GLAUCOMA 42 EWAP SEPTEMBER 2023 It’s clear to anterior segment surgeons that the landscape of glaucoma surgery is a spectrum, ranging from selective laser trabeculoplasty to the more invasive heavy hitters that are still considered the gold standard for IOP lowering (trabeculectomy and tube shunts). In the middle are a wide range of MIGS options. Patrick Gooi, MD, Davinder Grover, MD, MPH, and Paul Harasymowycz, MD, discussed best practices and special considerations for ab interno trabeculotomy, goniotomy, and canaloplasty. These procedures are attractive for certain patients, primarily because they can be performed without cataract surgery. Another reason, Dr. Harasymowycz said, is unlike stenting procedures, canaloplasty doesn’t leave hardware in the eye. Some patients might not like the idea of leaving a metal stent in the eye, and it might not be an option for patients who require by Liz Hillman Editorial Co - Director Contact information Gooi: patrick.gooi@gmail.com Grover: dgrover@glaucomaassociates.com Harasymowycz: pavloh@cliniquebellevue.com frequent MRIs, for example. Goniotomy/trabeculotomy In goniotomy and ab interno trabeculotomy, an opening is made in Schlemm’s canal and trabecular tissue is opened, removed completely, or ablated, depending on the device and procedure used. Dr. Grover said he thinks there is a lot of solid data supporting the safety and efficacy of goniotomy. In his practice, he has found it to be well tolerated and effective for milder or moderate forms of glaucoma in combination with cataract surgery or as a standalone procedure. Dr. Grover said he thinks goniotomy balances pressure- lowering ability with fast visual and physical recovery. “If a patient has mild to moderate disease on several drops, and I want the biggest bang for their buck, that’s when I would consider a goniotomy. If they need even more than that, say they’re moderate to advanced on several drops, that’s when I would consider a [gonioscopy - assisted transluminal trabeculotomy]. The more pressure lowering I need, the more invasive I get,” Dr. Grover said, adding later that he’d hesitate to do GATT or a larger opening of Schlemm’s canal if the patient cannot be taken off blood thinners or if they need to restart them quickly. “If they need significant pressure lowering and cannot be taken off blood thinners, that’s when I consider a smaller goniotomy opening … or one of the stenting procedures.” Dr. Harasymowycz said he thinks the best patients for goniotomy are those with pigment in the trabecular meshwork. “There are certain diseases in glaucoma that have more pigment in the trabecular meshwork, and in those cases, you’re more confident that if you excise the trabecular tissue, you’ll get more of an IOP-lowering response,” he Making Practice Perfect – Navigating the world of goniotomy/ trabeculotomy and canaloplasty This article originally appeared under the title “Navigating the world of goniotomy/trabeculotomy and canaloplasty” in the July 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. The spatulated tip of the iTrack Advance (Nova Eye Medical) permits easier piercing of the trabecular meshwork in order to access Schlemm’s canal. The 220-micron shaft permits 360-degree cannulation of Schlemm’s canal and contains a guidewire, a ViscoInjector (Nova Eye Medical), and optical fiber for illumination. Source (all): Paul Harasymowycz, MD
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