Eyeworld

72 | EYEWORLD | FALL 2026 G UCOMA Contact Frank: chfrank@med.umich.edu Levin: ariana.levin@nyulangone.org Murphy: jamestmurphyiiimd@gmail.com Provencher: lorrainemprovencher@gmail.com Rhee: dougrhee@aol.com Shafer: brian.shafer@shafervision.com Relevant disclosures Frank: None Levin: Alcon Murphy: Bausch + Lomb, Glaukos, Nova Eye Medical, Sight Sciences Provencher: AbbVie, Alcon, BVI Medical, Glaukos, New World Medical Rhee: AbbVie, Alcon Shafer: AbbVie, Alcon, Bausch + Lomb, Zeiss • Counsel patients that they are likely to even- tually need more interventions in the future, like GATT, tubes, and/or lens surgery. Dr. Shafer focused his presentation on plateau iris, which he said is one of the hard- est conditions to treat. To truly treat, we have to change the terrain, he said. We know that plateau iris is due to the anterior rotation of the ciliary body. It doesn't matter how many holes you make, the structure is not going to change, and therefore, your function is not going to be good, he said. For plateau iris, use ECP combined with cataract surgery (or perform in an already pseudophakic setting). This has been shown to posteriorly rotate the ciliary body, pulling the iris away from its plateau configuration and leading to opening of the angle, which fixes the structural issue at hand, he said, cautioning not to use a YAG laser. ECP doesn't just relieve the pressure; it changes the whole terrain, Dr. Shafer said. In her presentation, Dr. Provencher shared a satire video to help those who struggle with talking to patients about SLT. She simulated a mock conversation with another doctor on how to present this to patients. She suggested emphasizing the key points about SLT: It's first- line and a quick, non-invasive procedure that improves outflow. It also reduces visual field loss, with fewer surgeries and less drop toxicity. Then she said to "stop talking," and "let the LiGHT Trial do the talking." If patients insist on drops, you might need to explain that "drops are what we used to do." Some hesitation in these conversations may be due to the physician's fear of taking control of the treatment plan, she added. You just need to frame it correctly. At the end of this round of presentations, Dr. Levin was voted off. MIGS The second round of the session had presenters discussing different MIGS topics. Dr. Rhee first pointed out that SLT has a limited benefit after failed goniotomy (you can still try it, but it may not buy you a lot of time). "We've come a long way with MIGS," he said. We now have enough experience and level 1 evidence to approach our choice of MIGS. Preclinical models predict clinical trial results but separately provide corroborating evidence. Dr. Rhee discussed Hydrus (Alcon) vs. iStent (Glaukos) and iStent inject, as well as comparative studies; when you need more outflow and IOP control, Hydrus outperforms 2 iStents and 2 iStent injects (per the COMPARE Study), as was predicted by the preclinical stud- ies, Dr. Rhee said. Dr. Frank spoke about trabecular microby- pass stents and what happens when you have a patient in which you need to do more angle work but you're out of room in the nasal angle. His key takeaways were: Don't forget about the rest of the angle; get creative with positioning; use a mirrored goniolens to access the rest of the angle for goniosynechialysis. Dr. Murphy's presentation on MIGS cov- ered his use of immediate sequential bilateral cataract and MIGS surgery, which he likes to do with the Light Adjustable Lens (LAL, RxSight). He shared a case example where he did this with a microstent, canaloplasty, and goniotomy the same day. "I don't know why you would use a gonioprism that has a handle," he said, em- phasizing the value of going "hands-free." Dr. Shafer shared why you should "nur- ture the drain" but don't alter it. He noted four main methods used in MIGS surgery: trabecular meshwork bypass stent, goniotomy/trabeculoto- my, canaloplasty, and viscodilation. Canaloplas- ty and viscodilation can help nurture the out- flow system. There is no MIGS device that's far more superior to the others, he noted. But he suggested that using a product that can gain the same IOP reduction without altering the drain permanently can leave you in better shape. Finishing out the MIGS session, Dr. Provencher shared a cyclopexy technique on how to repair a nasal cyclodialysis cleft that occurred during MIGS. She stated that all sur- geons who perform MIGS should know how to close a cleft. Dr. Murphy was voted out of this round of presentations. The remaining rounds during the symposium included presentations on incisional glaucoma surgery, diagnostics, and a "wildcard" round. continued from page 71 Attendees of the 2026 ASCRS Annual Meeting can view recaps of these pre- sentations and find out who was the ultimate "survivor" on the 2026 ASCRS Annual Meeting On Demand.

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