Sponsored by Sight Sciences
The introduction of MIGS devices was revolutionary for glaucoma management. Over time, as new MIGS devices and procedures became available, and as new evidence demonstrating their benefits emerged, the role and rationale for earlier surgical intervention has been further solidified. Now, with the availability of data from clinical trials demonstrating the utility of MIGS in standalone procedures, the next evolution in MIGS is coming into focus: An era in which millions of patients not yet eligible for cataract surgery and those who have already undergone cataract surgery can benefit from the potential to achieve target pressure, restore physiologic outflow, and reduce medication burden.
Evolving the Standard of Care
By Lawrence Woodard, MD
The various benefits of standalone MIGS are obvious: The ability to gain control of IOP without relying on patients’ compliance with a safe intervention that has potential to reduce medication burden, all without having to consider the lens status. These are all things that general ophthalmologists already appreciate with MIGS in combination procedures, and they also apply to standalone procedures. As well, there are some additional benefits associated with standalone MIGS that reinforce why it is such a meaningful development in the management of glaucoma.
A Broader Perspective
In my view, there are at least five important reasons why the viability of standalone MIGS is poised to have a meaningful impact.
Reducing the Burden of Glaucoma
As the number of medications and complexity of the topical therapy regimen increases, compliance decreases. The ability to lower IOP without relying on the patient to assist in that is huge.
Impact on progression
Consistently low IOP is associated with a lower risk of glaucomatous progression. Topical medications could achieve that, but issues with adherence are well known. It stands to reason, then, that when we intervene with procedures that address the anatomy in the outflow pathway, we are increasing the chances of impacting the disease process for the patient, and thereby, lower the chances for progression.
Slowing the Risks for Progression
Slowing the risk for progression means less chance of getting to a stage of glaucoma that would require invasive surgery with high rates of complications.
Potential to Change the Economic Model
Glaucoma, especially if related to vision loss,1 is associated with significant economic burden—and that burden increases as the disease worsens.2 Earlier surgical intervention could have an impact on the economic burden to the health care system, which would really be an additional benefit after considering that the potential to reduce medication burden alleviates significant cost burden to the patient.
Greater access to care
Encouraging more general ophthalmologists to perform standalone MIGS and equipping them with procedures backed by clinical data may allow the ability for patients with mild to moderate glaucoma to have the option for earlier surgical intervention.
Improving Outflow Facility
One of the subtle shifts in thinking that has occurred with the evolution of MIGS is to direct the intervention to the anatomy rather than treating the pressure. Doing as much as we can to correct likely sources of resistance facilitates physiologic outflow, and as a result, can achieve target IOP. Thus, we are still aiming to lower pressure as the only modifiable risk factor for glaucomatous progression but doing so in a slightly different way.
At the start of the MIGS era, with all of the options subjected to clinical trials in which procedures were paired with cataract surgery, it was only natural that lens status became a part of our thinking. Now, with the availability of data on standalone MIGS, we can have confidence in forming new protocols for surgically managing glaucoma earlier in the disease.
For example, among 24 pseudophakic eyes in the ROMEO study, which studied the OMNI Surgical System (Sight Sciences) in mild to moderate primary open-angle glaucoma in standalone patients, IOP was reduced from a mean 21.8 mm Hg on 1.7 medications preoperatively to 15.6 mm Hg (28% reduction from baseline) on 1.2 medications (with 38% of patients achieving medication-free status) at 12 months.3
MIGS combined with cataract surgery has been a true game changer for patients with mild to moderate glaucoma eligible for lens removal. The evolution to performing MIGS as a standalone procedure further extends those benefits to the millions of patients with mild to moderate glaucoma who either do not need cataract surgery or else previously had an IOL placed but are now experiencing progression or challenges with topical therapy.
Expanding Indications for MIGS Means a Greater Role for Optometry in Glaucoma Management
By Leslie O’Dell, OD, FAAO
By now, we should all know the implications of the aging Baby Boomer generation: With about 10,000 individuals turning 65 every day, there is a huge demand for eye care services that will continue to grow over the next decade. To date, optometry as a profession has done a nice job of transforming into a role as primary eye care providers, facilitating and assisting in care of patients undergoing cataract and refractive procedures. It is only natural that optometry also take a greater role in educating patients about their options in glaucoma and referring patients for a surgical glaucoma consult when appropriate.
The most important reason for optometry to pay closer attention to the continual evolution in the glaucoma space: We have a tremendous opportunity to have an incredibly meaningful impact on our patients by preserving their vision.
Educate Early and Often
Introducing MIGS options is relevant at all stages, for all kinds of patients, and not just for those patients with a cataract. Educating about the treatment options early and often serves multiple purposes. For patients newly diagnosed, the message may be geared more to letting them know there are a multitude of options we can consider as we continue to monitor the disease. Nevertheless, knowledge of the options helps ameliorate a relevant source of anxiety and keeps them engaged in monitoring.
For patients with a glaucoma diagnosis, but early in the disease, MIGS becomes a more regular part of the interaction. Here we can focus on understanding how they are doing with their topical medications (if they are using them), asking about adherence with the regimen, figuring out their ability to use drops correctly and effectively, and discovering if they are experiencing any side effects or issues with accessing their medications.
Because the earliest stages of glaucoma development and progression are essentially symptomless, it is incumbent on those who see these patients on a regular basis to monitor closely and intervene early. Educating on MIGS is part and parcel of this mission: Letting patients know there is a safe and effective surgical option to manage their glaucoma and potentially reduce their dependence on topical therapy provides hope, so they should not get discouraged.
Simplify Treatment Options
One of the great benefits of MIGS procedures is that they offer to simplify treatment. In my view, once you start reaching for a second medication to control the IOP, you really start thinking about whether it is time to refer the patient for a consultation. Compliance decreases as the medication burden increases, and many patients are simply not able to use their topical drops as recommended. Therefore, restoring physiologic outflow, especially in early disease, is vitally important. If the outflow is working as it should, it should improve the outcome.
When MIGS first came on the scene, it was important to educate patients with glaucoma and a cataract that they had a unique opportunity to address two problems at once. The viability of standalone MIGS expands the utility of procedural intervention to the millions of patients not yet eligible for cataract surgery and to those who have already undergone the procedure, but need additional management of their glaucoma. In our role as the provider of primary eye care services, optometrists have a vested interest in adjusting to this changing paradigm accordingly for the benefit of our patients.
1. Wittenborn J, Rein D. Cost of vision problems: the economic burden of eye disorders in the United States. NORC at the University of Chicago; 2013. Available at: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/viewer.html?pdfurl=https%3A%2F%2Fpreventblindness.org%2Fwp-content%2Fuploads%2F2020%2F04%2FEconomic-Burden-of-Vision-Final-Report_130611_0.pdf&clen=1091576&chunk=true. Accessed: April 4, 2022.
2. Varma R, Lee PP, Goldberg I, Kotak S. An assessment of the health and economic burdens of glaucoma. Am J Ophthalmol. 2011;152(4):515-522.
3. Vold SD, Williamson BK, Hirsch L, et al. Canaloplasty and trabeculotomy with the OMNI System in pseudophakic patients with open-angle glaucoma: The ROMEO Study. Ophthalmol Glaucoma. 2021;4:173-181.
Dr. Lawrence Woodard is a paid consultant of Sight Sciences, Inc.
Dr. Leslie O’Dell is a paid consultant of Sight Sciences, Inc.
