EyeWorld India June 2017 Issue

63 June 2017 EWAP GLAUCOMA more of the midday IOP without medications; and/or a reduction of at least 3 mmHg. “There is a therapeutic dilemma, however, in this definition, regarding the target pressure concept because patients who have raised IOP of short duration, or slowly rising early IOP need a higher target IOP than patients who have advanced, long-standing, fast-rising IOP, who require a lower target IOP. Many factors play into deciding the target pressure for a patient,” he explained. Dr. Jünemann believes that patients with advanced long- standing or quickly-rising IOP are still best served by trabeculectomy. Apart from the Xen gel stent, which has been shown to be effective in increasing filtration of aqueous, trabeculectomy is likely to still be the surgeon’s best choice. “An experienced surgeon can create a good filtration bleb and tenon suture, making this an excellent, effective pressure- relieving surgery. The XEN bleb is much like the trabeculectomy bleb. However, the advantages of trabeculectomy over the XEN MIGS stent is that it is performed reliably from the outside of the eye allowing us to reliably surgically define a drainage shaft. By continuing to perform trabeculectomy, our young surgeons stay in practice, sew and suture, and continue to learn more about the eye tissues, through surgery. After all, experience is not inherited,” he said. EWAP by shunting aqueous into the subconjunctival space, but is performed ab interno, freeing up all points of resistance. So the question is: is this good enough? The results are compelling. However, I believe that even though making use of transtrabecular, suprachoroidal, and filtrating mechanisms to reduce IOP lets us treat every type of patient, we still need trabeculectomy,” Dr. Jünemann said. Case for trabeculectomy For Dr. Jünemann, the exceptional results achieved through MIGS to lower raised IOP in open-angle glaucoma patients do not preclude the further implementation of trabeculectomy. In fact, there are scenarios in which he would choose trabeculectomy as the best choice for the patient. “The idea of completely switching from a trusted ab externo procedure to MIGS is a true dilemma, because for me trabeculectomy has always been part of my armamentarium for glaucoma surgery. I may be accepting of new ideas, but I still hold on to this valued procedure. MIGS is still very new.” The American Glaucoma Society and the U.S. Food and Drug Administration convened in 2014 to agree upon a unified definition of MIGS. It was characterized as an ab interno procedure, with minimal tissue interaction (wound healing), effective IOP reduction, and high safety. The adequate IOP reduction for MIGS was set at a middle reduction of 20% or addition, lack of compliance can lead to the patients’ glaucoma getting worse, setting the patient up for more drastic and expensive future therapies. Undoubtedly, these microinvasive glaucoma surgeries used in appropriate patients can provide safe, effective therapies that also make sense financially. EWAP References 1. Grant WM. Further studies on facility of flow through the trabecular meshwork. AMA Arch Ophthalmol . 1958; 60 (4 Part 1):523–33. 2. Samuelson TW, et al. Randomized evaluation of the trabecular micro-by- pass stent with phacoemulsification in patients with glaucoma and cataract. Ophthalmology . 2011;118:459–67. 3. Reiter S. “Impact of surgeon experi- ence on efficacy of trabecular micro- bypass stent with phacoemulsification.” Presented at the Barkan Society Meeting, San Francisco. June 2016. 4. Neuhann TH. Trabecular micro-bypass stent implantation during small-incision cataract surgery for open-angle glaucoma or ocular hypertension: long-term results. J Cataract Refract Surg . 2015;41:2664–71. 5. Emi K, et al. Hydrostatic pressure of the suprachoroidal space. IOVS . 1989;233–8. 6. Höh H, et al. Two-year clinical experience with the CyPass micro-stent: safety and surgical outcomes of a novel supraciliary micro-stent. Klin Monbl Augenheilkd . 2014;231:377–81. 7. Grisanti et al. [Supraciliary microstent for open-angle glaucoma: clinical re- sults of a prospective multicenter study]. Ophthalmologe . 2014;111:548–52. 8. García-Feijoo J, et al. Supraciliary micro-stent implantation for open- angle glaucoma failing topical therapy: 1-year results of a multicenter study. Am J Ophthalmol . 2015;159:1075–81. 9. Brown R. Minimally invasive supracili- ary microstent for IOP control in combined POAG-Cataract surgery: 2-year COMPASS RCT results. Presented at the ASCRS Symposium and Congress. New Orleans. May 7, 2016. Editors’ note: Dr. Bacharach has financial interests with Glaukos. Contact information Bacharach : jbacharach@northbayeye.com MIGS – from page 60 References 1. Neuhann TH. Trabecular micro-bypass stent implantation during small incision cataract surgery for open-angle glaucoma or ocular hypertension: Long-term results. J Cataract Refract Surg . 2015;41:2664–71. 2. Kass MA, et al. The Ocular Hypertension Treatment Study: A randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary-open-angle glaucoma. Arch Ophthalmol . 2002;120(6):701–13. 3. Ahmed IK, et al. Prospective evaluation of microinvasive glaucoma surgery with trabecular microbypass stents and prostaglandin in open-angle glaucoma. J Cataract Refract Surg . 2014;40:1295–1300. 4. Wellik SR, Dale EA. A review of the iStent trabecular micro-bypass stent: Safety and efficacy. Clin Ophthalmol . 2015;9:677–684. 5. Voskanyan L, et al. Prospective, unmasked evaluation of the iStent Inject System for open-angle glaucoma: Synergy Trial. Adv Ther . 2014;31:189–201. 6. Pfeiffer N, et al. A randomized trial of a Schlemm’s canal microstent with phacoemulsification for reducing intraoc- ular pressure in open-angle glaucoma. Ophthalmology . 2015;122:1283–93. 7. Hoeh H, et al. Initial clinical experience with the Cypass Micro-Stent: Safety and surgical outcomes of a novel supraciliary microstent. J Glaucoma . 2016;25:106–12. 8. Sheybani A, et al. Phacoemulsification combined with a new ab interno gel stent to treat open-angle glaucoma: Pilot study. J Cataract Refract Surg . 2015;41:1905–09. Editors’ note: Dr. Jünemann has financial interests with Alcon, Allergan, and Glaukos. Contact information Jünemann: anselm.juenemann@med.uni-rostock.de