The Mindset Shift

Talk to a glaucoma specialist and before too long you’ll hear a familiar story – the three big problems of compliance, tolerability and adherence come up again and again. Patients find drops difficult, the pharmacy system by which they get their drops hard to navigate and the often complex regimen of drops hard to follow. All of this adds up to one thing – inevitable disease progression and vision loss. Happily, as some recent roundtable discussions show, there are more options than ever for doctors to treat patients without loading up the ocular surface with drops.

The roundtables brought together Nate Radcliffe, Davinder Grover, Paul Singh, Mark Gallardo, Deborah Ristvedt, Tom Samuelson, John Berdahl and Sahar Bedrood moderated by Ike Ahmed. To understand the changes that the last decade has seen in glaucoma treatment, Mark Gallardo pointed out that a decade or more ago, the treatment pathway generally moved from maxing out a patient on drops before laser treatment and then a filtration procedure. This depended on a patient already having progressed into moderate or severe glaucoma. Bedrood agreed, highlighting the ways in which this previous paradigm had been relatively inflexible and didn’t take into account the differences between patients. One of the upsides of the new plethora of treatment options is greater flexibility and tailoring in treatment design for each patient – something which has only increased as MIGS devices have built an ever-better safety profile.

As Davinder Grover highlighted, when the first MIGS devices were being introduced, regulators didn’t allow implants in patients who didn’t need surgery.  As the last decade or so has proven, the devices generally have a solid safety record, and as Grover put it, this has freed surgeons to move towards an interventional mindset. Nate Radcliffe explained an important aspect of this shift was in terms of patient wellbeing. Combining MIGS with cataract surgery has a huge positive impact on wellbeing and quality of life measures – even if patients are not permanently drop free post interventional glaucoma surgery. Here then, the flexibility of interventional glaucoma preserves the potential for further treatment in the future and leaves patients more likely to engage with that, as they’ve already experienced successful treatment.

The challenge of the new interventional mindset is to get surgeons to think about not only proactive screening and monitoring of patients recently diagnosed with glaucoma, but also to appreciate the extent of the options which are now available. Multiple participants – Ike Ahmed and John Berdahl – brought up the development of using Selective Laser Trabeculoplasty (SLT) as a front-line treatment  rather than drops. Ahmed brought up the LIGHT trial (1) a major study led by Moorfields Eye Hospital which compared the effectiveness of treatment between SLT and a standard drop regimen. The study results showed that over 36 months SLT was shown to be both more cost-effective and efficacious with 74% of patients in the SLT group requiring no medication to maintain their target IOP. As a result the National Institute for Health and Care Excellence has recommended SLT be adopted as the first line treatment for glaucoma in the UK.

However, this doesn’t seem to be adopted as widely in the US. For some, it may be that patients don’t respond well to hearing the term “laser” – Paul Singh described his approach as avoiding the term with patients, instead describing SLT as a beam of light which rejuvenates the trabecular meshwork. This shift in language certainly helps but as Nate Radcliffe pointed out, it’s important for physicians to be proactive and forthright in encouraging patients towards these more interventional approaches. With the interventional mindset shift in full swing, the next article in this series will go into more detail about one of the key MIGS devices pushing interventional glaucoma forward.

Supported by an unrestricted educational grant from Glaukos