, in cases in which the first MIGS procedure was not sufficient, glaucoma specialists would be more likely to perform them. Dr. Pokabla thinks the adoption of MIGS procedures by specialty depends on the market. In larger cities, there tends to be more special- ization, while ophthalmologists in mid-size and smaller communities are adopting procedures based on patient need, he said. "These patients don't like to travel; they're going to go with the local doctor. … You don't need to be a glaucoma specialist to do this. This isn't a skill set problem. People know when patients need very low eye pressure, they send them on to a glaucoma specialist. There is no reason why a general ophthalmologist or cornea or comprehensive ophthalmologist shouldn't be doing these procedures. It just takes a little time to learn how to navigate through these," Dr. Pokabla said. Relevant disclosures Camejo: Sight Sciences Noecker: Alcon, Allergan, BVI, Glaukos, Ivantis, New World Medical, Nova Eye Medical, Sight Sciences Pokabla: Allergan, Santen Contact Camejo: larissacamejo@mac.com Noecker: noeckerrj@gmail.com Pokabla: mjpokabla@yahoo.com

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