Case studies highlight advanced techniques in glaucoma management

(Image credit: AdobeStock/Pisahouse)

Himani Goyal, MD, takes glaucoma care to the next level by embracing advancements that extend beyond traditional treatment methods. As a cornea, cataract, and anterior segment surgeon at NYU Langone Health in New York, New York, Goyal presents insights through 3 case studies in a recent Ophthalmology Times Case-Based Roundtable^®.

“These cases present the different treatment options that are available over and above eye drops as well as highlight how much our patients can experience adverse effects from topical therapies,” Goyal says. “It is important for clinicians to keep this in mind and to remind patients to report any adverse effects.”

She recounts that microinvasive glaucoma surgery (MIGS) was introduced during her early days in practice and its availability has shifted the treatment paradigm. Although her subspecialties do not include glaucoma, she embraced the technological advances because of their distinct advantage for corneal and ocular health, and patient satisfaction, she notes.

Before the arrival of more advanced treatments, patients generally were started on low-maintenance medications (eg, once daily) to plant the seeds for patient adherence. The drugs included a nighttime prostaglandin or a morning β-blocker, Goyal explains. Based on the response, other medications could be added. However, adverse effects could be problematic.

Another shift in glaucoma treatment occurred in patients being evaluated for cataract or ocular surface disease. If these patients were taking glaucoma medications or were suspected of having glaucoma, clinicians ordered that all the testing be done before cataract surgery to facilitate introducing the idea of MIGS options that could be performed during the cataract surgery.

In another scenario, a patient with pseudophakia could be experiencing ocular surface disease as the result of their glaucoma medications. In that event, MIGS or a laser procedure might be a stand-alone option.

Exploring options

Case 1

Goyal describes a combined cataract surgery and MIGS. A 63-year-old woman had a history of open-angle glaucoma (right and left eye presenting IOPs of 22 and 24 mm Hg, respectively) that was treated with nightly latanoprost instillation for 6 years. Corneas were thin (490 and 484 µm); the treated IOPs were 14 and 12 mm Hg, respectively. Her best-corrected visual acuity was 20/40 due to the presence of cataract. Gonioscopy showed the angle was open to scleral spur or posterior trabecular meshwork. Examination results showed meibomian gland dysfunction, eyelid changes from latanoprost, injection and ocular surface disease, and a cup-disc ratio of 0.75. The visual field evaluation results were essentially normal.

Goyal opted to implant a microstent (iStent infinite; Glaukos) to lower the IOP with the hope of eliminating the need for latanoprost and associated adverse effects, she explains: “My algorithm was to use this as a reset point. We did not continue the preoperative medication immediately postoperatively but followed the patient closely.” Goyal explains that after the immediate postoperative period, the patient was seen monthly after the combined procedure to determine the response. Currently, the patient does not need medication.

Case 2

This case was that of a woman with pseudophakia and with open-angle glaucoma treated with a bimatoprost intracameral implant (Durysta; AbbVie). She presented with a burning sensation in the eyes associated with latanoprost and redness and had undergone cataract surgery a few years previously. The current IOP was 18 mm Hg, with latanoprost treatment at night, which caused burning, and timolol treatment in the morning. The patient complained of an allergic reaction to the drops. There was a history of bilateral selective laser trabeculoplasty (SLT) performed twice, which maintained her IOP in the goal range. The visual fields showed a slight loss in the right eye and nonspecific changes in the left eye. Examination results showed lid changes associated with prostaglandin, meibomian gland dysfunction, long lashes, slight injection, and diffuse superficial punctate keratitis.

We did a trial off of one eye drop at a time and documented a meticulous diurnal curve. The patient did not have any change in IOP after one month off of the prostaglandin. She did, however, have an increse in IOP to the mid to high 20s after stopping timolol. The felt immediate relief from the burning after the eyes after stopping latanoprost and relief from itchiness of the eyes after stopping the timolol. This was the most comfortable she had felt in years. We opted to do Durysta intracameral implants for her in an effort to relieve her of the side effects of the topical therapies and are monitoring her closely for a response. If there is she does not have a sufficient response, this may be a patient who would benefit from stand-alone iStent infinite.

Case 3

This was an open-angle glaucoma case with a rise in IOP two years after combined cataract surgery with MIGS. The patient underwent cataract surgeries combined with iStent inject (Glaukos), with eye axis goniotomy in the right eye and iStent inject with a Kahook Dual Blade goniotomy (New World Medical) in the left eye.

The patient had a history of pseudoexfoliation of the right eye. The bilateral cup-disc ratio was 0.7. The right eye had peripapillary atrophy and some optic nerve thinning on optical coherence tomography results. The visual fields were essentially full. The preoperative IOPs were 21 and 17 mm Hg when treated with Cosopt (Thea Pharma) and latanoprost. After a preoperative washout period, the IOPs were 23 and 19 mm Hg. The postoperative IOPs ranged from 14 to 20 mm Hg, with follow-up examinations every 4 to 6 months.

Following a loss to follow-up of 1 year, reexamination results showed IOPs of 20 to 26 mm Hg in the right eye and 21 mm Hg in the left eye. The visual fields were normal, and imaging results showed no changes from the previous year.

Considering his treatment history, the question arose about how to treat this patient, who was opposed to drop instillation. Performing SLT was a treatment option, Goyal points out. Approximately 1 month after treatment, the IOPs decreased to 18 and 14 mm Hg. The patient continues to be followed off of eye drops for now.

To watch the videos from this Ophthalmology Times Case-Based Roundtable^®, click here.