migs: minimally invasive glaucoma surgery ilya rozenbaum, md matossian eye associates june 2014
TRANSCRIPT
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MIGS:Minimally Invasive Glaucoma
Surgery
Ilya Rozenbaum, MDMatossian Eye Associates
June 2014
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Disclosures
Speaker/Consultant:Allergan
Alcon
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Human Cost of Glaucoma•Glaucoma is the second leading cause of blindness worldwide•Global estimates of glaucoma cases exceeded 60M in 2010 and are estimated to grow to 78M by 2020•Bilateral blindness is occurring at an alarming 7.5% of OAG cases globally, growing from 4.4M to 6M patients between 2010 and 2020•In the US, there are an estimated 2.2M cases of OAG, growing to more than 3M cases by 2020, with more than 88,000 of these patients going blind
1.Quigley HA. Number of people with glaucoma worldwide. Br J Ophthalmol. 2006 March; 90(3): 262–267.2.Congdon NG, De Jong PT, Klein BE et al.Glaucoma as a cause of blindness in the United States. American Glaucoma Society Annual Meeting 2003; abstract.3.Friedman DS, De Jong PT, Klein BE, et al. Glaucoma prevalence in the United States: results of a meta-analysis. American Glaucoma Society Annual Meeting 2003; Abstract.
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Problems with Glaucoma Meds Future surgery success rate may be lower
Quality of life
Cost
Compliance
Side effects:
Death from beta-blockers Fatal aplastic anemia (CAIs) Severe allergic reactions Retinal detachment (pilocarpine) Irritation, redness, etc
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Glaucoma: Surgical Disease
CIGTS:
Glaucomatous optic disc progression is higher in patients on medical treatment than surgical patients
Five-year Follow-up Optic Disc Findings of the Collaborative Initial Glaucoma Treatment Study. Am J Ophthalmol 2009;147:717–724.
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Surgical optionsTrabeculectomy or ExPress
Tube shuntsAhmed, Baerveldt, Molteno
Laser trabeculoplasty
Trans-scleral laser
Canaloplasty
MIGS
Glaucoma: Surgical Disease
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Trabeculectomy 2014Advantages
Still the gold standard surgery No device needed - available, cost-effective Can achieve low IOPs
Disadvantages Less standardized (hasn’t significantly
changed in 50 years) Complications in up to 40% Failure in up to 50% at 5 years Cataract in 50% at 5 years
Gedde SJ, Schiffman JC, Feuer WJ, et al. Am J Ophthalmol. 2012;153:789-803 e2.
Glaucoma: Surgical Disease
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TVT study: complications
Early postoperative complications: 21% (tube) and 37% (trab)
Late postoperative complications (up to 5 years after surgery): 34% (tube) and 36% (trab)
Cataract surgery: 54% of phakic tube eyes and 43% of phakic trab eyes
Reoperation for surgical complications: 22% (tube) and 18% (trab)
Gedde SJ, Herndon LW, Brandt JD, et al. Am J Ophthalmol. 2012;153:804-814 e1.
Glaucoma: Surgical Disease
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Bleb Leak
Evaluation must be done with high concentration fluorescein
Cascading darker/clear fluid with fluorescent edges is a leak
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Endophthalmitis
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Tube Erosion
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Plate Erosion
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Ideal glaucoma surgery?
As effective as trabeculectomy but safer
Reproducible/Predictable
No bleb
Easy to perform
Less post-operative effort
Cost-effective
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Mansberger SL, et al. Reduction in intraocular pressure after cataract extraction: the ocular hypertension treatment study. Ophthalmology. 2012 Sep;119:1826-31.
Cataract surgery vs. controls from OHTS:
16.5% reduction in IOP sustained for 36 months
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Centers for Medicare and Medicaid Services. 2002 – 2007. Medicare Standard Analytical File. Baltimore, MD. 2007.
Concomitant Cataract & Glaucoma (US)
1 in 5 Cataract Eyes on OHT Medication
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SITA-Standard HVF 24-2
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MIGS
MinimallyInvasive
GlaucomaSurgery
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Minimally Invasive Glaucoma Surgery (MIGS)
Ab interno microincisional approach Minimally traumatic to the target tissue Safe and (at least modest) IOP reduction Rapid recovery with minimal impact on the
patient’s quality of life Typically indicated for mild to moderate POAG
Curr Opin Ophthalmol 2012, 23:96–104
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iStent Trabecular Micro-Bypass Stent (Glaucos)
1 mm x 0.33 mm
Snorkel: 0.25 mm x 120 µm (bore diameter)
Weight: 60 µg
Surgical grade nonferromagnetic titanium
Heparin-coated to promote self-priming and facilitate outflow
iStent® is FDA approved in the U.S., C.E. marked in the E.U., and has Medical Device Approval in Canada
Open Half Pipe
Self-Trephining Tip
Snorkel0.3 mm
Retention ArchesLumen 120 µm
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iStent
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iStent: Indication
In conjunction with
cataract surgery
Mild to moderate open-
angle glaucoma
Currently treated with
ocular hypotensive
medication
iStent® is FDA approved in the U.S., C.E. marked in the E.U., and has Medical Device Approval in Canada
For patients with OAG/OHTN who also need cataract surgery
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iStent
Done with cataract surgery
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Designed to improve aqueous outflow thru the natural physiologic pathway
Creates a bypass thru trabecular meshwork to Schlemm’s canal
iStent: Mechanism
iStent® is FDA approved in the U.S., C.E. marked in the E.U., and has Medical Device Approval in Canada
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iStent
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iStent Surgical Video
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Ophthalmology. 2011 Mar;118(3):459-67.
