Lecture: Treatment Options for Moderate to Advanced Glaucoma: A Case-Based Discussion

During this highly-interactive panel webinar, a case presentation will be followed by a wide ranging discussion on treatment options for patients with moderate to advanced glaucoma. Topics will include optimizing medical treatment, laser therapy as well as incisional interventions for lowering intraocular pressure.


Dr. Malik Y. Kahook, University of Colorado, USA
Dr. Husam Ansari, Ophthalmic Consultants of Boston, USA
Dr. Pradeep Ramulu, Johns Hopkins Wilmer Eye Institute, USA


DR KAHOOK: Hello, everybody. I’d like to welcome all of you to another session on Cybersight. This is maybe my fifth or sixth time doing this, and each time I get a lot out of it. I love the discussions that we have. And in particular today, we’ll have an opportunity to do things a little bit differently than we have in the past. We’re gonna go over some case presentations about how we each treat glaucoma, with a focus more on moderate to end stage glaucoma, not necessarily in the mild category. And to help us today, we have two discussants, Pradeep Ramulu and Husam Ansari. Husam Ansari, MD PhD did his fellowship at Hopkins and at Bascom. Pradeep also did a residency at Hopkins and fellowship at Bascom-Palmer. We have two great discussants with a great pedigree, and we’ll have fun going back and forth. The format is going to be a discussion of specific cases, and I’m gonna throw it out to the panelists to give specific comments. I also want to say that we are accepting questions, and we’re gonna try to get to as many questions as possible. Some of you sent questions in before we even got started, and I’m gonna try to put those into the cases as well as I can. So first case. 61-year-old with Primary Open Angle Glaucoma, goal pressure of 14 right eye, and the current pressure is higher than what the goal pressure is. No prior glaucoma surgery or laser. Currently on medical therapy with a prostaglandin analog and a beta blocker. Visual field has been relatively stable over the last few years. So which medication would you add next? I’m gonna throw this over to Pradeep. If you had to add another medication on top of a PGA and beta blocker, what would you go for?

DR RAMULU: I think it’s nice whenever you add medicines, it’s nice not to increase the number of drops you add in a day, so I think you’re trying to find some combination therapy to add. Depending on where you are in the world, the options could be different. One could be to combine the prostaglandin and the beta blocker, if you have one of those in your country and then add another agent, or change the beta blocker to something that has a beta blocker in it, along with a carbonic anhydrase inhibitor or alpha agonist.

DR ANSARI: That’s exactly what I would do. But just to take a step back, if the current pressure is 17, and the patient is stable with respect to visual field, and the goal is 14, I think I may be checking the pressure a couple more times, over some span of time, to be certain that they’re not at target, before even considering adding another medicine. But if I were sure about adding another medicine, I would do what Dr. Ramulu recommended.

DR KAHOOK: Along those lines, if you found yourself adding a combination drop or a third drop on top of the beta blocker, what would you consider maximum tolerated medical therapy, and take away allergies or tolerance issues? What do you consider as maximum bottle number?

DR ANSARI: I think three is maximum for most people. Two is reasonable. Three is even pushing it. But I’m really — I prefer never to put someone on four bottles. So I accept three. But I don’t like three.

DR KAHOOK: Okay. And Pradeep, what do you think about that?

DR RAMULU: Yeah, I agree. Husam and I were co-fellows and published a paper showing that the likelihood that we’re gonna get even a modest reduction of eye pressure with a third or fourth agent, not a third or fourth bottle, but a third or fourth agent, is actually pretty low after about 2 years. It’s only 15 or 20%. But even when you’re in this situation, you’re already thinking a little bit — is this gonna be adequate therapy? Or is somebody gonna need something procedural?

DR ANSARI: Fortunately, in the case we’re discussing, the reduction that’s needed is somewhat modest. So we may actually achieve that, given Pradeep’s caveats about adherence and effectiveness of the extra medicines.

DR KAHOOK: I think one of the take-home messages there is: Each time you add a drop, you’re probably decreasing the adherence, and you’re probably not getting as much return on the drop that you’re starting. Right? A lot of the studies that Pradeep mentioned are more and more elucidating the fact that we might be getting a millimeter of mercury, but we’re getting a whole bunch of adverse events and troubles when we’re adding that agent on. More recently in the US and some areas around the world, we have access to newer medications in the ROCK inhibitor category. Pradeep, are you using ROCK inhibitors, and do you have any pearls about ROCK inhibitors?

DR RAMULU: I do use them. You have to tell patients that their eyes are going to be red, in some degree or another. I think once in a while you’re surprised and they don’t look that red. But the large majority of them do exhibit some redness. That being said, sometimes these drops do work, even when multiple other agents have not worked. And so it has been a pleasant surprise in that way. That it can’t — especially for people who really are not amenable to surgery, because of their health or because they’re just against the idea in general, it has been able to avoid operations in some people.

DR KAHOOK: Right. Husam, maybe you can speak to that. But also, what do you tell the patient about adverse events, other than hyperemia? Is there a discussion that happens with this class of medication?

DR ANSARI: Yes. I think that they’re good medications. They do lower pressure adequately. But there is a fairly high discontinuation rate in my practice because of side effects. And really, I don’t sugar coat it for patients, when I’m gonna start them on one of these medicines. I say: Look, there can be some — in Boston, we say “wicked”. There can be some really wicked redness from this medication, and you have to be ready for that. And if it’s a problem, I need you to call me and tell me, and we’ll talk about that. And I think that really helps, because patients are kind of expecting it. And when it’s not as bad as they think, it can be an effective treatment.

DR KAHOOK: Yeah, the two adverse events or side effects that are unique as far as glaucoma drops, if you look at the most recent history of what we’ve been using in the clinic, cornea verticillata — and in my experience it’s been 100% — is one part, and it tends to be more pigmented corneal verticillata, which is different from what we’re used to with other categories that can cause it. And the petechial hemorrhages have been concerning to some of the patients. I want to echo what you both said. This can be a home run when trying to avoid surgery, so it’s worth trying. Hopefully it can make it out to other parts of the international market and we can have some experience with it. Oh, go ahead.

