How Do You Treat Glaucoma?

Malik Y. Kahook, MD
The Slater Family Endowed Chair in Ophthalmology
Professor and Vice Chair, Dept. of Ophthalmology
Chief, Glaucoma Service
University of Colorado School of Medicine
Aurora, Colorado
 Panelists

Husam Ansari, MD PhD Pradeep Ramulu, MD PhD

Ophthalmic Consultants of Boston Wilmer Eye Institute (Johns Hopkins)
Patient Case:
• 61 year old with POAG and Goal IOP of 14 RE (current IOP 17)
• No prior glaucoma surgery or laser
• Currently medical therapy: PGA and BB
• Visual field shows nasal step that is stable

Next Steps:
• Which medication would you add next?
• What do you consider MTMT?
• Do you have any pearls to increase adherence to therapy?
Barriers to Adherence
Kahook Expert Review of Medical Devices 2007

**
Patient Case:
• 61 year old with POAG and Goal IOP of 14 RE (current IOP 17)
• No Prior glaucoma surgery or laser
• Currently medical therapy: PGA (allergic or CI to other meds)
• Visual field shows advancing nasal step

What is your next step?

• LT (SLT/ALT)?
• What if the patient had PXF?
• When do you skip LT and head directly to surgery?
 Lessons from LiGHT and SALT
• SALT

• Compared Steroids, NSAID and Artificial Tear therapy post SLT

• Significantly better IOP reduction at 12 weeks with steroid or NSAID

• Short-term (5 days) NSAID or steroid drops may improve IOP reduction

• LiGHT

• SLT provided stable and drop-free IOP control in 74.2% of patients for at
least 3 years reduced need for surgery, lower cost and comparable quality
of life

Groth SL, Albeiruti E, Nunez M, Fajardo R, Sharpsten L, Loewen N, Schuman JS, Goldberg JL. SALT Trial: Steroids after Laser Trabeculoplasty: Impact of Short-Term Anti-inflammatory Treatment on Selective Laser Trabeculoplasty Efficacy. Ophthalmology. 2019 Nov;126(11):1511-1516.
Gazzard G, Konstantakopoulou E, Garway-Heath D, Garg A, Vickerstaff V, Hunter R, Ambler G, Bunce C, Wormald R, Nathwani N, Barton K, Rubin G, Buszewicz M; LiGHT Trial Study Group. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and
glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet. 2019 Apr 13;393(10180):1505-1516.
 Patient Case:
• 61 year old with POAG and Goal IOP of 12 RE (current IOP 22)
and visually significant cataract
• Currently on MTMT
• Visual field shows advanced S/I defects

What is the role of MIGS in moderate

to end-stage glaucoma?
• Do you ever use MIGS in moderate to end-stage disease?
• How do you choose?
• Do you do standalone MIGS?
• Endocyclophotocoagulation?
 US Glaucoma Surgical Procedure Market Segmentation

Glaucoma Surgical Procedures

MIGS Canaloplasty Goniotomy Filtering Surgery GDDs

iStent Inject OMNI Kahook Dual Blade Xen Trabeculectomy AGV

Hydrus OMNI Ex-PRESS ClearPath

iTrack (ABiC)

Goniotome PreserFlo Baerveldt

Trabectome *Not Available
Patient Case:
• 61 year old with POAG and Goal IOP of 10 RE (current IOP 14)
and visually significant cataract
• No Prior glaucoma surgery and currently on MTMT
• Visual field shows nasal step with steady progression

What is your best surgical option?

• Is traditional trab the best option?
• Primary tube?
• Skip filtration and do something else?
• What if patient had CACG? PXF?
 Lessons from TVT and PTVT

AHMED CLEARPATH

Kahook MY, Noecker RJ, Pantcheva MB, Schuman JS. Location of glaucoma drainage devices relative to the optic nerve. Br J Ophthalmol. 2006 Aug;90(8):1010-3.
Patient Case
• Mr. JC is a 73 year pseudophakic
Latino male with 25 year history of
POAG and advanced disease
(Advanced cupping and VF loss
OU)
• Failed Trab and GDD bilaterally
• Current IOP 26RE and 24LE on
MTMT with goal of low teens
• Next step?
 Cyclophotocoagulation
• When do you do CPC in your
practice? Which patients?

• When do you avoid CPC?

• What settings do you use?

• Any other pearls for practice?

Pantcheva MB, Kahook MY, Schuman JS, Noecker RJ. Clin Exp Ophthalmol. 2007 Apr;35(3):270-4.
 Pearls From The Experts
• Can you share 1-2 pearls from your practice that you make sure every
fellow knows before finishing their training?

• Medical Therapy

• Laser

• Surgical

• Anything else?
Ophthalmology in the Time of COVID-19
Malik.Kahook@CUANSCHUTZ.EDU