Eyeworld

68 | EYEWORLD | WINTER 2025 G UCOMA Relevant disclosures Kamat: AbbVie, Alcon, Bausch + Lomb, Glaukos, Iantrek, New World Medical Kandavel: Alcon, Glaukos, Tarsus Pharmaceuticals Contact Kamat: shivani.kamat@gmail.com Kandavel: valleyeyedoctor@gmail.com rethreading the stent onto the original insertion trocar is most efficient." The next step, he said, would be learning to incise and access Schlemm's canal with a goni- otomy. "This can be accomplished with devices such as a Kahook Dual Blade, SION [Sight Sci- ences], or Trabectome [MicroSurgical Technol- ogy]," he said. "These procedures are quick and still have an excellent safety profile, however, they are more dependent on good visualization and identification of anatomical landmarks to avoid complications such as hyphema or cyclo- dialysis cleft formation." From there, Dr. Kandavel said the surgeon can begin to access Schlemm's canal via a canal threading procedure with viscodilation, such as the Via 360 (New World Medical) or Omni Surgical System (Sight Sciences). "Canalizing Schlemm's canal and introducing the suture successfully can be challenging without first developing comfort with performing incisional goniotomy. These procedures can be coupled with a goniotomy as the catheter tip can be pulled to create a trabeculotomy up to 360 degrees," Dr. Kandavel said. Once you've tried everything, you can more confidently recom- mend the appropriate treatment and really make a difference while already in the eye for cataract surgery or start to do standalone proce- dures, he added. Pharmaceutical treatments and sustained release Dr. Kamat said that sustained drug delivery is a great tool for the comprehensive ophthalmolo- gist to offer, whether it is in the form of Durysta (bimatoprost intracameral implant, AbbVie) prior to cataract surgery to optimize the ocu- lar surface disease preoperatively or placing iDose TR in combination with cataract surgery. "Any procedure that can improve IOP as well as diurnal IOP control while decreasing the de- pendence on topical medications can be hugely beneficial to a glaucoma patient," she said. "Reducing the cost, treatment burden, compli- ance issues, and ocular surface disease associ- ated with IOP-lowering drops can significantly improve patients' quality of life. Furthermore, these interventions tend to be the most effective in mild to moderate disease, which is a common subset of glaucoma patients being managed by comprehensive ophthalmologists." Dr. Kandavel thinks a surgical option is a better choice than topical medication for the sake of compliance and efficacy. "One of the best ways to get started with MIGS procedures is to perform standalone iDose TR in pseu- dophakic patients," he said. "Choose a patient who has difficulty putting in drops or is non- compliant and has already had SLT." He added that having the cornea at its clearest and having the smallest incisions possible leads to good chamber stability and the best view. "The iDose TR is truly a separate treat- ment modality from all other MIGS and in my opinion, can be added to any MIGS procedure in the appropriate patient," Dr. Kandavel said. "Currently, I implant iDose TR in any willing patient who is already on a prostaglandin while performing cataract surgery. I'm also looking forward to longer-lasting versions that are on the horizon." Additional insights Dr. Kandavel stressed that visualization is the key to getting comfortable with angle-based sur- gery. "Getting true en face position is the key," he said. "For the beginning surgeon, hands-free prisms are light on the cornea, introduce fewer striae, and improve the consistency of the view overall. There are many different versions. It is nice to have a prism that does not compete with entry into the main incision and has a half or elliptical moon shape. These prisms can add cost to the procedure, but prioritizing the view is the key to success and is well justified as a small additional cost of the procedure at current reimbursement rates." He also finds that using trypan blue can aid in properly visualizing the trabecular meshwork landmarks, especially if the angle is lightly pig- mented during preoperative evaluation. Using a dispersive viscoelastic on the gonioprism im- proves the view rather than a cohesive, he said. "Having a relatively pressurized eye to maintain chamber stability and reducing the incision size to prevent viscoelastic egress can be helpful as well. Tilt the scope and accentuate the patient's head rotation away from you. If you use an ORA aberrometer [Alcon], consider taking it off for these procedures until you get used to the angles so as to not interfere with some of the MIGS inserters." Dr. Kandavel added that watching videos and practicing can help. continued from page 67

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