Eyeworld

92 | EYEWORLD | SPRING 2026 G UCOMA by Ellen Stodola Editorial Co-Director About the physicians Lori Provencher, MD Cataract Surgeon and Glaucoma Specialist Vance Thompson Vision Omaha, Nebraska Emily Schehlein, MD Glaucoma Specialist Brighton Vision Center Brighton, Michigan References 1. Böke H. [History of cyclodialy- sis. In memory of Leopold Heine 1870–1940]. Klin Monbl Augen- heilkd. 1990;197:340–348. 2. Toris CB, et al. Aqueous humor dynamics in the aging human eye. Am J Ophthalmol. 1999;127:407–412. 3. De Francesco T, Ahmed IIK. Surgical augmentation of the suprachoroidal space: a novel material and implant. Clin Oph- thalmol. 2023;17:2483–2492. 4. Schehlein E, et al. Emerging minimally invasive glauco- ma devices and sustained delivery platforms – what is in the pipeline? Curr Surg Rep. 2024;12:326–332. 5. Ahmed IIK, et al. Corneal endothelial safety profile in minimally invasive glaucoma surgery. J Cataract Refract Surg. 2024;50:369–377. prior trabecular meshwork-based procedures. It's no surprise that glaucoma specialists have been dreaming of an option to access this space again." Which glaucoma patients would this be best for? Suprachoroidal procedures fill a glaring un- met need, Dr. Provencher said, adding that these could potentially help the patient who is post-trabecular meshwork intervention but does not warrant a minimally invasive bleb surgery (MIBS), trabeculectomy, or tube, i.e., filtration surgery. "Traditionally, these post-trabecular meshwork MIGS patients would go back on medications and progress until their disease 'warranted' the risk of filtration," she said. "Now, with suprachoroidal stents, we can do another safe, minimally invasive procedure that opens the 'second drain' of the eye, allowing us to stay ahead of progression, which aligns with the principles of interventional glaucoma." Dr. Schehlein offers these procedures to patients who have exhausted other MIGS pro- cedures and are facing an incisional glaucoma procedure, like a tube or trabeculectomy, in the future. "As we gain more experience with vari- ous devices, targeting the suprachoroidal space may move earlier in our glaucoma treatment regimen," she said. Available procedures and devices Currently, Dr. Provencher said there is one op- tion, cyclodialysis cleft creation and reinforce- ment with the AlloFlo Uveo (Iantrek). This is an allogenic processed scleral tissue stent that scaf- folds open an intentionally created cleft. "The perfect tissue match to the surrounding native sclera is designed to induce little to no inflam- mation and/or fibrosis of the cleft," she said. A side port incision and clear corneal tem- poral incision (Dr. Provencher uses a 2.4 mm keratome) is created. Then, she said the AC is filled with cohesive viscoelastic, adding that this is a better tamponade of bleeding. "Under a gonioscopic view, you create a 1-clock hour cleft by strumming posteriorly on the scleral spur with a cannula or cyclodialysis spatula," T he suprachoroidal space is an unmas- tered surgical pathway to reduce IOP, said Emily Schehlein, MD. "Surgical intervention in the suprachoroidal space is not new; Leopold Heine introduced the idea that this procedure could be used as a treatment for glaucoma in 1905," she added. 1 Dr. Schehlein and Lori Provencher, MD, discussed benefits to expanding access to the suprachoroidal space, which patients might benefit the most, and other important considerations. Dr. Schehlein said that minimally inva- sive glaucoma surgery has renewed interest in surgeries that are successful in lowering IOP, sparing the conjunctiva, and avoiding complica- tions attributed to blebs. "While most MIGS act on the conventional outflow pathway (trabecu- lar meshwork, Schlemm's canal, distal collector channels, veins), the uveoscleral pathway is gaining attention for surgical augmented out- flow," she said. "This pathway has been tradi- tionally thought to drain 10–15% of aqueous humor but has been shown to do much more, potentially up to 50–60% depending on age and other factors." 2 She added that the goal is suprachoroidal surgeries that are safe, efficacious, and predict- able. 3 "We still need randomized clinical trials and basic science research to elucidate much about suprachoroidal fibrosis and cleft closure," she said. Dr. Provencher said there are a variety of options to optimize the trabecular outflow system, through stenting, viscodilation, and/ or excision procedures. "Since the recall of the CyPass [Alcon], we have not had a surgical option to access suprachoroidal outflow," she said. "Ironically, our most prescribed first-line medical option, prostaglandin analogs [PGAs], targets this system. PGAs do a beautiful job of lowering IOP, but topical PGAs have some of the worst local side effects of our topical options." She also mentioned that the uveoscleral sys- tem may contribute to around 50% of outflow. "We also know that this is a pressure-indepen- dent system, with no episcleral venous pres- sure floor and hence, the potential to achieve lower IOPs," she said. "It is also agnostic of Expanding options in the suprachoroidal space

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