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Technologies under investigation will transform glaucoma surgery
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 Richard L. Lindstrom |
The proliferation of new surgical approaches for the treatment of glaucoma under study today around the world is nothing short of amazing. The combination of bright clinicians working together with well-funded companies and entrepreneurs is again proving its ability to tackle complex clinical problems and provide improved solutions.
We must all remember as health care reform advances that anything that negatively affects this “innovation cycle” will have a significant negative impact on physicians and patients by reducing our future ability to treat potentially blinding diseases such as glaucoma. In the glaucoma field, this investment of brains and dollars is on its way to giving us a much safer and more effective surgical toolbox for the treatment of glaucoma.
In the U.S. today, most of us start with medical therapy, usually beginning with a prostaglandin analogue. In a patient with a preoperative pressure of 25 mm Hg, we can usually anticipate about a 5 mm Hg to 6 mm Hg drop. The addition of a second and third drop can often increase this pressure reduction another 2 mm Hg to 4 mm Hg. Unfortunately, with even one drop a day for therapy, as many as one-third of patients demonstrate poor compliance, and adding another drop or two reduces compliance to less than 50%. Thus, even when medical therapy can be effective, it often is not because patients simply do not take their drops. In addition, the expense to many is a significant handicap.
It is the rare patient who would not gladly accept the option of a surgical “cure” if it were safe, effective and long-lasting. Unfortunately, our classical procedures of trabeculectomy and tube shunt, while quite effective, fall short in safety and in many cases do not generate a long-term pressure reduction. It is quite exciting to imagine the day when we can honestly offer our surgical patients a procedure that is as good an option for the glaucoma patient as LASIK is for the patient looking for an alternative to glasses or contact lenses.
Of special interest to me is the patient with combined cataract and glaucoma or ocular hypertension. Each year in America, 3.2 million patients undergo cataract surgery, and 10% to 15% of them have glaucoma or ocular hypertension as well. In the world, 15 million undergo cataract surgery each year. This makes management of the patient with combined cataract and glaucoma a very common occurrence for the comprehensive ophthalmologist.
Recent studies by several authors have confirmed that phacoemulsification combined with a posterior chamber lens implant may represent a treatment for glaucoma that is safe, effective and durable. Patients who undergo cataract surgery and utilize one drop postoperatively can anticipate a pressure reduction of 6 mm Hg to 10 mm Hg. In addition, several of the new technologies being studied appear capable of producing an even lower pressure with less dependence on continuing medical therapy with minimal increase in postoperative complications.
My expectation is that cataract and glaucoma surgeons will enthusiastically adopt these new minimally invasive glaucoma procedures initially in their patients with combined cataract and glaucoma. Once they prove safe, effective and durable in their ability to lower IOP, I predict many of these same surgeons will find themselves offering these procedures to glaucoma patients who simply want to reduce their dependence on medical therapy. If so, minimally invasive glaucoma surgery will be offered routinely as an alternative to medical therapy, much like LASIK is offered for those looking for an alternative to glasses and contact lenses. I am convinced that one or more of the technologies now under development will transition us into this new era, much to the benefit of patients and surgeons alike.