At 12 months:68% of iStent subjects with IOP ≤ 21 mm Hg without medication vs. 50% with cataract surgery alone (p=0.004)
0
20
40
60
80
100
Cataract Surgery iStent
Percent of Eyes With IOP ≤ 21 mm Hg Without Medication Use
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Ophthalmology. 2011 Mar;118(3):459-67.
At 12 months:
15% of iStent vs.
35% cataract group on
medication (p=0.001)
0
50
100
Cataract Surgery iStent
Percent of Patients on Ocular Hypotensive Medication
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Complication iStent + Cataract Surgery N = 111
Cataract Surgery N = 122
Anticipated early postoperative event 14(13%) 15(12%)
Stent obstruction by iris, vitreous, fibrous overgrowth, fibrin, blood, and so forth
4(4%) 0(0%)
Posterior capsular opacification 3(3%) 8(7%)
Stent malposition 3(3%) 0(0%)
Subconjunctival hemorrhage 2(2%) 2(2%)
Elevated IOP, other 2(2%) 1(1%)
Epiretinal membrane 2(2%) 1(1%)
Iris atrophy 2(2%) 0(0%)
Blurry vision or visual disturbance 1(1%) 6(5%)
Iritis 1(1%) 6(5%)
Dry eye 1(1%) 2(2%)
Elevated IOP requiring treatment with oral or intravenous medications or with surgical intervention
1(1%) 2(2%)
Macular edema 1(1%) 2(2%)
Foreign body sensation 0(0%) 3(2%)
Allergic conjunctivitis 0(0%) 2(2%)
Mild pain 0(0%) 2(2%)
Rebound inflammation from tapering steroids 0(0%) 2(2%)
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iStent
Lower IOPFewer medicationsNo bleb!!
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What's in the Pipeline?
2 “iStent inject” vs latanoprost/timolol
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Endoscopic Cyclo Photocoagulation(ECP) - EndoOptiks
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ECP
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ECP
ECP is the selective ablation of aqueous producing ciliary processes via an ab interno approach
Inhibits aqueous production, therefore reducing IOP and medication use
ECP has been performed globally for over 12 years
More than 50,000 patients treated to date
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ECP Indications
Mild to moderate glaucoma (any type)
or Refractory glaucoma (after multiple failed
glaucoma surgeries)
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Phaco-ECP: Phaco-ECP: Combined ECP and Cataract Surgery
Lindfield D, Ritchie RW, Griffith MF. BMJ Open 2012
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ECP COLLABORATIVE STUDY GROUPSAFETY STUDY: COMPLICATIONS
IOP Spike 14.5%Hemorrhage 3.8%Serous Choroidal Effusion 0.36%IOL Dislocation 0.36%CME 1.03%RD 0.27%Massive Choroidal Hemorrhage 0.09%Hypotony or Phthisis 0.12%NLP Vision 0.12%Cataract 24.5%Acute Graft Rejection 5.3%Chronic Graft Rejection 0Chronic Inflammation 0Flat AC 0Endophthalmitis 0Diplopia 0Wound Leak 0Bleb Complications 0
5824 PATIENTS
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Trabectome (Neomedix)
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Ablates and removes a strip of trabecular meshwork and re-establishes access to the eye’s natural drainage pathway
Trabectome
38
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Review of 115 Trabectome patients vs. 102 trab-MMC patients.
Success rates (IOP<21 mmHg or >20% reduction) at 2 years:
22.4% for trabectome and 76.1% for trab (P=0.001)
Ophthalmology. 2012 Jan;119(1):36-42.
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Trabectome had 100% hyphema POD #1, plus 4.3% other complications, compared to 35.3% complication rate for trabeculectomy (P=.001)
Ophthalmology. 2012 Jan;119(1):36-42.
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Side Effects and Complications Descemet’s injury
Ciliary body injury
Reflux bleeding, hyphema
Zonule injury
Trabectome
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The ICE Procedure
Cataract Extraction
ECPiStent
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What is ICE?
16.5% IOP lowering at 3 years
Mansberger. Ophthal. 2012; 119:1826-31.
33% IOP lowering with
cataract extraction
Samuelson. Ophthal. 2011;118:459-67.
43% IOP lowering with cataract extractionKahook; J Glaucoma. 2007;16:527-30.
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Mechanisms of ICE?
? Angle widening? Decreased
aqueous production
Increased trabecular outdlow
Decreased aqueous production
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% o
f ey
esPreoperative vs. Month 3-6 IOP Reduction
(n=48)
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% o
f ey
esPreoperative vs. Month 3-6 IOP
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Projected cost savings at 6 years in $:
What about Cost?
Iordanous Y et al. J Glaucoma. 2014 Feb;23(2):e112-8.
1 drop 2 drops 3 drops
iStent -20.77 1272.55 2124.71
ECP 779.23 2072.55 2924.71
Trabectome 279.23 1572.55 2424.71
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Summary
Appreciation for the risks and complications associated with traditional glaucoma surgery has ignited the MIGS revolution
MIGS, combined with cataract surgery, provides safe new options for IOP reduction
Lots of options, data is forthcoming Trabeculectomy and tube shunt surgery for
significant IOP reduction
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Thank you!
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Cell 646-263-3045