Speaker 1 (00:00) Did you know that 70% of patients primarily managed on drops were lost to follow-up at 12 months? Embrace interventional glaucoma, a procedure-based approach with drops used as bridge and supplemental therapy.

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Speaker 1 (00:36): Welcome to another episode of “Survey Says” with Dr. Paul Singh. On this special edition of GT the Podcast, Dr. Singh asks his guests to weigh in on a real patient case from his practice. Today, Dr. Singh is joined by Dr. Reena Garg to discuss next steps for a patient with difficulty adhering to drop medication. The case involves a 71-year-old man with moderate primary open-angle glaucoma and a history of SLT and cataract surgery with canaloplasty. The patient did well without medication for a few years following surgery. However, his IOP has since increased and he is now on three topical medications and experiencing issues with compliance. With no progression shown on visual field testing, Dr. Singh raises the question of whether the current treatment is appropriate or if the compliance concerns warrant exploring a procedural intervention. Dr. Garg shares how her approach to this type of patient has evolved as glaucoma treatment options have expanded and she explains the importance of looking beyond diagnostics and considering how the patient feels when determining whether to change course.

(01:47): They discuss counseling patients through a range of glaucoma treatment options and the telltale signs that a patient is experiencing barriers to medication and compliance. Later, they compare their opinions with the results of a social media poll of GT's audience and Dr. Singh shares what he actually did. Tune into “Survey Says” with Dr. Paul Singh.

Paul Singh (02:19): Hey everybody. Welcome to Another “Survey Says”. I'm Paul Singh from Southeastern Wisconsin—cataract, refractive, and of course, glaucoma geek at heart. And I'm so excited to hang out with you all today and talk with my good friend Reena Garg from the DC area. What's up, Reena?

Reena Garg (02:35): Hey, Paul. Thanks for having me. Excited to be here.

Paul Singh (02:37): Awesome having you. This is such a fun thing to do because it's really real-life stuff. Just going to take this real case from my clinic and you and I are going to talk about it and then we're going to see what the audience kind of decides what they would do. So we kind of sent this case to the social media world out there. I had people from Instagram and Instagram and all that good stuff and LinkedIn and say, "Hey, what would you guys do and where to see what those doctors out there would do in this case?" But I want to first hear from you, my guest, and kind of just talk about the case and all that good stuff as well. So, Reena, just tell everybody about you though real quick, what's your practice like in DC and all that good stuff.

Reena Garg (03:14): Yeah, absolutely. Well, thanks for having me. I mean, I have to say you're pretty brave putting it out there on social media, but I think we’ve got a lot of good friends out there to help us with this thing.

Paul Singh (03:23): There you go.

Reena Garg (03:24): I'm also a solid glaucoma nerd, cataract-refractive surgeon. I'm in private practice and I work at Georgetown with the residents as well. So hopefully I can add something to this discussion.

Paul Singh (03:35): I love it. I love it. One of the things that I love so much about—and people say, "Paul, you travel a lot and do all these meetings and dinner programs, et cetera”—is it really is an opportunity to hear what all our colleagues are doing around the country because so much of what we do and why we do what we do is based upon our experience, our patient population, our training, our outcomes. And everyone has a little different perspective on it. And that's what makes glaucoma so unique—and sometimes frustrating because there is no right answer—but that's what I love about these kinds of things. So let's get right into it. I'd love to hear your thoughts and wherever this takes us, let's keep it free and flowing. But I'm going to describe the case so everyone's on the same page and I'll ask you some questions too.

(04:12): This is a 71-year-old man, moderate glaucoma, POAG, history of SLT a couple times actually. Had a decent response, a moderate response, like 25% reduction and also on a PGA as well as a combination drop. So history of SLT a couple times, had some response, but back on a PGA and a combination drop. TMAX in the 29, almost 30 range as well. Had cataract surgery about five years ago with a 360 degree canaloplasty, no goniotomy. He actually did pretty well off of medications in the middle to upper teens, but pressures actually then started to go up like everything else in glaucoma. It's not forever. And now he's on three topical meds, like we mentioned, and really having some compliance issues, the cost, the dry eye thing, had some redness, hyperemia issues as well. The thing is, and I'd love to hear your thoughts, this is what I want to start with.

(04:47): The thing is this patient's not obviously progressing. So pressures are decent. They're in the middle-teens, upper-teens now, but he's on three topical medication drops and he's not—fields are not progressing or OCTs don't get worse—but he's having some compliance issues. I want to ask you before we get into further, is this patient in your hands warrant something to be done to get him off the drops just because he's not happy with them or is this patient controlled in your hands? Talk to me about what that means to you by having a patient who's having compliance issues, obviously, but not progressing.

