Click on right here to learn the Cowl Story, “ Interventional glaucoma mindset goes past conventional administration methods. “
Earlier than we begin a dialog about how to select between the completely different choices for MIGS, we have to acknowledge that there’s by no means going to be one MIGS algorithm for each physician.
Our medical selections are influenced by so many components, some medical however some not strictly medical.
One instance is affected person insurance coverage. Each insurance coverage firm has various things that it’s going to cowl or not cowl relying on the prognosis. That alone can put a affected person on a distinct pathway that may affect a number of selections.
There are additionally affected person components corresponding to their willingness to endure procedures. Some sufferers would moderately go to the working room yearly for an especially secure process simply to keep away from a higher-risk process. Different sufferers worry surgical intervention a lot that if they’ll convey themselves to undergo with it, they only need to do it in a single go and get it finished with. We should get to know each affected person, and it’s all the time tailor-made remedy.
One other issue that’s not strictly medical however is legitimate and necessary is every surgeon’s consolation with any given know-how. Everybody has a surgical procedure wherein they’ll make a greater final result. Medical doctors themselves have their very own tolerance for surgical threat, and naturally some docs can higher persuade sufferers to have interventions. Together with working room know-how and stage of coaching, that is a vital issue for lots of docs.
All of that is to say, you’re going to have comparable sufferers with completely different insurance coverage, completely different personalities and completely different docs who might validly have fully completely different therapy paths due to these components, which aren’t purely medical.
Now we will transfer into the medical selections that information MIGS alternative. We have now good proof that glaucoma begins as a illness within the trabecular meshwork. Latest information from the LiGHT examine that present how nicely laser works as step one in glaucoma therapy advance the idea of intervening early within the trabecular meshwork. Many sufferers, if not most, may have their glaucoma prognosis years earlier than their cataract is visually vital. This opens up the chance for so-called “stand-alone” procedures carried out on the trabecular meshwork. These embody a trabecular stent, for which the iStent (Glaukos) is FDA accredited. It additionally contains procedures that don’t contain stents, corresponding to goniotomy and canaloplasty, which have many devices that can be utilized for these procedures. Alcon’s Hydrus microstent may also be utilized in an off-label method.
As soon as we undergo the pretty apparent goal of intervening on the trabecular meshwork stage, now we have to say how drug supply suits into the world of MIGS. Most of us have gotten the sensation that topical pharmacotherapy doesn’t work nicely for our sufferers. Nonetheless, the 2 most important downsides of drops are the topical negative effects — dry eye and different ocular floor points — and compliance.
Workplace-based Durysta (bimatoprost intracameral implant, AbbVie) in addition to working room-based iDose (Glaukos) each sidestep the issues of topical remedy. Drug supply vs. stent can be a fantastic query to have answered with a analysis examine as a result of they each look like nice choices that deal with a whole lot of the problems we try to keep away from in glaucoma. Many surgeons will probably mix the 2.
Subsequent, now we have the rising class of the superciliary house, which incorporates AlloFlo bio-tissue, delivered utilizing the CycloPen (Iantrek). What pursuits me about this space is that it’s referred to as bio-interventional glaucoma surgical procedure. These methods use scleral allograft tissue to carry open a superciliary cleft or a cyclodialysis cleft. The hope, which I believe is pretty nicely supported by the info, is that by retaining the stent open on this manner, you should have much less fibrosis and cleft failure. The MINIject (iSTAR Medical) can also be being investigated on this space and could also be out there sooner or later. I’d predict that for folks focused on MIGS and interventional glaucoma, these interventions within the superciliary house are going to realize in reputation.
If we glance within the space of subconjunctival stenting, now we have the Xen gel stent (AbbVie), which has an impeccable security profile within the minds of most sufferers and docs. The method and approaches have advanced over time, and it stays an necessary a part of the therapy algorithm. We additionally await the PreserFlo microshunt (Glaukos), out there in areas exterior of the U.S.
For extra info:
Nathan M. Radcliffe, MD, a Healio | OSN Board Member, might be reached at drradcliffe@gmail.com.
Sources/Disclosures
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Healio Interviews
Disclosures:
Radcliffe experiences consulting for AbbVie, Alcon, Bausch + Lomb, Glaukos, Iantrek, New World Medical, Sight Sciences, ViaLase and Zeiss.
