ASCRS 2023: Combination MIGs may reduce treatment burden for patients

Xiongfei Liu, MD, is presenting a talk entitled, "Effectiveness and safety of combining 2 MIGS devices in patients with open angle glaucoma," at ASCRS 2023 in San Diego, California.

Video transcript

Emily Kaiser:
Hi everyone. I'm Emily Kaiser with Optometry Times, and I'm sitting down with Dr. Xiongfei Liu, who is presenting a talk entitled, "Effectiveness and safety of combining 2 MIGS devices in patients with open angle glaucoma," at ASCRS 2023 in San Diego, California. Welcome Dr. Liu. Thanks for taking the time to be here.

Xiongfei Liu, MD:
Thank you very much, Emily, for inviting me to be here. And I'd love to share some of the insights that we gained from this study with everyone here.

Fantastic. Well, can you tell us a little bit about the abstract that you're presenting?

Yeah. So traditionally, iStent inject W has been used in conjunction with cataract surgery to effectively control the intraocular eye pressure as well as to maintain a favorable safety profile. Last year, Glaukos came out with a new minimally invasive glaucoma devices called iAccess precision blade, which it allows the surgeon these days to perform goniotomy in the size of 200 micron. Because the size is so small we call them microgoniotomy. And for goniotomy is the purpose of stripping away trabecular meshwork from the eyes so you allow more fluid to flow out of the eyes, and that can lower the intraocular eye pressure.

So taking advantage of the iAccess, because it is a microgoniotomy, you preserve the trabecular meshwork. We want to use the additional trabecular meshwork to combine with other minimally invasive glaucoma surgeries. So we're trying to combine both the iStent inject with iAccess and trying to evaluate the safety and efficacy of these patients when they will underwent cataract surgery.

So we did a retrospective, non-masked, single center, 2-surgeon study where we have 31 eyes with open angle glaucoma and they all underwent cataract iStent and iAccess. And majority of these patients are mild-to-moderate glaucoma, and 2 of eyes are severe glaucoma.
The result of what we found is preoperatively, their pressure is 18.5, but they're on 1.7 and 2.8 medications. And post-operatively, month 1, the pressure was 14.6 and post-op month 3 become pressure of 16. But your eye medication changed from 1.8 down to 0.4. So a significant drop in their medication.

And overall in terms of the safety profile, it's pretty safe just like regular cataract surgery. One case with a transient inflammation, but that has resolved without any clinical significance.

So what's the implication for optometrists?

Great question, Emily. So, in our practice, we work a lot with our local ODs, and together through collaboration, you know, we deliver the next level of care for our patients. So what we typically say is mainly we work with a referral, right? Referral is a big part, where optometry sometimes they send the patient over to acknowledge for surgical management.

So in my referral, we always say look out for 2 types of patients. Based on this study, you can see you know, the first type of patient is easy to identify. Their pressure is borderline controlled or not controlled and they're on maximum tolerant eye medications. So there could be 3, 4 medications and their pressure's 18, the pressure is 20, 22, 26, etc. But you know, they're progressing with their glaucoma. So those patients are easy if you send them for a minimally invasive glaucoma surgery. And in our case, with iStent/iAccess, we reliably get their post-op pressure down to 16. And from previous landmark trial, were able to see that with every 1 point down in your eye pressure, that there's a 10% decrease in glaucoma progression. So it's definitely beneficial for patients as from their glaucoma standpoint.

Another group of patient is less, you know, if you don't look out for, it's less likely to identify them because they don't complain to you, and they don't jump out at you. But their pressure is probably 16, 15 or 17. And they're well controlled but are taking 2 or 3 different medications. And from our study, you can see if they go through iStent/iAccess, we can their get your pressure down to a similar level, maybe a little bit lower, but there eye drop medication, the number of their eye drops are going to be significantly lower.

And for that it's such an amazing experience. Because I ask my patients, and it's really a great experience for them. They say, "Oh, Dr. Liu, I don't have to set a time of the day to put in my eye drops and can focus on my work." Or, "If I do miss an eye drop, I don't feel too guilty about it because there's only one drop I really need to remember to put in." Or, "I don't have to put in any drop." Because if you see like the study basically showed, depending on what study you look at 50-70% of the patients are nonadherent to their medication because they forget.

And also in other categories, drugs—sometimes the third and fourth lines cost so much to the patient. And if you can just get rid of 2 drops, where they're only on the first line therapy is so much cheaper for them. And they're happier as well because the ocular surface, there's less dry eyes, you know, less irritations, and the patient's going to be happy about that.
And last but not least, if you look at the 24-hour eye pressure trend, having—when it comes to eye drops, it is just never as well controlled as when you do a surgery. The pressure is just a little bit more controlled in a 24/7 hour cycle [following surgery].

So with all these benefits, this is where you know looking out for these 2 categories of patients. And as you can also can see from the safety of this procedure, it is very safe; it is similar to cataract surgery. Maybe you can get a little bit more microhyphema during the first week after the surgery, but they all resolved spontaneously. So for optometrists, or an eye care provider who loves to manage these minimally invasive glaucoma surgery [patients] post-operatively, you know, it's not hard to manage. It's pretty easy, stress-free, and we all love that: our day to be stress-free.

Well, thank you so much for taking the time to chat today, and I can't wait to hear more.

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