Savak Sev Teymoorian, MD, MBA

During a most unexpected and challenging year, ophthalmic practices are looking for reasons to celebrate.

In glaucoma care, the introduction of minimally invasive glaucoma surgery has allowed us to shift our mindset from being reactive to proactive.

Unforeseen obstacles are an inevitable part of any journey in medicine and in life. Whether we treat them as hurdles or as stepping-stones makes all the difference.

One of the most rewarding aspects of being an adult is watching our children grow up, whether they are our own or those you know closely. Every day the world becomes clearer to them as they learn through experiences. This development is not limited to their mental capacities as their physical maturation can be just as astonishing. We can all relate to the same question when we look at our little ones — “How did you get so tall?” As a glaucoma specialist involved in the evolution of MIGS, I am experiencing the same feelings. The way we manage our patients today doesn’t look the same from just a few years ago. What is even more encouraging is that this situation will continue to improve with the addition and advancement of each MIGS intervention.

If you haven’t remained current with what is going on in the field of glaucoma, then you might have woken up in the eye of the hurricane. It actually started several years ago with a few clouds as selective laser trabeculoplasty was introduced. Among other things, SLT attempted to safely bridge the gap in the treatment paradigm between drops that had compliance issues and gold-standard trabeculectomy and tube shunt surgery that had significant risk. This led to a new breeze in the air with the adoption of Trabectome from NeoMedix. Then came some unexpected thunder bolts with iStent from Glaukos that startled some, causing them to put on their coats.

The concept of “structure vs. function” is commonly discussed in glaucoma. The thinking behind it revolves around the fact that structural changes, including in the optic nerve, occur before functional ones, such as in the visual field. In this setting, it is preferred to note changes in structure early in order to avoid visually impactful losses in function. But is this truly the ideal situation? The response is “no” because even in the best of cases, there is permanent loss of tissue. Our current approach is, therefore, reactive in nature. This thought process makes the management of glaucoma difficult as providers and their patients must simply try to minimize their losses.

The use of cataract surgery in the management of glaucoma, especially as first-line surgical intervention, is gaining rapid momentum for several reasons.

This holiday season may be one of the best ever for glaucoma patients and the doctors who care for them. The FDA approval of the Xen gel stent from Allergan now completes the Triforce for microinvasive glaucoma surgery. For those of you who are gamers and familiar with the Legend of Zelda series, you will naturally understand the importance of this occasion. If you are not one of those people, then let me explain.

The initial therapy for standard of care in glaucoma has been topical drops for a very long time. Although we are constantly working on better ways to deliver medications and perform surgery, primary and adjunctive therapies still depend on eye drops. The major obstacle remains the same: patient compliance and the factors that influence it. It is great having more drop options, especially after prostaglandin analogues. Unfortunately, we all know our patients’ ability to effectively get these in their eyes remains the major limiting step. This occurs for many factors. Dosing regimens for topical medications can be complicated, which is further exacerbated if the patient has other systemic diseases requiring oral drugs. Other factors include the side effects beyond those to the eyes that can be quite serious, including systemic, and the inability to effectively apply eye drops.

Over the past few years, the momentum for microinvasive glaucoma surgery has rapidly increased. However, the practical application has been different from the theoretical one in the U.S. This is due to having the Glaukos iStent be the only FDA-approved stent available for use in patients with other options in the pipeline. Now with the approval of the Alcon CyPass, the practical landscape is approaching the theoretical one. The availability of CyPass along with iStent will continue to transform the way surgeons think not just about MIGS but also glaucoma surgery in general. At first glance the addition of CyPass to a surgeon’s armamentarium appears to be another choice in the MIGS space, but a deeper examination into this event reveals three major effects.