Reena Garg (05:27): Oh yeah, absolutely. I mean, I think this is a really great case to talk about the diversity and how we take care of glaucoma patients. Earlier, I think you said the most important thing is that we all have different ways that we do things. And I was talking to someone earlier today that not only do we do things very differently, but we all have strong convictions on how we do it is the right way to do it. And I think one of the latest things that we've been—I say latest and I'm dating myself because back in the day when I was in training, this patient would have been a no-brainer. We wouldn't have touched this patient. It was an SLT times X number of times, then a trab, then a tube, and then maybe another tube and then you pray and that's kind of all that we had.

Paul Singh (06:12): The praying still happens though.

Reena Garg (06:14): The praying still, of course. Yeah, we never stopped praying. These patients, we didn't have a lot of options for them. So it was kind of like, "Well, I'm sorry you're unhappy. I'm sorry you're having trouble with your drops, but your pressure's fine. I'm not touching you." And I would say for me, and I'd love to hear your thoughts too, I think the way I've practiced has absolutely changed in the past decade. It's no longer about, have you had visual field loss? Is there discernible nerve damage? It's so much more than that. It's how are you? How do you feel? How do your eyes look? Realistically, how are you using your drops? And it used to be, do you use your drops? And now I ask my patients, how many times in a week do you miss them? And it kind of opens up that space for patients to be honest and say, "You know what, doc? Yeah, I’m not 100%.”

(07:01): And we do know with so much data out there that patient compliance as close to 100% is needed for true success with these drops. So in this particular patient, the fact that he's symptomatic, the fact that his pressures are sort of climbing up, I think we have a huge toolbox now of ways to deal with this patient so we don't wait until he progresses. So we don't wait until he has irreversible vision loss. And I would definitely, I would talk to him about potential surgical options. In my mind, this is a surgical candidate.

Paul Singh (07:29): Yeah, I love that. Thank you for sharing. I mean, I'm on the same page as you. I mean, that's kind of the biggest, I think, kind of paradigm shift for me in this world of MIGS and interventional glaucoma is this idea that what is controlled glaucoma? How do we define it? And I think what you just described is a great way to think about it. It's like, well, the definition is not just fields and OCTs and IOP, of course, that's still the foundation, but in the context of stability of those things, if the patient has a low likelihood of staying compliant on that current regimen, we have enough data now with the LiGHT trial and HORIZON trial and this trial and that trial to show that despite the same level of IOP reduction, drops versus being off of drops, we tend to see better results and better stability over time of people off of drops.

(08:10): And so, if I feel like someone's not going to stay on that regimen, maybe they've either already indicated they're not, or you have other risk factors that tell you, "Yeah, this patient's not compliant." That patient is not controlled. And I’ll put it in my chart, “uncontrolled due to compliance issues”, whether it's side effects, costs, forgetfulness, all the other X, Y, dot, dot, dot that we see in our practice. And so I think that's kind of what you're describing. I think it's awesome because it really is something that I see in my practice. I think you mentioned also that we have so many different options. And I think one of the things that I love about this case, and I want to talk to you about this too, is this idea that this patient had canaloplasty five years ago and a cataract combo or whether stenting canvas cataract combo or this or that, whatever you combine with cataract surgery, sometimes it doesn't last forever and pressure's going back up again.

(08:52): And so this idea that, and I'd love to hear your thoughts on how do you describe to a patient this idea of now we have a journey that it's not one procedure, one device that we have to hold our hats on. When I was younger and I came out of fellowship decades ago, it was like to your point, trab or tube and otherwise “oh crud”—I was going to say other words—but oh my gosh, what if it doesn't work? Now I'm really screwed. But here it's like, okay, your canaloplasty didn't work. Your goniotomy didn't do enough. Your iStent didn't do enough. Then you have your AlloFlo that didn’t do enough. Well, you still have the next thing you can do. So sorry, but just talk to me about how do you navigate that world of options and how do you describe the journey and expectations for the patient?

Reena Garg (09:30): Yeah. I think that's a really important thing, especially for younger glaucoma specialists or even someone like myself, this journey that I've gone through on how I counsel patients and how I talk to patients. And one thing that I've learned to tell patients is nothing lasts forever in glaucoma and that reframes kind of the whole story and it's not drops. Drops don't last forever. There comes a time where they’re unaffordable, inexpensive, intolerable, or they just stop working. The surgeries as well, everything has a half-life, even a trab or tube sometimes can fail. And so I kind of reframe it to the patient that way and I'll say, "Well, hey, you had this SLT a few years back and you've had three good years of good pressure with this SLT. That's amazing for this particular procedure." And now we have to think about taking the next step and are we going to repeat something that we've done because we had good success and maybe that will be enough or maybe we need to advance it and go to the next step, which means something slightly more invasive. And kind of take that step and take that journey with the patient and just say that, "Hey, let's celebrate the wins that we've had, but let's also look forward so that we're not looking back and saying, “Hey, we should have intervened at this point.”

