EyeWorld India December 2018 Issue

December 2018 EWAP SECONDARY FEATURE 29 Patient selection Dr. Trubnik said that in all of her patients, even moderate and advanced cases, she’s transitioning the traditional procedures to XEN Gel Stents. She’s had multiple pa- tients where she did a trabeculec- tomy before the XEN was covered by Medicare. They did well, but for the second eye, she did a XEN, and these patients did even better in terms of visual recovery. Dr. Moster noted that in cases where there is not a lot of disease, it’s not appropriate to take a lot of risk; therefore, the iStent is some- thing that she relies on in these mild cases. If there’s more moderate glau- coma, she will often use a CyPass or GATT, along with cataract surgery. Meanwhile, if the goal is to lower pressure for a patient who has a thin conjunctiva or a myope, she will consider a XEN, and she hopes the InnFocus MicroShunt will be approved soon. When asked if there’s a type of glaucoma that has remained “un- touchable” by MIGS, Dr. Trubnik said that she wouldn’t use that term. “I don’t think anything is untouchable,” she said. However, for uveitic patients, she doesn’t use options like the CyPass or iStent because she’s concerned about clogging of the stent with fibrin or white blood cells or inflammatory cells. Dr. Trubnik noted that she hasn’t used a XEN in a uveitic patient, but she would likely go straight to a tube for these patients. She added that neovascular glaucoma is also a concern. “You don’t want hyphemas or fibrin blocking stents like the CyPass or iStent,” Dr. Trubnik said, and she thinks the same would be true for the XEN. Dr. Moster said that she still finds trabeculectomy to be the “gold standard” to help bring a patient’s pressure down to the low teens or single digits. “There are patients who just need that,” she said. Some patients have a lot to lose if the pressure stays up, she said, and it’s not unheard of for the pressure to be uncontrolled in the immediate postop period after MIGS. Therefore, trabeculectomies are still Dr. Moster’s go-to proce- dure for the “real deal” glaucoma when patients need a low pressure and have a lot to lose if it’s not obtained. MIGS after a failed traditional glaucoma surgery Dr. Moster said she has performed MIGS after a failed traditional glaucoma surgery, specifically us- ing GATT. “I’ve done GATT after failed trabeculectomies and after failed tubes, however, the trabecular meshwork needs to be visualized InnFocus MicroShunt, 1 year after placement; from a preop IOP of 26 mmHg on three medications, the IOP is now 14 mmHg on no medications. Source: Marlene Moster, MD for 360 degrees. We can then split the trabecular meshwork in order to lower the pressure by increasing flow into Schlemm’s canal,” she said. Dr. Moster added that MIGS procedures have broadened the field for juvenile glaucoma, espe- cially GATT. Pressures can drop from 40–50 to 12 and stay there, she said, and this is a tremendous advantage in young people, espe- cially contact lens wearers. Though Dr. Trubnik has not performed MIGS after failed tradi- tional glaucoma surgery, she said she has certainly considered it. She has had multiple patients who had a trabeculectomy and tubes and both were not sufficient to control IOP. She’s also had pa- tients where the tube eroded once or multiple times. Dr. Trubnik said that in these cases, she wouldn’t want to put anymore hardware on the outer surface of the eye but would consider doing a CyPass, where everything is internal, and you don’t have to worry about the shunt or any material being exposed. EWAP Editors’ note: Dr. Moster has finan- cial interests with Santen, Alcon, Allergan, and Glaukos. Dr. Trubnik has no financial interests related to her comments. Contact information Moster: marlenemoster@gmail.com Trubnik: valerietrubnik@yahoo.com