Eyeworld

SPRING 2026 | EYEWORLD | 93 G Contact Provencher: lorrainemprovencher@gmail.com Schehlein: emschehlein@gmail.com Dr. Provencher said. "Think of the cannula (or spatula) following the curve of the sclera. You will see the white scleral back wall if you are in the right space. Fill this space with additional viscoelastic. You then enter the AC with the AlloFlo Uveo, insert it into the cleft, and retract the sleeve, which deploys the stent." She added that you want about 0.5 mm of stent in the AC, and the position can be adjusted easily by tapping it in farther with the inserter or pulling it out with a cystotome. "You can then expand the cleft and add another stent at the other margin of the cleft," she said. "Currently, I use two stents with 1–1.5 stent widths in between. Remember, these stents are designed primarily as scaffolds, though they do transmit fluid. You may encounter bleeding, but it rinses out with I/A." She added that postoperative hyphema is rarely significant. For cleft creation (if not being done with the stent handpiece or inserter), there are sev- eral instruments that can be used, Dr. Schehlein said. "Some surgeons may choose to create a cleft simply with the viscoelastic cannula, how- ever, a Koch spatula or cyclodialysis spatula can also be suited for adequate cleft creation," she said. Dr. Schehlein also cautioned that cleft creation can be difficult, and it may feel coun- terintuitive. However, she said that the structure of the cleft is important in procedure success. "Visually, surgeons should see the underside of the scleral wall (white)," she said. "After cleft creation, surgeons can dilate the cleft with viscoelastic to enlarge the cleft and tamponade heme." Dr. Schehlein said that surgeons who had the opportunity to work with the CyPass will be comfortable in this space, but younger surgeons who missed the on-market window may not have experience in the suprachoroidal space. "While cleft creation and stent insertion may have a learning curve, any surgeon who is comfortable with intraoperative gonioscopy and working in the angle can dive into this space," she said. Dr. Schehlein said some surgeons may cre- ate a cyclodialysis cleft prior to suprachoroidal stent implantation, while others may choose to use the device to create the cleft and inject the stent at the same time. She also noted a review that she was an author on, which mentions the iStent Supra (Glaukos) and the MINIject drain- age system (iSTAR Medical), as well as what is now the AlloFlo Uveo. Currently, only the AlloFlo Uveo is available in the U.S. 4 Other considerations in the suprachoroidal space As with many MIGS, postoperative IOPs spikes can occur, Dr. Provencher said, particularly within the first 30 days. She added that keeping patients on their glaucoma drops can help. "The spikes are usually short lived and controllable," she said. "If a patient's visual field would not tolerate a brief IOP spike, I would not recom- mend trabecular meshwork-based interventions or suprachoroidal stenting. These patients are better served with filtering procedures." Dr. Provencher also noted that she likes to prescribe 1 week of antibiotic drops, along with a steroid taper over a few weeks. "I have found it's also very helpful to keep patients on a prostaglandin analog to optimize uveoscleral outflow," she said. "The [CyPass] reduced endothelial cell count (ECD) and was removed from the mar- ket," Dr. Schehlein said. "We now know this occurred when the device was not in its optimal position, however, there is limited published long-term data on ECD and any MIGS device, including those in the suprachoroidal space. References (continued) 6. Lass JH, et al. Corneal endo- thelial cell loss and morpho- metric changes 5 years after phacoemulsification with or without CyPass Micro-Stent. Am J Ophthalmol. 2019;208: 211–218. 7. Fili S, et al. [Explantation of the CyPass implant in a case series of patients with corneal decom- pensation]. Ophthalmologe. 2021:118;42–49. Relevant disclosures Provencher: AbbVie, Alcon, Bausch + Lomb, BVI, Elios, Glaukos, Iantrek, Microsurgical Technologies, New World Medical, Radius, RxSight, Thea, Vialase, Zeiss Schehlein: Alcon, AbbVie, Glaukos, Iantrek, Nova Eye Medical An AlloFlo Uveo spacer is inserted in a patient with a previous trabecular micro-bypass stent (iStent). Source: Emily Schehlein, MD continued on page 94

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