Eyeworld

88 | EYEWORLD | MARCH 2020 G UCOMA by Liz Hillman Editorial Co-Director W ith newer stenting devic- es bypassing the trabecular meshwork or stenting open Schlemm's canal in different ways, is it still relevant to target collector channels? The physi- cians who EyeWorld spoke with said, in short, yes, though perhaps less import- ant than with single stents. "In every case that we perform—we perform canal stenting procedures for the treatment of glaucoma—the first step of the surgery consists of identifying the epis- cleral vessels in the nasal quadrant," said Paul Harasymowycz, MD. Dr. Harasymowycz said he was en- couraged to start targeting areas where segmental outflow would be most likely. While this might have been more relevant with single stents, he said he still identifies collector channels when using an iStent inject (Glaukos), which consists of two multidirectional stents. Targeting iStent inject, however, is more nuanced. "[T]he size of the wound limits the number of clock hours that one can target as the trocar used for implantation must be very perpendic- ular to the trabecular meshwork," he said. "In cases where we use the [iStent] inject, we will modify our main wound location to be between two separate collector channels, or simply make an additional incision to target a 'ripe' area." Arsham Sheybani, MD, said he was tar- geting collector channels more when using single stents, and while he still does try to target with larger stents, like the Hydrus Should you be targeting collector channels with MIGS? About the doctors Arsham Sheybani, MD Assistant professor Washington University School of Medicine St. Louis, Missouri Paul Harasymowycz, MD Head of the Glaucoma Research Unit University of Montreal Quebec, Canada • Patients liked the idea of fewer drops after surgery, but they felt that should be weighed against surgery's uncertainties. • Some patients said they were willing to ac- cept less improvement from surgery, if that improvement was guaranteed rather than uncertain. Tailoring patients' treatments to suit their lifestyle requirements would have a positive im- pact on the perception of glaucoma treatment outcomes, the researchers said. They also said discussing surgery at an early stage of treatment could help bridge the misconception that sur- gery is a last resort. Expert thoughts on the findings Ian Saldanha, PhD, said that while the field has known for awhile that patients greatly value outcomes related to visual field, such as the ability to drive, it is interesting that patients in this study were insightful about distinctions between visual acuity and visual field. He also noted that efforts in questionnaire development for patient-important outcomes, specifically for MIGS devices, are underway. 2 Howard Krauss, MD, sees a contrast between a focus among glaucoma leaders in the field to "maintain every retinal ganglion cell" often touted at meetings vs. maintaining functional vision throughout the patient's life. "We should certainly be more concerned about preserving the adequacy of visual function than saving every retinal ganglion cell," he said. The biggest lesson that Dr. Krauss sees based on this study is the need to devote more adequate time to serve each patient's individual needs. "All treatment options should be offered to patients with evidence-based outcomes analysis of risks and benefits, with the 'benefits' being translated to visual function outcomes rather than outcomes of statistically significant quantitative changes in perimetric or OCT analyses," he said. Rafael Salazar II, MHS, who has focused on patient-centered outcomes in his clinical and research work, found it notable how much patients rely on advice from their physicians. "I always tell professionals that I work with or stu- dents that I teach that the impact clinicians can have on a patient's decision and expectations about treatment is enormous," he said. continued from page 86

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