Eyeworld

I nnovation in glaucoma continues in all of the fundamental areas—diagnostic testing, medical therapy, and surgery. This month's cover focus updates us in all three areas. Medical therapy historically has been the mainstay for glaucoma treatment. But this is being challenged by MIGS devices, which seek to reduce the medical burden by eliminating an eye drop or two from the patient's treatment. Now medical therapy is fighting back with new classes of medications and new delivery innovations. These developments are critical since there have been very few medical break- throughs in the last 15 years. We are fortunate to have L. Jay Katz, MD, Jason Bachrach, MD, and Steven Simmons, MD, to review this topic. As recently as the 1980s, the treatment for angle-closure glaucoma was a surgical iridectomy. The laser iridectomy was a great step forward and saved patients an incisional surgery and three days in the hospital. Now an even greater seismic shift is occurring. Cataract surgery has been shown to be superior to laser iridectomy in preventing acute attacks, controlling pressure, reducing pressure spikes, and decreasing the need for a trabeculectomy or a tube shunt. We are fortunate to have Nicholas Bell, MD, and David Friedman, MD, discuss the latest findings and recommendations. Cataract surgery as an alternative to a trabeculectomy in angle-closure has met resistance with glaucoma specialists. This is unfortunate since in- creasing evidence has made it apparent that cataract surgery is very effective. It is amazing to be able to treat an angle-closure patient with elevated pres- sure on maximal medical therapy with a cataract surgery rather than a bleb- producing operation. I have many patients who have controlled pressures years after their cataract surgery, and some are not even on any medications. It is as if they are "cured" and don't have the ongoing worries of bleb failure or infection. The decision making is more complex when the lens is clear. However, if the patient otherwise would need a trabeculectomy, a clear lens extraction seems reasonable, and I have used it successfully in highly selected cases. The diagnostic tools for glaucoma continue to improve, and this topic is well covered by Robert Noecker, MD, Louis Cantor, MD, Brian Samuels, MD, and Jeffrey Liebmann, MD. All of our glaucoma treatments have risk, and the diagnosis of a blinding, incurable condition exacts a great psycho- logical toll. Therefore, it is critical that sufficient evidence be gathered so that the diagnosis is definite. The increasing sophistication of our diagnostic tools is very welcome. The ground-breaking meeting between the FDA and members of the American Glaucoma Society is discussed by Malvina Eydelman, MD, Steven Vold, MD, and Malik Kahook, MD. This innovative symposium focused on practical elements of studies involving MIGS devices. For exam- ple, the FDA currently requires MIGS studies to have 2 years of follow-up. Requiring 2 years rather than 1 year imposes an enormous financial burden for companies developing these devices and delays their availability to patients who need them. In spirited discussions, most clinicians felt that 1 year was adequate for follow-up. If this became the policy, it would greatly help the development of new glaucoma surgical technology. The willingness of Dr. Eydelman and the FDA to listen directly to clinicians in an open forum is an extremely encouraging sign for policy improvements in the future. Although the glaucoma spotlight is shining most brightly on MIGS, im- portant innovations are advancing other aspects of glaucoma management. The enthusiasm generated by MIGS seems to be spilling over into all areas of glaucoma. This is great news for glaucoma patients as we continue the drive to improve their care. Reay H. Brown, MD, glaucoma editor Publisher Donald R. 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The ideas and opinions expressed in EYEWORLDdo not necessarily reflect those of the editors, publisher, or its advertisers. P U B L I S H I N G   S T A F F May 2014 Volume 19 • No. 5 A S C R S The official publication of the American Society of Cataract & Refractive Surgery World view Glaucoma: Firing on all cylinders Reay H. Brown, MD, glaucoma editor

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