EyeWorld India September 2018 Issue

EWAP FEATURE 25 September 2018 the control of systemic inflamma- tion, and that has helped some uveitic patients avoid steroid-in- duced IOP elevation and maintain a healthier trabecular meshwork; the better their systemic inflam- mation is controlled, the better it is for them in the long run,” Dr. Rothman said. “Some of our newer surgical options available now and in the future are going to help these patients, since many tradi- tional surgical procedures tend to have unacceptable survival rates and permanently distort the con- junctiva and ocular surface.” Microinvasive glaucoma sur- gery (MIGS) procedures, as earlier surgical options for all patients, are becoming more prominent as surgeons gain experience in some of the more challenging patient populations. Dr. Rothman has managed pediatric patients with a his- tory of failed tube shunt surgery who have received the InnFocus Microshunt (Santen, Osaka, Japan) outside the United States. “After several months of follow up they look good,” Dr. Rothman said. Dr. Trubnik has found laser cataract surgery helpful in pseu- doexfoliation patients as well as patients with multiple retinal in- jections who may have weakened zonules and an unstable lens. “That creates a much easier procedure where I don’t have to put as much stress on the zonules,” Dr. Trubnik said. Additionally, Dr. Trubnik uses expansion devices, like iris rings or hooks, to help if the pupil is small. If it is a particu- larly dense lens and phacodonesis is present, she finds the miLOOP (Iantech, Reno, Nevada) has been useful to get the lens out safely in those patients in whom laser cataract surgery is not possible due to a miotic pupil. Dr. Radcliffe, one of the first U.S. surgeons to adopt Micro- Pulse laser cyclophotocoagulation (Iridex, Mountain View, Califor- nia) about 3 years ago, has found it effective both before and after surgical procedures. “It is different from all of the other options because it works by suppressing the amount of aque- ous humor produced,” Dr. Rad- cliffe said. “If a patient has failed a few other types of surgery, I have that in my back pocket, and it can be a life saver.” The FDA approval of the CyPass Micro-Stent (Alcon, Fort Worth, Texas) offered a treatment that accesses a different pathway— the uveal scleral pathway. “If someone has failed a few tubes, for example, the CyPass is a different mechanism, and it may work uniquely well,” Dr. Radcliffe said. “I love trabecular meshwork surgery and do plenty of it but usually these patients have already had that surgery because that is part of many surgeons’ routine algorithm for cataract/glaucoma surgery.” Dr. Radcliffe described the XEN Gel Stent (Allergan, Dublin, Ireland) as “very helpful because it can achieve low IOP and get people independent of drops but without the risk of a trabeculec- tomy.” New medicines that have es- pecially helped Dr. Radcliffe’s pa- tients are Vyzulta (latanoprostene bunod, Bausch + Lomb, Bridge- water, New Jersey) and Rhopressa (netarsudil, Aerie Pharmaceuti- cals, Irvine, California), both of which help with aqueous outflow through the trabecular meshwork. “Having new medical options always helps surgeries work better because it gives us more flexibility if patients are having intoleranc- es,” he said. Coming treatments Several companies are looking at devices that will drain externally in a controlled fashion, Dr. Roth- man said. “Those devices hold great promise for situations where significant scarring has been a problem, which tends to be the case with inflammatory glaucoma, chronic medication usage, and failed prior surgery,” Dr. Rothman said. “Those future devices are going to be helpful in the manage- ment of many of these patients.” Dr. Rothman is also looking forward to trying new medications for patients with contraindications to or lack of efficacy from some of the current therapeutic options. “Traditional medications have worked poorly in patients with Sturge-Weber syndrome,” Dr. Rothman said. “I am excited to try Rhopressa in patients with this problem to see how they respond, as it is the first topical agent that may directly impact episcleral venous pressure.” EWAP Editors’ note: Dr. Radcliffe has financial interests with Aerie Pharmaceuticals, Alcon, Allergan, Bausch + Lomb, and Iridex. Dr. Rothman has financial interests with Allergan, Aerie Pharmaceuti- cals, Bausch + Lomb, Camras Vi- sion (Research Triangle Park, North Carolina), and Qura Inc. (Boston). Dr. Trubnik has no financial inter- ests related to her comments. Contact information Rothman: rothman1@optonline.net Radcliffe: drradcliffe@gmail.com Trubnik: vtrubnik@ocli.net