EyeWorld India September 2017 Issue

September 2017 34 EWAP SECONDARY FEATURE Potential future procedures The success of a trabeculectomy or XEN Gel Stent relies on the avail- ability of mobile conjunctiva/ Tenon’s to facilitate bleb formation, Dr. Vinod said. In patients with a prior failed trabeculectomy, glau- coma surgeons may opt to perform a second trabeculectomy or a tube shunt, depending on the location and extent of conjunctival scarring. In the presence of a previously failed superotemporal trabeculec- tomy, she tends to place an infero- nasal tube shunt. The XEN Gel Stent, Dr. Vinod said, is easier to place in previously operated eyes, as it is implanted ab interno and therefore doesn’t re- quire a conjunctival flap. However, sufficiently mobile conjunctiva is still needed for bleb formation. The superonasal quadrant is preferred as it is accessible via a temporal clear corneal incision and allows room for future incisional surgery if needed. Typically, Dr. Grover puts the XEN in the superonasal quadrant and leaves the superior quadrant for a possible trab and superotemporal quadrant for a tube. If you do a trabeculectomy or tube and it fails, you can still do a XEN if the supero- nasal quadrant is untouched. The other thing that differentiates XEN, he said, is a faster visual recovery and faster recovery to activity. Phakic influence on procedure selection For phakic patients requiring very low intraocular pressure for dis- ease stability, Dr. Vinod usually favors trabeculectomy as a primary surgery. “My decision to perform a trab, tube, or XEN in patients who are already pseudophakic depends on a variety of patient factors other than target IOP, including age, prior non- cataract ocular surgeries, ocular co- morbidities likely to require surgical intervention in the future, ability to follow-up in the postoperative pe- riod, etc.,” she said. Like trabeculec- tomy and tube shunts, the XEN can be performed in conjunction with cataract surgery in patients with visually significant cataract and glaucoma, she added, with the potential for fewer complications in the postoperative period than com- bining cataract surgery with a trab or tube. “Ultimately, lens status is one of several factors that influence my decision-making process when selecting the procedure that offers the best chance for disease stability and quality of life in my patients,” Dr. Vinod said. EWAP Editors’ note: Dr. Grover has financial interests with Allergan. Dr. Vinod has no financial interests related to her comments. Contact information Grover: dgrover@glaucomaassociates.com Vinod: kvinod@nyee.edu Comparing glaucoma – from page 33 Travel Scholarships Available for Young Physicians