Why Quality of Life Matters

Minimally invasive glaucoma surgery (MIGS) has been around for more than a decade, with iStent technologies achieving the significant milestone of over one million implantations, globally.

We are currently experiencing an exciting period of change and innovation in the realm of MIGS; there are now a multitude of options available, each offering unique mechanisms of action. The efficacy and safety of MIGS is good and supported by an ever-expanding body of peer reviewed literature (1–7). But each MIGS has a different risk and benefit profile, so it is crucial to discuss this in detail with the patient before arriving at a treatment plan.

We should all strive towards providing individualized glaucoma treatment for each patient we treat. Addressing patients’ visual needs and expectations is vital – especially for those undergoing cataract surgery with premium intraocular lenses. There is no doubt that premium IOLs can greatly enhance the patient’s quality of life (QoL). At Innovation Eye Clinic, I routinely combine the iStent inject^® W procedure with either enhanced monofocal lenses (with the option of mini monovision in the non-dominant eye) or toric intraocular lenses for suitable glaucoma patients having cataract surgery. Although patients are aware that they have glaucoma or raised intraocular pressure, their primary concern after cataract surgery with MIGS is their visual recovery. A key consideration for me, therefore, is selecting a MIGS device that will not compromise the visual outcome or the speed of visual recovery – and that is a clear advantage of the iStent inject W.

We are now also realizing that MIGS is not just about reducing intraocular pressure; an increasing body of evidence demonstrates that early intervention with MIGS can reduce the risk of further glaucoma surgery in a patient’s lifetime (11) and preserve the visual field (6,7). Additionally, a recent analysis of randomized controlled data by Samuelson and colleagues demonstrated that the medication reductions observed following iStent inject surgery has a significant impact on patients’ QoL versus cataract surgery alone over 24 months; this is driven primarily by improvements in ocular symptoms and vision related activities (8).

There are many factors to consider when it comes to treating glaucoma, but the importance of QoL cannot be overstated. Surgeons must adopt a whole person approach, taking into account various factors that extend beyond intraocular pressure (IOP) reduction. By considering medication burden, patient compliance, ocular surface disease, patient anxiety, and overall QoL, we can achieve better – and more patientcentric – outcomes.

Though randomized controlled trials still remain the gold standard in terms of clinical evidence, a large proportion of the published data consists of retrospective case series, which add additional value by providing a “real world” perspective. To this end, we performed a study looking at the QoL of patients undergoing cataract surgery and MIGS (9). We used several validated tools, including the European Quality of Life in five dimensions (EQ-5D), glaucoma quality of life 15 (GLQ15), glaucoma symptom scale (GSS), and ocular surface disease index (OSDI). Additionally, we looked at easily measurable ocular surface parameters, such as the tear film break up time and corneal staining (Oxford grading scale). At four months postoperatively, all patient reported outcome measures showed a statistically significant improvement compared with preoperatively – and this was sustained at 12 months. The ocular surface disease and tear film break up time also showed a significant improvement, with the biggest improvement in OSDI; this is consistent with the findings of Samuelson and colleagues in patients that were off all topical medication. Of course, one could argue that the removal of the cataract contributes a large part towards this improvement in patient outcome measures; however, this is a reflection of clinical practice. There are peer reviewed studies looking at QoL in patients who have had iStent inject® as a standalone procedure and QoL and ocular surface improvements are similar (10).

On a more personal level, what I have observed in my post-op clinics (where we perform high volumes of MIGS) is that patients are clearly more confident after the surgery, have less anxiety about their glaucoma in the knowledge that their eye pressures are better controlled, and comment on the fact that their eyes are more comfortable after taking less medications. Importantly, by being on less or no glaucoma medications, they also feel less restricted in their daily activities. Research in this area is rapidly evolving, and the interventional glaucoma mindset is gaining momentum. By embracing this approach, we can provide timely and safe care – ultimately enhancing the lives of our glaucoma patients.

Recognizing the importance of QoL in glaucoma treatment decisions is paramount. By adopting a holistic approach and considering multiple factors beyond IOP reduction, surgeons can achieve better outcomes. MIGS procedures offer a safe and effective means of early intervention – particularly for mild to moderate glaucoma. As we navigate this period of innovation, it is crucial to embrace personalized, wholeperson care for our glaucoma patients.

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