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Bringing MIGS to the developing world
Encouraging results were reported after the Hydrus microstent was implanted in glaucoma patients in Ghana.
by Alan S. Crandall, MD, Roger C. Furlong, MD, Garry P. Condon, MD, and Angelina Ampong, MD
It can be easy to forget sometimes how readily available ophthalmology clinics and services are in the Western world, but many regions of the world are without easy access to eye care, have populations that cannot readily afford medication for chronic conditions such as glaucoma, and have low patient compliance with medical advice because of these socioeconomic issues. Such is the case in Ghana, where some research authorities consider glaucoma a “surgical disease” because surgery is thought to have more favorable outcomes in controlling IOP and medications may be cost-prohibitive for some communities and families. Estimates say almost 30% of Ghanaians live below the international poverty line of $1.25 per day.
Many people who go blind from glaucoma in Ghana are still of working age, and for every blindness attributed to glaucoma, 2.2 people are no longer able to contribute to the economy of the village — the blind patient and that patient’s caregiver, often a young female relative. Yet most African governments do not place ophthalmic care as a priority in their health care budgets. As much as 10% of some African nations’ populations have an aggressive form of glaucoma — most of whom are younger when visual field defects occur than people in other regions. We consider one of the biggest challenges in these low-income countries is a lack of options to treat glaucoma.
For more than 20 years, physicians at the Moran Eye Center have worked with native Ghanaian physicians to teach the latest surgical techniques and to sponsor visits to the U.S. for advanced training. In late 2016, the four of us worked together at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, to bring minimally invasive glaucoma surgery to KATH as a new method to treat glaucoma. The U.S.-based surgeons were there for a full week, and the Ghana-based group prescreened patients so that the maximum surgical procedures could be performed. Some of our potential MIGS candidates had previously undergone surgical interventions or were on maximal medical therapy — in other words, these were challenging cases, with half of the patients in advanced stages of glaucoma.
KATH outreach
In a region such as Ghana where patients have limited transportation options, conventional glaucoma surgery presents numerous challenges for the patient and surgeon alike; follow-up is likely difficult, and therefore, monitoring for disease control and/or complications is almost impossible.
MIGS devices may be the answer, presuming they are effective and safe enough. Using these would be a more appropriate step than doing nothing for patients or prescribing medications they cannot afford. MIGS devices allow the postop follow-up care to be mostly insignificant; these devices work based on the insertion and the nature of the device and not on rigorous postop care.
We worked with Ivantis to use its Hydrus microstent in Ghana. We felt confident that patients were not under undue risk because of the experience that we have had using this device in Haiti and the Dominican Republic, among others. In the U.S., this device is under evaluation for those with mild or moderate glaucoma and concurrent cataract, but in Ghana, we did not stratify patients along those lines.
We looked at the socioeconomics: Can patients return for follow-up? What access do they have to medications? We used this as an opportunity to gain experience with the device implantation techniques as well. For those patients who had severe glaucoma, we did perform more invasive procedures. Ultimately, we want to prevent glaucoma-induced blindness, but in the real world, even delaying blindness for 5 to 10 years is a huge improvement.
Another advantage with this type of surgery is that there is no need for specialized equipment. An understanding of ocular anatomy and a good microscope are really all that is necessary.
Surgery and outcomes
Overall, we took 24 Hydrus devices to Ghana. The Hydrus is an intracanalicular scaffold comprised of nitinol, a superelastic biocompatible alloy. The device is designed to be inserted into Schlemm’s canal; the 3 clock hours of scaffolding and canal dilation provide access for aqueous to multiple collector channels.
We treated 15 patients, seven binocularly and some as stand-alone procedures. We successfully implanted 22 devices with five different users over 4 days of surgery. As with other MIGS devices, ensuring good visualization will be crucial to successful implantation. Using the newest microscopes with variable tilting will also help reduce learning curves.
Initial results have been highly encouraging. Preoperatively, most of these patients had IOPs ranging from the mid-30s to about the 40 mm Hg range. At 1 month, about one-third of the patients had IOPs in the low teens without topical medication. We surgeons underwent Hydrus video and wet-lab training just before performing surgery. (Alan Crandall is the principal investigator in the U.S. for the Hydrus HORIZON study and was previously trained.) For those of us without prior experience in the U.S., we were pleasantly surprised that the implantation was intuitive even in these challenging cases, and there was simple visual confirmation of stent placement relative to other canal procedures.
Lessons learned
We are in unison when we say this was an incredible learning experience. The people of Ghana were overly welcoming, and the surgeries themselves were successful.
Devices such as the Hydrus are continuing to radically transform the kind of treatment we can provide patients, and that may be even more relevant in regions of the world where travel to facilities is difficult at best.
On the U.S. side, we cannot overemphasize firsthand the challenges these patients and doctors experience in a country such as Ghana, where access to the latest technologies and devices is not readily available. It made us appreciate how fortunate we are, and to be able to give some of that back to surgeons who work under much leaner conditions was, and will continue to be, rewarding for years to come.
Editor’s note: Alan S. Crandall, MD, recently received the inaugural Chang Humanitarian Award at the American Society of Cataract and Refractive Surgery meeting.
For more information:
Angelina Ampong , MD, can be reached at email: lina_ampong@hotmail.com.
Garry Condon, MD, can be reached at email: garrycondon@gmail.com.
Alan S. Crandall, MD, can be reached at email: alan.crandall@hsc.utah.edu.
Roger C. Furlong, MD, can be reached at email: roger@furlong.org.
Disclosures: The authors report no relevant financial disclosures.