EyeWorld Asia-Pacific December 2016 Issue

December 2016 59 EWAP GLAUCOMA IOP reductions were similar in the solo and combined cataract groups at month 12 (13.6 vs. 14.0 mmHg, respectively; p=0.501), Dr. Barton said. To further explore the efficacy of the XEN implant as a standalone procedure, a separate analysis was undertaken of the 111 cases in which implantation was not combined with cataract surgery. “In these eyes, the mean IOP reduction from baseline at month 12 was 8.0+4.6 mmHg, or a 35.8% reduction from baseline,” said Ingeborg Stalmans, MD, PhD, Leuven, Belgium. The number of medications needed to maintain IOP control postoperatively was reduced in 90% of patients, she said. “This includes 57% who required no medications at all at month 12.” Clinical implications These preliminary data suggest that the XEN gel implant may be an important addition to our arsenal of glaucoma surgical options. “The XEN gel implant offers a minimally invasive and effective surgical alternative that lowers IOP to the low teens and reduces medication needs in patients with moderate POAG not controlled with topical antihypertensive medications,” Dr. Stalmans said. Dr. Barton agreed, saying, “The gel implant offers an effective treatment option both as a solo procedure or in combination with cataract surgery.” EWAP Editors’ note: Dr. Barton and Dr. Stalmans have financial interests with Allergan. Contact information Barton : keith@keithbarton.co.uk Stalmans : ingeborg.stalmans@uzleuven.be superiorly and two 80-second treatments inferiorly at the limbus using the specially designed MP3 Probe (Iridex). The 80 seconds of treatment are given using eight 10-second “sweeps,” with each sweep going across the limbus from one end to the other, while avoiding the horizontal meridian. Dr. Tanaka, who only performs the treatment in an ambulatory surgery center (ASC), uses monitored anesthesia care, and provides a retrobulbar block. “The procedure is very painful without a block,” Dr. Tanaka said. Dr. Radcliffe applies two 50-second treatments split between the top half of the eye and the bottom half of the eye. He spares the 3 and 9 o’clock areas where there are nerves and blood vessels. “I have three power settings and I alter my treatment by increasing the power. Some people do it by increasing the time,” Dr. Radcliffe said. For instance, Dr. Radcliffe uses 2,000 mW in a patient who has not had cataract surgery, has good vision, and who is having his or her first treatment. He uses 2,250 mW for retreatments, patients with vision in the 20/100 to 20/50 range, or those with more severe glaucoma. He uses 2,500 mW in advanced glaucoma cases with very poor vision and elevated pressure despite many surgeries. Dr. Radcliff’s technique also includes a subconjunctival steroid injection at the time of the laser. A retrobulbar block is used by Dr. Radcliffe, who performs the procedure in either the office or ASC. “To me, the advantage with this laser is that it can be used instantly (and at odd hours) and in a variety of settings outside of the traditional operating room,” Dr. Radcliffe said. “Traditional operating room setups can put the patient through a lot—operating at odd hours is never the ideal setting because you are usually not with your regular team, and you may not feel comfortable letting the patient go over the weekend with such a high pressure. Now that we have MicroPulse laser, we can do it right then in the office.” Complications The complications that Dr. Radcliffe has seen from the treatment have been “very mild,” with no cases with cystoid macular edema that could occur with traditional transscleral cyclophotocoagulation. Some patients have developed dry eye after the treatment so Dr. Radcliffe is cautious using the laser in patients who have had a corneal transplant or patients with a bad ocular surface. Instances of inflammation and iritis are usually treatable with steroids, and mydriasis can occur, particularly if the laser treatment is delivered to the 3 and 9 o’clock positions. Complications seen by Dr. Tanaka include inflammation that usually subsides in a few weeks. “Occasionally, the inflammatory reaction can be severe with a fibrinous reaction in the anterior chamber,” Dr. Tanaka said. Serious complications in patients younger than 60 have included postop mydriasis and loss of accommodation. MicroPulse laser will likely further contribute to the general trend of glaucoma treatment including less trabeculectomies, more tubes, and more microinvasive glaucoma surgery. Dr. Radcliffe said the treatment has allowed better care for people with reduced vision and an option for those who have decided that they will not have a trabeculectomy or tube placement. Additionally, it has provided an option for patients who have had silicone oil placed or heavy retinal surgery. “Those are fantastic candidates and they are getting better care now because we have this option,” Dr. Radcliffe said. EWAP Editors’ note: Dr. Radcliffe has financial interests with Iridex and New World Medical (Rancho Cucamonga, California). Dr. Tanaka has financial interests with Alcon (Fort Worth, Texas), Allergan (Dublin), Merck (Whitehouse Station, New Jersey), Ellex (Adelaide, Australia), and Glaukos (Laguna Hills, California). Contact information Radcliffe : drradcliffe@gmail.com Tanaka : ghtanakamd@gmail.com Getting - from page 57