Eyeworld

12 | EYEWORLD BONUS ISSUE | FEBRUARY 2025 G UCOMA Contact Ristvedt: deborah.ristvedt@ vancethompsonvision.com Singh: ipsingh@amazingeye.com Yadgarov: yadgarovmd@gmail.com Relevant disclosures Ristvedt: AbbVie, BVI, Glaukos, Johnson & Johnson Vision, Osheru, RxSight, Sight Sciences Singh: AbbVie, Alcon, Bausch + Lomb, Glaukos, iStar Medical, New World Medical, Nova Eye Medical, Sight Sciences, ViaLase Yadgarov: Alcon, Glaukos, Iantrek, Sight Sciences them and are more willing to be honest about how they are really doing with their disease as well as management," she said. "The challenge continues to be the lack of guidance when it comes to who is going to progress and who will be stable for the rest of their life. We are looking at all of the risk factors, prior data, and what we know about quality of life to determine this staged approach to glaucoma. When the proce- dure is more risky than the disease itself, it is a no-brainer that we are cautious and wait until later to intervene. I am hopeful that all of our options will allow us to balance IOP stability, safety, less side effects, and improved quality of life from earlier intervention." Dr. Singh sees many opportunities to address patients either before or after cataract surgery, and he said it's important to assess if you should go in before or wait until after cata- ract surgery. He noted, however, that there are surgeon-focused issues to address with stand- alone MIGS, such as the fear of complications or the fear of not delivering on the expectation of either reduction of medications or reduction of IOP. With combined cataract surgery, pa- tients are usually happy with the postop visual improvement from the cataract removal, but with standalone MIGS, our patient satisfaction is tied to the expectation and goal settings we set ahead of time. Dr. Singh noted there is now a plethora of data to back up the efficacy of MIGS. A key definition of success for him is decreasing the topical drop burden, despite the same level of IOP reduction; this can be helpful because if people are off drops, they tend to maintain a higher quality of life and have less negative effects of poor compliance, thus the potential for less visual field progression, less secondary surgeries, and less cost to the whole healthcare system. MIGS with cataract extraction has now become standard of care, Dr. Yadgarov said. "There is enough literature and evidence that supports its use to stabilize glaucoma, and all surgeons who are planning cataract extraction in a patient with glaucoma should be offering a MIGS. The benefit to the patient is tremendous since there is a high chance the patients would not need daily glaucoma medication afterward, providing them an improved quality of life." "There are some nuances to know about coding and definitions that guide our treatment options," she said. "Refractory glaucoma means that patients are on maximal tolerated medical therapy and need IOP reduction, such as with a XEN. iStent infinite is for those with POAG who have failed medication and surgical treatments," she said. "It really comes down to the individu- al. For example, I have had patients in their 50s who are phakic, have failed SLT and medical therapy, and do beautifully with restoring the outflow pathway with OMNI and iStent infinite. I have had pseudophakic patients who are struggling with ocular surface disease, econom- ics of buying drops, compliance issues, looking for less drop dependence. For those who are progressing who need IOP reduction and have had angle-based surgery with cataract surgery, I am looking toward a MIBS like XEN, as long as I do not think they need single digit pressures." When taking a step back and looking at all the options in the standalone space, it allows us to continue to treat this disease in a safe and effective manner, Dr. Ristvedt said. "I love the opportunity to be able to improve the quality of care and quality of life more than ever before. Patients are happy that there are options for continued from page 11 continued on page 14 "Interventional glaucoma affords us the opportunity to be proactive and take great care of patients earlier in the disease process," Dr. Ristvedt said. Source: Deborah Ristvedt, DO

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