Eyeworld Daily News

2017 ASCRS Los Angeles Daily Saturday

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EW SHOW DAILY 6 Saturday, May 6, 2017 ASCRS News Today by Liz Hillman EyeWorld Staff Writer punctum for 1 minute after admin- istration, is one technique, while gel formulations could help as well. Another pearl is having patients not blink for 6–10 seconds prior to instilling the medication, decreasing the natural barrier of the tear film to increase medication absorption. 4) Choose the ideal regimen for each patient: When adding a second agent, use drops that work by a different mechanism. Kelly Muir, MD, Durham, North Carolina, discussed the ev- ergreen issue of increasing patient compliance. She said this can be improved with clear communication with patients, using an active voice in materials, limiting dense text with clear, simple graphics. She also said physicians should ask patients about problems they might be having with compliance and provide personalized suggestions in those cases. Finally, Dr. Muir recommend- ed having the patient show you how they, or their companion, instills drops. There are also cheap devices for drop bottles for those having trouble targeting the eye or squeez- ing the bottle, Dr. Muir noted. Next, Quang Nguyen, MD, La Jolla, California, described several new classes of drugs in the pipeline and drug delivery systems that could improve efficacy or sustained release of medication. The paradigms for laser glau- coma surgery are changing. Robert Noecker, MD, Fairfield, Connecti- cut, discussed the different types of laser trabeculoplasty and which type to use, while Jeffrey Kammer, MD, Nashville, Tennessee, presented in- dications for cyclophotocoagulation, which he said is "not the dangerous, sight-threatening treatment" many feared. Shan Lin, MD, San Fran- cisco, presented on indications for iridotomy, iridoplasty, and endocy- clophotocoagulation EW Editors' note: Drs. Barton, Nguyen, and Noecker have financial interests related to their comments. Drs. Patrianakos, Muir, Kammer, and Lin do not have any financial interests related to their comments. Other practical concepts for improving glaucoma care also discussed K eith Barton, MD, London, international guest speaker for ASCRS Glaucoma Day, covered the topic of "MIGS … for a few dollars more." While managing a patient with cataract and glaucoma has been a major issue, due to cataract surgery's potential to cause trabeculectomy to fail, Dr. Barton said, "potential solutions are knocking on our door every single day." However, he acknowledged that it can be "bewildering" to decide which microinvasive glaucoma surgery (MIGS) to use. Dr. Barton gave an overview of the various options available starting with iStent (Glaukos, San Clemente, California), which he said is the market leader in the U.S. in terms of glaucoma device usage. "What do new entrants need to do to achieve [similar success]?" Dr. Barton asked. In addition to being easy to combine with cataract surgery, when applicable, he said other MIGS need to have little risk to the patient and limited to no additional postop management. "There are many competing technologies for this market … all are safe and predictable and require similar implantation skills and have similar efficacy," Dr. Barton said. In Europe, iStent, XEN (Aller- gan, Dublin, Ireland), and CyPass (Alcon, Fort Worth, Texas) are all approved in conjunction with cat- aract surgery as well as standalone procedures. In the U.S., however, only XEN is approved as a stand- alone procedure. In the U.S., the surgeon and care center are paid for performing iStent with cataract surgery, but Dr. Barton noted that in the U.K., there is a major financial disincentive to combine MIGS with cataract surgery. Dr. Barton went into further de- tail as to the different "nuances"— indications, surgical learning curve, targeted pathway—of the current MIGS options, adding "where this goes, it will be interesting to see." After Dr. Barton's speech, presentations focused on practical concepts that can improve glaucoma care with medications and lasers. Thomas Patrianakos, MD, Chicago, offered four pearls for optimizing ef- ficacy of topical medication, "a.k.a., how can I make the current drops that we have work better." 1) Educate patients: The informed patient, Dr. Patrianakos said, is one who is more likely to be adherent. He said patients need to understand the disease process, how the drops work, and any side effects. Asking open ended questions can reveal to the physician problems the patient is having with adherence. 2) Teach proper instillation techniques: This can be done in the office, but Dr. Patrianakos also said YouTube offers more than 6,900 vid- eos on how to instill drops. Waiting 5 minutes between drops can help avoid the washout effect as can the use of combination medications, when appropriate. 3) Increase exposure time: Punctal occlusion, using the thumb and index finger at the lower Glaucoma Day international guest speaker focuses on competing technologies in the MIGS market Dr. Barton, international guest speaker, says "potential solutions are knocking on our door" to manage glaucoma patients.

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