This article is more than 5 years old. Information may no longer be current.
Elective patient-pay glaucoma surgery may be on verge of popularity
Click Here to Manage Email Alerts
 Richard L. Lindstrom |
A decade ago, for us to describe most techniques of glaucoma surgery as minimally invasive would truly have been an oxymoron.
Of course, argon laser trabeculoplasty and selective laser trabeculoplasty are surgical procedures and they are minimally invasive, but the classic trabeculectomy with mitomycin C and tube shunt, whether Molteno, Baerveldt or Ahmed, is much more invasive when compared with modern cataract surgery. The recent Tube vs. Trabeculectomy Study demonstrated potentially sight-threatening complications in 30% to 50% of patients, much higher than the less than 5% numbers familiar to the cataract surgeon.
The classical indications for tube shunts or trabeculectomy remain glaucoma damage progression in the face of maximally tolerable medical therapy. This indication generates fewer than 200,000 procedures a year in the U.S. But there are several other interesting indications waiting for a less invasive glaucoma procedure.
First and foremost is the patient with combined cataract and glaucoma or ocular hypertension. Evaluation of the Medicare database suggests that as many as 20% of patients who undergo cataract surgery also have glaucoma or ocular hypertension as a comorbidity. While cataract surgery alone is capable of lowering IOP significantly, if a glaucoma device that generated a greater reduction in IOP could be implanted at the time of cataract surgery with minimal to no additional risk, another 600,000 potential procedures a year could be added in the U.S. alone, and nearly 4 million worldwide.
In addition, the baby boomer generation that drove the corneal laser refractive surgery boom is now entering the age in which glaucoma becomes more prevalent. Many of them hated being dependent on devices such as glasses and contact lenses enough to undergo surgery, and they will likely detest glaucoma drops as much or more. With minimally invasive glaucoma surgery, or MIGS as coined by Dr. Ike Ahmed, we might become bold enough to offer these patients surgery as an alternative to drops, even when drops are medically effective.
The decision to have surgery would be a lifestyle/quality-of-life vs. cost-value analysis, similar to the decision made by the patient who opts for LASIK or refractive lens exchange to overcome their dependence on glasses. Such a glaucoma surgery is not medically indicated, so third-party payers such as Medicare would not be expected to provide reimbursement. The responsibility to pay the costs would rest with the patient or their family, just as they do for refractive surgery.
This concept of elective patient-pay glaucoma surgery to reduce dependence on glaucoma medications makes nearly every glaucoma patient a potential surgical candidate. Elective patient-pay glaucoma surgery might seem far fetched to some. But the safety data from several emerging technology glaucoma device companies make me brave enough to predict that in a decade, elective patient-pay glaucoma surgery performed as an office-based procedure could challenge corneal refractive surgery as the second most common incisional surgical procedure performed by the comprehensive ophthalmologist.