An Interventional Approach to Glaucoma Management

Mehul H. Nagarsheth, MD

Preeya K. Gupta, MD

This post is sponsored by Glaukos

Join Mehul H. Nagarsheth, MD, and Preeya K. Gupta, MD as they discuss the latest innovations in the face of prevailing management strategies for patients with glaucoma.

In this installment of Interventional Mindset, Preeya K. Gupta, MD, sits down with Mehul Nagarsheth, MD, to discuss the role of artificial intelligence (AI) in anterior segment disease and glaucoma management.

Dr. Nagarsheth is a glaucoma specialist and cataract surgeon at Eye Consultants of Pennsylvania, a practice that he joined after completing his glaucoma fellowship at Tufts New England Eye Center and Ophthalmic Consultants of Boston in 2013. Dr. Nagarsheth is also on staff at Pennsylvania Eye and Ear Surgery Center, Reading Hospital-Tower Health, Physicians Care Surgical Hospital, and Physicians Care Surgery Center in Pennsylvania. He is an active member of the American Academy of Ophthalmology, the Pennsylvania Academy of Ophthalmology, and the American Glaucoma Society.

Watch the full interview with Dr. Nagarsheth to learn about:

The current role of topical medications in the management of glaucoma
Recommended treatment paradigms for newly diagnosed glaucoma patients
The role of early intervention with SLT and MIGS in glaucoma management
Benefits and limitations of invasive glaucoma surgery, including tube shunts and trabeculectomy.

The current state of glaucoma therapy

Dr. Gupta initiated the conversation by discussing historical treatment paradigms for glaucoma, noting that while she was in training, nearly all new cases were started on topical therapies, which remain part of the foundational therapy to this day. However, with the advent of in-office procedures such as selective laser trabeculoplasty (SLT) and micro-invasive glaucoma surgery (MIGS), there are now numerous viable options for interventional management of glaucoma.

Dr. Nagarsheth responded by saying that his training, like so many others, followed the caveat of employing the least invasive therapies first, and resorting to surgical options only when the treatment effect could not be readily achieved or maintained. Today however, we realize that topical medications, especially when used concurrently and over long periods of time, can be detrimental to the ocular surface, and can lead to unwanted signs and symptoms that impact patient compliance.

Dr. Nagarsheth explained that, particularly in the wake of the LiGHT Trial,¹ he recommends the use of SLT as initial therapy for all new open angle glaucoma cases. He acknowledges that there will always be patients who prefer to be in control of their own disease for whom topical medications remain a viable option, but at some point we need to remind these patients that we do have more advanced options for managing glaucoma. Additionally, he performs angle-based MIGS procedures to help restore and enhance the eyes’ natural drainage system via episcleral venous outflow. This really began in 2012 with the advent of iStent, and since that time we’ve seen a real boom in MIGS devices, with greater advances coming in recent years. Currently, Dr. Nagarsheth finds great value in the iStent infinite® Trabecular Micro-Bypass System Model iS3, an implantable device indicated for adults with primary open-angle glaucoma in whom previous medical and surgical treatment has failed, and represents the first micro-invasive standalone implantable alternative.

For a deeper discussion of the iStent infinite® system, watch the full interview with Dr. Nagarsheth!

Dr. Nagarsheth concluded by discussing a 12-month multicenter pivotal trial of patients with open-angle glaucoma who had failed prior surgical intervention and underwent standalone iStent infinite® implantation. The iStent infinite® demonstrated exceptional results demonstrating sustained efficacy throughout the course of the study while also providing exceptional intraoperative and postoperative safety.

PM-US-2394

Dr. Nagarsheth was compensated by Glaukos for his time on this initiative.

INDICATION FOR USE. The iStent infinite® Trabecular Micro-Bypass System Model iS3 is an implantable device intended to reduce the intraocular pressure (IOP) of the eye. It is indicated for use in adult patients with primary open-angle glaucoma in whom previous medical and surgical treatment has failed. CONTRAINDICATIONS. The iStent infinite is contraindicated in eyes with angle-closure glaucoma where the angle has not been surgically opened, acute traumatic, malignant, active uveitic, or active neovascular glaucoma, discernible congenital anomalies of the anterior chamber (AC) angle, retrobulbar tumor, thyroid eye disease, or Sturge-Weber Syndrome or any other type of condition that may cause elevated episcleral venous pressure. WARNINGS. Gonioscopy should be performed prior to surgery to exclude congenital anomalies of the angle, PAS, rubeosis, or conditions that would prohibit adequate visualization that could lead to improper placement of the stent and pose a hazard. MRI INFORMATION. The iStent infinite is MR-Conditional, i.e., the device is safe for use in a specified MR environment under specified conditions; please see Directions for Use (DFU) label for details. PRECAUTIONS. The surgeon should monitor the patient postoperatively for proper maintenance of IOP. Three out of 61 participants (4.9%) in the pivotal clinical trial were phakic. Therefore, there is insufficient evidence to determine whether the clinical performance of the device may be different in those who are phakic versus in those who are pseudophakic. ADVERSE EVENTS. The most common postoperative adverse events reported in the iStent infinite pivotal trial included IOP increase ≥ 10 mmHg vs. baseline IOP (8.2%), loss of BSCVA ≥ 2 lines (11.5%), ocular surface disease (11.5%), perioperative inflammation (6.6%) and visual field loss ≥ 2.5 dB (6.6%). CAUTION: Federal law restricts this device to sale by, or on the order of, a physician. Please see DFU for a complete list of contraindications, warnings, precautions, and adverse events.