(10:44): You've already lost some vision. You're symptomatic now. You have glare, you have a loss of peripheral vision, you're having trouble with driving, you're having trouble with bright light situations. We don't want to wait till patients get to those situations. And that's kind of how I frame it to my patients when they're sitting in front of me. And I say that, look, if you don't want to do a treatment, we don't have to, but you've got to use your drops. There's no question about it. It's got to be one or the other. And I think that helps reframe for patients to understand that this is, like you said, a journey. This is not just a, there's no cure, there's not a one-stop fits all. We have to follow the glaucoma as it goes along. And oftentimes I actually relate it to other chronic conditions. Hey, you have diabetes, you still have to use your medication.

(11:29): If you stop using your medication, your sugar goes out of control, you have high blood pressure. And a lot of times that also helps patients understand that, hey, okay, this is a chronic thing. This is something that's going to be with me forever.

Paul Singh (11:39): No, that's a great analogy. I think I love using systemic related issues. You don't feel your high blood pressure sometimes, your blood sugars, or your cholesterol, but it's going up. And look what happens as you get older, those numbers start to rise and you have to add a second medication or a third medication to treat your diabetes or high blood pressure. So really good point. Before we get into the case and talk more about this, what we do next, I'm curious, do you have any tricks or clues to help our colleagues out there on how to efficiently identify if patients are noncompliant? Are there any ways or any tricks just by listening to them or hearing that or any complaints that you can say, "This patient's probably not compliant no matter what their pressure says”?

Reena Garg (12:17): Yeah, there's definitely, I think you do this long enough, you figure out some of the tricks in their book. I think obviously if a patient isn't running out of medications, they're not getting refills, that's the sure tell sign that they're not using it. If they're acutely red on a netarsudil or something that you think is going to wear off over time, but every time they come in, they're acutely red, that makes me feel like, "Okay, are you really using this regularly or is this something you're putting in right before you come in to see me?" And then of course, if patients don't have side effects, if their eyes are pristine and clean and white and their pressures are high and they’re insistent that they're using it, we have kind of a real heart-to-heart that, “It really doesn't look like it. I don't know that you're using these medications”.

(13:02): What do you do?

Paul Singh (13:04): Isn't that sad?

Reena Garg (13:05): It is.

Paul Singh (13:06): We've got this saying, "You're going to be red, so just deal with it."

Reena Garg (13:09): Yeah honestly, that's what it used to be. Yeah absolutely.

Paul Singh (13:12): I think along the same lines, I think there's a couple of things I've probably noticed that you notice to your point. I train my staff. I'm trying to train my staff at least to really listen to these kinds of symptoms and ask these questions. A patient comes in and says every time they come in, "Please, do you have a sample? Please, do you have a sample?" Like kind of begs you for samples. That's a telltale sign that that patient probably has a cost issue, and they're probably extending that bottle as long as they possibly can once a week kind of thing, to your point. If they always complain that their vision comes and goes, I don't care what their surface looks like, that's dry eye, that's unstable ocular surface film, right? That's dry eye. And then that's another trigger to say, "Hey, let me do something to help get this patient's surface better." Last thing I would say is if they don't know the name, fine—no one knows the name of the drops—but if they don't know the color of the top and they've been on a PGA for literally 10 years and they still can't tell you it's green—like green or teal—that's really scary.

(14:06): It's like, "Come on man, you've been on the drop for 10 years."

Reena Garg (14:07): Agreed.

Paul Singh (14:08): “You really haven't seen the top?” So, I think those little clues. And the reason I bring this up is because sometimes people say, "Paul, I don't have time to ask questions and sit there and figure it out. Patients don't tell me." They're never going to tell you they're not compliant. They very rarely do, as you know, but these are the clues. If you have these clues, kind of think, okay, you know what? I'm going to think twice now, maybe just talk to them because, and here's why if you identify the barrier of compliance, I'd love to hear your thoughts on this. There's a big fear for a lot of our colleagues and myself included sometimes too, where you don't want to sell something, you don't want to feel like I'm doing surgery because I want to do this for you. Reena, I want to do surgery on you.

(14:40): No, I don't. I want to help you out with the problem. So that's the key. If you can identify the barrier to compliance, you identify the cost, the side effects, the forgetfulness, the irritated eyes, whatever it is, right? And you then say to that patient, "Look, you're having these issues. Here's a solution to that problem that you're having. I'm just trying to help you with your problem." Then it becomes less about, "I want to do surgery because I want to do it versus I'm trying to help you. " And if it doesn't do enough, you go back to drops or you try something else, but you were trying to help them with something that they were having issues with. What do you think about that? Is that something you do as well or do you feel like that's a unique way of looking at it?

(15:15): Talk to me about that.

Reena Garg (15:16): Oh yeah, absolutely. I think that's a really unique way of looking at it and really kind of treating the problem at the source instead of just trying to put a Band-Aid on it or trying to figure out why a patient is progressing or their pressure is climbing up. In my clinic, I do also train my staff. They have a set of five questions that they ask all of my patients, "Do you have any discomfort? Do you have any redness? Do you need refills? Do you have trouble affording your medications?" And oftentimes patients are more likely to tell a staff member than they are to tell me directly because I think they're afraid to let me down and complain about the treatment that I put them on. We also actually text our patients before every visit and they get kind of like a glaucoma questionnaire text.

