AGS 2024: Glaucoma management is all about the patient

Andrew G. Iwach, MD, sat down with Ophthalmology Times Group Editorial Director Sheryl Stevenson to highlight the key takeaways from his Glaucoma Surgery Day Lecture at the 2024 American Glaucoma Society annual meeting. Iwach urged the necessity of active listening, customization, and individualization of treatment plans based on patients' evolving needs and life circumstances.

Video Transcript

Editor's note - This transcript has been edited for clarity.

Sheryl Stevenson: We are joined today by Dr. Andrew Iwach, who is presenting the Glaucoma Surgery Day Lecture at this year's American Glaucoma Society. It's great to see you again. And really interested to learn more about your talk. I know you're talking about 'Glaucoma Management: It's All About The Patient.' What can you tell us about your presentation?

Andrew G. Iwach, MD: Thank you for the invitation. So what we did is we had a chance to talk about what really counts in all this and that is the patient. The lecture was dedicated to my mentors: Dr. [Robert N.] Shaffer; Dr. [John] Hetherington, and Dr. [H. Dunbar] Hoskins [Jr]. As their fellow—and I had the privilege [and] honor of working with them for many years, I joined their practice—the focus of everything we did was the patient, how they perceive them. Of course, we want them to keep seeing.

So with that as an introduction, there were some provisos, some limitations, and that was that the data I presented was what we're currently doing at our center at the Glaucoma Center of San Francisco. The point being is that different practices, different settings will have different patient profiles, different needs. What I wanted to do was share where we were because we have evolved over the past decades, and give some basis to it.

Now with that said, I actually shared two personal stories which really impacted my life over the past few years, and I think will help not only the audience, but their families and then also their patients.

One was about an unusual story about my shoulder, where a few years ago out of the blue, I was healthy, I had no injuries, I had problems with my left shoulder. To make a long story short, my first reflex was to see an orthopedic surgeon who recommended massive shoulder replacement surgery. But there was a bump on my shoulder and so I ended up seeing five different orthopedic surgeons and that included X-rays, a fancy MRI, and all of them had the same exact recommendation. You need major shoulder surgery. And I said, what about this bump? And so well one of them said we could take the bump out and do the shoulder replacement surgery. I said but how about just the bump? And he said, well, that would be two surgeries. I said I'll take that chance. So after a year of kind of researching this, they just took this lump out, and I was fine.

And what I learned is it turned out to be a lipoma. Now, I don't know exactly why it was there but curiously, it's the same place I'd received 4 COVID vaccines. From that, I then, of course, had to go to physical therapy. And I went to the physical therapist, and I told her the story, and she kind of sheepishly said, this happens not infrequently.

And so I think what it really reminds us is that when we look at tests, you need to talk to the patient. And here, I was giving very specific pointers. It actually turned out to be a large lipoma but the surgeons were so focused on the interventions that they wanted to do that that was their wheelhouse. And so, I think there's a lesson there for us in glaucoma. And that is we need to listen to our patients and also be very careful not to do things unnecessarily, that we have to do things the right thing at the right time.

The second story I shared with the audience, a personal story, was a patient back in early December of 2022. Very nice lady. She's a physician. I see her every few months. She has bad glaucoma and she usually doesn't talk too much but boy she wanted to share with me that she'd lost 10 pounds, which was great. And she said there's this medication, and I didn't know what she was talking about, which is kind of old school. She didn't email me. She didn't fax me. She mailed me these two articles. And I read them. I said, geez, this sounds amazing. It hadn't come across my desk.

So I talked to some of my colleagues. I said, Am I missing something? This sounds really amazing. And they said, no, it's new, but it could be very important. So I went ahead and started this medication. And what my patient did not know is I was in trouble. I'm a physician. I'm motivated. I'm educated. I'm disciplined. But was my weight was going up. My blood pressure was on four different medications. I had a good internist. I was getting side effects from the medications, and they were talking about metformin. They were worried that I was going to develop diabetes.

To make a long story short, I took my first shot on New Year's Eve on 2022 and within about 6 weeks I lost 17 pounds. And then within 3 or 4 months, I dropped down 30 pounds. All of a sudden, my blood pressure was 110/70 on less medicine. Obviously, my hemoglobin A1C was normal. My fasting glucose was normal. And I realized I was sleeping better at night. And my goodness, I actually probably had some sleep apnea.

So these medications are fascinating. But there are other implications for glaucoma patients and glaucoma surgeons. There are many different effects of this medication, but one of which is it slows down the GI transit time. So preoperatively typically, we would say, you know, don't eat or drink anything after midnight. The rules are all now invalid with patients on these medications.

The American [Society] of Anesthesiologists in June of last year put out a formal recommendation that patients should be off these drugs at least 1 week before surgery. Personally, based on how my body responds these medications, I would say 10 to 14 days. It's enough of a concern that I'm on the board of OMIC [Ophthalmic Mutual Insurance Company] and in the next week or so we're going to release an alert to our insured that they need to make sure that this is enough that they're aware of this to document this. And I had a slide that listed...there are many different now available medications in this class of drugs. So you need to know what questions to ask to make sure you avoid those problems.

The other thing I mentioned to them is that it's really important to communicate. I gave some tips on how to minimize the issues that you may have with legal with a lawsuit at some point. And communication is very, very important.

