Eyeworld

JULY 2023 | EYEWORLD | 69 G by Liz Hillman Editorial Co-Director About the physicians Patrick Gooi, MD Cloudbreak Eye Care Calgary, Canada Davinder Grover, MD, MPH Attending Surgeon and Clinician Glaucoma Associates of Texas Dallas, Texas Paul Harasymowycz, MD Associate Professor University of Montreal Quebec, Canada BEST PRACTICES Dr. Grover said he thinks goniotomy balances pressure-lowering ability with fast visual and physical recovery. "If a patient has mild to moderate disease on several drops, and I want the biggest bang for their buck, that's when I would consider a goniotomy. If they need even more than that, say they're moderate to advanced on several drops, that's when I would consider a [gonios- copy-assisted transluminal trabeculotomy]. The more pressure lowering I need, the more invasive I get," Dr. Grover said, adding later that he'd hesitate to do GATT or a larger opening of Schlemm's canal if the patient cannot be taken off blood thinners or if they need to restart them quickly. "If they need significant pressure lowering and cannot be taken off blood thin- ners, that's when I consider a smaller goniotomy opening … or one of the stenting procedures." Dr. Harasymowycz said he thinks the best patients for goniotomy are those with pigment in the trabecular meshwork. "There are certain diseases in glaucoma that have more pigment in the trabecular mesh- work, and in those cases, you're more confident that if you excise the trabecular tissue, you'll get more of an IOP-lowering response," he said. "Whenever you see a lot of pigment in the angle, you're more likely to get a good pressure drop if you remove the tissue because you know that's where the problem is. There are other diseases where some patients may have a con- genital abnormality of the trabecular meshwork. … On gonioscopy you look at the angle and you I t's clear to anterior segment surgeons that the landscape of glaucoma surgery is a spectrum, ranging from selective laser trabeculoplasty to the more invasive heavy hitters that are still considered the gold standard for IOP lowering (trabeculectomy and tube shunts). In the middle are a wide range of MIGS options. Patrick Gooi, MD, Davinder Grover, MD, MPH, and Paul Harasymowycz, MD, discussed best practices and special considerations for ab interno trabeculotomy, goniotomy, and canaloplasty. These procedures are attractive for certain patients, primarily because they can be per- formed without cataract surgery. Another rea- son, Dr. Harasymowycz said, is unlike stenting procedures, canaloplasty doesn't leave hardware in the eye. Some patients might not like the idea of leaving a metal stent in the eye, and it might not be an option for patients who require frequent MRIs, for example. Goniotomy/trabeculotomy In goniotomy and ab interno trabeculotomy, an opening is made in Schlemm's canal and trabecular tissue is opened, removed completely, or ablated, depending on the device and proce- dure used. Dr. Grover said he thinks there is a lot of solid data supporting the safety and efficacy of goniotomy. In his practice, he has found it to be well tolerated and effective for milder or mod- erate forms of glaucoma in combination with cataract surgery or as a standalone procedure. Navigating the world of goniotomy/ trabeculotomy and canaloplasty continued on page 70 The spatulated tip of the iTrack Advance (Nova Eye Medical) permits easier piercing of the trabecular meshwork in order to access Schlemm's canal. The 220-micron shaft permits 360-degree cannulation of Schlemm's canal and contains a guidewire, a ViscoInjector (Nova Eye Medical), and optical fiber for illumination. Source: Paul Harasymowycz, MD

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