Eyeworld

78 | EYEWORLD | WINTER 2024 G UCOMA Relevant disclosures Robin: None Rosdahl: None Contact Robin: arobin@glaucomaexpert.com Rosdahl: jullia.rosdahl@duke.edu contains a prostaglandin. It can last for months. iDose is a refillable implant; it's small, and it's placed in the area of the eye where fluid leaves slowly over time [and] gives a constant amount of a prostaglandin analog." Dr. Robin noted the expense of both of these products. The question is how to decide if a patient needs surgery. He said this depends a lot on the patient's age. "If they're young and healthy, I want to be more aggressive in the sense of keeping their pressure low because their life expectancy is longer. If someone loses a little bit of visual field every year, if they're 90 years old and have a 5-year life expectancy, they're not going to go blind. But if they're 40 years old and have a 40-year life expectancy, they could go blind or be visually disabled in their lifetime." Depending on the amount of damage and the rate of progression, the surgeon chooses which surgical intervention to go with, he said. There may also be physician preferences at play. Sometimes a surgeon may need to try multiple treatment options for the patient. The main reason to move onto another treatment, Dr. Rosdahl said, is when what is currently be- ing done is not working due to side effects, doc- umented progression (on visual field or optic nerve imaging), or high risk of progression (for example, if the IOP is higher than the target). Another reason to try a different treatment, she said, is if the patient is having cataract surgery; patients with mild to moderate open angle glau- coma might be able to decrease their eye drop burden if they get a MIGS device along with their cataract surgery. Challenges in patient education "I think the most challenging thing for me is to know if a patient is adherent," Dr. Robin said. We have to improve compliance, he said, adding that this is on both the patient and the doctor. He stressed the importance of physicians in- structing patients how to put drops in correctly. Dr. Robin also emphasized the importance of protecting the optic nerve. There's a lot of research currently going on looking at the best ways of protecting the optic nerve. There are companies with all different approaches, he said, adding that he hopes there will be a new development soon to make this easier. Patients are afraid of going blind, Dr. Rosdahl said. "For some people, that is motivat- ing to have surgery, to decrease the long-term risk of vision loss; for other people, that is a huge barrier to having surgery, with the fear of shorter-term risk of postoperative complications and vision loss," she said. "The hardest part of patient education for glaucoma, though, is not having treatment options to bring vision back that has been lost." She recommended a num- ber of resources from the American Glaucoma Society, the National Eye Institute, the American Academy of Ophthalmology, and others that of- fer handouts, podcasts, workshops, educational videos, and more. continued from page 77 Lorraine Provencher, MD, Glaucoma Editorial Board member, shared what evolving treatments and techniques in ophthalmology she is excited about: "We've had the suprachoroidal space on our wish list since the recall of CyPass [Alcon]. I'm excited to once again have the option to harness the power of uve- oscleral outflow, either by endoscleral allograph reinforcement of a cyclodialy- sis cleft (available in the U.S.; Iantrek) or by a novel silicone stent, like the MINIject (not yet FDA approved; iSTAR Medical). EVOLVING

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