AAOpt 2023: Navigating the evolution of glaucoma and MIGS

At the 2023 American Academy of Optometry (AAOpt) Meeting, Gleb Sukhovolskiy presented lecture entitled, "Optometrist’s Guide to MIGS and the Continuing Evolution of Glaucoma Treatment."

Video transcript

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

Kassi Jackson, Editor:
Hi everyone. I'm sitting down with Dr. Gleb Sukhovolskiy to discuss his presentation: "Optometrists' Guide to MIGs and the Continuing Evolution of Glaucoma Treatment," which he gave at the American Academy of Optometry meeting this year in New Orleans. Thanks for joining us, Dr. Sukhovolskiy.

Gleb Sukhovolskiy, OD:
Thank you for having me.

Jackson:
Of course. So can you please share with us an overview of your presentation?

Sukhovolskiy:
I talked about MIGs, which stands for minimally invasive glaucoma surgeries. It's something that's becoming more of a mainstream procedure done by ophthalmologists around the country. It used to be that glaucoma surgery was invasive and high risk to the point where, you know, ultimately, the drops were used until they couldn't be used, and then the surgery was saved for a last resort. And in the last decade or so we got a new group of glaucoma procedures, MIGs; it's a very heterogenous group of procedures that allows for doing surgery with a lot less risk. And so what we are finding is that some of the benefits of these procedures, especially in early to moderate glaucoma, carry on for many years, allowing patients to depend on drops less, have a lot less fluctuations with their intraocular pressure, and also have less progression over the years.

Jackson:
So what are some key takeaway points for clinicians to take home with them from this talk?

Sukhovolskiy:
Oh, yeah, great question. So I think as optometrists we should be really in the know about this, because I think some of us still like to practice the way we've practiced for many years where we start with with drops and kind of see where things go. And with the glaucoma surgeries becoming a lot safer, I think they should really be considered often as a first line treatment, sometimes sometimes as a second line treatment to where you don't go for years maxing out all the medications. All surgeries work better when the eyes [are in] kind of, you know, less medicated states. So a lot of the stents and the canaloplasty can be often used as a treatment to get a patient to use less medications and achieve more stability over the years.

So for optometrists, I think that means setting up good relationships with ophthalmology, and the glaucoma specialists and general cataract surgeons in their area, knowing how to co-manage them. And that means when should I refer for this? When would be a good time? What does each procedure in involve? What risks am I looking at? How do I manage them after the surgery? When do I take them off medications? When do I expect the pressure to normalize? What sort of side effects am I looking at? If there's any issues after surgery? How do I deal with them? So those are important things to know. Those are some of the things I tried to cover as well as some of the differences. They're specific to each procedure.

Jackson:
Yeah, so it sounds like there's a lot of information kind of, you know, packed into this lecture. So why is this important for optometrists to know and take back to their own clinics?

Sukhovolskiy:
Well, just because we're not doing some of these procedures doesn't mean that you should not recommend them or not think of them because we all have the option of drops. You know, certainly there's option of SLT, which should be done more and more as a first line treatment. But I think this is good to keep in mind particularly with patients who are undergoing cataract surgery and have glaucoma; they will benefit from this the most.

But nowadays, we are entering the era where MIGs are often done as a standalone treatment as well. So patients who maybe had cataract surgery or maybe they don't yet have a cataract; there are now procedures that are available for those patients where you think maybe I'm already on 2 drops and I should do something, but you know, a shunt, a trabeculectomy seems too invasive at this point. That's where MIGs really fit in.

Jackson:
Wonderful. So yeah, kind of building off of that from the patient side of things. What does this mean for patient care?

Sukhovolskiy:
There are several good benefits from MIGs, and one of them is obviously reducing intraocular pressure. Another big one for patients is reducing their glaucoma medication burden. That's tough. Taking medications every day is tough, remembering them. The irritation that comes with the medications is also significant over years of use of these drops, you're more likely to get significant ocular surface issues. And so limiting that, starting from an earlier point, you're more likely to have a patient whose glaucoma is controlled because it's easier for them to adhere to therapy. They're not having issues with drops or as many drops at the very least. And in addition to that, the glaucoma may not deteriorate quite as fast. So those are certainly some benefits.

In addition to that, another benefit that's not talked about a lot is the decrease in the diurnal intraocular pressure variation. So, usually, intraocular pressure varies throughout the day, you have low points, you have high points, and it's not reduced very much with the medication. In fact, with the medication, you also have a curve wherein the medication acts the most in the pressures lowest. And as it wears off, the pressure rises. And so it's these up and down cycles that something like a stent in the eye can can greatly reduce and keep a more stable 24 hour pressure.
Is there anything else you'd like to add that we haven't touched on?
No, it was it was great speaking on this topic. I work at a surgical center where we do a lot of comanagement. There's a lot of collaboration between optometry and ophthalmology. And it's my goal to just share that, share how we do things and share what the community out there can be doing and seeing and I'm thankful I get to do that.

Jackson:
Well, we appreciate your expertise for sure. So, Dr. Sukhovolskiy thank you so much for your time today.

Sukhovolskiy:
Thank you.