Defining the benefit. Most patients with glaucoma have no symptoms. They're asymptomatic. And so whatever we decide to do, we have to really carefully look at the profile for what is the risk to determine do we have to do that intervention today? Can we invest more in diagnostics to make sure we're not missing anything?

I also talked about the importance of the informed consent. Those documents are always evolving. And I gave a QR code on one slide where even if you're not insured by OMIC, OMIC will provide to the ophthalmic community up-to-date informed consents. And so I gave that information for everyone. You know, set it once a year, maybe every summer, at the holiday breaks, but just once a year, have your staff go to that website [https://www.omic.com/risk-management/consent-forms/] and make sure you have everything updated.

Then we shifted the discussion on how do we manage glaucoma patients at our center. And certainly we try to keep them out of the operating room and we talked about MIGS [minimally invasive glaucoma surgery], which we use, but we use them typically at the time of cataract surgery. That way you would leverage the fact that you're already there and the incremental additional risks of the MIGS procedure is very, very acceptable. That's doesn't always...that's not enough.

So then I talked about the fact that we shifted over to using more of the glaucoma drainage devices, particularly Ahmed valves. I shared some Medicare data that just became available through our colleagues at the [American] Academy [of Ophthalmology] offices in Washington, DC. Madison Switalla [AAO Health Policy and Advocacy Manager] was actually very helpful at the office to provide that.

Actually, we talked about diagnostics and how we are working so hard and all the things we're doing. Looking more recently, we're actually for glaucoma utilizing it seems about the same number of visual fields as OCTs [optical coherence tomography]. Then when we looked at the surgical intervention, the trabeculectomy line just has really fallen over the years and for many reasons. In about 2018, all of a sudden these glaucoma drainage devices were being utilized more. But why?

The reason was to make trabeculectomies work. Eyes have been now 'marinated' for many years with medications. And so we have to use these strong anti-scarring medicines to get those trabeculectomies to keep working. But as a result that creates a risk for trauma and serious infection. At the same time, our techniques in implanting glaucoma drainage devices have improved. I specifically talked about...it's worth the extra incision to make sure you know where the insertion of the muscles is. Put that plate back at least 8 if not 9 mm posteriorly. And then we talked about where to put the tube into the eye. There's some debate as to where to go but we found that in fact if it can go posterior enough, and even if it touches the iris, it seems to be tolerated.

Now, curiously, in the last few weeks on the American Glaucoma Society network, a colleague from Wisconsin, Jeffrey Kalenak [MD], had just posted on a discussion that for the last 20 years, he saw the same thing. So I got his permission to show that and he said, You can do that but just make sure you say it's not wasn't a study. It's just data that I've collected anecdotally. And I said that's exactly what we have. So I think that's an important tip, how to reduce the risk of placing these devices.

And finally, we know that these devices often but don't always lower the pressure enough. In fact, we showed some data in our series. About 30% of our patients need more. What is that more? Well, there was a study published in 2022 comparing do you put another glaucoma drainage device or you do this laser cyclophotocoagulation treatment. They're both pretty equal, but there were fewer complications in the laser group. However, in the study, they could only do two laser treatments after the placement of the glaucoma drainage device. Clinically, we actually do on average two to three. You have to be careful. Too much laser with a glaucoma drainage device in place can lead to too low of a pressure. That actually was well documented back in the early 1990s when we published or brought in one of these lasers that that was a risk. So with a judicious use of those of the laser treatments after placing it in our center...we used Ahmed valves...we looked at our success rate and it was quite high. And our patients...it was a simpler protocol.

And the final slide I showed was something that's funny. During the COVID, the peak of the COVID crisis, we had more time to read industry papers as yours. And I thought I saw a quote from Ike Ahmed, that during the COVID crisis, he was basically he was using Ahmed valves only. And so I couldn't find the article. I reached out to him. And he gave me permission to share the email exchange between us when he confirmed. During the peak of the COVID crisis when patients couldn't come in as often, when we couldn't go to the operating room, he shifted away from the MIGS and actually went to the Ahmed valve.

And that actually I think is very insightful. Because for patients what we want to do is we want to create a plan, a treatment plan, that minimizes the impact on them. So that there are fewer trips to the office, there are fewer trips to the operating room. And I think that's why at our center, we found the combination of using in those difficult cases where the simpler things don't work an Ahmed valve and doing a laser treatment where the recovery is very quick—a great combination for patient satisfaction.

And finally I mentioned that our center...we actually have a full bar downstairs at our building. We occupy the upper three floors and downstairs is a very successful bar. And I invited people [if they're] in town [to] let us know, we'll meet them downstairs and have a toast to our mentors, Dr. Robert Shaffer, Jack Hetherington, and Dunbar Hoskins. And I left them with a quote that I first learned from or heard from Dr. Schaffer and that is: Cure sometimes, treat often, but comfort always. It's all about the patient.

Stevenson: Thank you! Certainly a lot of information packed in that presentation, a lot of practical pearls for clinicians. What would be the one or two takeaways that you would really advise clinicians to really take heed to?

Iwach: I think the most important thing is we are privileged that these patients are coming to us. There are studies, there are means and averages, but we treat individuals. Listen to the patients. Understand what their needs are. This one patient added 10 years to my life by introducing me to this medication.

Customize, individualize, and patients are constantly changing. It's all based on their life expectancy. If they develop pancreatic cancer, their glaucoma is no longer a big issue. So listen to your patient. We are doctors, we're not providers. And in doing that, it's the right thing to do and I believe it's the right way to practice medicine.