(16:03): Compliance with that is hit or miss with the elderly population, but it's another opportunity for patients to engage without directly engaging with me so that I can come to them and I can just say, "Hey, I got this information. I'm glad you told me. Let's do something about it. " Instead of just me kind of coming in like the teacher with the ruler and checking to see if they're listening or behaving as they should.

Paul Singh (16:25): That's a great, great point as well. Thanks for sharing.

Reena Garg (16:27): That might be the Indian in me with that analogy coming up.

Paul Singh (16:30): The desi vibe, man. I'm with you. I know how that goes. No, thanks for sharing. I'll move on for the sake of time, but these are great points. And there's so much we could spend a whole three hours talking about compliance and patient education, but we'll move on for now. But before we move on, I just want to do a quick little timeout. We have some sponsors on the show now, man. This is awesome. So I'm going to give a couple seconds so that way we can have some sponsors to say hi to everybody up.

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Paul Singh (17:23): Thank you for that sponsorship. I appreciate that as well. And just go ahead and move on to our actual questions and see what you would do and then let's see also what the audience did. So let's go ahead and I'm going to ask you first before we get the audience participation question.

(17:39): So we asked, by the way, some polling questions to Instagram and to LinkedIn and a couple of the questions were, what would you do next with this patient? So, the first question is, this patient who's getting kind of irritated with the drops and redness and cost issues on three meds, pressures are slowly rising, everything we talked about, would you then next just observe and wait for the fields to get worse? Would you perform SLT again? It's the third time, which is definitely doable or do a drug delivery, would you do a MIGS/MIBS or do a MIBS only? So, basically a MIBS or a MIGS? So, basically what would you do next? Wait, SLT again, a drug delivery, MIGS or a MIBS?

Reena Garg (18:19): So, I don't think I would wait. If the pressure's climbing up, I think that's an easy no for me. I think before jumping to a MIBS, I'd probably talk to the patient a little bit more in depth. I mean, this patient going into their third SLT, they're unlikely if they're already on three agents, they're unlikely to get off of all of the medications. So, I think this would be kind of shared decision making with the patient to see where they're at in terms of how aggressive they want to be on getting off of their drops completely.

Paul Singh (18:47): That's awesome. Talk about that. So that's a really, really important question because this is where people say, "Well, you would do an SLT possibly or would you not? " And I think you made a good point. If someone's on three meds and the pressures are still climbing, do you think an SLT is enough? Doesn't mean it's not worth it, but let's say this patient was not on any meds or just on one med and the pressure was slightly climbing, would you then say, maybe SLT is worth trying then? Would that be a different scenario for you?

Reena Garg (19:10): Yeah, no, absolutely. And even if they're on three meds, I think a third SLT is also a different beast than a first SLT. So, I think being a third SLT, if they're on one med, I'd be more inclined to try that again versus third SLT on three meds. But again, having that conversation with that patient, maybe it's an SLT and a sustained drug delivery and they may have a better shot that third time of getting off of their meds completely if that's the goal, if the patient agrees that that's the goal. I think ideally for this particular patient, I would probably go more towards the MIGS because they're already showing signs of non-compliance, like we talked about. Their pressure is rising. They've gone through SLT twice. We know there's a law of diminishing returns with SLT. So that's probably where my conversation would be centered with that patient.

Paul Singh (20:00): Yeah, no, I love that. And actually, the audience, so 3% of the audience said observe. So, I think we're seeing most of the audience saying, look, we got to do something and love that.

Reena Garg (20:10): That's great.

Paul Singh (20:11): And then– that’s awesome right? And then we had 32% of– this is actually the Instagram people. Thirty-two percent of the Instagram people said, let's do a repeat SLT and/or drug delivery. So, let's say you're in the office, you do an SLT again, do say a Durysta or set them up for an iDose or something and that will give you, maybe you get them off the PGA with the drug delivery for a period of time and then maybe the SLT might get you off of one of the drops and maybe you're only on one drop potentially. So, there's definitely a role for that and that's not a bad thing. It doesn't limit your ability to go back and do a canal-based MIGS or some other MIGS-based MIGS. So absolutely, I think that's a really good option and your comfort level and discussion with the patient, here's what's next kind of thing.

(20:49): Absolutely. And if it doesn't do enough, you can do your MIGS. So, let's look at 42% of people agree with you though that they would do a MIGS as well and then MIBS was 23%. So, we have basically a good split between 30% doing SLT and their drug delivery. Again, MIGS 42%, MIBS 23%. So, a good breakdown. And then if you look at LinkedIn, it was very similar. About 24% said SLT again/drug delivery. About 46% said MIGS and 27% said MIBS. So, I think they're all very similar between Instagram and LinkedIn. They all kind of agree with you. So good job. They all agree with you.

