Sponsored by Glaukos
The concept of interventional glaucoma (IG) has attracted a lot of discussion within the ophthalmic community, but what exactly does it mean?
Interventional glaucoma is a mindset that entails a proactive glaucoma management approach, one that considers the use of MIGS surgeries, lasers, and devices, as well as medications, early in the disease continuum. Interventional glaucoma also challenges the traditional treatment algorithms that involves targeting IOP or vision loss as the only endpoint.
Overall, what the term means may be less important than how and why it is relevant for everyday patient encounters. According to Sahar Bedrood, MD, PhD, a glaucoma and cataract specialist at Advanced Vision Care in Los Angeles, California, interventional glaucoma is a way to individualize patient care while also considering the impact of treatment on patients daily living. Removing the need to rely on drop compliance also leads to fewer diurnal fluctuations, suggesting greater control with interventional approaches. Brian Shafer, MD, who recently opened an anterior segment surgical practice in Plymouth Meeting, Pennsylvania, likewise appreciates the ability to reduce drop burden, and fundamentally, to get the pressure under control without the patient having to worry about actively participating in the process.
In the following, Drs. Bedrood and Shafer offer their take on the meaning of interventional glaucoma and why it would be a good idea to rethink some of the historical dogma around the treatment paradigm.
Evidence from large, well-run clinical trials suggest that interventional options such as selective laser trabeculoplasty (SLT) are viable first-line options, conferring certain benefits over the use of topical drops.1,2 Other emerging evidence suggests that options which lower IOP without relying on patients’ compliance are both preferred by patients and lead to better long-term outcomes. Is the mindset changing about the role of medications in treating glaucoma, especially early in the disease?
Brian Shafer, MD: The advent of interventional glaucoma has changed the paradigm about how medications are used in real-world practice. When we encounter patients early in their glaucoma journey, we still educate them about lowering the pressure, but now we can talk about devices, lasers, and surgery, in addition to medications, and how over their lifetime, we’ll probably use multiple treatment options. Right away, patients know there is a plan for today and for the future. And, because we have evidence, we can reasonably start that patient with an intervention—for example, an SLT or DURYSTA (bimatoprost intracameral implant, Allergan) and the recently approved iDose® TR (travoprost intracameral implant) 75 mcg (Glaukos)—and then utilize drops for additional IOP-lowering as needed between the interventions. It’s because of this new mindset that we can think about strategies to maintain a drop-limited, high quality of life for our glaucoma patients.
Sahar Bedrood, MD, PhD: As clinicians, we are all trained to follow evidence-based practices. The growing evidence about the utility of MIGS and other interventional options very early in the disease, and even first-line, should cause us to rethink our approach. That’s not necessarily because we want to eliminate medications all together. It’s because using an interventional mindset allows us to consider other endpoints and outcomes. Years ago, we learned that drops lower the pressure and help reduce visual field progression. Now we have added data points that laser treatment as first-line therapy has a similar result, and it has the additional benefit of preserving the ocular surface and reducing drop burden for patients. Based on that, SLT has become my mainstay for first-line treatment for patients, and I use drops as a bridge to further intervention if needed.
Does the use of MIGS in standalone settings align with the thinking about following evidence-based practice?
Dr. Bedrood: I think it does. Devices like the iStent infinite (Glaukos) are indicated for standalone procedures. Their FDA clinical trial was based on standalone surgeries, and 76% of the patients had greater than 20% IOP lowering.3 Notably, the study purposely enrolled classically hard-to-treat patients, so that is evidence. The next step with that, and any new device, is to get it into more surgeons’ hands so that real-world-data, which may be different than what is considered by the FDA, can be generated. Having an indication for standalone procedures and the growth of MIGS use in comprehensive ophthalmology are two things that are helping to push wider adoption. Both of those things are driven by evidence and will generate additional useful evidence for evolving our techniques and choosing patients.
Are there outcomes and endpoints you consider in real-world practice that may be different than regulatory endpoints?
Dr. Shafer: The biggest one to me would be the amount of medication reduction we can achieve. The data point Dr. Bedrood mentioned from the iStent infinite pivotal study—76% of patients, most of whom had refractory glaucoma, achieved a 20% reduction in IOP3—is real and meaningful. But in practice, getting the IOP lower is not the only outcome we think about. As an example, for a patient on 1 to 2 medications with stable glaucoma, we may offer a MIGS with the understanding that the pressure may be the same, but there is a good chance we can eliminate one or both of those daily drops.
Dr. Bedrood: I echo that, and I will add that interventional glaucoma allows us to redefine what we can consider a successful outcome. Patients enter into our care at various points of their journey, but by and large, in our practice, we see patients at both ends of the spectrum. Either they come to us and need to get their pressure down urgently, or more commonly, we are seeing patients with early glaucoma where pressures are likely controlled on 1 or 2 medications. In the historical definition of a successful outcome, we would have called that second patient a win. But now, we can have a conversation with that patient about interventional options that reduce their drop burden while also eliminating IOP fluctuations. We can discuss options that potentially improve a patient’s quality of living, but that takes a different mindset. The old thinking was really to wait until the problem got emergent and then doing everything you can, up to and including invasive surgery. Contrast that with the interventional mindset, which is really about being proactive and incorporating low-risk interventions to achieve our clinical goals.
How do you define interventional glaucoma?
Dr. Bedrood: For me, interventional glaucoma is a way to customize care for my patients in a proactive way, to identify the minimum number of topical medications that they need, and achieve their IOP target by way of less risky interventions earlier in their disease process.
Dr. Shafer: To me, it’s the ability to intervene on a patient’s intraocular pressure, and to deliver it to a level where their glaucoma is no longer progressing without relying on them utilizing eyedrops. That means we aren’t depending on compliance and patients aren’t being exposed to potential side effects they might incur from using drops.
Is quality of life improvement an implied benefit of your definition?
Dr. Bedrood: It definitely is. When I talk to a patient, my first thought is, “Is this patient really going to take topical drops, every day and as instructed? How often are they going to be burdened by this?” Patients forget or they have trouble affording medications. And, there are a lot of ways that having to take drops interferes with daily living, not to mention that their use can lead to dry eye or side effects. I think that if we can improve their quality of life and lower the pressure by reducing the number of drops they’re on, we’re doing a huge favor. I hope that someone does that for me if I were in that situation.
