Eyeworld Daily News

EW SHOW DAILY 34 ASCRS Symposia Monday, April 16, 2018 by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer In light of these facts, Dr. Sark- isian said ophthalmologists should stop thinking their patients are taking their drops. Doctors need to build rapport with their patients to get them to open up to the reality of non-compliance. Doctors should be honest and non-judgmental, and encourage their patients to educate themselves about their disease until they "own it." Finally, Dr. Sarkisian recom- mended considering SLT or earlier phaco with MIGS to remove the burden of medication. He offered a few suggestions for how to talk to patients about MIGS procedures. Personally, he likes "shower drain analogies." Imagine a shower drain clogged by a clump of hair: The iStent is like a straw stuck through the clump of hair; the TRAB 360 (Second Sciences, Menlo Park, California) is used to perform a procedure that is like taking the entire drain off. Disparagingly, Dr. Sarkisian compared traditional trabeculectomy to drilling a hole in the side of the bathtub and putting a bucket under the hole. Doctors can also compare MIGS to surgical interventions for coro- nary artery disease or to the differ- ence between laparoscopic surgery and the use of open incisions to help patients better understand their options. "Don't assume your patients wouldn't want surgery," Dr. Sark- isian said. "Many will be relieved they can be free from the drops and may wonder why you didn't offer surgery sooner." The MIGS Street Boys conclud- ed the symposium with an encore presentation of their music video, edited by Dr. Singh, with original lyrics set to the music of the Back- street Boys' 1997 hit "Everybody (Backstreet's Back)." "Go get your gonio, don't forget the visco, 'coz we're gonna do something, gonna save the patient's sight, every- body … MIGS Street Boys are here." EW Editors' note: Dr. Sarkisian has finan- cial interests with Alcon, Allergan, Beaver-Visitec International (Waltham, Massachusetts), Glaukos, Katena (Denville, New Jersey), New World Medical (Rancho Cucamonga, Califor- nia), Omeros (Seattle), Santen (Osaka, Japan), and Sight Sciences. Dr. Sarkisian said that up to 90% of patients are non-compliant with topical glaucoma treatment, with around 50% stopping at 6 months. This is a significant risk for disease progression. While it might be frustrating for doctors, it isn't entirely unreason- able. Among other things, glaucoma medications are expensive, present- ing a significant economic burden on patients. They are also not easy to take—some bottles are too hard to squeeze, resulting in the instillation of too much or too little medicine at a time, and all too often patients miss. Moreover, there are significant side effects that make patients averse to taking their drops. For instance, around 60% of medically treated glaucoma patients have ocular sur- face disease. Dr. Sarkisian said he has given up prescribing prostaglandins due to their irreversible side effects. In addition, doctors share the responsibility for non-compliance. Citing his own experience with his wife, who stopped taking drops as soon as her symptoms were re- lieved, Dr. Sarkisian said that he realized that in terms of encourag- ing patients and making sure they take their medication, "we're pretty terrible at it." goniotomy, ab interno viscodillation or canaloplasty, and the Hydrus Mi- crostent (Ivantis, Irvine, California) improve the conventional aqueous pathway; the CyPass Micro-Stent (Alcon, Fort Worth, Texas) opens the supraciliary space; the XEN Gel Stent (Allergan, Dublin, Ireland) shunts aqueous to the subconjunctival space; ECP and micropulse lasers— the latter potentially expanding the technical definition of MIGS—de- crease aqueous production. Considering these options, Dr. Sarkisian provided four key points on which personalizing glaucoma treatment depends: the number of medications a patient requires to control IOP; the existing level of control; severity of glaucoma; the patient's occupation and visual needs. While there are no prospective studies comparing different MIGS devices, there is data for each device; surgeons can take this data and fur- ther extrapolate from experience, as the MIGS Street Boys have done. Why are MIGS procedures so hot these days? First of all, Dr. Sark- isian said, older procedures, quite simply, "kind of suck," but just as importantly, patients aren't taking their drops. M eet the MIGS Street Boys, representatives from the ASCRS Glau- coma Clinical Com- mittee: moderators Jacob Brubaker, MD, Sacramento, California, and Steven Sarkisian Jr., MD, Oklahoma City, with panelists Paul Harasymowycz, MD, Mon- treal, Canada, Inder Paul Singh, MD, Racine, Wisconsin, and Arsh- am Sheybani, MD, St. Louis. They introduced themselves as a subset of glaucoma doctors who have largely turned away from traditional trabe- culectomy and embraced MIGS. "Here's the deal," said Dr. Sark- isian, laying down the rationale for the symposium "Tolls, Detours, and HOV Lanes: Navigating the MIGS Superhighway to Personalizing Out- comes for Your Glaucoma Patients." "You guys have been to numerous sessions of video after video, out of context … the goal is to put them in context for you, give you a sense of why we do things when we do them." The world of glaucoma surgery, he said, is "ever changing and new." Currently, the available means of modulating the aqueous humor pathway can be categorized by method: the iStent (Glaukos, San Clemente, California), ab interno Owning up to non-compliance and personalizing glaucoma treatment with MIGS Dr. Sarkisian introduces the MIGS Street Boys.

• Cover