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BLOG: Do MIGS early and often
This is an exciting year for glaucoma. We have not only seen the approval of Bausch + Lomb’s Vyzulta (latanoprostene bunod ophthalmic solution 0.024%) and Aerie’s Rhopressa (netarsudil ophthalmic solution 0.02%), but before the end of the year we are likely to see at least one more glaucoma MIGS implant become FDA approved — the Hydrus from Ivantis.
New drug options are fantastic, especially when they involve a new drug class. Rhopressa in particular broadens our therapeutic treatment options with a new and quite effective class that may well replace beta-blockers as second-line therapy.
But the more I practice, the more I become convinced that glaucoma should be treated as a surgical disease. The world’s best drugs do little good if the patient does not use them, and we know that poor compliance happens 50% of the time. Until we have new drug options that do not depend upon patient effort, surgery will be a more logical first choice.
In the U.K., trabeculectomy as first-line therapy has been widely practiced for more than a decade. Today, we do not need such an invasive surgery to lower pressure significantly and permanently. Trabecular bypass with the iStent (Glaukos), trabeculotomy with the Trabectome (NeoMedix), the Trab 360 instrument (Sight Sciences) or the Kahook dual blade work extremely well. Ciliary bypass with the Alcon CyPass device works well, and for challenging cases, drainage into the subconjunctival space with the Allergan Xen stent is approved. Newer-generation devices, such as the iStent inject and the Hydrus implant, both soon to be approved, give us even more effective treatment options.
And we know that cataract surgery alone, which is required to perform most of these above stents, reduces pressure significantly and in a sustained way.
Many cataract surgeons believe — and many glaucoma specialists agree — that the first question to ask when a patient is newly diagnosed with glaucoma is whether the patient has any degree of cataract. If so, removal of the cataract and performance of MIGS is a very appropriate first step. The clinical evidence in favor of this approach is clear. There is a reasonable reimbursement pathway, and after surgery, compliance is no longer part of the picture. Furthermore, the long-term toxicity of drugs, which has caused blindness in many patients with chronic “controlled” glaucoma, also is a nonissue.
It’s a triumph that we have these new drugs (and more coming) available to treat our patients, but I’m even more excited about the difference we can make with the growing list of options for MIGS for permanent and drama-free treatment of glaucoma.
Disclosure: Hovanesian reports he is a consultant to Glaukos, Ivantis, Alcon and Sight Sciences.