Reena Garg (21:28): Thank you.

Paul Singh (21:29): Well done, well done.

Reena Garg (21:30): I feel relieved.

Paul Singh (21:32): I know you're like, I'm the outlier.

Reena Garg (21:33): I haven't been canceled yet. I know. I'm not canceled yet.

Paul Singh (21:35): The audience doesn't know what they're talking about. No, it's awesome. It makes sense. And I think I agree with you as well. We'll talk about what I did at the end here. So, if that's the case that you're thinking about, I think SLT, drug delivery, like we talked about, great opportunity, definitely not going to hurt a patient, safe. And if it doesn't do enough, you still have the opportunity to do your MIGS of choice. It makes sense. But if you go straight to MIGS, what kind of MIGS would you do? And this is what we ask the audience. I'd love to hear your opinion too, Reena. So, we have repeated canaloplasty or do a goniotomy or do both depending on the device we use. You can do a stenting like an iStent infinite, let's say, as a standalone because you had cataract surgery or an AlloFlo. And I'd love to hear your thoughts on supraciliary spaces as well as then even something like an ECP “endocyclo”.

(22:19): We’ve kind of been talking about that. There are new technologies out now and new ones coming out for to kind of revitalize ECP. So, what are your thoughts on those options and let's talk about them, see what you think.

Reena Garg (22:29): Yeah. I mean, these are all great options, and I think it goes back to what we were saying at the beginning of all the great options we have and tools that we have, which does make it a little bit more confusing when you're looking at this patient. The way that I would think about this patient, one way that I never really had to think about in training was thinking about outflow pathways. It was always just either trabecular or uveoscleral via pharmacologic means or it was bypassing all-natural outflow and do a filtering procedure. And now we have so many ways to manipulate both outflow pathways. And so, what I usually do is I look at my patient and I think about what have we been doing up until now and it's clearly not working or it's starting to wear off so maybe I need to think about it in a different way.

(23:18): And in this particular patient, you've done a lot of trabecular work between the SLT, the canaloplasty, though there could be room for a goniotomy if there's resistance focally at the trabecular meshwork and you can make a case for that if the pressure's not super high. But in this particular patient, again, in shared decision making, especially because I think in the initial stem, you had said they had good response to latanoprost or the prostaglandin. I'd probably lean towards supraciliary something to open up the uveoscleral space because that's something that has potentially been untouched in this patient. You may get more bang for your buck in this particular patient before I move on to a filtering procedure.

Paul Singh (24:02): I love that. Absolutely. I mean, I think that the beautiful thing about this case and about all these options is they're all valid and they're all acceptable and all kind of unlabeled, whatever you want to call it. So, I think let's talk about that. So why would you repeat a canaloplasty goniotomy? There are actually data sets out there on repeating canaloplasty. iTrack has shown that as well and a number of other studies have shown that too, that you can repeat it as well and doing a goniotomy at same time. If you didn't do a goniotomy the first time, you say, okay, let's do a canaloplasty with an OMNI or iTrack or IVIA or the other ones streamline. There's a bunch of other ones that are out there now but open up that flow again and then just remove 90 to 180 degrees, whatever you want to do, even 360, depending on your comfort level.

(24:46): There's definitely an opportunity for that as well. Absolutely. And stenting, iStent infinite. I mean, I was part of those studies. It's pretty powerful having three stents. And the key is can you get them far enough away from each other to really access a collector system? It's not about necessarily doing three very close by, but if you separate them, you have a better chance of getting a collector system that's active. It can be very powerful if you look at their data as well, which is in a refractory population of patients who had previous surgery or maximum tolerant medical therapy. The MTMT patients did really well with stenting. So absolutely it's an opportunity and you don't minimize the potential to do an AlloFlo or something else. AlloFlo, which you mentioned is really cool. I mean, I've done a lot of AlloFlo too, which is theis supraciliary stenting, allowing us to create that cleft and then put those spacers, one or two spacers to keep that cleft open.

(25:31): And it's very powerful, extremely powerful because you have a negative pressure radiant. So talk a little bit about that, and AlloFlo a little bit about that because I know not everybody out there maybe has had experience with it unlike stenting and canaloplasty and goniotomies. Why is it so unique for you and kind of how do you determine that? Again, you mentioned earlier about the mechanism, but does number of meds, does the IOP at presentation make a difference to you? Severity? Talk about all that stuff.

Reena Garg (25:56): Yeah. I mean, I think you kind of alluded to it when you talked about the negative pressure. I think the unique thing about the uveoscleral pathway is that there really is no floor. And so, if you have someone whose pressure is in the mid-teens, if you go through traditional outflow, you have that episcleral pressure kind of pushing back at you. And so, you're always going to have that kind of floor of how low the pressure can go. If you're in the mid-teens, you're probably not going to get a lot more if you're going in the angle again. And so going to uveoscleral space, you can get a couple more points because it's that negative pressure space. There's nothing really kind of preventing further IOP lowering. And so, depending on where this patient pressure is landing and the fact that they had good response to PGA, it might be the right next step if your goal is to keep them to a lower pressure, low teens 10 to 12 in that range.

