First-line treatment for glaucoma is typically pharmacologic and aimed at lowering intraocular pressure, which is the only modifiable risk factor to date. However, successful treatment with traditional topical glaucoma medications may be limited by their well-known barriers of adverse effects and poor patient adherence to drop instillation. Tune in to hear Dr. Qi Cui and Dr. Davinder Grover discuss the novel pharmacological therapies and minimally invasive glaucoma surgery procedures that can lower treatment burden and increase compliance.
Advances in Glaucoma Treatment: MIGS (Part 2)
Advances in Glaucoma Treatment: MIGS (Part 2)
Welcome to CME on ReachMD. This episode is part of our MinuteCME curriculum.
Prior to beginning the activity, please be sure to review the faculty and commercial support disclosure statements as well as the learning objectives.
Hi, this is CME on ReachMD, and I’m Dr. Davinder Grover. We’re going to talk today about some of the microshunts.
So there are a lot of different stenting options for blebless MIGS procedures, and let’s take a look at them, the iStent and the Hydrus Microstent. First, we’ll talk about how they work. Now when we talk about the iStent, there is the iStent inject W and the iStent infinite. Now interestingly, they’re both exactly the same, as far as what they look like. They have you know, a flange that’s 360 µm, and they have 4 outflow pathways on the side, and then an inner diameter of 80 μm. The difference is really the platform of delivery and the indication. So the iStent inject W is 2 stents on a preloaded injector, and it’s indicated to be used in combination with cataract surgery, whereas the iStent infinite is 3 of the same exact stent, preloaded, but there’s an infinite number of clicks. And this is the first FDA-cleared device for standalone trabecular bypass. Not really tied to cataract surgery or disease state. Now at 2 years for the iStent inject at 24 months, 75.8% of treated eyes, versus 61.9% of control eyes had a 20% reduction from baseline IOP [intraocular pressure]. And 63.2% of treated eyes versus 50% of control eyes were free of medications at 24 months. And interestingly, when you look at the 5-year outcomes of the iStent inject W, there were really no significant concerns about endothelial cell loss.
Now the infinite was done in a more refractory group. This study showed there were 72 eyes in 72 patients, with a mean preoperative IOP of 23.4 mmHg on 3.1 meds. 61 of these eyes had failed prior surgery, whereas 11 eyes were uncontrolled on a max medical therapy. A total of 76.1% of the enrolled patients met the endpoint, which was a greater than or equal to 20% reduction in mean IOP on the same or fewer medications. Now 53% of these eyes had a greater than 30% reduction in mean IOP without any additional surgical interventions, and the safety was favorable with no real concerns. This is impressive for a refractory group of patients.
So now let’s talk about the Hydrus implant. Now this is an 8-mm nitinol implant. And the HORIZON trial, which I’m going to talk about, had 360 eyes that randomized to the Hydrus microshunt and 187 eyes that were cataract surgery only. And 5-year follow-up was completed with 80% of patients, and at 5 years, the Hydrus group had a higher proportion of eyes with an IOP of 18 mmHg or less without medication than the cataract group – it was 49.5% compared to 33.8% – and a greater likelihood of IOP reduction of 20% or more without medications than the cataract surgery alone group. And the number of glaucoma medications in the Hydrus group at that timepoint was 0.5 meds, versus in the control group was 0.9 meds. The cumulative risk of incisional glaucoma surgery was lower in the Hydrus group – 2.4% compared to 6.2% – and there was really no significant difference, all the way from 3 months to 60 months, in terms of endothelial cell health. So, you know, it was also quite impressive as far as safety is concerned.
Now the study showed that the addition of the Schlemm’s canal microstent – that’s this Hydrus implant – in conjunction with cataract surgery was safe in lowering medication use and IOP, and also reducing an eye’s need for incisional glaucoma surgery. And this is 5-year data, so it’s quite impressive.
