EyeWorld India September 2017 Issue

Laying the groundwork – from page 25 September 2017 26 EWAP SECONDARY FEATURE preoperative IOP and number of meds,” Dr. Sarkisian said. “This has been proven to be superior to phaco alone in the U.S. pivotal trial and as effective as a standalone procedure in patients outside the U.S.” Although there is still noth- ing as effective as trabeculectomy at lowering IOP, Dr. Sarkisian said, complications from trabeculectomy prompt him to avoid it unless all other options have failed. One other factor tracked by surgeons is reduction in medication use. In the COMPASS trial, mean medication use decreased from 1.4 to 0.2 in the microstent group com- pared with 1.3 to 0.7 in the group having cataract surgery alone. 1 “Mean 24-month medication use was 67% lower in microstent subjects ( P <0.001); 59% of control versus 85% of microstent subjects were medication free,” according to investigators. The complications associated with CyPass are self-limiting with no long-term effects, Dr. Nguyen said. One complication that he has seen is a larger-than-expected cleft, due to surgeon error from not enter- ing straight at the time of implanta- tion. “Although I have yet to experi- ence it, one can postulate that if you make lateral movements, you can cause a cleft,” Dr. Sarkisian agreed. “The CyPass has an intui- tive implantation technique, but it is not easy, and you have to be trained properly to implant the device.” Another possible complication is a higher IOP right after insertion, Dr. Craven said. “This happens in patients with more significant glau- coma. It usually gets better with patient observation. Use aqueous suppressants and steroids and wait,” he advised. Bleeding and a low IOP are pos- sible but are fairly uncommon, Dr. Flowers added. Options for cataract surgeons Cataract surgeons should be prepared to have a microinvasive glaucoma surgery (MIGS) approach they can use, said the surgeons interviewed by EyeWorld . “You can’t afford to not have a MIGS procedure in your arma- mentarium,” Dr. Sarkisian said. “The learning curve for the CyPass is reasonably short, and once a surgeon has gotten over that, the opportunity to use the CyPass will avail itself frequently.” One other advantage that Dr. Nguyen sees is the opportunity to intervene earlier in the course of glaucoma and offer better IOP con- trol, with the possibility of reducing glaucoma medications. “From a technical standpoint, it’s doable. If you can do phaco, which is a relatively complex skill to learn, you could certainly learn this,” Dr. Flowers said. The device also now has an improved inserter, which makes CyPass implantation more seamless, he added. “General ophthalmologists are afraid of extremely low pressures, but I haven’t had that with the new inserter,” Dr. Flowers said. One area getting mixed results is reimbursement. Some surgeons have had no problems, while others are still struggling. Dr. Sarkisian’s billing team has received help from those at Alcon to achieve reim- bursement for use of the device. EWAP Reference 1. Vold S, et al. Two-year COMPASS trial results: Supraciliary microstenting with phacoemulsification in patients with open-angle glaucoma and cataracts. Ophthalmology . 2016;123:2103–12. Editors’ note: Dr. Craven and Dr. Sarkisian have financial interests with Alcon. Dr. Flowers and Dr. Nguyen have no financial interests related to their comments. Contact information Craven: ercraven@yahoo.com Flowers: bflowers@oafw2020.com Nguyen: nguyen.quang@scrippshealth.org Sarkisian: steven-sarkisian@dmei.org