(26:49): And I've actually had really good success combining AlloFlo with sustained drug delivery. Both of our options currently commercially available are prostaglandins and I've had good success with AlloFlo and using those modalities to help keep that pathway open and then also to get patients off of drops because sometimes that can be a limitation with AlloFlo because you do need to keep them on medications. So that combination has worked really well for me. I think you're absolutely right. I think all those options are viable. I'd look to see how their initial response to the original canaloplasty was, how long sustained that response was to see if I'd want to go back there in that same pathway or if I want to go to AlloFlo because I want a much lower pressure than what I might be able to hit through the trabecular pathway

Paul Singh (27:36): Yeah, that's a really good point. I think where I would say is where the outflow really hits, especially if you're on a number of medications when you're on three, four and your pressures are high, that means the outflow system, the canal, the conventional system, whether it's the episcleral venous system, something's not right. And especially the more moderate to advanced they get, you see these kinds of conventional outflow systems just not functioning as well. It doesn't mean it can't work with something like the iStent infinite, et cetera, as well, it can make a difference. But I do think there is definitely a role for stenting and for canal dilating and goniotomies in those patients, but your expectation might be a little bit different. The nice thing about the supraciliary space is regardless of where the outflow system is let's say blocked or not functioning, you don't have to worry about that because you have that negative pressure gradient, that supraciliary space.

(28:23): What I had noticed in the studies with the CREST trial there is it does show that it does do a little bit better in the earlier mild to moderate patient in general with the AlloFlo. So, I think there is something to the scleral rigidity, the uveoscleral absorption, et cetera. In these people who are really advanced, it's just nothing works. It seems like AlloFlo, but it does work. But they tend to have a little more potential for rises in pressure, et cetera. So, I think we have to be careful no matter what you do in those advanced patients. But those moderate patients on multiple drops, pressures are high, I think it's a great opportunity. One thing we don't talk enough about is ECP. Do you do any ECP? Do you still do it? What are your thoughts on that?

Reena Garg (29:03): I did for a while. It's kind of fallen to the wayside for me, not for any particular reason, but I think that's a really good point. I think all of our modalities generally that we talk about are the things that take the spotlight are more about outflow. We don't really talk about reducing production and I think in combination perhaps with an outflow procedure, doing an ECP could be really helpful for this patient because clearly they had a response.

Paul Singh (29:40): Yeah. And that's the thing that's so unique about it is we talk about mechanism of action. We don't really talk a lot about decreasing inflow much, but topical medications, we're talking about all the time with your Cosopts.

Reena Garg (29:49): Absolutely. We don't even think about it. We just put it on.

Paul Singh (29:51): You’re like, why not? Combined mechanism. You know this is the same thing.

Paul Singh (29:54): So, I've done a lot more now. And we have the new Leos, which is kind of a cool, really high-definition ECP with these new disposable probes. There's a new company coming out too with some kind of handheld ECP. So, we're going to have some really cool technology. I think you're going to see a lot more ECP talk with these new technologies come up, and it's pretty neat to see that we have these options. I actually signed a couple of people up today for ECP. So, I started to reuse it again as well more than I had before, especially with these new technologies, seeing how they're a little bit easier to use and better quality of optics nowadays as well. But let's see what the audience would've done. Then we'll talk about what I did here and wrap it up as well.

(30:30): So, the audience in the Instagram world said they would do, 23% said repeated canaloplasty or perform a goniotomy. We didn't talk about 90 versus 180 or 360. Maybe another time we can talk about that. There's 37% said stenting. So stenting was the most common next step, whether it's an iStent infinite or off-labeled do like a Hydrus, but usually it’s iStent infinite, my guess would be. And then AlloFlo, which is about 30%, 29% rather, and then ECP about 11%. So, a good spread really across the board of all the different options. So really your comfort level and expectations. I think with an iStent infinite having three meds, I can get them off of all meds, may not be, but that's okay. Maybe get them off of two meds and you keep them on a PG or something like that. Or you combine that with, I've done a lot of iDose and iStent infinite.

(31:13): That's a great combination where you can get them off of three meds.

Reena Garg (31:15): Great combination. Yeah.

Paul Singh (31:16): Yeah. To your point, AlloFlo, 29%. So AlloFlo and stenting and canaloplasty, all very similar in terms of percentages. In that case, 11% said ECP, which is I think interesting. And if you look at the LinkedIn world, LinkedIn world was actually very similar, but a little bit more stenting. About 23% again said canaloplasty or goniotomy, which is almost identical to that of the Instagram world, which I thought was kind of unique. But then 50% of the LinkedIn posts or LinkedIn people said stenting. So, a little more of the stenting in LinkedIn. Then 19% said AlloFlo and 8% said ECP. So, what are your thoughts on that? Does that make sense what you were thinking also?

