EyeWorld India September 2017 Issue

September 2017 EWAP SECONDARY FEATURE 25 by Vanessa Caceres EyeWorld Contributing Writer Glaucoma surgeons familiar with the MIGS device share surgery and patient selection pearls F or cataract surgery in mild to moderate glaucoma pa- tients, the CyPass Micro- Stent (Alcon, Fort Worth, Texas) now offers another treatment option. The CyPass was approved in the U.S. last summer by the U.S. Food and Drug Administration. The device was approved specifically for mild to moderate glaucoma, and that’s a description that surgeons who are familiar with CyPass support as well. “It’s for patients with open angles who have an IOP in the 20s [and who are] on one or two medications,” said E. Randy Craven, MD , Wilmer Eye Institute, Johns Hopkins Uni- AT A GLANCE r 5IF $Z1BTT .JDSP 4UFOU DBO CF VTFE JO DPOKVODUJPO XJUI DBUBSBDU TVSHFSZ UP MPXFS *01 JO QBUJFOUT XJUI NJME UP NPEFSBUF HMBVDPNB r 5IF $Z1BTT TIPVME CF BWPJEFE JO QBUJFOUT XJUI BEWBODFE HMBVDPNB JOáBNNBUPSZ HMBVDPNB BOE JO DPNQMFY DBTFT r 4VSHJDBM QFBSMT JODMVEF UJMUJOH UIF QBUJFOU T IFBE TMJHIUMZ MFTT UIBO ZPV XPVME GPS BOHMF TVSHFSZ BOE HFUUJOH DPNGPSUBCMF XJUI HPOJPTDPQZ r 1PTTJCMF DPNQMJDBUJPOT JODMVEF B MBSHFS UIBO QMBOOFE DMFGU CMFFEJOH BOE B MPXFS *01 BMUIPVHI UIFTF BSF VODPNNPO r 5IFSF JT B MFBSOJOH DVSWF XJUI $Z1BTT CVU JU T NBOBHFBCMF GPS DBUBSBDU TVSHFPOT Laying the groundwork for CyPass use versity, Baltimore. “Since you’re taking the cata- ract out at the time of the proce- dure, the person’s angles will be open, so there’s no worry about narrow angles,” said Brian Flow- ers, MD , Fort Worth, Texas. “I do find that it works even in patients on multiple medications.” Patients who would not do as well with the CyPass are those with an uncontrolled high IOP who are on multiple medications and those with inflammatory or neovascular glaucoma. “I would avoid doing the CyPass in ‘train wreck’ scenarios. Keep it to people controlled on medications first,” recommended Steven Sarkisian, MD , clinical professor and glaucoma fellowship director, Dean McGee Eye Institute, University of Oklahoma, Oklahoma City. He added that the microstent has not yet been tested in pediatric glaucoma. A nanophthalmic patient would also give Dr. Flowers some pause. Surgical pearls There are a few ways you can bet- ter manage CyPass implantation, according to surgeons who are familiar with the device through its clinical trials. “You have to be comfortable with intraoperative gonioscopy and have a clear view of the angle anat- omy and know the surgical land- mark of the angle,” said Quang Nguyen, MD , associate head, Divi- sion of Ophthalmology, and direc- tor of the glaucoma service, Scripps Clinic, La Jolla, California. “When inserting, the height of the elbow seems to predicate the angle of approach. You need the tip to ‘glide’ along the sclera. It’s better to under-insert and then tap into place. If it hangs up, stop,” Dr. Cra- ven advised. “The angle of insertion needs to be adjusted. This is usually where you want the elbow up.” “Avoiding 3 and 9 o’clock is also helpful because the ciliary plexus is there, and the patient may feel the implant as it goes in if under topical anesthesia,” Dr. Sarkisian said. Dr. Flowers advocates tilting the patient’s head less than you do for angle surgery. “People doing angle surgery are used to rotating the head by 45 degrees. But with this, since you’re trying to implant perpendicular to the iris, you don’t want the head rotated as much— probably 10 to 15 degrees less,” he said. He also recommends implant- ing the device slightly deeper versus superficially. “You could get some corneal changes with superficial implantation,” Dr. Flowers said. Planning on IOP reduction, avoiding complications The CyPass is able to offer greater IOP reduction than phacoemulsifi- cation alone, Dr. Nguyen said. “The COMPASS trial revealed unequivo- cal scientific data that demonstrates the additive effect of CyPass to phaco surgery to provide excellent control long term,” he said. “You can expect a 20% to 40% drop in IOP, depending on the CyPass in the eye Source: Quang Nguyen, MD continued on page 26