EyeWorld India December 2018 Issue

Figure 1. Trab 360 handpiece used to perform GATT, followed by ECP Figure 2a. Cypass placed in the supraciliary space Figure 2b. An iStent placed, followed by iStent-R facing in the opposite direction Figure 2c. At completion, two iStents and a CyPass allow for out ow of aqueous through multiple patheways. Source (all): Won Kim, MD teens with Trabectome alone,” he said. Factors he considers when combining procedures include tar- get pressure (if it’s below what you might get with a single procedure, then a combination procedure makes sense), glaucoma severity, and disease pathophysiology. The use of ECP is common because it’s a natural pairing with many MIGS procedures, Dr. Rad- cliffe said. “It can be performed with goniotomy, canaloplasty, and other procedures such as the CyPass Micro-Stent [Alcon, Fort Worth, Texas] and even the XEN Gel Stent [Allergan, Dub- lin, Ireland],” he said. “Similarly, MicroPulse laser cyclophotoco- agulation can be paired with any of these.” One caution he shared is that he might not pair Micro- Pulse with the CyPass because you could induce some inflammation in the ciliary body and possibly the choroid, which could lead to a little more ciliary effusion. “It’s a theoretical concern, but it’s not an unreasonable one. With ECP, you’re just targeting the anterior ciliary processes.” Another example of an effec- tive combination for Dr. Sarkisian has been the Omni Combined Procedure System (Sight Sciences, Menlo Park, California) along with the CyPass. He said this has led to consistently lower IOP. The combination of proce- dures that target different areas— such as supraciliary and trabecu- lar—give surgeons options in case one approach does not work, Dr. Radcliffe said. “You only go into the eye once, and you have separate paths for outflow,” he said. Dr. Kim has combined two trabecular microbypass stents with a supraciliary stent and has even further combined these with other procedures among nearly half of the 56 patients he has followed. “If I had my druthers, I’d use the CyPass and the iStent in the same eye,” Dr. Sarkisian said. “For now, Medicare is bundling them, and the surgeon only gets paid for one.” continued on page 32 December 2018 EWAP SECONDARY FEATURE 31