DR RAMULU: One quick question to you about the ROCK inhibitors. Do you ever stop people if they show verticillata? Sometimes it starts to look pretty severe.

DR KAHOOK: So in the studies that were done for FDA approval, as well as subsequent studies that were done looking at the visual acuity issues that might arise from it, there hasn’t been a one to one relationship with severity of verticillata and decrease of visual acuity. Although FDA approval studies for this class of medication has shown that visual acuity can decrease. So the question on my mind is: Are the corneal effects causing the decrease in vision? And because of that, I’m always quick to ask the question and consider discontinuation. But a lot of times, when I’m using this medication, I’m using it to try to keep the patient away from the operating room. When these patients form verticillata, we do the surgery, get them off the medications, we do see an improvement. For that reason, if I didn’t take the patient back to the operating room, and they were gaining this verticillata and getting decrease in vision, I would be quick to discontinue the medication. So we need this class of medication, we need everything we can get to fight the disease, and I do think this has a role. We just need to understand what type of experience the patient is going to have and like Husam said, speak to it preemptively, because that will increase the experience and potentially the adherence, which is the next topic on the list here. I’m gonna go to the next slide, and show a table on barriers to adherence. Pradeep, what are some of the pearls you use in practice to increase adherence to the therapeutic regimen that you have a specific patient on?

DR RAMULU: We actually did a study where we went to people’s homes, and we were evaluating their homes for safety, and as part of that, we actually looked at what medicines they took in the home. And when you ask people to say: Can you show me your medicines at home? It was sometimes very alarming how long it took them to even find where their medicine was, like I usually put this over here, but they couldn’t find them. I tell people: You have to put things in the same place every time, and take them at the same time every time. So try to link your medication use to something you do every day. You hope people brush their teeth every day, so I say put it by your toothbrush. Or if you want to put it next to the bowl you eat your breakfast in, or whatever else, but try to find something you can link the usage to.

DR KAHOOK: What about you, Husam? What do you do?

DR ANSARI: I think I probably don’t do enough, frankly, but what we do is fairly basic, in that we — pretty much at every single visit, every single one of my patients is gonna get a written document that describes the name, cap color, the eye, the dosing, times of day. So I would say nearly 100% of my patients, even the ones that are coming frequently, are getting that piece of paper every day, and we always ask patients to bring their medications into the office, so that we can physically confirm, visually confirm what they’re taking, and that what they’re taking is what they’re supposed to be taking. And then this is probably a bit far-fetched, but I actually really try to emphasize patients learning the names of the drops. Not referring to them solely by cap color. Really emphasizing saying the word slowly. Dorzolamide, timolol. It’s not dorzolamide. It’s dorzolamide-timolol. And trying to emphasize that whenever I can.

DR KAHOOK: Those are great points. The cap color is a little bit unique to the US market. I know we have a lot of people watching from around the world, and not every country where that’s the rule, where each class should have a specific bottle cap color. But just for those who are listening, in the US, oftentimes when the patients come in, and they tell us they’re on a yellow capped bottle, we know they’re on a beta blocker. But what we found out in a study that Pradeep and I did is that what the patient says isn’t always what the physician is understanding. Sometimes the color difference that can happen between what the patient is trying to express, and what we’re understanding, can be different. So communication, I think that’s one of the themes in what you guys both alluded to. And I think it’s a nice pearl for — especially if we have any trainees that are listening in, that communicating with a patient, looking at their drops, making sure they understand, I think is a big part. Let’s take it a step further, just to move along here. 61-year-old patient — this is gonna sound pretty similar to what the past patient sounded like. Pressure is currently 14. You can see we’re not quite where we need to be. No prior glaucoma surgery or laser. Currently the patient is on a PGA, and just to make the discussion a little bit sweeter here, the patient is allergic or has contraindications to all other medications. Visual field shows advancing nasal step. What is the next step? Pradeep, what are some of the criteria you look for as far as predicting success with laser trabeculoplasty? What do you think about the probability of success?

DR RAMULU: We have a lot of residents with us in clinic and trainees, so I always try to make things simple for them. I have my three out of four rule. The rules are: You have to be on one or zero medications. This patient is passing that. You want to have to have a pressure drop of 20%, and we’re definitely no more than 25%. So this patient probably meets that as well. You want to have a starting pressure that’s high. LT doesn’t do well when you’re trying to get to lower numbers. Starting pressure of 20 or greater. This patient fails that. And also pseudoexfoliation. There’s a really exaggerated response in pseudoexfoliation. I like that as one of those criteria. If they have three of the four, I say yes. This patient has two of the four. Does that mean I don’t do it? Well, it depends on other situations, and how averse they are to surgery, and how much inconvenience and difficulty that would play into their care.

DR KAHOOK: In this case, given your three out of four rule, would you skip and go to surgery? Since this patient is intolerant of other medications? Or would you break your three of our and jump into SLT first?

DR RAMULU: I think we might jump ahead to discussions of some of the new surgical options we have. If this is someone with a modest or visually significant cataract, we’d have a different discussion as opposed to if they’re 55, and have no cataract whatsoever.

DR KAHOOK: Yeah. We’ll get into that a little bit more with subsequent cases, as you said. Husam, in this case, would you do trabeculoplasty?

DR ANSARI: I think I probably would. I think Pradeep’s criteria are fantastic, and I just learned a tremendous amount from hearing that just now. Just like the rest of our audience did. I can say that without having thought about those criteria, prior to this, my instinct for this patient would have probably been to offer laser trabeculoplasty, simply because in my hands, I feel like it’s been successful in this type of patient. Especially if — you know, we tend to want to avoid incisional surgery in general, when we can, and I just think that this is one of those situations where doing the laser trabeculoplasty is worth a shot. Because if it fails, you probably haven’t lost that much time, and can still safely proceed to incisional surgery, without the patient having lost much vision.