References

1. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial: Six-Year Results of Primary Selective Laser Trabeculoplasty versus Eye Drops for the Treatment of Glaucoma and Ocular Hypertension. Ophthalmology. 2023;130(2):139-151. doi:10.1016/j.ophtha.2022.09.009

About Mehul H. Nagarsheth, MD

Mehul H. Nagarsheth, MD joined Eye Consultants of Pennsylvania after completing his Glaucoma Fellowship at Tufts New England Eye Center and Ophthalmic Consultants of Boston in July 2013.

He grew up in Marlboro, New Jersey and received his bachelor's degree Cum Laude in Neuroscience and Behavioral Biology with a dual major in Political Science from Emory University in Atlanta, GA in 2004. Dr. Nagarsheth received his medical degree from Drexel University College of Medicine in June 2008 where he continued to complete his internship. He performed his ophthalmology residency at Case Western Reserve University Hospital in Cleveland, Ohio from 2009 to 2012. During his chief year of residency, Dr. Nagarsheth also traveled abroad to Hyderabad, India where he completed a medical and surgical ophthalmology elective at the LV Prasad Eye Institute.

Dr. Nagarsheth has extensive experience in medical research of the eye. He has presented several projects at national conferences and published studies in numerous scientific journals. He received the Best Resident Research Award at Case Western Reserve University Hospital's Department of Ophthalmology Annual Research Symposium in June 2012. He was also the recipient of the National Eye Institute Travel Grant in May 2011. He remains interested and active in pursuing new and innovative ways of managing glaucoma both medically and surgically.

As an ophthalmology resident and glaucoma fellow, Dr. Nagarsheth was very active in teaching junior trainees and medical students. Dr. Nagarsheth also performed refractions and ophthalmic screenings at MedWorks and the Philadelphia and Cleveland Free Clinics throughout his postgraduate training.

Dr. Nagarsheth is currently on staff at Pennsylvania Eye and Ear Surgery Center, Reading Hospital-Tower Health, Physicians Care Surgical Hospital, Physicians Surgical Center of Lebanon, and Phoenixville Hospital Outpatient Surgery Center Limerick.

His medical society memberships include:American Academy of OphthalmologyPennsylvania Academy of OphthalmologyAmerican Glaucoma SocietyPennsylvania and Berks County Medical Societies

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About Preeya K. Gupta, MD

Dr. Gupta earned her medical degree at Northwestern University’s Feinberg School of Medicine in Chicago, and graduated with Alpha Omega Alpha honors. She fulfilled her residency in ophthalmology at Duke University Eye Center in Durham, North Carolina, where she earned the K. Alexander Dastgheib Surgical Excellence Award, and then completed a fellowship in Cornea and Refractive Surgery at Minnesota Eye Consultants in Minneapolis. She served on the faculty at Duke University Eye Center in Durham, North Carolina as a Tenured Associate Professor of Ophthalmology from 2011-2021.

Dr. Gupta has authored many articles in the peer-reviewed literature and serves as an invited reviewer to journals such as Ophthalmology, American Journal of Ophthalmology, and Journal of Refractive Surgery. She has also written several book chapters about corneal disease and ophthalmic surgery, as well as served as an editor of the well-known series, Curbside Consultation in Cataract Surgery. She also holds several editorial board positions.

Dr. Gupta serves as an elected member of the American Society of Cataract and Refractive Surgery (ASCRS) Refractive Surgery clinical committee, and is also is the Past-President of the Vanguard Ophthalmology Society. She gives presentations both nationally and internationally, and has been awarded the National Millennial Eye Outstanding Female in Ophthalmology Award, American Academy of Ophthalmology (AAO) Achievement Award, and selected to the Ophthalmologist Power List.

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