Eyeworld

OCTOBER 2020 | EYEWORLD | 69 G Contact Goldman: drdavidgoldman@gmail.com Tai: ilana.nikravesh@mountsinai.org surgeons need to take time to know how to manage a bleb well to be safe and to enhance the efficacy of the surgery," Dr. Tai said. However, she added a caveat for if a com- prehensive ophthalmologist practices in an area with limited glaucoma specialists and a strong need for more advanced glaucoma manage- ment. "I can see how it would be reasonable in those areas where there aren't a lot of glaucoma specialists. … This is an easier procedure for them to do than a full trabeculectomy or a full glaucoma drainage device," she said. To learn this procedure and its manage- ment, Dr. Tai advocated for following a glauco- ma surgeon who does a lot of subconjunctival MIGS procedures and their management. She also said that these cases could be comanaged with experienced optometrists if they are familiar with evaluating blebs and identifying patients who need more intervention. Surgical intervention should be done by the surgeon, Dr. Tai said. David Goldman, MD Cornea specialist Dr. Goldman was such a doctor who saw a need in his area and, thus, learned how to perform XEN. Prior to offering XEN, Dr. Goldman said he was referring out at least one patient per week to a glaucoma specialist for filtration surgery. In his area, there were not a lot of glaucoma specialists. "They were all super overwhelmed. [Learn- ing XEN] was helping them in that they weren't drowning in those cases," he said, adding that it also helped patients get the care they needed more efficiently. Dr. Goldman thinks it's important to have a good relationship with a glaucoma specialist so that they can take over cases you might be un- comfortable with or patients who need a more intense filtration surgery. Dr. Goldman said he's comfortable with conjunctival surgery, which is required of XEN and PRESERFLO, due to his experience with pterygium, but he said he'd never done glauco- ma surgery outside of residency. When he first sought out XEN, he had a glaucoma specialist with him through the procedure. Bleb management intimidated him at first, but once he gained experience in needling, when to needle, and bleb revision, it "wasn't that scary," he said "Once you do it, [it's] not as challenging as you thought it was," he said, adding that dexterous surgeons will do bleb revisions in the office, but he thinks it's "absolutely OK" to take patients back into the OR for this. It is important to remember to manage patient expectations at the outset, Dr. Goldman continued, so that if you do have to do a revi- sion, the patient doesn't see it as a complication. Dr. Goldman is not sure if he's going to bring PRESERFLO into his practice when it becomes available in the U.S. He said he's going to have to wait to evaluate the clinical data and how it performs in the "real world" before jumping into this procedure. Relevant disclosures Goldman: Allergan, Glaukos, Sight Sciences Tai: None "[The glaucoma specialists] were all super overwhelmed. [Learning XEN] was helping them in that they weren't drowning in those cases." —David Goldman, MD

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