July 2018

COVER FEATURE

Challenging cases
Innovations in challenging glaucoma cases


by Rich Daly EyeWorld Contributing Writer


Optic nerve with moderate glaucoma damage
Source: Robert Rothman, MD


Surgeons identify the latest treatments and innovations to help their most challenging glaucoma cases

Glaucoma specialists agree that emerging treatments offer growing hope for their most challenging cases.
“As a specialist, the pseudoexfoliation patients can be the most challenging when it comes to combined cataract and glaucoma cases,” said Valerie Trubnik, MD, attending physician, Ophthalmic Consultants of Long Island. “Also, patients who have retinal comorbidities and elevated intraocular pressures requiring surgery are challenging.”
Dr. Trubnik said these cases can be difficult because the patients have had multiple intracameral injections, compromised zonules, and may have smaller pupils.
Among the most challenging glaucoma cases seen by Nathan Radcliffe, MD, assistant professor of ophthalmology, Icahn School of Medicine at Mount Sinai, New York, are cases that don’t respond to several glaucoma surgeries.
“Usually when you’re on your third or fourth glaucoma surgery, you’re running probabilities that these eyes are going to have some complication with each surgery. We always think one surgery ahead so if this surgery doesn’t work, what am I doing next?” Dr. Radcliffe said. “These are the patients where you keep throwing surgeries at them and they fail through them all.”
Other challenging patients Dr. Radcliffe identified are those who do not tolerate any medications; patients with difficult personalities or unrealistic expectations; and late disease or “little-room-for-error cases.”
“In my practice, about one-third of the people I operate on only have the one eye,” Dr. Radcliffe said. “They lost their other eye before I met them—often from glaucoma—so there is little room for error.”
Among patients who present with intraocular pressures in the 50s while on all available IOP-lowering medications and with almost no vision remaining, Dr. Radcliffe must quickly move to surgery, even as he has to warn patients that not even perfect surgery is guaranteed to maintain their vision.
The most challenging glaucoma cases seen by Robert Rothman, MD, partner, Glaucoma Consultants of Long Island, are related to either severity of disease or age of onset. “Younger patients with secondary conditions—inflammatory glaucoma associated with uveitis, young diabetics, Sturge-Weber syndrome—tend to be the most challenging cases for me,” Dr. Rothman said. “I also would include normal tension glaucoma as a significant challenge both diagnostically and therapeutically, in terms of management decision making.”

Treatments improving

Treatment options have expanded for younger patients—including infantile glaucomas—with secondary conditions.
“There has been some improvement in the available options for the control of systemic inflammation, and that has helped some uveitic patients avoid steroid-induced IOP elevation and maintain a healthier trabecular meshwork; the better their systemic inflammation is controlled, the better it is for them in the long run,” Dr. Rothman said. “Some of our newer surgical options available now and in the future are going to help these patients, since many traditional surgical procedures tend to have unacceptable survival rates and permanently distort the conjunctiva and ocular surface.”
Microinvasive glaucoma surgery (MIGS) procedures, as earlier surgical options for all patients, are becoming more prominent as surgeons gain experience in some of the more challenging patient populations.
Dr. Rothman has managed pediatric patients with a history of failed tube shunt surgery who have received the InnFocus Microshunt (Santen, Osaka, Japan) outside the United States.“After several months of follow-up they look good,” Dr. Rothman said.
Dr. Trubnik has found laser cataract surgery helpful in pseudoexfoliation patients as well as patients with multiple retinal injections who may have weakened zonules and an unstable lens.
“That creates a much easier procedure where I don’t have to put as much stress on the zonules,” Dr. Trubnik said.
Additionally, Dr. Trubnik uses expansion devices, like iris rings or hooks, to help if the pupil is small. If it is a particularly dense lens and phacodonesis is present, she finds the miLOOP (Iantech, Reno, Nevada) has been useful to get the lens out safely in those patients in whom laser cataract surgery is not possible due to a miotic pupil.
Dr. Radcliffe, one of the first U.S. surgeons to adopt MicroPulse laser cyclophotocoagulation (Iridex, Mountain View, California) about 3 years ago, has found it effective both before and after surgical procedures.
“It is different from all of the other options because it works by suppressing the amount of aqueous humor produced,” Dr. Radcliffe said. “If a patient has failed a few other types of surgery, I have that in my back pocket, and it can be a life saver.”
The FDA approval of the CyPass Micro-Stent (Alcon, Fort Worth, Texas) offered a treatment that accesses a different pathway—the uveal scleral pathway.
“If someone has failed a few tubes, for example, the CyPass is a different mechanism, and it may work uniquely well,” Dr. Radcliffe said. “I love trabecular meshwork surgery and do plenty of it but usually these patients have already had that surgery because that is part of many surgeons’ routine algorithm for cataract/glaucoma surgery.”
Dr. Radcliffe described the XEN Gel Stent (Allergan, Dublin, Ireland) as “very helpful because it can achieve low IOP and get people independent of drops but without the risk of a trabeculectomy.”
New medicines that have especially helped Dr. Radcliffe’s patients are Vyzulta (latanoprostene bunod, Bausch + Lomb, Bridgewater, New Jersey) and Rhopressa (netarsudil, Aerie Pharmaceuticals, Irvine, California), both of which help with aqueous outflow through the trabecular meshwork.
“Having new medical options always helps surgeries work better because it gives us more flexibility if patients are having intolerances,” he said.

Coming treatments

Several companies are looking at devices that will drain externally in a controlled fashion, Dr. Rothman said.
“Those devices hold great promise for situations where significant scarring has been a problem, which tends to be the case with inflammatory glaucoma, chronic medication usage, and failed prior surgery,” Dr. Rothman said. “Those future devices are going to be helpful in the management of many of these patients.”
Dr. Rothman is also looking forward to trying new medications for patients with contraindications to or lack of efficacy from some of the current therapeutic options.
“Traditional medications have worked poorly in patients with Sturge-Weber syndrome,” Dr. Rothman said. “I am excited to try Rhopressa in patients with this problem to see how they respond, as it is the first topical agent that may directly impact episcleral venous pressure.”

Editors’ note: Dr. Radcliffe has financial interests with Aerie Pharmaceuticals, Alcon, Allergan, Bausch + Lomb, and Iridex. Dr. Rothman has financial interests with Allergan, Aerie Pharmaceuticals, Bausch + Lomb, Camras Vision (Research Triangle Park, North Carolina), and Qura Inc. (Boston). Dr. Trubnik has no financial interests related to her comments.

Contact information

Radcliffe
: drradcliffe@gmail.com
Rothman: rothman1@optonline.net
Trubnik: vtrubnik@ocli.net

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