Eyeworld

SUMMER 2024 | EYEWORLD | 65 G Contact Provencher: lorrainemprovencher@ gmail.com Rhee: dougrhee@aol.com Singh: kuldev@yahoo.com Teng: christopher.teng@yale.edu Van Tassel: sjh2006@ med.cornell.edu Dr. Provencher discussed her "OctoKnot" non-valved tube occlusion technique for how to occlude a non-valved tube to get a watertight closure. Dr. Teng said that a stepwise approach to incisional glaucoma surgery is OK. He listed several steps. • Step 1: TM bypass stent, goniotomy, visco- canalostomy • Step 2: Ab interno trabeculotomy +/–visco- canalostomy • Step 3: Microinvasive bleb-forming surgery • Step 4: Trabeculectomy or glaucoma drainage implant leave a strip of dispersive OVD in that area. In the first 24 hours, Dr. Provencher is strict with activity precautions, and she added that cataract plus MIGS is not the same as cataract surgery. She asks patients to sleep with the head of the bed elevated 30–45 degrees for the first night. She also has strict postop lifting precautions and institutes shield use to prevent rubbing. Dr. Provencher offered an additional tip, a mnemonic (M-STAGES) she created to help pro- viders decide when to "go big" (like an incision- al surgery) or when to stick with MIGS. • M – Mechanism of disease • S – Severity • T – Target IOP • A – Age • G – Gtt tolerance and duration of use • E – Expectations of the patient • S – Synergy with cataract surgery Dr. Teng's MIGS pearl was to use the wound as a fulcrum. With the device in the eye, tilt forward on the wound to pivot the eye in order to maximize the view. Incisional glaucoma Dr. Van Tassel said for gel stents, look for luminal flow. Be meticulous and patient about anterior chamber irrigation until luminal flow is observed, she said. What's important is that you lift the Tenon's over the tissue, and be sure there is no Tenon's entanglement with closure. Her bonus pearl was that she has found better refractive outcomes with the modified Wise/ Condon closure. Dr. Singh's pearl was that trabeculectomy beats all other procedures in patients with advanced disease who are at substantial risk of blindness from glaucoma. In addition to lowering IOP better than any other procedure, trabeculectomy is more likely to get patients off of IOP-lowering medications. Having a low IOP without medications decreases the likelihood of IOP swings related to non-compliance as well as peak and trough effects of such drugs. Better IOP control without medications is more likely to preserve vision. Dr. Rhee said trabeculectomy with anti-me- tabolite is still the gold standard for incisional glaucoma surgery. More invasive glaucoma sur- gery is most reliable to achieve less than 12 mm Hg IOP and is most able to be adjusted postop- eratively, he said. It's also the most likely to help patients be medication-free postoperatively. In the session, Dr. Provencher discussed her "OctoKnot" non-valved tube occlusion technique (shown here) for how to occlude a non- valved tube to get a watertight closure. Source: Lorraine Provencher, MD ASCRS physician registrants to the ASCRS Annual Meeting have on demand access to this and other sessions from the meeting. Access ASCRS On Demand

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