NTERIOR SEGMENT
GLAUCOMA TREATMENT
Improve Quality of Life with Early Surgical Intervention in Glaucoma Treatment by April Ingram
“E
arly detection and early treatment lead to better outcomes.” This statement is the driving force behind so many screening and treatment programs in ophthalmology … except when it comes to surgical intervention. Indeed, surgery is often only considered after limited success with topicals and once all other treatments have been exhausted. But what if surgery was moved earlier in the treatment model? Thanks to recent advances, this shift is happening in glaucoma, and surgeons are now looking toward taking a more proactive — rather than reactive — approach to glaucoma management.
The battle against IOP reduction
the next visit. In this treatment pattern, the physician and patient had better enjoy each other’s company because the relationship is a long one. We’ve known for years (and have the studies to prove it) that outcomes are better with earlier, effective treatment and IOP reduction. For each mmHg of reduced IOP, there is a 10% reduced risk of disease progression.1 In 2008, Joseph Caprioli wrote an editorial in the American Journal of Ophthalmology describing the effect on visual disability of glaucoma patients as a function of the rate of progression and time of intervention — importantly noting that with earlier intervention in eyes with fast progression, visual function can be preserved.2
In glaucoma management, it’s a daily challenge for ophthalmologists to meet the patient’s desired intraocular pressure (IOP) goals and preserve optic nerve function. There are various (and important) things to consider, such as selecting the optimal therapy or combination of therapies to hit that IOP target. Other factors include: managing the delicate balance of patient compliance, adherence and side effects, as well as maintaining their quality of life.
The arrival of Minimally Invasive Glaucoma Surgery (MIGS) has provided an opportunity for early treatment in patients whose IOP reduction needs do not necessitate the plunge into a more invasive trabeculectomy or tube shunts. It has been established that MIGS delivers effective IOP reduction and reduces medication burden. And there are a growing number of options for MIGS devices; these can be divided by their approach or pathway: subconjunctival, suprachoroidal or Schlemm’s canal. Subconjunctival draining devices like the XEN Gel Implant (Allergan, an AbbVie company, Dublin, Ireland) or PRESERFLO® MicroShunt (Santen, Osaka, Japan) can be used in solo MIGS procedures and have better potential to achieve single digit IOP levels. Additionally, patients can combine their scheduled cataract surgery with MIGS — and who wouldn’t want the efficiency of getting two eye disorders treated at the same surgical appointment?
Could early surgical intervention (ESI) be the solution?
It goes on and on — and often, it can feel like going into battle. Pressure increases, we react, change the therapy, hope the patient is compliant and keep our fingers crossed until
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So, if the surgical intervention can safely maintain acceptable IOP while reducing adherence issues and side effects, then why are we waiting and watching … and waiting again for other options to fail, or eventually become intolerable to our patients?
Dr. Chelvin Sng, from the National University Hospital in Singapore, supports MIGS options earlier for glaucoma patients. “The introduction of MIGS devices has improved surgical
| June/July 2021