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.
Lessening Glaucoma Treatment Burden: Clinical Cases (Part 2)
Lessening Glaucoma Treatment Burden: Clinical Cases (Part 2)
Welcome to CME on ReachMD. This episode is part of our MinuteCME curriculum.
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Hi, this is CME on ReachMD, and I’m Dr. Davinder Grover. We’re going to talk about, now, about the MIGS approach and really individualizing a patient’s care, and I want to show some examples of clinical cases where I’ve really kind of found that these MIGS devices have been very appropriate for patients.
So case Number 1 is a 75-year-old male with a visually significant cataract, and he has mild glaucoma. He has definitely thinning on the inferior rim of his optic nerve, and he has just a mild nasal step on visual field, with a mean deviation of -3.5 dB. His IOP [intraocular pressure] is 20 mmHg on 2 antiglaucoma medications, and my goal is to get him around 17 on 1 drop. He’s had a prior SLT [selective laser trabeculoplasty] which had a pretty good response, and he’s been on glaucoma drops for about 4 years. He’s also on blood thinners, and he needs to stay on them for Afib. On exam, in addition to his mild glaucoma and his optic neuropathy, he has wide open angles with well-defined structures and landmarks. And he’s also relatively active and he still exercises on a regular basis. Given his need for blood thinners, as well as his stage of glaucoma and his active lifestyle, I chose to perform a Hydrus implant as opposed to a goniotomy or a trabeculotomy given the risk of a high – recurrent hyphema. His case went well, and during the surgery I could visualize the entire Hydrus implant in the canal, for the entirety of the length. Postoperatively, he had a very fast visual recovery and physical recovery. He did not have a postoperative hyphema. I treated him on antibiotics and steroids, as I would for routine cataract surgery, with the exception that he was on topical steroids for maybe an additional week. He is now over a year out, and his IOP has been well controlled, in the mid-teens, on 1 prostaglandin drop at night.
Now the second case I want to highlight is an 82-year-old female, with moderate to advanced glaucoma. She has previously undergone cataract surgery and a goniotomy a few years ago, but her IOP has been slowly increasing. My goal for her is to be under 15 on as few medications as possible. Her IOP is 18 on 4 agents, and I’ve detected, just over the last couple years, a slow decline in her nerve fiber layer on OCT, and her family tells me they’re concerned that she may not be getting her drops in as frequently because she’s just not as compliant as she has been lately.
The patient does report that her eyes are getting a little red and irritated, and they’re drying them out. She has definitive glaucoma on her visual field. She has a mean deviation of -8, and a dense nasal step as well as a mild inferior arcuate defect. She’s had, prior, 2 SLTs previously, and as I mentioned, a phaco goniotomy. Her conjunctiva superiorly is very mobile, and given my goal for IOP in the low teens, as well as trying get her off as many drops as possible, I opted for an ab interno, close conj, XEN-45 Gel Stent, and I used 40 μg of mytomycin C. The technique that I used is really, I’ve described as kind of the POST technique, where while after I implant the XEN, I sweep away the Tenon’s, essentially kind of doing a primary needling on the table, with a microshunt spatula. And that’s been reported by a couple of different groups. She tolerated the procedure well. Given her prior goniotomy, she did have a little micro-hyphema on postoperative week 1, but it resolved pretty quickly, and on post-op day 1, her pressure was a 7, her anterior chamber was formed and deep, and her vision was actually unchanged. I treated her with topical antibiotics and steroids, similar to what I would do for a cataract surgery, but I tapered her steroids over a 5-6 week period. After about 10-14 days, she was able to return to her normal activity. She is now over 18 months out. Her pressure is around 12, on 1 drop of timolol in the morning, and she thankfully has a nice, diffuse low bleb that’s mildly vascularized.
You know, I think these 2 cases exemplify kind of how we’re now able to tailor the surgery to the patient’s lifestyle, their disease state, their comorbidities, their blood thinner status, and their activity. And that’s the exciting time – it’s an exciting time to be a glaucoma doctor. We have a lot of options, and we’re truly able to intervene the way we need to, and it’s much safer than it was 20, 30 years ago, when all we had were trabs and tubes.
Again, this is Davinder Grover. Thank you for tuning in, and 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.
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This activity is supported by independent educational grants from AbbVie, Inc and Alcon.
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