Why the future of glaucoma care is in the operating room

An incremental or gradational approach to glaucoma management has dominated the collective mindset of specialists for much of the modern era. But as surgical interventions become more sophisticated, and as ophthalmic research findings make recovery less burdensome for patients, shouldn’t that mindset change? What if the future of glaucoma care was in the surgical suite?

FIGURE. Glaucoma Surgeries in Germany, by Type, 2005 vs 2012. (Figure data courtesy of Schuster AK, Wolfram C, Pfeiffer N and Finger RP)²

That is the argument put forth by Norbert Pfeiffer, MD, who is the medical director and the Head of Department of Ophthalmology at the University Medical Center of the Johannes Gutenberg University Mainz, Germany. At the 2024 European Glaucoma Society meeting in Dublin, Ireland, Prof Pfeiffer participated in a symposium on The Future of Glaucoma Care, focusing his presentation on developments in the operating room.

Chief among the predictions Prof Pfeiffer shared was that, as the years pass, glaucoma specialists will have a different approach to the question, Who needs surgery? Prof Pfeiffer cited a sentiment from German ophthalmologist Heinrich Harms, who in 1975 said, “All glaucoma patients should have glaucoma surgery…if there were the ideal glaucoma surgery.” As surgical interventions become more sophisticated, so too will surgery become more inclusive of patients who need long-term, efficacious treatment.

Trends in glaucoma care already reflect a tendency towards customised procedures, especially in the realm of microinvasive glaucoma surgery (MIGS), Prof Pfeiffer said (Figure).

A 2021 survey by Luebke and colleagues demonstrated a 75% increase in glaucoma procedures performed in Germany from 2006 to 2018.¹ Rates of filtration surgery without implants, overall, fell during the survey period (Table). Among the procedures examined, surgeons performed fewer trabeculectomies, ab externo trabeculotomies, goniotomies and cyclodestructive procedures during this 12-year duration. Laser trabeculoplasty peaked in 2014 and decreased in frequency after that year. MIGS procedures increased in frequency during that period, especially after 2012; XEN implant surgery, first made available in Germany in 2013, increased at a high level from 2015 on.

TABLE. Numbers (and Percentages of Total) for Total Number of Surgeries, MIGS (Minimal Invasive Glaucoma Surgery) and Different Types of MIGS.

Prof Pfeiffer used these figures to substantiate the primary hypothesis of his presentation: the number of surgical glaucoma procedures will continue to increase, especially newer methodologies.² “Surgeries perceived as ‘lighter’ or ‘minor’ will increase,” Prof Pfeiffer said, though reimbursement will play a major role in deciding which surgeries grow in frequency, and in which localities. In addition, more “traditional” surgeries will be adapted in ways that change how surgeons consider them. Modern medicine can make postoperative life look very different for patients, Prof Pfeiffer said. As an example, he stated, “In trabeculectomy, modulation of wound healing will improve, thanks in part to rho kinase inhibitors and antisense nucleotides."

Diagnostic surgeries and combined procedures will also become a regular part of the ophthalmology workflow, Prof Pfeiffer said. In particular, clinicians can expect combined surgeries (such as micro-stent implantation during phacoemulsification) to increase as new IOP-lowering technology makes its way into the eye. Ultimately, Prof Pfeiffer said, “Pumps will replace tubes, and those pumps should and will be connected to sensors.” Implantable pressure sensors are an increasingly feasible option for IOP monitoring.³ Per Prof Pfeiffer, an all-inclusive implant will be foundational to the future of glaucoma surgery. “Surgeons will take over medical glaucoma therapy,” he said. In essence, the combination of slow-release injectables and implantable sensors will ease patient burden, improve accuracy of IOP monitoring for clinicians and encourage robust interventional measures that are customised to each patient.

Glaucoma specialists should be prepared to embrace gene and cell therapy, Prof Pfeiffer said. So-called genetic surgery will be a major aspect of future surgical glaucoma interventions. As new data emerge, glaucoma clinicians will expect to consider CRISPR-cas modification and messenger RNA vaccination as suitable therapies for certain patients.

The boom in new devices and novel surgeries does present one major obstacle, and that is a market shortage—not of glaucoma drugs or devices, but of specialists. “Glaucoma surgeons will be in short supply,” Prof Pfeiffer warned, and that lack of human capital will become more obvious as devices and drug candidates receive global approval. It is vital for specialists in academic settings to put an intentional focus on upcoming treatment modalities and surgical techniques, and work with colleagues to create repositories of institutional wisdom. And, Prof Pfeiffer said, this is an ideal time for young surgeons to choose glaucoma as a specialty. Next-generation medicine will rely on the next generation of surgeons to become a reality for patients.

References

1. Luebke J, Boehringer D, Anton A, Daniel M, Reinhard T, Lang S. Trends in surgical glaucoma treatment in Germany between 2006 and 2018. Clin Epidemiol. 2021;13:581-592. Published 2021 Jul 13. doi:10.2147/CLEP.S310542

2.Schuster AK, Wolfram C, Pfeiffer N, Finger RP. Where do we stand?: an analysis of the treatment situation in Germany. Ophthalmologe. 2019;116(9):829-837. doi:10.1007/s00347-019-0894-2

3. Raveendran R, Prabakaran L, Senthil R, et al. Current innovations in intraocular pressure monitoring biosensors for diagnosis and treatment of glaucoma-novel strategies and future perspectives. Biosensors (Basel). 2023;13(6):663. Published 2023 Jun 18. doi:10.3390/bios13060663

Norbert Pfeiffer, MD | E: norbert.pfeiffer@unimedizin-mainz.de

Prof Pfeiffer is the Medical Director and Head of the Department of Ophthalmology at the University Medical Center of the Johannes Gutenberg University Mainz in Germany. Financial disclosures: Pfeiffer has received research grants or served on advisory boards for Alcon, Abbvie, Allergan, Isarna, Sanoculis, Santen and Sensimed