DR KAHOOK: Okay. That’s great. And before we go on to the next slide, Pradeep, if you don’t mind, could you just list your four criteria? I really like them a lot and I think it’s good for people to hear it again. I’m gonna put you on the spot. You can’t forget any of the four right now.

DR RAMULU: One or zero medications. You want 20%, no more than 25% IOP lowering. Pseudoexfoliation. And starting pressure of 20 or greater.

DR KAHOOK: That’s great.

DR RAMULU: If you have three of those, it’s a great candidate. If you have two, it’s something you can consider.

DR KAHOOK: Those are not criteria I’ve used in the past, but I’m gonna start teaching it in clinic to the residents and fellows, as if I’m the one who created the list. Thank you for sharing that.

DR ANSARI: Me too! I’m gonna do that too.

DR KAHOOK: So let’s talk about studies that have come out in the world of trabeculoplasty that are significantly influencing the way we care for patients. SALT trial compared steroids, NSAIDs, and tear therapy drops post-SLT, to see if there was any efficacy. And they found significantly better IOP reduction at 12 weeks. Not at the 6 week time point, but 12 weeks for steroid and NSAID, over the other drops. So they gave the patient the drop to use four times a day, prior to laser and subsequent to laser, and said it might improve IOP reduction. And I have the bar graph on the right hand side for the audience to take a look. And the LiGHT study — SLT provided stable and drop free IOP control in 74.2% of patients for three years. Reduced need for surgery, 0 in the case of SLT and 11 in the case of the medication arm, lower cost overall, and comparable quality of life in the two groups. So Husam, how are these two studies influencing the way that you practice, with laser trabeculoplasty? And you can touch on both studies before we throw it over to Pradeep.

DR RAMULU: Sure. The SALT study has been very interesting. This debate about whether patients after SLT should use any prescribed drops has been going on for a while. I used to prescribe a steroid, then I went to an NSAID, then I went to nothing. And this study has piqued my interest into going back to prescribing an NSAID. The IOP reduction that’s been shown in the study at 12 weeks is pretty impressive. And what we don’t know is: Does this result in a sustained IOP lowering, beyond 12 weeks? So I would say that I want to prescribe an NSAID for all my SLT patients, based on this study, because I think it’s a safe medication to use, that seems like it may have some benefit. The barriers to me are actually primarily just really regulatory-based. Some patients simply can’t get the NSAID. Either there’s a shortage in the US, in terms of manufacturing, or there’s just a high cost, because they’re not getting prescription drug coverage. And so that has been a barrier. Because I do so many SLTs, that if I’m gonna prescribe this for every single patient, there’s gonna be a lot of callbacks, and it becomes a practice management issue. With respect to the LiGHT study, this very dramatically reaffirms my typical practice of offering SLT as first line treatment for most of my newly diagnosed glaucoma patients. I think that these results from the LiGHT study are remarkable. In fact, I dream about having 75% of my patients drop-free at three years. I think it might be a situation where, once again, the studies are slightly better than real life. But I think the take-home message is very, very important, and very real. That SLT should be offered as first line.

DR KAHOOK: Pradeep, what do you think? Anything to add for either SALT or LiGHT?

DR RAMULU: I think those are great insights already. I don’t have too much to add. I would add for NSAIDs, we showed it was very similar, in terms of outcome with laser iridotomy. So I think you can probably consider this in essentially any laser treatment for glaucoma. You can probably think of capsulotomy as well. I don’t think you really need steroids. And probably in a lot of the countries that attendees are practicing in, you can get steroids over the counter, and sometimes they reduce itchiness and irritation in the eye. And so you do get some steroid abuse. Which can even lead to substantial vision loss. So it’s a really nice option in your countries. With SLT and the LiGHT trial, I think what was interesting is: Before the LiGHT trial, I would never do SLT. Twice, especially if it didn’t work within six months. But in the LiGHT trial, many patients got two treatments and had a sustained effect. I used to tell people if it works for a year or two, I’m willing to repeat it, but now I’m willing to repeat it, even if it stops working for six months.

DR KAHOOK: And I think to that last point, the repeatability has always been a question with laser trabeculoplasty, as soon as SLT was introduced to the market as a cold laser or less destructive in nature. But in the LiGHT trial, they were able to do retreatment within a couple of months, and it was actually much earlier than I would consider doing a repeat in. There is a subsequent study that addresses retreatment and the efficacy of that in the LiGHT trial. The other thing I want to mention is: We always have to look at the patient population that was studied. In the case of the LiGHT trial, the majority of patients were ocular hypertensives or mild glaucoma. So if we try to extrapolate these results to moderate or severe, which is what we’re talking about today, it speaks to your dream of having 75% of patients off of drops. In many of the patients we treat, when we’re getting to SLT after two medications, we’re not seeing this response. Always look at the patient population that’s being studied.

DR ANSARI: I’ll just add one other thing about that study. When we talk about the medication arm needing more surgeries than the SLT arm, it’s important to know in that study, the medication arm was not allowed to have SLT. In real life, a lot of our medication patients would have SLT, prior to having surgery.

DR KAHOOK: Great point. All these little points that come with reading the paper are extremely important, especially for the residents and trainees that might be listening in today. Let’s move on. 61-year-old. We’re staying with the same theme, around the same patient with changing a few of the parameters. Goal pressure is 12 but pressure is high. It’s 22. Visually significant cataract. Currently on maximally tolerated therapy, visual field shows advanced S/I defects. What is the role of MIGS in moderate to end stage glaucoma? Do you ever use MIGS in moderate to end stage disease?