Reena Garg (31:53): Yeah, no, I think it makes sense. And while I was hearing you go through the percentages for each different procedure, it just kind of showed I think to me how as glaucoma specialists, we're pretty lucky because we have a lot of really strong procedures that work in a lot of different patient populations. And a lot of this is kind of what works in your hands and what you've seen success in your clinic. And it kind of shows that there's not really a wrong answer here. And it’s kind of also job security for us because it's not algorithmic. It's the patient in front of you. It's a conversation you're having with the person that's sitting in your chair and making that decision with that patient as a next best step.

Paul Singh (32:36): Yeah. No, I appreciate that. Absolutely. I think what this shows us too is that glaucoma is a disease now and a condition that we really got to think, and we can't just say bye-bye. We have to really talk to patients, educate patients more, communicate with patients more. But I think the idea too is as well is thinking about how we can utilize these different technologies along the course and journey of the patient. So, for instance, let's say you did a stenting and an iDose or canaloplasty and an iDose in this patient. And then let's say you did a canaloplasty again and a little goniotomy and an iDose that may help them out for a few more years. You can always go back and do an AlloFlo then even years after that.

Reena Garg (33:11): Absolutely.

Paul Singh (33:12): You know what I'm saying?

Reena Garg (33:13): Absolutely, yeah.

Paul Singh (33:14): If you want, you could drag this thing out before you have to do any subconj surgery, but also do, like I say, like we talked about Durysta in the office or even like a XEN, let's say.

(33:23): So, I mean, we have so many different tools at our disposal before we have to think about doing a subconj, trab, or tube, which is still out there. But I think that we all know that the risks of those are so much different than a risk of some of these MIBS procedures like a XEN or even an AquaLumen as well. So, I want to tell you what I did, but any thoughts before I give you my spiel of what I did to this patient?

Reena Garg (33:47): No, no. I'm excited to see what you did. I think it's a really great case and obviously a lot of discussion and I'm glad to hear that the community was split, so I didn't have the wrong answer here.

Paul Singh (33:57): Yeah, no, absolutely. So, I'm a big fan of drug delivery. So, I definitely did the iDose, but I also combined it with, I did a little bit more canaloplasty and goniotomy at this time. I went in there and then I did about 95 to about 110 degrees goniotomy or so with that as well because then I could, the reason why I did that, you could do an iStent also with this too. I was toying between those two, honestly, but then you can do an SLT after that as well. I've done some studies too with showing that you can do SLT after you kind of flush the system out as well. And then the iDose at the same time. The iDose to me has become this little, I think almost a little bit of hedge-your-bets kind of a vibe where, you know what, at least I know I got the drug in there kind of thing.

Reena Garg (34:39): Oh yeah, for sure. It’s like a game changer. Absolutely.

Paul Singh (34:44): I feel so much easier now going into surgery as a standalone indication.

Reena Garg (34:47): A hundred percent.

Paul Singh (34:48): Not being so stressed is my X, Y, and Z MIGS, canal-based MIGS, going to work because I have the iDose in there, at least giving me that 30% PGA kind of world that we live in as well. But the thing is you could use that iDose with any of those MIGS—AlloFlo, ECP, iStent, canaloplasty. So that's what I did. You can always go back in later on and do an AlloFlo, which I think is something I'm using a lot too. So, if I have someone who's on higher pressures, like they're in upper 20s, let's say on three or four meds, I would probably go straight for an AlloFlo. Then that's kind of what I do a lot of times. And even now though, I'll go straight for that too. But I think for me, this patient was still with it, it was fairly well-controlled on the three topical medications.

(35:26): So, it climbed up, but on meds back down in the middle to upper teens. So, I felt like, okay, the pressures are doing okay, which is why I didn't feel like I had to change my outflow. I could just go ahead and kind of redo the outflow system a little bit more. If they were not controlled, then I probably would've gone straight for a supraciliary space or something more as well. What are your thoughts on that? Anything? I know you mentioned AlloFlo earlier, would you do anything differently or do you think that it would be the same thing you'd do now after all this?

Reena Garg (35:51): Yeah, no, I mean, I think that makes a lot of sense. And I think you having been the original surgeon is helpful too because you know how much of a canaloplasty you did the first time. So, you know when you're going back, you can add a little bit more oomph with that goniotomy in there. And I agree, iDose, I've combined it with goniotomy, canaloplasty, AlloFlo. It's been really a game changer for a lot of reasons that we talked about—the compliance, the success of the surgery, patient buy-in. I think there's a lot of positives to using that with any of these procedures that you put in. But I think it's a great example of you look at the patient in front of you, have that conversation, and then maybe something that you've already done can maybe work again and revive that like you did.

