MAY 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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May 2013 Glaucoma February 2011 challenges/MIGS ventional outflow and bypasses the inner wall, Dr. Ahmed said. "It provides some additional value from the scaffolds in the canal, which is a little different from stents," he said. How this parlays into clinical differentiation is yet to be fully determined, he clarified. More than 130 patients have been implanted with the Hydrus, and Dr. Ahmed is finding similar success and safety rates as with the use of multiple iStents. The Hydrus cannulates an 8 mm portion of the canal compared to 1 mm with the iStent, "so surgeons are more likely to incorporate some collector channels within the portion of the canal that is influenced by the Hydrus," he said, and the Hydrus "stretches" the canal a bit. "That does make for a bit more delicate implantation," he said. CyPass The CyPass (Transcend Medical, Menlo Park, Calif.) works on the suprachoroidal space, and the uveoscleral area "is a well described mechanism of aqueous output in the human eye, but an area that is perhaps not as well understood as conventional outflow," Dr. Ahmed said. "As this device allows IOP lowering without utilization of transtrabecular flow, there is potential for substantial IOP lowering, even in those with a non-functional conventional outflow pathway, either at the level of the trabecular meshwork or downstream. We should know much more about this device soon as the large pivotal trial undertaken for regulatory approval in the U.S. recently completed enrollment," Dr. Singh said. Dr. Vold said international clinical data show patients achieving approximately 30-35% IOP drops with the CyPass. "If we can do that consistently, that would be fantastic," he said. Dr. Samuelson is withholding judgment, believing that data must first show the suprachoroidal space is as safe as canal-based procedures before he will apply the procedure to patients with early glaucoma. In the meantime, "I'd reserve the CyPass for patients who either need a more aggressive procedure or have failed canal-based surgery," he said, but added patients with angle closure glaucoma or failed trabeculectomy may be particularly suited for this type of device. Ultimately, it will be the safety of these devices that determines market (and maybe regulatory) acceptance. "It's quite possible there will be subgroups of patients for whom one device is particularly better suited than the others," Dr. Singh said. "For patients with advanced uncontrolled glaucoma and cataract, we'll still do cataract plus trabeculectomy, and for those with ocular hypertension or very mild glaucoma, cataract surgery alone may be enough. The big question on everyone's mind is how large is the unmet need between these extremes where cataract surgery alone is not enough and phacotrabeculectomy is too much. My guess is there is substantial room in between where an adjunctive device could be beneficial, but the size of this space is largely dependent upon the efficacy, safety and some day, the cost of these novel devices. If the incremental effect of a MIGS device pales in comparison to the effect of phacoemulsification alone and/or the safety of the device is not substantially better than traditional filtration surgery, there will be little room in the middle for such an approach." Dr. Singh, however, is optimistic that the profile of some of the MIGS devices will have a "favorable impact" on the battle against glaucomatous diseases. EW Editors' note: Dr. Ahmed has financial interests with Alcon (Fort Worth, Texas), AqueSys (Irvine, Calif.), Glaukos, Ivantis, and Transcend Medical. Dr. Samuelson has financial interests with Abbott Medical Optics (Irvine, Calif.), Alcon, AqueSys, Glaukos, Ivantis, and Transcend Medical. Dr. Singh has financial interests with Alcon, Allergan, Bausch + Lomb (Rochester, N.Y.), Ivantis, and Transcend Medical. Dr. Vold has financial interests with Alcon, AqueSys, Glaukos, Ivantis, Neomedix, and Transcend Medical. Contact information Ahmed: 416-625-3937, ike.ahmed@utoronto.ca Samuelson: 612-813-3628, twsamuelson@mneye.com EW FEATURE 35 Singh: 650-575-8849, kuldev.singh@stanford.edu Vold: 479-442-8653, svold@cox.net CAPSULORHEXIS Many Choices - Same Excellent Results ST5-1602 Masket Capsulorhexis Forceps - Titanium Fine angled tips perfect for grasping delicate capsule. Curved shafts with stop allows for freedom of movement in the anterior chamber. Flat handle. Also available in stainless steel. ST5-1603 Utrata Capsulorhexis Forceps - Titanium Fine angled tips perfect for grasping delicate capsule. Angled shafts with stop allows for freedom of movement in the anterior chamber. Flat handle. Also available in stainless steel. ST5-1611 Inamura Style Capsulorhexis Forceps - Titanium Cross action allows for use within a minimal incision. Delicate tapered shanks seal the incision during continuous curvilinear capsulorhexis. Also available in stainless steel. ST5-7035 23ga MicroSure Capsulorhexis Forceps - Titanium 23ga allows for optimal use in Micro Incision Surgery. Squeeze handle allows for optimal control within the eye. 2500 Sandersville Rd., Lexington, KY 40511 USA Phone: 800-354-7848, 859-259-4924 Fax: 859-259-4926 E-Mail: stephensinst@aol.com www.stephensinst.com

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