EyeWorld Asia-Pacific June 2018 issue

shows a higher capacity of outflow accommodation than the trabecu- lar space and has a similar safety profile. “I hope that we will soon see trials of supraciliary stenting as a stand-alone procedure in pre- Trab patients, where we can see MIGS devices open more options for glaucoma patients outside the limitations of concomitant cata- ract surgery,” he said. Dr. Waring highlighted the “fabulous safety and efficacy profile” of the Hydrus, the next generation iStent inject device, and the XEN Gel Stent (Allergan, Dublin, Ireland). The iStent inject includes two stents preloaded in an auto-injection mechanism. “All of these—particularly the Hydrus and the XEN—open up the door to treat more advanced states of glaucoma and provide the opportunity to truly help people get off eye drops,” Dr. Waring said. Among the lingering concerns Dr. Waring has about the technol- ogy is the likelihood that they can delay refractive benefits in com- bined procedures when compared to a standalone refractive IOL surgery. “Although we routinely combine MIGS and presbyopia- correcting IOLs, for example, the patient counseling is important because they are excited about their refractive outcomes, but we have to explain to them that first we are doing a medical procedure that may slow down their recov- ery if we combine it with a MIGS procedure,” Dr. Waring said. Another issue he highlighted is the potential in certain MIGS devices, such a the CyPass, to be associated with a rare myopic or refractive shift. In such cases Dr. Waring would not recommend the use of a presbyopia-correcting IOL. Femto limits One technology with expanding applications that appears to have found little benefit so far in the MIGS area is femtosecond laser systems. Dr. Waring noted that the in- creasing adoption of femtosecond lasers means the use of the lasers is more common in lens-based surgery that also involves MIGS. “But we don’t think there are any distinct advantages for MIGS when we are doing this,” Dr. War- ing said. Dr. Ianchulev agreed that femtosecond technology has not proven highly applicable to the glaucoma space and is still search- ing for clinical utility. “New solutions are needed,” he said. IOL benefits Future intraocular lens develop- ments that might benefit the MIGS space include utilizing them to hold IOP telemetry devices or as drug delivery device, Dr. Wortz said. “We have not properly lever- aged the inert space inside the lens capsule to even a fraction of its potential,” Dr. Wortz said. The potential for implanted IOP monitors is exciting to Dr. Ian- chulev. “Continuous IOP monitor- ing is a perfect piggy-back technol- ogy for IOLs and MIGS. This could open new advanced IOL technol- ogy and even premium surgical options for glaucoma patients,” he said. “For the glaucoma patient, it is important to nail down IOL power as precisely as possible and to come up with better premium options for glaucoma patients who have lower contrast sensitivity,” Dr. Ianchulev said. “This is where I think new solutions will start to emerge.” Modular IOLs, such as the lens from Omega Ophthalmics (Lexington, Kentucky), can offer a potential intracapsular space for intraocular pressure sensors, such as microchips, Dr. Waring said. “Now, not only are we helping the glaucoma with the MIGS, but we may be implanting a microsen- sor for intraocular pressure at the same time,” he said. Such lenses would allow self- monitoring at home and provide real time information on diurnal fluctuations, which might not get caught at the clinic. “They may have high diurnal IOPs at a certain time of day when they are not at the clinic where we may need to consider an alterna- tive to help them further,” Dr. Waring said. EWAP Editors’ note: Dr. Waring has finan- cial interests with Allergan, Glau- kos, Ivantis, and Omega Ophthal- mics. Dr. Ianchulev has financial interests with Alcon, Eyenovia (New York), and Iantech (Reno, Nevada). Dr. Wortz has financial interests with Allergan, Johnson & Johnson Vision (Santa Ana, California), and Omega Ophthalmics. Contact information Ianchulev: tianchul@privatemedicalequity. com Waring: gwaring@waringvision.com Wortz: 2020md@gmail.com What’s coming – from page 44 June 2018 46 EWAP SECONDARY FEATURE Gonio image of the CyPass post-implantation Source: Sean Ianchulev, MD