DR RAMULU: I do. I mean, the indications are more for mild or moderate, but sometimes I will use it in more advanced disease, and I think it’s largely a patient preference. I think the advantage of these devices, and Dr. Kahook has one that’s named after him, which I think is a very good option, is that the recovery is very, very fast. And the surgical course is very smooth. And so people hardly really know that they have an operation. Especially combined with cataract surgery. I think the recovery of a cataract surgery alone, versus one that’s done with one of these MIGS procedures, is essentially identical. And so I think that there is a point of this. If you have somebody who is willing to take a staged approach to their care, I understand if somebody is not trusting, or really is gonna let you do one thing in their eye, this is not a good option for them. But if somebody wants to get back to work fast, understands that they might need a second procedure, I think this is certainly something you can try.

DR KAHOOK: What do you think, Husam, about that, and also standalone MIGS?

DR ANSARI: I agree completely. When I see a goal IOP of 12, my first feeling within myself is… That patient is gonna need a trabeculectomy. That’s the procedure that’s gonna deliver that result reliably. Having said that, though, it is a big leap for a lot of people to have a trabeculectomy. I think if you counsel a patient about how we can try this other thing, MIGS, and it has worked in my practice, if it works on you, we’re gonna be happy we did it. If you can go into this, understanding that three months from now we may say it didn’t work and we have to do this other procedure called a trabeculectomy, if you sort of phrase it that way, and patients are on board with that, then I’m very much in favor of trying a minimally invasive procedure, on a patient like this.

DR KAHOOK: Go ahead, Pradeep, before we move to standalone?

DR RAMULU: I think what makes it particularly appealing in this particular patient is that their pressure isn’t 15. If you told me their visual fields have gotten worse at a pressure of 15 or 16, there may be less of a role for a MIGS procedure. But if the pressure is 22 and the target is 12, you may not know that they don’t do just as well at 15 or 16. If they’ve been really getting worse at 15 or 16, it’s a different story.

DR KAHOOK: I always say that the goal IOP is aspirational. It’s something we pray and hope for. It’s not something we’re really working towards. A lot of times we take what we can get. I’ve had patients where they’re 2 or 3 points away from goal after surgery, and they’ve been stable for years. We try to get them as low as possible for the individual patient. Husam, do you do standalone MIGS procedures?

DR ANSARI: I do. I would say I feel I reserve standalone MIGS procedures for patients who have either had cataract surgery or seem to have minimal or no cataract. I would say that in this patient, it feels like it would be a mistake to not take out the cataract, if you’re going into the operating room. We know that cataract surgery alone drops pressure in a lot of patients. And adding the MIGS procedure just seems — the two together just seem like a home run, or at least a triple. Anyway, but I do standalone MIGS procedures in patients where just cataract surgery doesn’t seem to be indicated because it’s either already been done, or cataract is not present. And for a patient like this, if they didn’t have a cataract, it would also be on the table.

DR KAHOOK: Okay. And Pradeep, I’ll ask you for the sake of time, if you want to comment on ECP, do you use it in practice? How does that fit into your algorithm?

DR RAMULU: I do. We probably have — amongst our group, we have different opinions on how useful and successful it is. To me, I like it as an adjunct in someone who has probably already had IOP lowering surgery already. Especially people who have had prior tube shunt surgery. I find it to be extremely effective. Maybe if they’ve had a prior trabeculectomy, it still seems to work a little bit better. It’s something you would do just in combination with cataract — just to get a lower pressure, I don’t notice that much extra effect.

DR KAHOOK: It’s a great point. One of the primary places where we use it is if you have a tube shunt that’s functioning, but maybe not at the goal pressure. In that case, it tends to work pretty well. Unfortunately, ECP isn’t available in many parts of the world, but it does have great utility in a segment of our patients. I just wanted to show this table. This is really to me one of the greatest stories about glaucoma, and glaucoma training. It used to be that we didn’t really have enough to put different boxes on a slide, when I was in training. It was basically trab and tube. But look at all of the options we have right now, from all of the MIGS procedures, canaloplasty, ab interno canaloplasty, goniotomy procedures, filtering surgery, in some places in the world more accessible than in the US. And of course, with glaucoma drainage devices, we have so many choices. So for the sake of time, we’re not gonna go into all the different algorithms that we can use, but this is just to point out how many different options we have right now, and how exciting it is to be able to have access to many of these. So let’s just go over another patient here. 61-year-old with a goal pressure of 10. Current pressure is 14. Has visually significant cataracts, no prior glaucoma surgery, currently on maximal targeted therapy. Seeing a theme here. Visual field shows nasal step with steady progression. Let’s talk about trabs and tubes here. Starting with Husam, is traditional trab the best option, with goal pressure of 10?

DR ANSARI: I would say yes. Without knowing any more details about this patient, my choice would be trabeculectomy. Goal pressure of 10, no previous eye surgery, that’s what I would do. The conjunctiva is gonna be cooperative, except for the fact that they’re on maximum tolerated medical therapy. So they might need steroid to cool down the conjunctiva. But that’s what I would do.

DR KAHOOK: What would make you go to tube instead of trabeculectomy?

DR ANSARI: If there was significant scarring of the conjunctiva for some reason, I would consider a tube, but TVT results notwithstanding, you see these patients — if you take care of patients for a long time, and you do a tube too early in their life, this patient is only 61 and has a low target pressure. They’re probably gonna need — they may really well need another procedure sometime in their lives. And I would hate to use up the real estate with the tube. So I have a high threshold for putting a tube in this patient.

DR KAHOOK: Pradeep, what do you think?

DR RAMULU: I think Husam said exactly what I would say. The advantage of trabeculectomy is that, despite all the new surgical options that we have, a lot of them are just plug and play. You put the device in, and the pressure you get with minimal exceptions is the pressure you get. Trabeculectomy is really unique, in that we can modulate the pressure. We have the options of removing sutures, lysing sutures, so it’s really the only surgery where we can kind of try to dial in a pressure, based on what we do in the postoperative period. When you’re trying to get a pressure this low, I think you need some of that ability, to be able to customize the operation in some way.

