Glaucoma care remains patient-focused
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Modern glaucoma care is all about the patient, according to a speaker at the American Glaucoma Society meeting.
Andrew G. Iwach, MD, said specialists look at metrics such as IOP, number of medications and visual field change to determine the success of a patient’s glaucoma treatment. However, patients perceive success in a different way.
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“The FDA is trying to look at different metrics, particularly with MIGS, because IOP doesn’t fully capture their benefit,” he said during the Glaucoma Surgery Day Lecture. “The real voice in all this is the patient. We are essentially subcontractors. Medicare is the general contractor, but the customer is the patient, so we need to empower them and educate them.”
Since 1995, the number of glaucoma cases has gone up, but the use of trabeculectomy has gone down due to the introduction of microincision glaucoma surgery devices. Since 2014, iStent (Glaukos) and later Hydrus (Alcon) have been the leaders in glaucoma care, he said.
It has also become common for MIGS procedures to be done at the same time as cataract surgery. While less severe cases may benefit from cataract surgery alone, more advanced disease may benefit from the Hydrus, the Omni (Sight Sciences) or a modified goniotomy, Iwach said.
“The incremental additional risk of doing a MIGS procedure is relatively small,” he said.
Iwach also discussed how he and his team have come up with a coordinated plan for glaucoma drainage devices.
First, they make a slightly larger conjunctival incision to identify muscle location before placing the plate. Then, they get the plate at least 8 mm posterior to the limbus, which they feel reduces the risk for diplopia. A 30-gauge needle is used to place the initial track in the right position before moving to a larger needle.
The final step is where to put the tube. Iwach said he started placing the tube more posterior in the anterior chamber because he was concerned about the cornea.
“When we’re talking about where to put the tube, I think there are different options,” he said. “What works in your hands? Interestingly, in our experience ... when the tube is up against the iris, it’s surprisingly well tolerated.”
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Iwach AG. Glaucoma management 2024: It’s all about the patient. Presented at: American Glaucoma Society meeting; Feb. 29-March 3, 2024; Huntington Beach, California (hybrid meeting).
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