NTERIOR SEGMENT
GLAUCOMA TREATMENT
Improve Quality of Life with Early Surgical Intervention in Glaucoma Treatment by April Ingram
“E
arly detection and early treatment lead to better outcomes.” This statement is the driving force behind so many screening and treatment programs in ophthalmology … except when it comes to surgical intervention. Indeed, surgery is often only considered after limited success with topicals and once all other treatments have been exhausted. But what if surgery was moved earlier in the treatment model? Thanks to recent advances, this shift is happening in glaucoma, and surgeons are now looking toward taking a more proactive — rather than reactive — approach to glaucoma management.
The battle against IOP reduction
the next visit. In this treatment pattern, the physician and patient had better enjoy each other’s company because the relationship is a long one. We’ve known for years (and have the studies to prove it) that outcomes are better with earlier, effective treatment and IOP reduction. For each mmHg of reduced IOP, there is a 10% reduced risk of disease progression.1 In 2008, Joseph Caprioli wrote an editorial in the American Journal of Ophthalmology describing the effect on visual disability of glaucoma patients as a function of the rate of progression and time of intervention — importantly noting that with earlier intervention in eyes with fast progression, visual function can be preserved.2
In glaucoma management, it’s a daily challenge for ophthalmologists to meet the patient’s desired intraocular pressure (IOP) goals and preserve optic nerve function. There are various (and important) things to consider, such as selecting the optimal therapy or combination of therapies to hit that IOP target. Other factors include: managing the delicate balance of patient compliance, adherence and side effects, as well as maintaining their quality of life.
The arrival of Minimally Invasive Glaucoma Surgery (MIGS) has provided an opportunity for early treatment in patients whose IOP reduction needs do not necessitate the plunge into a more invasive trabeculectomy or tube shunts. It has been established that MIGS delivers effective IOP reduction and reduces medication burden. And there are a growing number of options for MIGS devices; these can be divided by their approach or pathway: subconjunctival, suprachoroidal or Schlemm’s canal. Subconjunctival draining devices like the XEN Gel Implant (Allergan, an AbbVie company, Dublin, Ireland) or PRESERFLO® MicroShunt (Santen, Osaka, Japan) can be used in solo MIGS procedures and have better potential to achieve single digit IOP levels. Additionally, patients can combine their scheduled cataract surgery with MIGS — and who wouldn’t want the efficiency of getting two eye disorders treated at the same surgical appointment?
Could early surgical intervention (ESI) be the solution?
It goes on and on — and often, it can feel like going into battle. Pressure increases, we react, change the therapy, hope the patient is compliant and keep our fingers crossed until
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So, if the surgical intervention can safely maintain acceptable IOP while reducing adherence issues and side effects, then why are we waiting and watching … and waiting again for other options to fail, or eventually become intolerable to our patients?
Dr. Chelvin Sng, from the National University Hospital in Singapore, supports MIGS options earlier for glaucoma patients. “The introduction of MIGS devices has improved surgical
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back to Peng Khaw’s 10/10/10 rule: A 10-minute technique that will reduce the IOP to 10 mmHg for at least 10 years.3
Slow Progression Earlier intervention Visual Function
Fast prograssion
We hope that with innovative devices and techniques which demonstrate safe, consistent and effective IOP lowering results — together with a more proactive attitude and earlier approach to surgical glaucoma management will get us closer to that “Holy Grail.”
Later intervention
Level of visual disability
Birth
Death
Effect of timing of intervention on rate of progression. [Source: Caprioli J. The importance of rates in glaucoma. Am J Ophthalmol. 2008;145(2):191–192.]
DISCLAIMER: The Santen styrene-blockisobutylene-block-styrene (SIBS) Microshunt is CE-marked in The European Union and currently marketed under the brand name of PRESERFLO®. It is not yet approved for use in other countries except Canada and Australia. This educational article is based on Dr. Sng’s own clinical experience and has no financial interest to disclose.
REFERENCES: 1.
safety, allowing us to offer glaucoma surgery to patients earlier in the treatment algorithm. In particular, cataract surgery provides an opportunity to have a glaucoma procedure performed at the same time, even if the glaucoma is medically controlled,” she said. Let’s consider the benefits of MIGS: These procedures reduce medication burden and adverse effects of topical treatments. They are safer, less tissueinvasive and are associated with a faster recovery than traditional filtering surgery, such as trabeculectomy or aqueous shunt implantation. As with any procedure or intervention, it’s critical to select the right patient for the correct procedure, based on treatment goals and the patient’s specific needs. So, what are some characteristics to consider with early MIGS intervention? In addition to the ultimate treatment goals, other key factors may include the patient’s age, progression rate, their response to other therapy, and their adherence and tolerance to topical treatment. Additionally, assessing the degree and cause of IOP increase and determining outflow impairment's location will help to decide which type of early intervention should be considered. (Think patient, disease type and target pressure.)
For example, a subconjunctival MIGS approach, like with the PRESERFLO® MicroShunt (Santen, Osaka, Japan), may be an ideal solution for a relatively young patient who has documented slow progression shown by visual fields. This approach is also a good fit for someone with modest IOP reduction requirements and who does not tolerate topical medication side effects very well. Plus, having to carry around several bottles of topical eye drops can be frustrating for younger patients — while older patients may find applying the drops difficult due to dementia, arthritis or other issues. These are further instances where MIGS may improve quality of life. This year, COVID-19 has been a new wrench in glaucoma practices. Of course, the goal remains to manage each patient’s IOP effectively, but this has been easier said than done — especially when trying to keep clinic visits to a minimum. The circumstances of the pandemic have forced physicians to adapt and evolve to a more proactive treatment approach. For many, this meant utilizing MIGS earlier in their treatment plan to achieve IOP control and reduce the need for frequent follow-ups. There are numerous challenges to managing glaucoma patients and glaucoma specialists are still searching for the “Holy Grail” solution. This harks
Leske MC, Heijl A, Hussein M, et al. Factors for glaucoma progression and the effect of treatment: the early manifest glaucoma trial. Arch Ophthalmol. 2003;121:48–56.
2.
Caprioli J. The importance of rates in glaucoma. Am J Ophthalmol. 2008;145:191–192.
3.
Thomas R, Billson F. The place of trabeculectomy in the management of primary open-angle glaucoma and factors favouring success. Aust N Z J Ophthalmol. 1989;17:217.
Contributing Doctor Associate Professor Chelvin Sng is a glaucoma consultant at the National University Hospital in Singapore. She completed her glaucoma fellowship at Moorfields Eye Hospital, and was named as one of the “Top 50 Rising Stars” in the global Ophthalmology Power List in 2017. A/Prof Sng has a special interest in glaucoma drainage devices, including minimally invasive glaucoma surgery (MIGS) devices. She is the Convenor of the Asia-Pacific Glaucoma Society (APGS)MIGS Interest Group, and has conducted training courses on MIGS at the ESCRS and APAO meetings. A/Prof Sng is also the co-inventor of the Paul Glaucoma Implant, which has attained CE mark and is currently undergoing international clinical trials. She has served in less fortunate communities which have little or no access to healthcare, and volunteers regularly in medical missions to the less accessible areas in South East Asia, India and Africa. In her leisure time, she enjoys traveling, reading and spending quality time with her two adorable sons. chelvin@gmail.com
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