Eyeworld

64 | EYEWORLD | SUMMER 2024 G UCOMA Relevant disclosures Provencher: Alcon, Allergan, Beyeonics, Elios Vision, Glaukos, MicroSurgical Technology, New World Medical, Thea, Vialase Rhee: AbbVie, Alcon, Iantrek Singh: Alcon, Belkin Vision, Elios Vision, Novartis, Santen, Sight Sciences Teng: None Van Tassel: AbbVie, Allergan, Carl Zeiss Meditec Efficacy of bimatoprost sustained release is no worse than goniotomy done without cataract surgery. Dr. Provencher reviewed the flaws of topical medications, like ocular surface disease, compli- ance issues, etc. "Our dream would be to have 100% intervention, 100% control, and 0% topi- cals. However, the reality is meds do still play a role as bridge therapy or because of poor access to a surgeon or patient preference." When one must use meds, Dr. Provencher encouraged sur- geons to choose wisely, selecting options with a novel mechanism of action that keeps con- ventional outflow open, like ROCK inhibitors. Reach for meds that work synergistically with interventional glaucoma. Dr. Teng suggested using the jab technique. The cornea has many layers, he said. If you use a constant force, when you break through the cornea, you will advance far into the AC and may hit the iris, lens, or deeper. By jabbing, you naturally stop yourself before going too deep. It takes 2–8 jabs to break through, and this comes in handy on soft or firm eyes, Dr. Teng said. MIGS Dr. Van Tassel said to use MIGS as an opportu- nity to reset. She said to work hard to reduce or eliminate drops. It's also a great time to deploy SLT or sustained release, if the patient is not at his or her goal. If needing to add back drops, optimize simplicity, tolerability, cost, and efficacy. Dr. Singh's pearl was to choose procedures based on safety and efficacy, not reimburse- ment. He pointed out that over the past few years, large shifts in which glaucoma proce- dures are performed have been seen following reimbursement changes. Such changes suggest that reimbursement, rather than efficacy and safety data, has been the primary driver of what procedures patients receive. Hopefully, this will not be the case in the future, he said. Dr. Rhee said not all MIGS devices are the same. Evidence from the COMPARE clinical trial showed that the Hydrus Microstent (Alcon) has better IOP control. Furthermore, two separate laboratory studies using cadaver eyes found better enhancement of outflow with the Hydrus. Dr. Provencher's pearl related to avoiding hyphemas. Intraoperatively, use reverse Tren- delenburg, leave the final IOP in the mid-20s, and if you get hyphema coming from the angle, he said, and he expects that ongoing research will support this approach. In the past, we have done SLT and waited for the effect of the treatment to be lost before treating again. The concept of maintenance SLT at regular intervals, to avoid periods of time when IOP is not well controlled, is gaining traction. Dr. Rhee's laser tip referenced the Laser in Glaucoma and Ocular Hypertension (LiGHT) trial. The data has been out since 2022 that patients who start with laser do better with IOP control, visual field, and fewer numbers of inter- ventional glaucoma surgery. Dr. Provencher's tip pertained to the XEN Gel Stent (AbbVie). "When in doubt, YAG it," she said. If you see sudden, late XEN failure, do gonioscopy first. If the XEN looks grossly nor- mal, consider occult intraluminal cellular debris. Before you needle the bleb, perform YAG laser just anterior to the internal ostium of the XEN to create a fluid "shock wave" to clear the lumen. Success is when you see the pressure drop and the bleb rise. Dr. Teng said that hand positioning is important. In order to achieve a smooth 360 rotation with the Abraham lens, hold the lens with the thumb and index finger, and place the middle finger under the lens, he said. The mid- dle finger supports the lens, thereby enabling the rotation. Medications/sustained delivery Dr. Van Tassel said don't wait for patients to complain about side effects. There are a lot of reasons that patients will withhold a com- plaint. They may be uncertain of the connection between the drop and the effect, there may not be time during their visits, or they may not have the confidence. But she said not to wait. Most glaucoma is asymptomatic, and the treatment shouldn't be worse than the disease. Dr. Singh's pearl was when possible, make no more than one change at a time when adjust- ing therapy. Since IOP fluctuates over time, and the IOP-lowering effects of a particular treat- ment vary among patients, assessing the impact of a single treatment change is difficult enough. Making multiple changes at one time makes assessment even more challenging. Dr. Rhee said that sustained release bimato- prost (also even topical PGAs) have a prolonged effect in some patients. He added that bimato- prost induces lymphangiogenesis-like changes. continued from page 63

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