Is Glaucoma a Surgical Disease?
Early in my medical career, I approached glaucoma predominantly as a medical disease. I typically started patients on a prostaglandin analogue or timolol as first-line treatment, and I considered laser trabeculoplasty to be a viable alternative or adjunct. I reserved incisional surgery for cases of advanced glaucoma and disease uncontrolled by topical medication.
My perspective changed with the FDA’s approval of microinvasive glaucoma surgery (MIGS) procedures such as ab interno goniotomy/trabeculotomy using the Trabectome (NeoMedix) and Kahook Dual Blade (New World Medical), the Trab360 (Sight Sciences), ab interno canaloplasty using the iTrack 250A microcatheter (Ellex), the iStent Trabecular Micro-Bypass Stent (Glaukos), the CyPass Micro-Stent (Alcon), and the Xen Glaucoma Treatment System (Allergan). More promising MIGS devices are closing in on FDA approval, including the Hydrus Microstent (Ivantis), the iStent Inject and iStent Supra (both from Glaukos), and the InnFocus MicroShunt (Santen).
Not only glaucoma subspecialists but also comprehensive ophthalmologists are embracing trabecular bypass and supraciliary MIGS procedures. The Xen and MicroPulse laser technology (Iridex) make surgical intervention for advanced glaucoma more palatable. Today, I operate on patients using two to four topical glaucoma medications more frequently than ever before. Meanwhile, my patients’ enthusiasm for glaucoma surgery rises as the risks of these procedures decline. I now have patients approach me to request information about early surgical intervention for glaucoma.
Reimbursement has been a sticking point in surgeons’ decision to adopt MIGS procedures, but the problem has begun to abate. Collaboration between physicians and industry has made insurance companies more amenable overall to paying for the iStent (0191T Current Procedural Terminology [CPT] code). Recently, Alcon and Allergan achieved breakthroughs on reimbursement with Medicare providers and even commercial insurance companies for the CyPass (474T CPT code) and Xen (0449T and 0450T for each additional device CPT codes), respectively.
Moving forward, I expect challenges in maintaining the level of reimbursement for MIGS procedures because of increasing utilization by physicians and what the Centers for Medicare & Medicaid Services may perceive as ease of use. Moreover, many patients who undergo MIGS will eventually require further treatment. Thankfully, the pharmaceutical industry has not stood still. This issue of GT focuses on new drug products and delivery systems that may offer greater safety and compliance compared with current medical therapy. Both patients and their physicians stand to benefit tremendously from these advances.
Steven D. Vold, MD
Chief Medical Editor