EyeWorld/ASCRS reporting live from Hawaiian Eye 2020 in Kauai, Hawaii, Wednesday, January 22, 2020


EyeWorld/ASCRS reporting live from Hawaiian Eye 2020 in Kauai, Hawaii, Wednesday, January 22, 2020
Sessions on Wednesday’s program focused on glaucoma topics.
Approaching new patients

Kicking off the first session, Nathan Radcliffe, MD, New York, New York, shared his approach for the initial glaucoma patient visit, noting that “you can’t just jump to laser; you have to examine the patient.”

Generally, when patients first come in, they are wondering if they’ll go blind, Dr. Radcliffe said. It’s the ophthalmologist’s job to try to prevent that. The surgeon often wonders if the patient will need surgery, which we’re also trying to prevent, he said.

Dr. Radcliffe sees patients referred to him from a variety of other physicians, and questions from other doctors can vary from “Can you handle this patient?” to “I want you to do this procedure.” Dr. Radcliffe’s general rule is that a patient with glaucoma should be managed by a single glaucoma specialist. The goal of the first visit, he said, is to provide hope and excellent care.

Moving forward, you need to understand the disease duration, velocity, baseline IOP, and prior medical, laser and surgical treatments, Dr. Radcliffe said. In terms of history, there’s so much that it’s hard to cover it all, he said. One thing to look out for is a brimonidine allergy. Patients also have trouble knowing what laser they’ve had, he said, and if they’ve had a bad response to drops/surgery, it will come up. He stressed the importance of “no visit without prior records,” because you could be making the same mistakes as the past.

Dr. Radcliffe mentioned a number of risk factors to consider, including age, hysteresis, if a family member is blind, if they are blind in one eye, and if they have an eye with superior or inferior field loss. Every eye drop allergy/intolerance dramatically increases the risk of needing surgery, Dr. Radcliffe said, adding that you may want to consider re-challenging some medication intolerances and re-challenging “med non-responders.”

Glaucoma may be under staged and determining the disease velocity can often be difficult because of limited data, Dr. Radcliffe said.

He then stressed several key things not to miss: angle closure, endothelial disease, brimonidine allergy, and exfoliation. Angle closure, he said, is the “most consequential thing one can miss.” It is also very common in cases of escalating glaucoma that are not responsive to maximal therapy, he said.

Determining the appropriate medical management is also important. Dr. Radcliffe said he will hear from a lot of patients that they tried something and it didn’t work, but it’s important to really know what they have tried and give it the appropriate time to work. SLT is a first line therapy, he said, and although he finds that pilocarpine is rarely used by other doctors, for Dr. Radcliffe, “it’s a go-to.”

Editors’ note: Dr. Radcliffe has financial interests with a variety of ophthalmic companies.

Cornea considerations in glaucoma surgery

Preeya Gupta, MD, Durham, North Carolina, shared some information on important cornea considerations in glaucoma, highlighting both ocular surface disease and the corneal endothelium.

Glaucoma management causes dry eye and ocular surface disease (OSD), she said. Both medications and surgery can disrupt the surface.

OSD has a real impact in glaucoma management, she said, and has significant impact on vision quality and visual function. It can also negatively impact drop compliance.

Dr. Gupta highlighted several modern therapies that may reduce OSD, including preservative-free glaucoma medications, SLT, and MIGS as a standalone procedure or combined with cataract surgery. Future options could include a drug delivery implant.

The corneal endothelium is another consideration, Dr. Gupta said. The purpose of the endothelium is to keep the cornea clear, she said, but it does not regenerate, and many things can damage it (including glaucoma surgery). For endothelium surveillance, Dr. Gupta mentioned pachymetry, slit lamp examination, and specular microscopy all as viable options. Monitoring endothelial cell count is important, particularly in those post-glaucoma surgery who may be at risk for endothelial cell loss, but there is currently no firm consensus on the use of endothelial cell count monitoring, Dr. Gupta said. With new technologies, ophthalmologists will want to determine how to best follow these patients, she said.

Editors’ note: Dr. Gupta has no relevant financial interests.

Complex cases in glaucoma

During a video session, Brian Francis, MD, Los Angeles, California, shared some of the lessons learned from a complex case of recurrent UGH syndrome, which he treated over numerous visits.

The patient was a 62-year-old male who had cataract surgery 12 years prior. He had a sudden decrease in vision and an in-the-bag IOL dislocation. The patient was also on warfarin blood thinner.

