EyeWorld India September 2019 Issue

FEATURE 16 EWAP SEPTEMBER 2019 T he subspecialty of glaucoma is now teeming with new technology to assist with surgical procedures, IOP management, and diagnostics. However, just like any new technology, surgeons must constantly monitor for better usage, cost, and effectiveness. Here’s a rundown of some of the new glaucoma technology that ÃÕÀ}iœ˜Ã >Ài w˜`ˆ˜}…i«vՏ° Management through MIGS Innovation for microinvasive glaucoma surgery (MIGS) has yœÕÀˆÃ…i` ˆ˜ ÀiVi˜Ì Þi>ÀÃ] ܈̅ a few newer MIGS devices in particular getting praise and attention. “In terms of devices that target the trabecular meshwork, the newly designed iStent inject [Glaukos] comes with two preloaded devices on one injector that are smaller than the original model,” said Allison Angelilli, MD. “They are injected into the nasal trabecular meshwork and have a central Õ“i˜ ܈̅vœÕÀ œÕÌyœÜ «œÀÌà `iÈ}˜i` ̜ `iˆÛiÀ >µÕiœÕà yՈ` directly into Schlemm’s canal.” Glaukos also has other iStent innovations on the horizon, such >à ̅i -Õ«À> >˜` ̅i ˆ˜w˜ˆÌi] À° Angelilli said. Like iStent inject, the Hydrus Microstent (Ivantis) has encouraging pressure-lowering and medication reduction results when combined with cataract surgery, Dr. Angelilli said. “They are fairly straightforward to implant, although there is a learning curve as with most MIGS,” said Valerie Trubnik, MD, about the Hydrus. “The Hydrus, much like the iStent, allows the patient to have a fast visual recovery and the opportunity to get off of one or two drugs that they were on before.” Among other MIGS choices, the XEN Gel Stent (Allergan) bypasses the trabecular œÕÌyœÜ LÞ VÀi>̈˜} > `ˆÀiVÌ pathway for aqueous egress ̅ÀœÕ}…> “ˆVÀœÃVœ«ˆV yi݈Li stent implanted into the subconjunctival space, Dr. Angelilli said. Even though it theoretically carries the risks of an aqueous bypass procedure like trabeculectomy, it lessens the risk for hypotony and delayed visual recovery. Many }>ÕVœ“> ÃÕÀ}iœ˜Ã…>Ûi Àiw˜i` their XEN technique by using an ab externo approach that delivers the stent from the subconjunctival space into the anterior chamber, said Nathan Radcliffe, MD. The idea behind the approach is to lessen initial challenges with the XEN. The new approach has made a big difference for Dr. Radcliffe. “Once I developed my new technique, I started using the XEN 10 times as often,” he said. This new use of the XEN also demonstrates how glaucoma surgeons likely will continue ̜ Àiw˜i ̅iˆÀ ÕÃi œv >˜Þ ˜iÜ technology that reaches their hands, Dr. Radcliffe said. Another MIGS technology approved in Europe but not yet in the U.S. is the InnFocus MicroShunt Glaucoma Drainage System (Santen), which bypasses aqueous into the subconjunctival space. “It shows promise as an effective addition in the MIGS space due to [its] thermoplastic elastomeric material,” Dr. Angelilli said. IOP management “Precise measurement of IOP is the cornerstone of glaucoma management,” Dr. Angelilli said. œÜiÛiÀ] ̅i œVV>Ȝ˜> ˆ˜‡œvwVi measurements are less than ideal for management, particularly in patients with glaucomatous progression. That’s why both new devices to measure IOP and new drugs to help control IOP are always needed. Patient adherence to eye drop use is always a major struggle, so many glaucoma surgeons are excited about newer ways to approach IOP management, including punctal plugs and injections. “Data supporting these newer approaches to therapy will require time before we can best assess which procedures are indicated for which individual patients,” said Louis Cantor, MD. Although Dr. Cantor thinks Giving new glaucoma technology its time in the spotlight by Vanessa Caceres EyeWorld Contributing Writer AT A GLANCE • Newer MIGS devices such as the iStent inject, Hydrus, and XEN are getting praise from glaucoma surgeons for helping to lower IOP and reduce medication use. • A variety of approaches may help with IOP management, including newer drugs as well as devices that can release medications, such as punctal plugs. • Some concerns with newer technology include cost, coverage, frequency of insertion, and how to handle patients lost to follow up. • Newer approaches for glaucoma diagnostic technology include OCT angiography and the use of corneal hysteresis to help predict patient success with various treatments. Successful trabeculectomy with a low and FKHHWUG ƂNVGTKPI DNGD CPF UVCDNG +12 QH to 10 mmHg for more than 10 years. Source: Lou Cantor, MD Contact information Angelilli: aangelilli@ocli.net Cantor: lcantor@iu.edu Radcliffe: drradcliffe@gmail.com Trubnik: vtrubnik@ocli.net 6JKU CTVKENG QTKIKPCNN[ CRRGCTGF KP VJG /C[ KUUWG QH EyeWorld . It has been UNKIJVN[ OQFKƂGF CPF CRRGCTU JGTG YKVJ RGTOKUUKQP HTQO VJG #5%45 1RJVJCNOKE Services Corp.