EyeWorld Asia-Pacific March 2011 Issue

March 2011 15 EW FEATURE gov. That study is being led by investigators at Bascom Palmer Eye Institute. Some surgeons are using an aqueous drainage device in place of trabeculectomy, although this is not universal, Dr. Netland said. Others use it when patients are not good trabeculectomy candidates, he added. Dr. Netland recently wrote a paper about the use of the Ahmed device to treat neovascular glaucoma, which is traditionally very hard to manage. Dr. Herndon uses a recent iteration of the Molteno called the Molteno 3. He believes its shape has contributed to better visual results, and he has had positive experience with it over a three- month period. Expressing opinions on the Ex-PRESS Although some may argue that the Ex-PRESS is not a glaucoma shunt because there is no reservoir plate in the subconjunctival space, the device is still used in a similar manner as other drainage devices, Dr. Rhee said. Additionally, new placement positions for the Ex-PRESS, such as under the scleral flap, are intriguing surgeons, Dr. Rhee said. “The big debate is whether or not the Ex-PRESS is better and whether it’s worth the money,” Dr. Rhee said, noting that the device can cost several hundred dollars. Those who favor the device cite predictability. “Surgeons like it because it’s more efficient, more predictable, and it’s associated with fewer complications,” Dr. Netland said. “There’s less early post-op hypotony, but it has not been proven more effective than trabeculectomy.” Dr. Herndon says he almost consistently uses the Ex-PRESS and finds that eyes are quieter with it. He believes that many early adapters were eager to try the technology when it was first approved by the US Food and Drug Administration (FDA). Still others have been cautious due to initial early complications and would like to see more long-term data from it. Dr. Herndon said that Alcon’s recent acquisition of Optonol, the company that originally made the Ex-PRESS, will continue to trigger renewed interest in the product. Still, Dr. Herndon cautions that surgeons should not get a false sense of security when using the Ex-PRESS. “You still have to be a glaucoma surgeon and use particular techniques when inserting it,” he said. Dr. Rhee said he takes a more centrist view on the Ex-PRESS, noting that he finds it helpful in patients where the target IOP is less than 10 mmHg and in the subset of patients with advanced disease. Although he agrees that the Ex-PRESS results are reproducible and lead to a stable anterior chamber, he does not back the claim that some make regarding less hypotony associated with the device. “I don’t think the Ex-PRESS does anything to reduce hypotony. I believe it’s how tight you tie the sutures that relates to this—that’s the important step,” he said. “This is my anecdotal experience, and that opinion hasn’t changed over the last 18 months.” For this reason, he uses the Ex-PRESS when aiming for a lower IOP in patients, although in most patients he will initially aim for a higher IOP and then gradually bring it down. Looking ahead Glaucoma surgeons said they’re excited to try out other drainage devices on the horizon, some of which have been approved in other countries and are in FDA Phase III trials, and others of which have a further way to go. The iStent Trabecular Micro- Bypass (Glaukos Corporation, Laguna Hills, Calif., USA), which is inserted into the trabecular meshwork, received a favorable statement from the FDA Advisory Panel, although it is not yet approved for use in the United States, Dr. Herndon said. He finds information on the iStent “compelling.” The iStent is in Phase III trials and is expected to be approved, Dr. Netland said. Devices that are placed in the suprachoroidal space, such as the Gold Shunt (SOLX, Medway, Mass., USA), are also attracting attention, Dr. Netland said. He works at one of the Phase III trial sites for the device, which is already approved in Canada and Europe. The device is made of 24-karat gold, lowers IOP without a bleb, and usually leads to pressures in the mid teens, Dr. Netland said. Yet other surgical non- drainage-device options, such as the Trabectome procedure (NeoMedix, Tustin, Calif., USA) and canaloplasty are also generating discussion in a field with a growing number of options, Dr. Netland said. EW Editors’ note: Dr. Rhee has financial interests with Alcon, Allergan (Irvine, Calif., USA), and BD Ophthalmic Systems (Waltham, Mass., USA), among other ophthalmic companies. Drs. Netland and Herndon have no financial interests related to their comments. Contact information Herndon: hernd012@duke.edu Netland: dap2b@virginia.edu Rhee: dougrhee@aol.com OCULUS Pentacam ® The indispensable tool for anterior segment analysis Whether keratoconus, cataract or other corneal diseases - the OCULUS Pentacam ® detects it! Various software modules such as the Belin/Ambrosio Enhanced Ectasia display, advanced IOL calculation and many others support your daily work precisely and efficiently. Visit us at APAO booth no. 448 to learn more about the Pentacam ® and other versatile OCULUS devices. Oculus Asia Ltd. Hong Kong Tel. +852 2987 1050 • Fax +852 2987 1090 www.oculus.de • info@oculus.hk www.pentacam.com