DR KAHOOK: Okay. I’m gonna actually answer the last question on this slide, just for the sake of time. I don’t want you to guess as to why I put it in, but chronic angle closure glaucoma and pseudoexfoliation — those are a few cases where I still think about going to angle surgery. Because sometimes you can get a lot of IOP lowering, much more than you think, into the 12 or 13 range. If the patient is hesitant to have filtration surgery, I feel comfortable counseling those patients that breaking up the synechiae, doing a goniotomy, unplugging the trabecular meshwork with the various devices we can use can oftentimes get them to a much better place and buy them a year or two away from filtration surgery. I wanted to get to a little bit more of the conversation of primary tube, and also trab versus tube. We have the TVT trial and the PTVT trial. We’re getting a lot of information. I wanted to show all the different tubes that we have access to, just keeping in mind that the large studies don’t use all of the different tubes. So we always have to keep that in mind, when we’re interpreting the results. But Husam, how has TVT or PTVT — you can pick one or both, if you want — how has that changed your algorithm for doing surgery on patients, when they come in to see you?

DR ANSARI: I’ll be interested. Pradeep and I trained together at Bascom Palmer Eye Institute, during the peak of TVT follow-up. And we definitely trained in an environment where primary tubes were very commonly done. And so when I ended training a dozen years ago, I thought: I’m probably gonna not do a lot of trabeculectomies in my life. I would say that the dozen years of experience now have really changed my thinking. I actually feel like I have a very high threshold for doing a primary tube. There has to be a really good reason for me to do a primary tube, and it has to do with what I said before. Which is that a trabeculectomy, when you do it, you haven’t burned any bridges. Meaning that you can do a tube later. You could — even if you had to, you could do a second trabeculectomy. Though I don’t do that very often at all. And so if you do a tube first, I just feel like you end up losing options too quickly. And when you end up taking care of patients for a dozen or more years, you really want to have each patient to have those options.

DR KAHOOK: What do you think, Pradeep?

DR RAMULU: I agree completely. We needle a lot of trabeculectomies also. And we do it in the operating room, under an infusion. And honestly, our success rates are very, very good. About 75%, 80%. And that’s both for early failure and for failure a few years down the line. And so I think that when you think about doing a trabeculectomy, it’s not like — oh, you only have one shot. You can needle it. You can consider a second trabeculectomy. In a 61-year-old, you really leave yourself a lot of additional options. And for somebody whose disease you’re gonna be treating for 20 years, I like Dr. Ansari are really worried about starting out with tube.

DR KAHOOK: My goal for the rest of the talk is to get you guys to have an argument and disagree about something. We’re gonna be pushing towards that. I did want to show this video, and I showed this to both of you before we hopped on to this session. But one of the questions that came in, pre-session, was: Do you have any pearls for practice for putting a tube in? Because some people are struggling with getting the tip of the tube in, and getting it into the anterior chamber. This is my partner, Leo Seibold. One of the biggest pearls I like to teach is: When you’re coming out with a needle, do a sideswipe to the side after most of your bevel is out of the wound. You don’t want to widen the entire hole that you’re creating into the eye. As soon as you’re coming out, once you see the bevel, swipe to the left in this case. And that gives you a tunnel to go into, and it directs the tube into the anterior chamber. Do you guys both do this? Just curious. Do you do the sideswipe?


DR KAHOOK: Can you disagree with that, Pradeep? Tell him it’s not necessary?

DR RAMULU: I don’t do it. I like to have it really tight. But it may be worth… I don’t know if either of you do… Patchless tubes also? But I think a lot of the people on the call may not have access to patch graft material. I’m curious to hear your opinions on doing tubes without a patch at all.

DR KAHOOK: Certainly in mission work, when I’m outside of the country, when we don’t have access, doing a flap or doing a much longer tunnel — Felix Gil out of Mexico City popularized entry in the anterior chamber going much further away from the limbs and obviating a need for patch graft. Do you always use a patch graft, Husam?

DR ANSARI: I actually do always use a patch graft. I did try tunneling for a while. And frankly just found it to be very challenging. My tubes ended up being vaulted anteriorly towards the cornea. And I just had a hard time kind of making it work for myself. Fortunately, when I was doing it, I wasn’t getting exposures, which is what our fear is when we don’t use a patch. So that really — exposure wasn’t the problem. I just felt like my tube was vaulted too close to the cornea, so I stopped doing it.

DR KAHOOK: Good learning. Good pearls. Hopefully that was helpful to the doctor who sent in the question. Let’s get towards the end of our cases here. 73-year-old pseudophakic Latino male with 25-year history of Primary Open Angle Glaucoma, advanced disease, failed trabeculectomy and GDD in both eyes. Current IOP 26 in the right and 24 in the left. And goal is low teens in this patient. What would be the next step in a patient like this?

DR RAMULU: As you alluded to earlier, cyclodestructive procedures in these cases are really, really good, and often work much more dramatically than one would ever expect. It probably would depend on what kind of machine you have, and what the patient’s visual acuity is. I think when the visual acuity is high in these cases, it’s really an ideal place for endolaser, if you have that device. But even if you don’t, I think cyclophotocoagulation done externally works very well, and I don’t think you should feel like you’re doing some inferior or like you’re giving your patients second class treatment if you go external. This is a great idea for cyclophotocoagulation.

DR ANSARI: Sorry, but I’m gonna agree with Pradeep again. Sorry! I learned a long time ago not to disagree with Pradeep.

DR KAHOOK: No, same here. I get it. I get it.

DR ANSARI: But I will say the other advantage to an external approach with cyclophotocoagulation is that if it doesn’t work, it’s actually — I’m very comfortable repeating this. If you don’t achieve target IOP with one treatment, of transscleral cyclophotocoagulation, I will do it again. I think there is something about the presence of a drainage device that seems to somehow enhance the outcomes of cyclophotocoagulation. So this patient in particular that has an implanted drainage device, a tube shunt that’s failed, is someone I would absolutely do CPC on.

