EyeWorld Asia-Pacific December 2017 Issue

December 2017 EWAP FEATURE 17 Views from Asia-Paci c YAO Ke, MD Professor, Eye Insittue of Zhejiang University Eye Cen- ter, Second Af liated Hospital of Zhejiang University, College of Medicine 99 Jiefang Road, Hangzhou, 310009, China Tel. no. +86-571-87783897 Fax no. +86-571-87783897 xlren@zju.edu.cn Managing cataract with advanced glaucoma I agree with the issues mentioned on the present situation of glaucoma management, especially MIGS. Currently, thanks to the effectiveness of anti- glaucoma drops, a large proportion of patients with mild to moderate glaucoma refer to medications, while trabeculectomy is more often performed in those cases with IOP out of control on maximum medical therapy. Trabeculectomy has been widely used in China and has revealed impressive efficacy especially in advanced glaucoma patients. However, its application is limited due to its invasiveness and high risk of complications, such as shallow anterior chamber, hypotony, and trab failure caused by bleb scarring. Therefore, trabeculectomy is gradually being replaced by novel eye drops and MIGS. More and more patients have turned to MIGS since its advent. Ab interno canaloplasty (ABiC) is a new, comprehensive MIGS procedure which first came out in 2015. Earlier this year, we successfully performed the first case of ABiC in China. Recent research indicates collector channel ostia herniation, especially complete herniation, to be one of the leading causes of primary open-angle glaucoma (POAG). The main mechanism of ABiC is to reopen and dilate collapsed Schlemm’s canal as well as to separate adhesion and herniation of collector channel by microtube and viscoelastic. ABiC has many advantages compared to other MIGS. It is a more minimally invasive procedure with much less hemorrhage than gonioscopy- assisted transluminal trabeculotomy (GATT). No suture or permanent implant is involved, which makes it safer and more convenient. Conjunctiva is well-preserved, which gives chance to following filtering surgeries such as trabeculectomy, if needed. As well, we can either do ABiC alone or combine it with cataract surgery. The combination is highly recommended since it can avoid the risk of cataract acceleration caused by glaucoma surgery and cataract surgery itself may also help to lower IOP. Up until now, only one case study including 23 eyes has been published worldwide regarding the efficacy of ABiC. 1 So far, we have done 10 cases of ABiC altogether. According to our preliminary experience, this procedure showed impressive efficiency of IOP reduction in mild to moderate POAG. We will continue to study its long-term efficacy and stability, as well as its efficiency when combined with selective laser trabeculoplasty (SLT) after surgery. Reference 1. Korber N. Canaloplasty ab interno - a Minimally Invasive Alternative [J]. Klin Monbl Augenheilkd . 2017;234(8):991–5. Editors’ note: Dr. Yao declared no relevant nancial interests. “ Trabeculectomy has been widely used in China and has revealed impressive efficacy especially in advanced glaucoma patients. However, its application is limited due to its invasiveness and high risk of complications...trabeculectomy is gradually being replaced by novel eye drops and MIGS. ” - Yao Ke, MD used to do trabeculectomy and tubes, however, the results with the XEN were so impressive and reliable, the safety margin was better and the surgery was easier on both the doctor and patient in terms of it being minimally in- vasive, that I only offer the XEN at this point. I do not see why I should do a trabeculectomy when I can get better results with XEN in a minimally invasive manner, which is much less stressful on the patient,” he said. Yes to CyPass for advanced glaucoma The more avenues eye doctors have to lower the IOP in patients who are already on max medical therapy, the better. John Odette, MD , Austin, Texas, said that MIGS devices have been a great addition to the eye doctor’s surgi- cal armamentarium. He thinks, however, that trabeculectomy and tubes will continue to play a significant role in glaucoma treatment for use in patients with refractory IOP elevations, despite the encouraging results obtained using MIGS devices to lower IOP. “I currently use both the iSt- ent and the CyPass. Since it was approved for use earlier, I have placed more iStent devices, but I am finding the CyPass device to have more IOP-lowering ef- fect than using one iStent. The XEN will hopefully help decrease many of the complications from bleb-related surgery,” he said. The CyPass redirects aqueous flow to the suprachoroidal space and therefore has a large capacity to significantly reduce IOP. The device is FDA approved for im- plantation in the eye at the time of cataract surgery. Dr. Odette prefers not to combine glaucoma procedures, electing to perform them one at a time. “Thus far I typically do not perform more than one glaucoma procedure at a time, with the exception of cataract removal and MIGS. Since many of our glau- coma procedures are unpredict- able depending on the patient, I prefer to determine the effect of one procedure prior to doing a second,” he said. While the iStent, CyPass, and XEN are FDA approved, reim- bursement is challenging for all three. Dr. McKee explained that the iStent received reimburse- ment but that the Medicare carrier in his area just reduced reimbursement to $200 per stent, which is untenable. The XEN is currently a cash pay procedure. He said that although patients pay cash, lifting the irritating burden of drops associated with advanced glaucoma has left them completely satisfied. Dr. Odette also corroborated the current reimbursement challenges for almost all glaucoma and MIGS procedures, which is even harder when trying to combine proce- dures. “In our practice we will re- sort to a private pay model when necessary. However, many of the patients that have the most need for these procedures are those who can least afford a self-pay model,” Dr. Odette said. EWAP Editors’ note: Dr. McKee has finan- cial interests with Allergan. Drs. Kim and Odette have no financial interests related to their comments. Contact information Kim: wonkim74@hotmail.com McKee: mckeeonline@mac.com Odette: jodette@austineye.com