Paul Singh (36:36): Absolutely. Absolutely. The key is just to educate the patients, and manage expectations. Nothing's going to last forever, as you mentioned so clearly early on and that this is just another step in their toolbox and their journey to keep them hopefully at the highest quality of life while protecting them from losing vision from their pressures as well. And that's kind of the beautiful balance now that we have in glaucoma as well. Last thing I want to say, and I hate to get too, not political, but hate to get too intense with this, but there's some new LCD proposed changes going on.

Reena Garg (37:02): I was just going to say that.

Paul Singh (37:03): I want all of us out there. I'm not sure if this will air in time before we can do anything because the public hearings are coming out soon, but we cannot let these macs tell us that we cannot combine a drug delivery with our MIGS. It is not a MIGS. Remember everybody, drug delivery is procedural pharmaceuticals. And as someone like this who's on three meds, moderate, this is a patient who needs that combination to get them off that medication. If a patient's having a hard time with meds, I mean, it doesn't make sense to not put an iDose at the same time for whatever MIGS you're doing as well. And some of these LCD proposals have a fail-first kind of mentality. It doesn’t make sense. What are your thoughts on that? They want to limit the, we can't combine items with the MIGS now because they're trying to limit that.

Reena Garg (37:45): I mean, my thoughts are very much in line with yours. I think it's so difficult to be a glaucoma specialist right now or a doctor really kind of in more in a global sense because not only are we making decisions, like I keep saying the patient in front of you talk to the person there, but then we have to look at their insurance and what's covered and what combination and what’s this. We're not only looking at what's best for the person that's sitting in front of us. And it's incredibly frustrating that there are becoming more and more hoops that we have to jump through in order to provide the best care for our patients. So, I couldn't agree with you more. And I think the second part of it is really having patients talk to their insurance providers and they're the consumers at the end of the day, right?

(38:28): We're the healthcare providers, but they're the consumers of this insurance and they've got to be vocal. We've got to educate our patients to go and say, "Hey, let our doctors be doctors” and not sit here and try and decipher all the different codes and hoops that they have to get through just to give them the care that they need.

Paul Singh (38:45): Yeah, I appreciate that. Anyway, the idea of having to do a MIGS procedure and then say, "Oh, it's not enough." And then go back and do an iDose later on, or vice versa. Adding more costs, risk of opening up the eye doesn't make sense as well. So that's my little PSA. So yes, get your staff, get your patients, get everybody you know involved with kind of submitting your concerns for having these proposed LCD changes as well. If you haven't had a chance to look at the proposed changes in your max, because there's a few other things that are making you fail SLT first, failed on two different drops first, all these things, we can't let that happen because it's too beneficial as well. But the last thing I'll say also is that now we do have algorithms out there. Some people always want to know, hey, is there an algorithm that you use to help you decide how do you manage this IG journey we talked about?

(39:30): Christine Funke and others have done a great job with presenting and actually publishing a proposed roadmap on an algorithm for what to do in mild, moderate, and severe glaucoma, and even ocular hypertensives. And a lot of times it does start with SLT and then drug delivery and then MIGS, et cetera. So, if you want to look that up too as well, that's been published as well, look up Funke and a proposed regimen for their journey as well. Have you seen that at all? Have you seen that publication?

Reena Garg (39:57): Yeah. Yeah. No, it’s great.

Paul Singh (39:58): It's kind of nice to look at that as well. But anyway, first of all, thank you so much. This was awesome. I know it's already been like half an hour.

Reena Garg (40:04): Yeah. Thanks for having me.

Paul Singh (40:05): What a cool discussion, right? I love this.

Paul Singh (40:08): I could geek out.

Reena Garg (40:09): Yeah, fellow glaucoma nerds. We could talk forever.

Paul Singh (40:12): It's sad. It's sad that I actually get excited about this. It pumps me up actually thinking about it.

Reena Garg (40:17): You're in good company.

Paul Singh (40:19): I think it also is a little bit of therapy too because we're like, "Is anyone else suffering like I am?" Reena, thank you for joining.

Reena Garg (40:28): We're all in them together.

Paul Sing (40:29): Oh, you are absolutely right, but you were awesome. I really appreciate your insights. I hope everybody out there also got a chance to learn from you. I know I did and thank you to everybody out there for taking the time to listen to this podcast. It's really fun. I mean, I hope we can keep this going because I think we all can constantly learn from each other. These cases are always unique, and everyone has them, I'm sure in their office.

Reena Garg (40:49): Thanks for having me. This is awesome.

Paul Singh (40:51): Awesome. Thank you. Enjoy and hopefully we'll see you all next time in the next episode. Take care.

Speaker 3 (40:57): Thank you for tuning into this episode of GT: The Podcast. If you have any feedback or topic suggestions, find us on Instagram, LinkedIn, Facebook, or Twitter and stay tuned for more hot topics in glaucoma care on GT: The podcast.