Eyeworld

66 | EYEWORLD | WINTER 2025 G UCOMA OPENING DOORS by Ellen Stodola Editorial Co-Director About the physicians Shivani Kamat, MD Associate Professor Director of the Glaucoma Fellowship Glaucoma Service Lead University of Texas Southwestern Medical Center Dallas, Texas Rom Kandavel, MD Volunteer Clinical Instructor Jules Stein Eye Institute Colvard-Kandavel Eye Center Encino, California S urgeons who routinely perform cata- ract surgery could better help patients by learning basic glaucoma procedures and incorporating them into cataract surgery, according to physicians who spoke to EyeWorld. For those who aren't sure where to start, Rom Kandavel, MD, and Shivani Kamat, MD, discussed how they think cataract surgeons can gain experience with glaucoma procedures and when it makes sense to incorpo- rate them. Dr. Kandavel said that if cataract surgery is imminent, it makes sense to consider angle surgery while the patient is already in the OR if the patient has glaucoma and is on treatment or would benefit from lower pressure beyond what the cataract surgery alone could offer. There is minimal risk involved with the additional pro- cedure, he said. "In fact, some may say that not performing an additional glaucoma procedure in a patient who could benefit from the tech- nology is a lost opportunity," he said. "Adding angle-based surgery is a natural evolution for an anterior segment surgeon who is already com- fortable with cataract surgery skills." For cataract surgeons interested in expand- ing into glaucoma procedures, Dr. Kamat said she would recommend starting with procedures that build naturally on their existing surgical skillset, such as MIGS. She offered the following steps to consider: 1. Build the foundation in clinic: Perform gonioscopy on every cataract patient for a month; document angle grade, pigment, and the presence of peripheral anterior synechiae (PAS). If you commit to MIGS, commit to gonioscopy. 2. Get trained and credentialed: Pick 1–2 MIGS to start (e.g., goniotomy or trabecular bypass). Attend a wet lab, watch surgical videos, and consider having an experienced colleague available for your first cases. 3. Set up the room: Ensure your OR is stocked with all the instrumentation you may need, including a gonioprism (Dr. Kamat prefers Swan Jacob gonioprisms because she likes the control offered by the handle, but she noted that a physician could also start with a hands-free gonio- prism). "It is also helpful to practice patient positioning and using the goniolens before you have a scheduled phaco-MIGS case. For patients scheduled for cataract surgery alone, I suggest practicing turning the head and scope (~30–45 degrees), ensuring you have a clear en face view of the angle, plac- ing the gonioprism on the eye, and practic- ing touching the trabecular meshwork with a cannula." Being comfortable with the maneuvers and having a good view is more than half the battle, she said, adding that practicing can set one up for success. 4. Choose straightforward cases at first: Choose phaco candidates with mild to mod- erate POAG, open angles without PAS, and good corneal clarity. 5. Debrief and review video: Record your first several cases, review them with your proctor/mentor, and keep a simple log (procedure, IOP, medications, complica- tions, reoperations). Use it to refine case se- lection and technique for the best outcomes in your hands. Add-on procedures during cataract surgery Dr. Kandavel thinks that the biggest learning curve for the cataract surgeon is mastering the technique for achieving excellent, consistent angle visualization, regardless of which proce- dure is chosen. "Mastering direct gonioscopy is the best way to get consistency in MIGS pro- cedures and their outcomes," he said. "Once visualization is achieved, the most straightfor- ward procedure now available, in my opinion, is the implantation of the iDose TR [travoprost intracameral implant, Glaukos]. Placement into the angle is relatively forgiving, and since it is scleral fixated, the target is much larger than the trabecular meshwork. There's also less risk of obscuring your view with heme, and once in position, it tends to be secure and introduces the surgeon to a trigger-based implantation device. This sets the stage for iStent [Glaukos] implantation as a next step." He noted that insurance coverage and patient acceptance vary with the patient population, but iDose TR and iStent are the most straightforward entry points to MIGS procedures for the cataract surgeon. Glaucoma procedures for cataract surgeons

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