OCT 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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82 EW FEATURE February 2011 Combined glaucoma and cataract surgery October 2013 Trabectome continued from page 80 Intraoperative goniophotograph with Trabectome in position for canal entry. Note the slightly angled up position of the tip; this greatly facilitates proper atraumatic entry. This patient has pigmentary glaucoma and underwent phaco/Trabectome. Intraoperative goniophotograph with Trabectome engaged to the canal. The arrow points to Schlemm's canal; the white strip is already visible because the trabecular meshwork and inner wall of the canal have been removed. Intraoperative goniophotograph of angle post Trabectome. A significant portion of the canal is open after Trabectome surgery revealing several clock hours of Schlemm's canal. Note the absence of the pigmented trabecular meshwork. Episcleral vein. The location of this episcleral vein is notated by the black and green arrows and corresponds to the exact location in the next figure. During foot position zero of the irrigation and aspiration portion of phaco, the IOP drops allowing blood to reflux in the veins and into the anterior chamber. they can induce really bizarre amounts of astigmatism at all angles." Meanwhile, Dr. Condon uses the Trabectome in patients who are undergoing cataract surgery who are in that grey zone where you think they might do better with lower pressure or it would be nice if they weren't on as many medications. This falls in the mild-to-moderate disease category, he finds, adding that this is the same group for whom the iStent is indicated. "The advantage of the Trabectome is that if I can get similar results with it as I can get with the iStent, I've accomplished the same thing without leaving a foreign body in the eye," Dr. Condon said. He tells patients that they have a chance to improve their pressure control. "How much of it I eventually attribute to the Trabectome ver- sus the cataract portion remains a question." Yet Dr. Condon feels that the Trabectome serves many well. "I would say that in at least 50% of cases we're better than where we started," he said. "In some cases I've seen a really nice drop—more than 25%." However, he stressed that this is very patient-dependent. "I think the patients with pseudoexfoliation do better than the non-pseudoexfoliation ones," Dr. Condon said. "That might be because their disease process is more proximal and perhaps closer to the trabecular meshwork than some of the primary open angle glaucoma cases." Douglas J. Rhee, MD, chair, Department of Ophthalmology, Case Western Reserve University, University Hospital, Cleveland, believes that at best the improvement with the Trabectome is modest. "I can tell you from anecdotal experiences that it does offer something beyond cataract extraction alone," he said. "But my strong suspicion is that it is no better than one iStent." He stressed that only about 5 to 10% of patients will be free of glaucoma medications following the procedure. "If they cannot tolerate medication then these procedures are not necessarily very good and you should consider trabeculectomy or even a transscleral procedure," Dr. Rhee said. drainage system that can't possibly be low enough," he said. "But it turns out that now surgeons are removing not just two clock hours of this drain but 180 degrees of trabecular meshwork; you get better pressure responses." Final pressures are lower, he said, noting that these are closer to the 14- or 15-mm Hg range. "This is often low enough even for very advanced glaucoma," he said. "I've operated on even end-stage glaucoma because this surgery is very fast, it can be very efficient, and it leaves no hardware behind in the eye that harms patients." Dr. Loewen said that the complication rate is 1/20 of conventional glaucoma surgery. In his view everyone deserves a shot at Trabectome treatment. Efficacy overall with the Trabectome he finds is quite high. "Our success rate is in the range of 80% even at two years, Monthly Pulse T Widening the scope In addition to mild-to-moderate patients, some practitioners are now using the Trabectome in advanced glaucoma cases. Dr. Loewen sees a paradigm shift occurring. "In the past, people thought the Trabectome could only be used in very early or even pre-glaucoma stages because if you drain something in the natural Keeping a Pulse on Ophthalmology he topic of the October Monthly Pulse Survey was "Combined glaucoma and cataract surgery." When asked about using an EX-PRESS device when doing a trabeculectomy, only 17.8% responded that they usually use an EX-PRESS; the majority (40.4%) said that they don't do trabeculectomies. As far as using the iStent, 17.8% responded that they have started using it, 34.6% would like to start using it, and 47.6% have no plans to start using it. The majority (65.9%) of respondents to this survey are not performing intraoperative gonioscopy. Finally, we asked, "With regard to ECP, which describes you best?" The majority (43.3%) have no interest in ECP, however, 31.3% would like to try it and wish they had access to it. Check out this month's Feature section to learn more about all of these procedures.

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