Eyeworld

73 EW GLAUCOMA May 2017 As for combining MIGS proce- dures, Dr. Berdahl said that while he might use some MIGS off-label, and he does think combining different mechanisms of aqueous outflow will allow ophthalmologists to achieve lower pressures in patients, it's still too early to know which combina- tion is going to be most appropriate for which patient. Dr. Liu also said she hasn't started combining MIGS procedures, but she has used ECP and GATT in patients after tube shunt procedures haven't been effective. Dr. Crandall said he does com- bine some MIGS that have different mechanisms of action. "I'll do one of the micro-stents with endoscopic laser or full goniot- omy with endoscopic laser," he said, adding that combining MIGS can be beneficial for patients with more ad- vanced disease but for whom a tube shunt or trabeculectomy might not be the best option, such as active patients with a higher contact injury risk or high myopes where hypotony could be an issue. "With all of these options now, we're getting a better feel for how we stratify them in a patient's inter- vention planning," Dr. Condon said. "iStent is the least disruptive device in what it does to the canal and tissue structures. After that, things like a Trabectome [NeoMedix, Tus- tin, California] or anything directed at the canal. Beyond that … then you're into things like Cypass and XEN devices. We might reserve those until further down on the list of patient interventions. Because we've got all of these devices, sometimes it's hard for a young ophthalmolo- gist to decide, which one should I do? That's the other hurdle, being able to think about them as to the degree of their invasiveness … Think about what the patient needs and think about what the MIGS limita- tions are." EW Editors' note: Dr. Berdahl has financial interests with Alcon, Allergan, Glaukos, and New World Medical. Dr. Condon has financial interests with Allergan and Alcon. Drs. Liu and Crandall do not have any financial interests related to their comments. Contact information Berdahl: johnberdahl@gmail.com Condon: garrycondon@gmail.com Crandall: dackakarot@hotmail.com Liu: yowsers@gmail.com Selecting the right patient for MIGS The biggest challenge most people don't realize when it comes to MIGS, Dr. Liu said, is learning how to select appropriate patients for these pro- cedures, among many other factors you need to be aware of pre- and postoperatively. Dr. Berdahl's advice on the pa- tient-selection front is to start with on-label approaches with MIGS. In most cases, this involves coupling the MIGS procedure with cataract surgery. In that case, Dr. Berdahl also advised starting them with straightforward cataract cases. He also shared that he finds MIGS easier under topical anesthesia rather than a retrobulbar block because it allows the patient to adjust their eye for better visualization of the angle anatomy. David Crandall, MD, Henry Ford Eye Care Services, Detroit, said younger surgeons just getting into MIGS should start with patients who have earlier stages of glaucoma and a visually significant cataract. The latter, he said, helps the patient appreciate visual gains after surgery. Dr. Crandall said he would advise young eye surgeons to avoid MIGS in patients with narrow angle issues, evidence of scarring in the angle, and neovascular glaucoma. Surgeons can differ on if they'll perform the MIGS procedure before or after cataract surgery, but Dr. Condon said he prefers to do it before. "I do every single angle-based procedure before doing the cataract because the view is unsurpassed and it's easy to make the angle and anterior chamber super deep with a viscoelastic agent in just about every case," Dr. Condon said. "It's really a myth that you get a better view of the angle after the cataract proce- dure; I just don't think that's true." Dr. Crandall said he'd also advise less experienced surgeons to perform the MIGS portion of a MIGS-cataract surgery before the cataract portion for a clearer view of the angle. For himself, Dr. Crandall said he'll do mini-shunt procedures before cataract surgery but reserves goniotomies and trabeculotomies for after cataract surgery because of the bleeding that can occur. Dr. Condon said in selecting MIGS candidates he focuses more on the patient's level of disease activ- ity rather than their disease stage. "You don't want to start on patients who have uncontrolled pressures; you want to start on patients who have controlled pressures and who also would have backup [treatment] strategies, either the addition of more medications or the option of something more invasive, but you're going to go this [MIGS] route first," he said noting that most MIGS approved by the U.S. Food and Drug Administration (FDA) are for patients with controlled, mild to moderate disease. Dr. Berdahl said he finds himself being more aggressive with MIGS. "I'll do it on more severe glaucoma patients as a first-line attempt to avoid more aggressive trabeculecto- my or tube shunt—we've been able to do that successfully—but those are patients you need to watch very closely, because you may not get the efficacy that you need and will need to move on to a more aggressive ap- proach," Dr. Berdahl explained, not- ing that he'll make sure the patient understands that another procedure might be necessary. "I do use a number of MIGS in off-label ways on patients," Dr. Ber- dahl said. "My belief is that I took an oath to do the right thing for the patient … and often that isn't con- sistent with strict on-label approach- es determined by the FDA-moni- tored trial. That said, when treating off label, the evidence is generally weaker." Dr. Liu said a non-ideal MIGS candidate might include those who need significant IOP lowering or those with central vision threat- ening glaucoma damage and high eye pressures. Dr. Condon advised asking yourself what is directing you to intervene with the patient at the moment. Is it glaucoma or is it the cataract? "If the glaucoma is directing you, then I would think twice about going the MIGS route. In cases with moderate or advanced disease that you feel is less controlled—those are patients who are going to go toward the filtering procedure, the more effective procedure albeit with more risk," he said. MIGS in combination and other considerations After a cataract-MIGS procedure, postop drop regimens vary from patient to patient, Dr. Condon said. "A patient with mild disease on one medication and they undergo cataract surgery with MIGS, I might stop their glaucoma medication im- mediately and see how they do after the first postoperative visit. If they're someone with more moderate dis- ease or someone with a more precar- ious level of pressure control before the surgery, then I might continue their glaucoma medications for sev- eral weeks before considering start- ing to wean them off some of them on a trial basis. It would depend on how advanced the patient's disease is, my level of concern, and how confident I was in the MIGS proce- dure I did," Dr. Condon explained, adding that lowering the pressure in the eye and infusing fluid can reveal blanching in the episcleral vascula- ture, which could suggest successful MIGS placement. Dr. Liu said for her combined iStent (Glaukos, San Clemente, Cal- ifornia)-cataract patients, she won't change her standard cataract postop drops, but she might consider taking the patient off glaucoma drops, watching them carefully for any ste- roid response. After endoscopic cy- clophotocoagulation (ECP), Dr. Liu said she'll tailor glaucoma medica- tions based on a patient's pressures postop, and she'll use pilocarpine in gonioscopy-assisted transluminal trabeculotomy (GATT) patients to prevent scarring that could reduce the efficacy of the procedure. Dr. Crandall also said he would add pilocarpine to his standard postop drop regimen after GATT and trabec- ulotomies, while with ECP patients, he'll increase steroids. Dr. Crandall said if the patient had mild glaucoma and controlled pressure to start, he'll take them off glaucoma medications 1-day postop, telling them there is the potential the drops might come back. With more advanced stages of disease, Dr. Crandall said he'll keep patients on drops, backing off them in the fol- lowing weeks if pressures improve. Dr. Berdahl said for trabecular procedures—iStent and Kahook Dual Blade (New World Medical, Rancho Cucamonga, California), for example—he starts peeling off medications at 1-week postop if the patient's pressure is at an accept- able range. For suprachoroidal or subconjunctival sent procedures, like Cypass Micro-Stent (Alcon, Fort Worth, Texas) and XEN (Allergan, Dublin, Ireland), Dr. Berdahl said he stops their glaucoma medication the day of surgery. With XEN specifical- ly, Dr. Berdahl said he is a little more aggressive with steroids and uses mitomycin C. Emerging continued from page 71

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