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EW FEATURE 50 Glaucoma's armamentarium • August 2018 by Rich Daly EyeWorld Contributing Writer AT A GLANCE • FDA-approved stents have undergone clinical trials that demonstrate their efficacy. • Among options, stenting of the trabecular meshwork is seen as straightforward and the most widely learned approach. • A fundamental question on the canal remains whether to open one area, a few areas, or the whole canal for maximum IOP reduction. Another stent is the Hydrus (Ivantis, Irvine, California), which uses a clear corneal incision at the time of cataract surgery and serves as a stent and scaffold for several clock hours of Schlemm's canal. That device has not yet received FDA approval but may in the near future, said Nathan Radcliffe, MD, assistant professor of ophthalmol- ogy, Icahn School of Medicine at Mount Sinai, New York. Beyond stents, surgeons have a number of different ways to address the trabecular meshwork, includ- ing two trabecular procedures that remove or expand parts of the canal without a stent. Both the Trabectome (NeoMe- dix, Tustin, California) and Kahook Dual Blade (New World Medical, Rancho Cucamonga, California) are performed through a clear corne- al incision, unroof the trabecular meshwork, and can perform trabec- ulotomy for several clock hours. Another trabecular outflow op- tion is gonioscopy-assisted translu- minal trabeculotomy (GATT), which can be performed through a clear corneal incision and uses an ab in- terno approach with either a suture or the iTrack microcatheter (Ellex, Adelaide, Australia) to perform 360 trabeculotomy. "If performed with the iTrack microcatheter, viscodilation can be performed concurrently, which can improve outflow through Schlemm's canal," Dr. Wallace said. "It can be done independently of cataract surgery." Approaches to canaloplasty include use of the iTrack microca- theter, the Visco360 device (Sight Sciences, Menlo Park, California), which can perform a 360 ab in- terno canaloplasty, and the Omni Combined Procedure System (Sight Sciences), which uses an ab interno approach to perform both 360-de- gree viscodilation of Schlemm's ca- nal and a 360-degree trabeculotomy. Choice matters Surgeons' choices among the op- tions should be considered for safety and efficacy. Dr. Radcliffe noted that FDA-ap- proved stents have 1 or 2 years of clinical trials that demonstrate their efficacy with prospective studies of hundreds of patients. Trabecular procedures have less efficacy and safety data—usually a retrospective or prospective single-armed series of data. The advantage of such proce- dures is that they use established CPT codes, can be performed on any stage of glaucoma, and can be used on patients with any type of insurance. Stents are more limited for both indication and insurance. Clinical considerations should include the way the interventions are used. Surgeons address the growing number of trabecular outflow options and their preferences T he growing number of trabecular outflow surgical options require careful con- sideration. The iStent (Glaukos, San Clemente, California), a trabecu- lar bypass device instilled at the time of cataract surgery through a clear corneal incision, was FDA approved in 2012 and followed by the iStent inject, which received FDA approv- al in June 2018. The latter device allows for the implantation of two devices, noted Dana Wallace, MD, glaucoma specialist, Thomas Eye Group. Trabecular outflow options EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthal- mologist. Each month we send an online survey covering different topics so readers can see how they compare to our survey. If you would like to join the physicians who take a minute a month to share their views, please send us an email and we will add your name. Email taylor@eyeworld. org and put "EW Pulse" in the subject line. In a pseudophakic patient with glaucoma who needs additional IOP or medication reduction, I would: Repeat SLT 1 year after prior SLT Place a trabecular meshwork stent off-label Place a supraciliary stent off-label Perform canaloplasty As a cataract surgeon, subconjunctival MIGS is: A procedure that scares me A procedure that interests me although I have not done it A procedure I perform routinely " It makes sense that the practitioner who is also treating glaucoma patients would want to be using both stents and the procedures to best tailor options to a patient, taking into account the cataract status, health insurance, and disease state. " —Nathan Radcliffe, MD Perform a goniotomy A procedure I am learning to perform Monthly Pulse Glaucoma's armamentarium

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