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Viewpoint

Glaucoma treatment, then and now

FROM THE CHIEF MEDICAL EDITOR

This issue of OM focuses on glaucoma; never in my career has there been a more exciting time to treat this disease. When I started in the mid-eighties, we had pilocarpine and Propine (now discontinued). Timolol was still new. We also had Diamox, or for the wealthy, Diamox Sequels. Argon laser trabeculoplasty was catching on but only performed when the maximum tolerated medical therapy was exhausted. That meant pilocarpine 4% QID, Propine BID, Timolol ½% BID, and Diamox 250 mg QID — an arduous regimen, just to control one’s pressure — but people went for years being treated this way. There were surgical procedures, such as trabeculectomy, and full thickness sclerectomy procedures for really bad glaucoma. We had aggressive external cyclodestructive options for terrible end-stage glaucoma. Seriously, glaucoma was no fun.

We had no Lumigan/Travatan/Xalatan. Or Alphagan. No topical CAIs. And no combo drugs. No SLT or ECP. And no MIGS — perhaps among the most important new developments. Because at the end of the day, most of us consider ourselves surgeons, and glaucoma is ultimately a surgically managed disease. Back then, we often could reduce IOP surgically, sometimes to nearly zero for days!

These newer, safer procedures only make the surgical argument more complete. There is a much stronger safety profile. Not only on the front end but also in the long run. Even a perfectly performed trabeculectomy has a significantly increased, lifetime risk of endophthalmitis.

Today, many of us offer selective laser trabeculoplasty as a first-line option. It’s less expensive, arguably safer, and certainly more convenient, plus the conjunctiva stays healthier should a filtering procedure be needed. And while it may not last forever, it can be repeated. MicroPulse’s P3 cyclophotocoagulation is another new approach with the Cyclo G6.

When it’s time for cataract surgery, we have new cool outflow procedures. Beyond the iStent, there’s the Trabectome, the new Kahook dual blade, the very new CyPass, and the very, very new XEN gel stent. And some of these procedures can be done stand-alone, without cataract surgery.

There exists another add-on approach that my son and others have used and have found to be successful: While you’re performing your cataract procedure and implanting your outflow MIGS procedure of choice, why ignore the inflow? Do a “triple” procedure by including ECP and help reduce the aqueous inflow at the same time your MIGS procedure is increasing outflow! Don’t forget, while glaucoma is thought to be an “outflow” problem more than an “inflow” problem, we have likely treated millions of patients with Timolol over the years, which of course reduces aqueous production.

But, we could come full circle, if therapies like Rhopressa prove to help chemically open up the trabecular meshwork. Back to the future? OM