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EW GLAUCOMA 42 July 2015 by Ellen Stodola EyeWorld Staff Writer on 1 or 2 drops a day (MIST), the ef- ficacy is enhanced; this allows MIGS to be incorporated into the glauco- ma management plan for patients with somewhat more advanced disease, Dr. Samuelson said. It's just another step in glaucoma management. EW Editors' note: Dr. Samuelson has financial interests with Alcon (Fort Worth, Texas), AqueSys (Aliso Viejo, Calif.), Glaukos, Ivantis (Irvine, Calif.), and Transcend Medical (Menlo Park, Calif.). Contact information Samuelson: twsamuelson@mneye.com Possibilities for MIGS procedures continue to grow, including in more advanced cases, a physician says W ith the development of MIGS procedures, applications for their use in a wide variety of glaucoma patients are continuing to expand. Thomas W. Samuelson, MD, Minneapolis, presented "Managing Severe Glau- coma in the MIGS Era," at the 2015 ASCRS•ASOA Side X Side meeting in Aventura, Fla. As of now, we do not have a single procedure that is best suited for all levels of glaucoma severity, he said. However, he does believe that there is improvement across the board. When first examining a patient, it's important to check if the patient is phakic or pseudophakic. Other factors to be aware of are how bad the disease currently is, the patient's IOP level, and the velocity of the disease. When considering phakic eyes with a surgical cataract, Dr. Samuelson said, the largest group fits into phaco plus MIGS, including the iStent (Glaukos, Laguna Hills, Calif.) and the Trabectome (NeoMe- dix, Tustin, Calif.). He recommend- ed using phaco alone for untreated ocular hypertension. Phaco plus enhanced MIGS should be used if there's evidence of damage. Pha- co plus a trabeculectomy or tubes should be used for eyes with a high risk for functional impairment. Meanwhile, for pseudophakic eyes, Dr. Samuelson said he's far more inclined to filter or place a tube. Other options in the MIGS space include endoscopic cyclopho- tocoagulation (ECP, Endo Optiks/ Beaver Visitec, Waltham, Mass.), and the iTrack catheter (iScience, Menlo Park, Calif.). However, he questioned if it's possible for MIGS to be utilized in more advanced stages of glaucoma. This would involve improving the efficacy of current MIGS procedures because in its current form, MIGS ef- ficacy is modest, Dr. Samuelson said. We have superb glaucoma drugs, Dr. Samuelson said. "But it's a fact that we overuse them." Surface toxicity from glaucoma medications is rampant. Dr. Samuelson stressed that a procedure doesn't necessarily need to completely eliminate medication to be a success. He suggested simply converting a patient from an unreal- istic and unsustainable medication schedule to a more reasonable one would be an effective treatment. MIST, or minimally intrusive sustainable therapy, is what Dr. Samuelson calls 1 or 2 medications postop. When you are utilizing pro- cedures that are safer but less effica- cious, you cannot always eliminate medications, and patients are still going to have to take them postop- eratively, he said. In such cases, it is best to establish your postoperative medication plan at the last visit before surgery. That way, there is no guesswork or going back to look at the chart in the recovery room. It is best to write the expected postop medication regimen directly in your surgical plan. "I think it's OK to have a qualified success," Dr. Samuelson said. While the goal of "complete success," defined as controlled IOP and stable visual function without medication, is laudable, the risks to achieve this with current options are too great for most patients with early to moderate glaucoma, he said. "The beauty of the MIGS pro- cedures is the safety," he said. Not included in the safety data are the adverse events that were avoided by not doing other more aggressive procedures. Dr. Samuelson suggested picking 1 or 2 MIGS procedures and getting really good at them because it's hard to do them all. With MIGS, physi- cians have a safe procedure that is light on efficacy, but when you plan Pearls for MIGS success Eye undergoing cataract surgery that had a trabeculectomy several months earlier through a separate incision. Phaco plus a trabeculectomy or tubes may be used for eyes with a high risk of functional impairment since MIGS is not generally used in advanced stages of glaucoma. Source: Uday Devgan, MD supplemental oxygen delivered via continuous positive airway pressure (CPAP). Likewise, nocturnal hypo- tension is a known risk factor for glaucoma. Ambulatory 24-hour blood pressure monitoring is routine in clinical practice and can identify patients in whom nocturnal dips in blood pressure may be contributory to their glaucoma, Dr. Wax said. "In these patients, a reduction in the nighttime dose of blood pres- sure medication may be helpful," Dr. Wax said. If the patient's primary care provider deems this inappropriate, ingestion of a salty snack such as a small bag of potato chips before bed may help prevent the nocturnal dip in blood pressure. IOP is and always will be an important strategy for glaucoma therapy. However, novel therapeutic target are being explored, and pre- liminary studies suggest that we may soon have entirely new treatments for glaucoma that will complement IOP reduction. EW Editors' note: Dr. Pasquale has financial interests with Allergan (Irvine, Calif.), Bausch + Lomb (Bridgewater, N.J.), the National Eye Institute (Bethesda, Md.), and Novartis (Basel, Switzerland). Drs. Goldberg, McKinnon, Quigley, Wax, and Weinreb have no financial interests related to their comments. Contact information Goldberg: jeffrey.goldberg@stanford.edu McKinnon: stuart.mckinnon@duke.edu Pasquale: louis_pasquale@meei.harvard.edu Quigley: hquigley@jhmi.edu Wax: mbw817@yahoo.com Weinreb: rweinreb@ucsd.edu How will glaucoma continued from page 40

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