So in conclusion of the whole microshunt group – the iStent and Hydrus discussion – both groups helped accomplish a couple things, both studies did. The goal was decreasing a patient’s dependence on glaucoma drops and modestly decreasing their IOP compared to the control group with cataract surgery. So these were relatively long-term studies demonstrating safety and long-term endothelial cell health. So both very promising and showing some quite high success rate and safety in both these microshunts.
So thank you again for tuning in. This has been CME on ReachMD.
You have been listening to CME on ReachMD. This activity is provided in partnership with the National Eye Institute of the National Institutes of Health, of the U.S. Department of Health and Human Services along with Prova Education, and is part of our MinuteCME curriculum.
To receive your free CME credit, or to download this activity, go to ReachMD.com/Prova. Thank you for listening.
In accordance with the ACCME Standards for Integrity and Independence, Global Learning Collaborative (GLC) requires that individuals in a position to control the content of an educational activity disclose all relevant financial relationships with any ineligible company. GLC mitigates all conflicts of interest to ensure independence, objectivity, balance, and scientific rigor in all its educational programs.
Qi Cui, MD, PhD
Assistant Professor of Ophthalmology
University of Pennsylvania
No relevant relationships reported.
Davinder S. Grover, MD, MPH
Glaucoma Specialist, Ophthalmologist
Glaucoma Associates of Texas
Fort Worth, TX
Advisory Board: CATS Tonometer, iSTAR Medical, Sanoculis, Versant Health
Consulting fees: Allergan, New World Medical, Nova Eye Medical, Olleyes, Reichert, Sanoculis
Research: Allergan, New World Medical
- Stephen Chavez has nothing to disclose.
- Cindy Davidson has nothing to disclose.
- Elizabeth Lurwick had nothing to disclose.
- Andrea Mathis has nothing to disclose.
- Colleen Resnick has nothing to disclose.
- Robert Schneider has nothing to disclose.
- Stephanie Wenick, MPhil, has nothing to disclose.
After participating in this educational activity, participants should be better able to:
- Describe topical therapies and sustained-release formulations of antiglaucoma medications that may improve patient adherence
- Recognize minimally invasive glaucoma surgery (MIGS) uses and indications
- Evaluate clinical data of recently approved topical therapies, sustained-release formulations of antiglaucoma medications, and MIGS for patients with early- to moderate-stage glaucoma
- Implement strategies to individualize therapy for patients with early- to moderate-stage glaucoma
This activity is designed to meet the educational needs of ophthalmologists and optometrists.
In support of improving patient care, Global Learning Collaborative (GLC) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.
Global Learning Collaborative (GLC) designates this enduring activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Global Learning Collaborative (GLC) designates this activity for 1 nursing contact hour. Nurses should claim only the credit commensurate with the extent of their participation in the activity.
Prova Education designs and executes continuing education founded on evidence-based medicine, clinical need, gap analysis, learner feedback, and more. Our mission is to serve as an inventive and relevant resource for clinical content and educational interventions across a broad spectrum of specialties.
Prova Education's methodology demonstrates a commitment to continuing medical education and the innovative assessment of its effects. Our goal is clear—to develop and deliver the very best education in the most impactful manner and to verify its results with progressive outcomes research.
This activity is supported by independent educational grants from AbbVie, Inc and Alcon.
The views and opinions expressed in this educational activity are those of the faculty and do not necessarily represent the views of GLC and Prova Education. This presentation is not intended to define an exclusive course of patient management; the participant should use his/her clinical judgment, knowledge, experience, and diagnostic skills in applying or adopting for professional use any of the information provided herein. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients’ conditions and possible contraindications or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities. Links to other sites may be provided as additional sources of information. Once you elect to link to a site outside of Prova Education you are subject to the terms and conditions of use, including copyright and licensing restriction, of that site.
Reproduction of this material is not permitted without written permission from the copyright owner.
Our site requires a computer, tablet, or mobile device and a connection to the Internet. For best results, a high-speed Internet connection is recommended (DSL/Cable/Fibre). We also recommend using the latest version of your favorite browser to ensure compliance with W3C standards, such as Chrome, Safari, Firefox, or Microsoft Edge.