DR KAHOOK: Pradeep, what are your settings when you do CPC?

DR RAMULU: I do some of the micropulse. I don’t know if people have access to that. So I have a 2250 for 50 seconds, in two different quadrants. One at a time. If I’m doing the traditional cyclophotocoagulation, then I’ll do 20 burns for 1250 milliwatts for 4 seconds. And honestly, I haven’t noticed a huge difference between those two.

DR KAHOOK: Do you use similar settings?

DR ANSARI: For the second-degree continuous pulse diode, I do a 4-second burst of about 1200 to 1500 milliwatts, and I’ll usually end up doing 25 to 30 applications. For the standard use. Micropulse, I actually don’t have a lot of personal experience with, to be able to tell you about settings.

DR KAHOOK: Okay. I’ll add that we haven’t seen a ton of difference between micropulse or traditional here as well. And I think they’re both cyclodestructive, if they’re gonna have efficacy. So to keep that in mind, and micropulse isn’t available. There’s access to it around the world, but not necessarily affordable in many markets. If I could do one thing for global ophthalmology, it would be to have every ophthalmologist able to get access to cyclophotocoagulation. There’s a lot of utility for it, around the world, but one of the pearls that Pradeep mentioned — Husam, it sounds like you used very similar settings — in my travels, oftentimes I see much higher energy, for a shorter amount of time, and I think slow and low for the trainees or anybody starting CPC that’s listening in to this call, is really important. So around 1500 milliwatts, around four seconds, the slow and low tends to do much better. Patients tend to have fewer adverse events. You don’t get the popping you can get, that causes inflammation. I want to go over the pictures. On the top left, ciliary processes are normal, lacy epithelium around the ciliary processes. On the upper right hand side is post-CPC, where you see destruction, necrotic tissue, disruption of the laciness and the epithelium around the ciliary processes. So this is a serious procedure, and the slow and low has a tendency to do better in these patients. So I’m gonna skip this slide for now. I’m gonna hold pattern here, because we addressed a lot of these things. But what I want to do, if it’s okay with you guys, is go to the question and answer list. I’m just gonna pick some of the questions that were called in, before jumping back into the slide deck. And let me just work through here, and see… So a lot of questions about some of the stuff that we’ve already discussed. SLT. There’s a question here — and I’ll ask Pradeep this question. Three medication maximum or three bottles? What if PGA and beta blocker are combined? Can you add another bottle on top of that? You alluded to this, but maybe you can speak to it again.

DR RAMULU: I think people have showed that even with the third agent, the success rate of lowering pressure by 20% in two years is very, very low. Once you’re going to a third bottle, of course you’re going to a third agent, but even changing a second bottle so it has two agents, in general doesn’t give you long lasting success. Would I try it in that patient? Of course I would. Because I think you have an obligation if people don’t want surgery. You have an obligation to try that before you move to surgery. But I think it’s the time in the conversation with the patient for telling them that they may end up needing surgery. Like you’re gonna try this, but it might not end up being successful.

DR KAHOOK: Okay. Husam, another question for you here. This is about using Rho kinase inhibitors in patients and doing subsequent trabeculectomy. Have you noticed increased fragility in the conjunctiva on patients who are on Rho kinase inhibitors? We’re starting to hear this now. I want to know what your experience it.

DR ANSARI: I believe it to be a real problem, when you’re trying to do conjunctival surgery on a patient with inflamed conjunctiva, and the Rho kinase inhibitors can be pretty inflammatory. I’ve mitigated that by simply stopping the Rho kinase inhibitors at the time we decide to do the surgery, which may be a few weeks before the actual surgery. By the time they get to the operating room, they’ve been off the medication for a few weeks, and pretreatment with a topical steroid for a few days before surgery in a situation like that is also very helpful. But it should be addressed by stopping the medicine and retreating.

DR KAHOOK: Excellent point. Some of the teachings from a decade ago that we’re not always in touch with is the idea of a medication honeymoon and starting the patient on a steroid before going in to surgery. I know Stewart did a lot of this work. I often try to do that. For Pradeep, how do you set IOP in clinic?

DR RAMULU: It depends on the severity of the disease, what the starting pressure is also. Some of the work done by Martin Bryant way back when set the stage for a lot of the rules people still use today. If you have a high pressure glaucoma with pressures starting in the 25 or plus range, if there’s disc damage but no field damage, you have a target of 20 to 21. If you have visual field damage in one hemifield but not the other, setting the target around 18, and if you have damage in both the superior and inferior hemifields, starting around 15. I think we have more and more glaucoma now coming in with lower pressures, especially in older patients, and so you have to adapt the rules for that group. Instead of 21, I say 20%. Instead of 18, I say 25%. Instead of 15, I say 30%. That’s kind of a starting point for me. And of course, as the patient’s course progresses, you may need to alter that upward or downward.

DR KAHOOK: We have several questions for you to repeat the four criteria that you used for SLT.

DR RAMULU: I was trying to put it in. I don’t know if I’m able to type it in on the Q and A.

DR KAHOOK: Go ahead and repeat it, and maybe Husam and I can also repeat it a few more times.

DR RAMULU: So the first is that the starting pressure needs to be 20 or greater. The second is that at baseline the patient needs to be on zero or one medications. The third is that you should want no more than a 25% lowering of pressure, ideally 20 to 25%. And the fourth is that they have pseudoexfoliation. The point is if they have pseudoexfoliation, you can break some of the other rules.

DR KAHOOK: Okay. Do you find that laser trabeculoplasty increases the success rate of trabeculectomy?

