Closing the Gap in Glaucoma

Until about a decade ago, glaucoma experts were in a quandary when it came to treating patients whose disease existed somewhere between mild and severe, says Jella An, M.D., the new chief of the Wilmer Eye Institute’s Bethesda clinic and a glaucoma specialist. For patients with mild glaucoma, doctors would start treatment with eye drops or in-office lasers. When the glaucoma had progressed significantly, the treatment was a trabeculectomy, “a big-gun, high-risk surgery, which can have vision-threatening complications,” says An. As technology and the understanding of the disease improved, doctors were able to diagnose glaucoma earlier. For a growing number of patients, that left a large gap when drops and lasers were not sufficient and the serious surgery was not warranted.

“Then the MIGS came along and that really revolutionized the treatment of glaucoma,” says An. MIGS refers to micro, or minimally, invasive glaucoma surgeries. “MIGS have a significantly superior safety profile because they enhance the eye’s natural drainage system rather than create a hole in the eye, or a filter, as a trabeculectomy surgery does. They can be offered earlier in the disease and reduce the medication burdens for most patients.

“The fact that there are many different types of MIGS with varying efficacy and safety profiles allows us to personalize procedures for each patient based on the uniqueness of their disease, their lifestyle and their visual goals,” says An. “Treatment in general is going toward personalized medicine and finally, glaucoma as a specialty is getting there.”

Glaucoma is essentially a plumbing problem inside the eye, explains An. Compromised drainage (or trabecular meshwork) function causes fluid inside the eye to build up. Uncontrolled eye pressure eventually damages the optic nerve, which can progress to permanent vision loss. From eye drops, to lasers, to MIGS, to trabeculectomies and tube surgeries, all interventions aim to reduce the interocular pressure of patients.

For MIGS procedures, surgeons use microscopic equipment and tiny incisions that often self-seal. Some surgeries seek to maximize the natural drainage system of the eye — either with or without a stent. Others aim to bypass the natural drainage system and create a new one. “We always want to maximize natural drainage in the eye first, and if you're diagnosed early on, all we need is a little bit of stenting of a collapsed area, and then it will function just fine,” says An. “The patients with more severe disease don't tend to have a very good natural drainage capacity, so we create an alternative drainage system.”

When the surgical interventions work well, “it really reduces the medication burden,” says An. Reducing or eliminating the need for medication improves the vision and quality of life for patients whose treatment regimen prior to surgery consists of applying different kinds of eye drops several times a day to control eye pressure. Many of these eye drops can irritate the eye, and some patients cannot use the drops long-term.

An’s current research focuses on identifying the predictive factors for the best surgical outcomes. “I've done hundreds and hundreds of these cases, so I have a big database,” she says. Using this information, she performs statistical analyses on medical records to see which factors are linked to which surgical outcomes. She runs the analysis on data such as patient demographics, disease type and severity, starting eye pressure, medications and other medical conditions. The goal is to pair the right MIGS procedure with the right clinical characteristics to achieve the optimal outcome for each patient.

As the new chief of Wilmer’s growing Bethesda clinic, An has the same goal for the institute’s presence in the National Capital Region: optimizing treatment for patients. There are not many academic ophthalmology sites available in this area,” she says, “and there are so many patients who need tertiary-center level of care, which focuses on complex diseases. Wilmer is able to provide such care because we are part of a big institution with highly trained and skilled physicians and staff dedicated to excellence and innovation.”

Central to her plan is developing a clinical trials program for glaucoma treatments at the Bethesda clinic. “Our patient volume is very high compared to other academic centers, and we have great relationships with the industry too. So there’s a good potential to be able to collaborate on a lot of clinical trials,” says An. “These trials are time-consuming and expensive to run. So that's why we need to work with industry.” She sees collaborating on clinical trials as a vehicle to gaining early access to the most innovative and groundbreaking diagnostics, devices and treatments for Wilmer patients before they are available to the general population.

“Clinical trials are very important because they are how you innovate and move the field forward, eventually changing the practice pattern for better,” says An. As a participating center in clinical trials, “we can be a site that really shifts the needle for future glaucoma treatments.”