Pressing Questions and Unmet Needs for 2021 and Beyond

Xiongfei Liu, MD

The year 2020 has proven to be a time of resilience and adaptation. The year 2021 will likely be a time of exploration with the hope of returning somewhat to prepandemic normalcy. In 2021, more established patients will return to ophthalmic practices, some of whom were lost to follow-up in 2020. A pressing question for interventional glaucoma in 2021 and beyond is how to alter the treatment plan for those patients who were previously lost to follow-up. Further, as the Preserflo MicroShunt (Santen) will likely be an available tool in the United States, for whom and when should surgeons use this device, especially under the circumstances of 2021? Last but not least, interventional glaucoma’s ethos is to utilize up-to-date treatment therapy to alter the course of glaucoma. That said, bench and clinical research is paramount. In 2021, how do we maintain that innovative spirit in bench research while reestablishing a rapport with patients and encouraging them to enroll in clinical trials amid uncertainty they feel regarding their safety?

Michael D. Greenwood, MD

To me, the most pressing question related to interventional glaucoma is when will sustained-delivery medications (and perhaps MIGS) become the preferred first-line therapy? I believe that topical medications have a place in glaucoma care, but in the not-so-distant future they will likely become supplemental to other interventions that are longer-lasting and more preferable from a patient lifestyle standpoint.

Daniel Lee, MD

Our clinical mindsets must evolve alongside our surgical tools. Glaucoma surgeries have become much safer, but many practitioners have yet to adjust their treatment algorithms, despite mounting evidence that earlier intervention may, on average, yield improved outcomes. On the other hand, there is a nonzero risk of vision loss from complications associated with these procedures, our payment models incentivize more treatment, and the risk of overutilization is real. A balance must therefore be struck. What are some of the metrics or warning signs we should be looking out for to ensure that the pendulum has not swung too far in favor of intervention? What tools will we use to determine which surgery is ideal for which patient?

John T. Lind, MD, MS

Interventional glaucoma is patient-centric care that incorporates vision-preserving diagnostics and therapeutics to enhance outcomes. As we approach 2021, advances in glaucoma care will include improved mechanisms of diagnosis and enhanced understanding of how to interpret diagnostic findings; in turn, this will ultimately help us determine which patients require more aggressive treatment and which treatments will maximize efficacy while minimizing risk. Opportunities in 2021 include incorporating AI into our clinics, advancing IOP monitoring and assessments, enhancing diagnostics, expanding our understanding of advances in medical therapy, and optimizing our surgical outcomes.

Alena Reznik, MD

In the future, I will likely intervene earlier to prevent glaucomatous progression in my patients because a few individuals experienced disease progression while avoiding office visits during the COVID-19 pandemic. Additionally, we need a safe stepwise approach to standalone MIGS as well as new drug-eluting devices.

Oluwatosin Smith, MD

“The term interventional glaucoma refers to more than simply technology. It is a mindset that the available technologies bring to us as surgeons and clinicians. Instead of being passive and watchful, waiting for our patients to progress, interventional glaucoma allows us to be actively involved in their care by providing interventional therapies that change the course of the disease. I am very excited about interventional glaucoma and how it shapes the future of glaucoma care.”¹

—Iqbal Ike K. Ahmed, MD, FRCSC

Looking at Ike’s remarks in this article excerpt, I know that intervention allows active involvement in glaucoma care to change the disease course by avoiding a passive and watchful approach. However, I look forward to a time when improved disease monitoring can provide better insights into our interventional decisions. With new technologies on the horizon, how do we plan to employ other aspects of care to optimize the multiple interventional glaucoma options that continue to become available to us?

Husam Ansari, MD, PhD

When considering the future of interventional glaucoma care, several key questions emerge. When can we start repairing and protecting the optic nerve? When will we be free from patient self-administration of glaucoma treatment? When will we have glaucoma surgery that is as safe, effective, and predictable as cataract surgery?

Larissa Camejo, MD

As we approach a new year, several pressing questions remain. Which of the surgeries on the horizon will be the most effective in patients with the strongest episcleral fibrosis? Will material or lumen modifications make a difference? Will the future indications for MIGS, currently indicated for use in combination with cataract surgery, include IOP lowering in pseudophakes? Which of the drug delivery systems, both existing and in the pipeline, will be the strongest candidates based on safety, efficacy, and repeatability? Just as the past 5 to 10 years have drastically changed the glaucoma space, I think the next 5 to 10 years will bring a significant leap in progress.

Shakeel Shareef, MD

MIGS has revolutionized the field of glaucoma and has grown exponentially over the past 2 decades. It is important to conduct prospective randomized head-to-head studies in the MIGS space to see which procedures and devices provide the best IOP lowering for patients. This is especially crucial in the developing world, where patients do not have access to such procedures due to economic constraints. We must take into consideration the cost factor in providing affordable glaucoma care not only locally but also globally.