DR ANSARI: I haven’t found it to have an impact. What we’re looking at in our group is whether previous laser trabeculoplasty has any effect on outcomes with angle-based procedures. Because there’s a lot of interest there. It turns out we have a lot of patients that have had angle procedures, MIGS procedures, after laser trabeculoplasty. So stay tuned. We’ll hopefully have some interesting information.

DR KAHOOK: There’s a question here about NPDS from a filtration standpoint. Something that’s used much more out of the country than what we do here in the US. But I think this is a sign for me that at some point, when we do these sessions, it might be good to have somebody speak about NPDS. I apologize to the speaker. I just wanted to point that out. I think it is important, but I assume both of you don’t do NPDS. A lot of you as surgeons don’t have a great amount of experience. Is that fair?


DR RAMULU: Randy Craven in our group does do them. Sometimes there are selected patients we’ll send to him. Somebody where you don’t want a fully penetrating procedure.

DR KAHOOK: He’s a great asset to have there. So let’s see here. Why don’t you do only cataract extraction to lower IOP from 15 to 10? I want to generalize that question a little bit more. One of the things with MIGS trials: We didn’t just learn how efficacious the different devices or approaches are. We learned how extremely effective cataract surgery alone is, at lowering intraocular pressure. So how do you think of that, when you see a patient? When do you decide to just do cataract surgery, versus combining it with an angle surgery? Let’s call it mild to moderate disease, where you’re trying to get 3 or 4 millimeters of mercury lowering?

DR ANSARI: I would say I feel like the reason — you certainly can do cataract surgery alone, on a patient like that, and expect to have a positive outcome, and a better pressure. One of the things that’s tricky to figure out — we’re always trying to do the most that we can, with the least impact that we can. And if you’re gonna go to the operating room to take out a patient’s cataract, if the environment is favorable for you to also do an angle procedure, it feels like a wasted opportunity to not do so. Because the safety profile is so high, and you’re already there. So assuming things like the procedure is covered by the patient’s insurance, assuming that there isn’t any obvious contraindication to doing the angle procedure, I feel like it’s hard to justify not — at least not offering it to the patient. And almost leaving it up to them. And tell them to give you a reason to not do the angle procedure.

DR KAHOOK: What do you think, Pradeep?

DR RAMULU: You know, I think people often make the argument that if you look at the trials of the minimally invasive glaucoma surgery devices, that the number of people who have a successful outcome, even in the cataract alone group, is pretty high. That being said, that has never matched my experience. And I think that there probably is some regression to the mean in those studies. Because the outcomes that I see in my practice from adding the device is so much better than cataract surgery alone that it’s really, you know — I don’t really understand why the success rate is so high in the control group, in those studies. So I agree with Dr. Ansari. I don’t know that we’re there yet, but I think at least in a country like the United States, where when you offer somebody cataract surgery, you have to also at least bring up the idea of premium lenses, I think we’re probably not that far away that if somebody is on an eye drop, you’re gonna start getting some patients angry with you, if you don’t discuss with them a treatment that gets them off their drops. And I think almost everybody wants that.

DR KAHOOK: Yeah, yeah. I would consider it standard of care. And standard of care is defined by your area of practice. So I think in Colorado, in Denver, where I practice, it’s considered standard of care in my opinion, at least, to suggest doing an angle procedure, if you’re going in. And you’re gonna be in the eye doing the phacoemulsification anyway. So you might as well get the patient off their drops. So let’s go on to a question that is on everybody’s mind in glaucoma. Some of the stories of MIGS devices causing endothelial cell loss. There are some questions about glaucoma drainage devices and endothelial cell loss, but maybe we can answer two questions at the same time. Do you see a decrease in endothelial cell count in glaucoma patients in general, versus non-glaucoma patients? And let’s say you have a patient with Fuchs or decreased cells. Does that make you choose one device versus another or one approach versus another?

DR ANSARI: I would say I feel that these devices are almost certainly contributing to endothelial cell loss. And therefore if I feel that someone is already compromised in that regard, an angle procedure that doesn’t involve placement of a device, I think, is appropriate. Is the best option for that patient. And that’s what I will offer them. I have to admit that if I’m not concerned about their endothelium, meaning I don’t have any evidence that their endothelium is compromised, and they’re having cataract surgery, I am leaning towards a device-based approach, simply because they’re so easy to use. And I guess perhaps I’m a little bit affected by the fact that they’re popular, and they’re in vogue, and patients know about them and they ask about them. And they almost want a stent rather than a non-stent, because of some of the hype about them. So nevertheless, I am concerned about endothelial cell loss, and I think it’s something we have to seriously think about. And if a non-device approach is available, it probably should be favored. Assuming equal efficacy.

DR KAHOOK: For the sake of time, different question for you, Pradeep. One thing we didn’t touch on was the use of Vyzulta. Do you use that in your practice? Again, it’s not available everywhere around the world. But when do you use it in your practice? Does it have a role?

DR RAMULU: I don’t use it very much. I haven’t been as impressed with it as I have with Rhopressa, where it gives these dramatic additional pressure lowerings, beyond what I was already using. I will try it in a few cases, where I’ll change the prostaglandin to Vyzulta. Really in a setting to try to avoid surgery — but I have to say I’ve not been as impressed with it, as I have been with Rhopressa.

DR KAHOOK: For the sake of time, I’m gonna move to this last topic. For everybody listening in, I know you have a ton of questions that come in, and there are a bunch that we for time’s sake here we weren’t able to get to. One suggestion I did have for the Orbis team is maybe we just have a two-hour session where a few of us get on and just answer questions, no slides, where we just have a session like that. I think that would be great, and if they’re amenable to that, I’ll help organize that, and we’ll get that done. But because of the time that we’re in right now, the time of COVID, everybody who’s listening in is going through some sort of life or professional change that is being dealt to us by COVID-19. What I was wondering is: Maybe we can close off here with a little bit of a discussion about how COVID-19 is affecting you personally, and how is it affecting your practice? What are the things that you’re doing differently? And what do you plan to do, as things start to open up? Maybe, Husam, we can start with you, and move to Pradeep. Professionally and personally, whatever you want to share with the group.

