As we approach the era of interventional glaucoma, it’s worth taking a moment to consider some of our headwinds and tailwinds. Innovation, careful research, and the minimally invasive glaucoma surgery (MIGS) revolution have given us new tools. There is solid support that, given the tolerability and compliance challenges of topical therapy, earlier intervention with safe glaucoma procedures can lead to better outcomes.
However, just as innovation has bolstered glaucoma surgery, innovation has also improved the traditional paradigm of topical therapy. We finally have a preservative-free latanoprost available, and this option could extend the time horizon of glaucoma patients who desire to use topical therapy. Significant expansion of the fixed-combination options has meant that for almost any patient, there is a two-bottle topical solution that will represent maximum medical therapy. Finally, dry eye therapies are becoming more diverse and available, and these therapies can be helpful for glaucoma patients with dry eye, regardless of its cause.
Patient preferences for topical therapy over interventions continue to be a significant headwind for interventional glaucoma. I think this represents a flaw in human reasoning and perhaps points to an educational opportunity for our patients. For example, any physicians familiar with the LiGHT trial results would select SLT laser for themselves rather than primary topical therapy. So, when we encounter patients who are reluctant to accept a “no brainer” therapy like laser, we should recognize the obvious knowledge gap and take the time to educate. I find talking to my colleagues about how they educate patients to be very valuable.
The next significant headwind I see for MIGS is that clinicians must recognize that there is a window of opportunity for trabecular procedures early in glaucoma’s disease course that closes as the disease matures. Simply put, advanced glaucoma on 4 drops with a central island is not the time for a standalone MIGS procedure. The patient would have benefited from that procedure 10 years earlier. Yet, the overwhelming majority of the standalone MIGS referrals I receive are simply too far advanced at the time of referral. Not only is radical IOP reduction (>10 mmHg) needed at that stage, but advanced eyes, in my experience, don’t respond to angle procedures as well as earlier stage eyes. I suspect that one must treat the physiologic outflow system while it is still salvageable (and await more evidence to prove this). We need to treat mild and moderate glaucoma before it tips over to the refractory stage. This headwind also represents a knowledge gap. We need to spread the word to our colleagues that interventional glaucoma procedures benefit patients in the early and moderate stages of the disease, ideally before significant dry eye, vision loss, and physiologic outflow dysfunction occur.
In this issue of Glaucoma Physician, we aim to address knowledge gaps on the topics of sustained-delivery devices, laser therapy, and MIGS in uveitic glaucoma. Thank you for reading and helping to fill the knowledge gaps that stand in our way when it comes to providing the finest possible glaucoma care. GP