In these cases, Dr. Francis would usually perform in-the-bag suture fixation of the IOL/bag complex. In this case, he performed a vitrectomy and removed the capsule and lens material. He sutured a 3-piece IOL to the iris. The patient had postop hypotony that just wouldn’t go away. Dr. Francis injected viscoelastic and intravitreal steroid. The pressure went up to the 50s and wouldn’t come down, he said. Dr. Francis then did trabeculectomy without mitomycin to try to get the pressure down.

But the vitreous hemorrhage kept coming back, Dr. Francis said. He did UBM and noted that because the patient had high myopia, he might be more at risk for a floppy iris.

Dr. Francis’ removed the iris sutured IOL and placed a scleral sutured IOL more posterior to the iris. Though the vision improved to 20/50, the patient came back again with a recurrent hemorrhage problem 2 weeks later.

With exploration in the back of the eye, Dr. Francis discovered that there was a piece of the iris fixated IOL left in the eye, so after taking it out, he thought this would resolve the recurrent hemorrhage.

But 1 week after the patient restarted his medication (warfarin), the hemorrhage returned, and vision dropped.

Ultimately, Dr. Francis recommended the patient get off his blood thinner, and he got a device to address this (the WATCHMAN device, Boston Scientific). The patient’s vision eventually returned to 20/40.

Editors’ note: Dr. Francis has financial interests with a variety of ophthalmic companies.

Glaucoma debates

The final session of Wednesday’s glaucoma program featured debates on a variety of topics. Christine Larsen, MD, Minneapolis, Minnesota, and Dr. Radcliffe debated between using medication or SLT as an initial therapy.

Dr. Larsen said she would show why using medication as the first-line treatment is still the standard of care. She acknowledged results of the LiGHT trial, which she said has potential to change practice patterns for some physicians, but she also reminded the audience that “we practice glaucoma in the real world and need to consider the patient population outside of the confines of a highly standardized study.”

The study initially included more than 16,000 patients, she said, with only 718 eventually enrolled, the vast majority excluded because they were not a candidate for SLT or had been treated for other ophthalmic diseases. So, can we really extrapolate that data to everyday practice?

Dr. Larsen said she advocates for medication first because there are some laser-related risks and complications. Though the risk of complication is low, no procedure is without risk, she said. Adverse events noted in the FDA trial for the laser include anterior chamber inflammation, pain/discomfort, redness, and IOP elevation. Furthermore, some other possible (though unlikely) complications could include choroidal effusion, hyphema, macular edema, and more.

There are also efficacy concerns, she said. The typical first-line prostaglandin analog (PGA) treatment vs. SLT treatment is relatively equivalent based on similar trials, Dr. Larsen said. But is laser enough to reach target IOP for the long term? Dr. Larsen argued that the effect of the laser can wear off over time.

On the other side of the issue, Dr. Radcliffe said that “SLT is the only reasonable way to initiate glaucoma therapy.”

He brought up several problems with drops: drops cause dry eye; nobody takes them; patients miss when they try; when drops work, they cause side effects; and they don’t seem to work.

Meanwhile, he said there is ample evidence for SLT as a primary and secondary therapy in the treatment of glaucoma. Both patients and surgeons can benefit, he said.

The risk of glaucoma surgery is infinitely higher after medications than after SLT, he said.

Dr. Radcliffe also questioned if you’re really “choosing” drops. With drops, there are many people affecting the drops actually getting to the patient. The physician can prescribe the medication, he said, but then the drug plan and pharmacist also come into play, as do the patients and their caregivers who decide whether to fill the prescription and then ultimately whether or not to take it.

With SLT, the process is simple, he said. The physician makes the recommendation, and the therapy is delivered. So many things can go wrong with drops, Dr. Radcliffe said, but SLT is much more straightforward.

Editors’ note: Dr. Larsen has financial interests with Allergan and Aerie. Dr. Radcliffe has financial interests with a variety of ophthalmic companies.

EyeWorld Onsite is a digital publication of the American Society of Cataract and Refractive Surgery and the American Society of Ophthalmic Administrators.

Medical editors: Eric Donnenfeld, MD, chief medical editor; Rosa Braga-Mele, MD, cataract editor; Clara Chan, MD, cornea editor; Nathan Radcliffe, MD, glaucoma editor; Vance Thompson, MD, refractive editor

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