DR ANSARI: Personally, of course, it’s a very difficult time for everyone. Myself included. And the world. I consider myself fortunate and lucky. Myself, my family, we feel safe. We feel healthy. Because I’m not going to work as much, I’m spending more time with family, and I’m spending more time working on side projects like looking at outcomes. That’s something that we as a group decided to do in our glaucoma service. Let’s take this time to really extract our surgical outcomes, and start thinking about them and talking about them, and maybe even publishing on them. So that’s something that’s been very stimulating. And having that kind of time is something that I don’t think I’ve ever had in my life. From a practice standpoint, we’re basically open to seeing urgent patients only. Patients that we feel must be seen — maybe they just recently had surgery, or recently had a medication change. Our overall clinical practice is reduced to 20% of our usual volume, and we pretty much suspended all surgeries, other than something that is immediately vision threatening.

DR KAHOOK: Pradeep, how about you? Both professionally and personally?

DR RAMULU: So I’m actually a COVID survivor.

DR KAHOOK: I didn’t know that!

DR RAMULU: Yeah, it was a very, very mild case, but I think it is… It just goes to show that in our practice, we’re at risk of getting it. I hadn’t really been going out, except to see patients. And so probably what’s overwhelmingly likely is that I did get it seeing patients, even when I was wearing a mask. It kind of emphasizes the importance of really taking these regulations seriously. And minimizing the time you spend around people. And how much you ask your patients to come in. Thankfully, I caught it early and I got tested, and I was able to not go in, and I hope I didn’t spread it to anybody. But that certainly would be my worst fear, is that I would have been able to send it to anybody else. Regarding the clinics, I think we’re in a very similar position as Dr. Ansari, and now we’re actually thinking about: What is the next phase gonna be? As I’m sure many of you are as well. And I think we’re gonna be in a very new reality. In terms of our practice. I think we can’t expect to go back to the way things were. And probably what many of you are thinking and realizing is what we’ve realized. Is that we have to move to essentially a zero-wait model. And how do we do that? We’re gonna start experimenting with iPad perimetry, we had a doctor doing a drivethrough tonometry for somebody in an assisted living community. If they had gone into the clinic, they would have had to get tested before they go back. So we’re thinking about how to change our flow. But there’s an idea that this could be for the better. The idea that we had waiting rooms packed full of people, people spending two or three hours in our clinic — that’s not good for anybody. So maybe this will move us — so I think in any time of crisis, when you have to change things, we have to think about how we can come out with an even better practice model than where we started. So I would encourage all of you to use this as an opportunity for innovation, and see how you can make something which ends up being better than it was before.

DR KAHOOK: I’ll just throw in my two cents on both topics. I think the last part that you just mentioned, Pradeep, has been the silver lining. Not just sharing with my colleagues here at the university, but also talking to people like you, and Husam, and trying to figure out how everybody else is doing. You know, surviving, essentially, through the practice issues that have come up. For us, virtual health has been a huge effort that we put together. Pediatric, plastic, neuro-ophth have been able to use it extensively. Glaucoma not as much, but still using it for certain things. We’ve created hybrid models, where people come in for testing. They’re by themselves in the building. And we do a virtual health follow-up, after they have the pressure checked with the technician, and it’s just the two of them in the building with some of our satellite offices. We’ve tried to innovate. We’re trying to do things with the hope that it’s gonna stick post-COVID. We’re putting in workflows that we’re going to try and sustain. We’re also planning the drivethrough pressure checks. We have the lanes and the technicians picked out, computers on wheels that we’re gonna take outdoors. We’re gonna do a lot of that stuff. And I think a lot of it is gonna stick for a significant amount of time. There’s also the economic impact. Some are more affected than others. So just trying to figure out how to keep people employed. How to kind of spread the hurt around, making sure that we’re not just targeting one piece of our team for getting affected. So we’re learning a lot, and hopefully we can share a little bit more. From a personal standpoint, I would say the number one thing — for a lot of people who know me personally, social distancing is actually in my blood. I have a lot of people who are texting, saying: Hey, this is your dream come true! You can kind of work in your loft and get a lot of stuff done. But the equation has to factor in the fact that we’re home schooling our son here. So about half of my wife’s day is spent with math and English. Our son is 7 years old. So there’s the personal side of this, that we don’t always factor into our professional discussions. But it can seep into the professional part. All my Zoom calls — you probably didn’t notice, but as we were doing this session, my son came to the side over here, grabbed his iPad, looked at me, and just walked right back up. Just thinking — hey, there’s another Zoom call. So we’re all going through this, professionally, personally. I love sessions like this. I love the fact that we can all get together. We have well over 1,000 people that have signed up to take time to listen to this discussion. We have various groups and big rooms that are also listening in, so they can also have a discussion after this. I’m hoping that we can do more of these. More discussions, more question and answer. And because our time is up, I just want to take a couple of seconds here to say thank you. So Husam Ansari from Ophthalmic Consultants in Boston. Great pearls. I always learn from you. So I appreciate all of the time that you put in to get ready for this, and all of the disagreement that you had with Pradeep Ramulu, who is from Hopkins, one of the best institutions in ophthalmology, second only to the University of Colorado. But I think your pearls are well regarded. And your list of four things, I think, was the hit for SLT today. How to think of it. So now what you have to do is publish evidence-based medicine that that’s actually true. So that’s your mandate. And I’ll sign off. Malik Kahook, from the University of Colorado, just to say thank you to everybody, and hopefully we can meet back here on Cybersight soon to learn more. We also have stuff on Cybersight with the KEOGT link. You can find videos and other discussions, and again, thank you to both of you. Thank you to Orbis for organizing, and I hope everybody stays safe and copes very well with what we’re dealing with. Thank you.

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April 23, 2020

Last Updated: October 31, 2022

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