In 2014, ophthalmologists championed further refinements in minimally invasive glaucoma surgery (MIGS) and learned how these procedures can best be applied. Learning where iStent (Glaukos) fits into the surgical management of mild to moderate glaucoma has been a continual process. The most exciting thing about the iStent in 2014 is that surgeons are now using our own data instead of relying only on the FDA pivotal trial data1 to refine patient selection.
EMERGENCE OF TWO TRENDS
I do not believe that we will see major changes over the next year in glaucoma medical therapies. Regarding surgery, however, I think two trends will continue to emerge.
Customized MIGS. We will continue to see an upward trend in the use of the iStent and other MIGS devices. Many surgeons, both general ophthalmologists and glaucoma specialists, have had exposure to MIGS as a direct result of the iStent approval. It should be noted that we have been using the MIGS approach for many years. Devices and procedures such as the Trabectome (NeoMedix) and endoscopic cyclophotocoagulation (ECP; Endo Optiks) have long track records of success and safety and are associated with less collateral damage and enhanced safety profiles compared with more traditional filtration surgeries. I believe the increased exposure to the MIGS concept that accompanied the approval of the iStent will also increase adoption of ECP and Trabectome in the coming year and beyond. The fact that we now have several MIGS devices available will also allow us to customize glaucoma surgery as never before.
Combined procedures. Another area that is poised to have a bigger role in glaucoma management in 2015 is minimally invasive combined procedures. The classic example would be a patient referred with uncontrolled glaucoma despite both maximum medical therapy and laser treatment and with a visually significant cataract. The typical next step would be to combine trabeculectomy or implantation of an Ex-Press glaucoma shunt device (Alcon) with cataract surgery. But now we can take one step back and do a less invasive procedure: cataract surgery with iStent implantation, cataract surgery with ECP, or cataract surgery with Trabectome (eyetube.net/?v=lofro Figure 1).* Any of these combinations may postpone the need for filtration surgery and the risks it entails. We may also see new devices coming on the market during 2015 that will allow physicians to become even more comfortable with less invasive combined approaches to glaucoma treatment such as the Dual Blade goniotomy device (New World Medical) and perhaps the Xen full-thickness filtration device (AqueSys).
*Video and Figure 1 are courtesy of Nathan Radcliffe, MD
Malik Y. Kahook, MD, is the Slater Family Endowed Chair in Ophthalmology; Vice Chair, Clinical and Translational Research; and Director, Glaucoma Service and Glaucoma Fellowship, for the Department of Ophthalmology at the University of Colorado School of Medicine in Aurora. Dr. Kahook states that he is a consultant to Alcon, Allergan, Aerie Pharma, Glaukos, and Ivantis and has patents licensed to Glaukos, Oasis, Abbott Medical Optics, ClarVista Medical, Mile High Ophthalmics, ShapeTech, and ShapeOphthalmics. He may be reached at tel: +1 720 848 2020; e-mail: email@example.com.
- Glaukos iStent Trabecular Micro-Bypass Stent (Models: GTS-100R, GTS-100L) and Inserter (GTS-100i) - P080030. Issued June 25, 2012; updated July 16, 2012. US Food and Drug Administration. http://www.accessdata.fda.gov/scripts/cdrh/ cfdocs/cftopic/pma/pma.cfm?num=P080030. Accessed November 11, 2014.