OCT 2013

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

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October 2013 Combined glaucoma and February 2011 cataract surgery Washout of episcleral vein due to a fluid wave of balanced salt solution. The arrow colors corresponds to the exact episcleral position of the prior figure. A surge of balanced salt solution flows into the anterior chamber and is forced into an exposed collector when foot position is changed from zero to two. Source (all): Ronald L. Fellman, MD which is more or less equal to our own personal result in our team with glaucoma drainage devices," he said. Dr. Rhee has had limited success with the Trabectome in more advanced glaucoma. "It is more useful when the pressure reduction needs are minimal to modest," Dr. Rhee said. "You're trying to prevent an intraocular pressure spike." Occasionally he does use the Trabectome with cataract surgery in advanced cases. "In advanced cases if the patient is already well controlled or the need for further pressure reduction is small then Trabectome combined with cataract surgery can be a very effective combination," he noted, adding, however, that if the pressure reduction need is high this might not be the best option. In his view, treating a wider area past a certain point with the Trabectome is not of any additional benefit. He cited the work of Arthur J. Sit, MD, Mayo Clinic, Rochester, Minn., who performed a correlational study on this. "It did not show any difference," Dr. Rhee said. "Anecdotally, after 500 cases, I do not see that with wider ablation beyond 100 or 110 degrees that you get anything more." Dr. Condon, however, typically only treats as much as he can reach through a phacoemulsification incision, which he finds is about 3 to 4 clock hours. He worries about consequences of expanding the treatment area too much when treating patients on a medication or two who are already reasonably controlled. "Remember everything we do with microinvasive glaucoma surgery is traumatic, it's just that the scarring occurs on a microscopic level instead of a macroscopic one," Dr. Condon said. "The Trabectome study has not been completed on attempting to take out 180 degrees or 270 degrees of trabecular meshwork; I think that before I do that in somebody who is doing OK, I would think twice about it." However, he concedes, for someone who needs a tube shunt or who is definitely headed for trabeculectomy, it's another ballgame. Meanwhile, Dr. Fellman pointed out that if healing is favorable, having 2 or 3 clock hours of the angle open may be enough because studies show that if you happen to be adjacent to the "veins of Ascher," that's all you need. "The problem is we don't have any preoperative test that tells us where those are," Dr. Fellman said, adding that's why the procedure can go well and still not work. He likens it to first getting an angiogram that tells the doctor what vessel to fix before heart surgery. Also, there's currently no test done on whether other needed vessels are still functioning. "We don't have any test that tells us what the state of demise is in the patient's collector system before surgery," he said. "If you're doing an operation this is designed to make the collector system work better, wouldn't it be nice to know if it's salvageable?" Dr. Loewen concurs. "Everyone who has had an obstructed drain at home knows that sometimes it's not just the strainer but in the pipes further downstream where the obstruction can be," he said. The center at which he works, UPMC, now has imaging technology that can allow practitioners to examine this drainage system, something he views as pivotal for the future. "Right now we're doing these new microinvasive surgeries and hoping that it works in [each] particular patient," he said, concluding, "Five years from now everyone will get EW FEATURE 83 what's called a canalography, where the canal is imaged and then we'll know how to approach the tissue." EW Editors' note: Dr. Condon has financial interests with Allergan (Irvine, Calif.), Alcon (Fort Worth, Texas), and MicroSurgical Technologies (MST, Redmond, Wash.). Dr. Fellman has no financial interests related to this article. Dr. Loewen has financial interests with NeoMedix. Dr. Rhee has financial interests with Aerie Pharmaceuticals (Bedminster, N.J.), Alcon, Allergan, AqueSys (Aliso Viejo, Calif.), Johnson & Johnson (New Brunswick, N.J.), Merck (Whitehouse Station, N.J.), and Santen (Napa, Calif.). Contact information Condon: 412-359-6300, garrycondon@gmail.com Fellman: 214-360-0000, rfellman@glaucomaassociates.com Loewen: 412-944-2554, loewenna@upmc.edu Rhee: 617-573-3670, dougrhee@aol.com EyeWorld @EWNews Keep up on the latest in ophthalmology! Follow EyeWorld on Twitter at twitter.com/EWNews Poll size: 212 EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send a 4-question online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the current 1,000+ physicians who take a minute a month to share their views, please send us an email and we will add your name. Email daniela@eyeworld.org and put EW Pulse in the subject lineÑthatÕs all it takes. Copyright EyeWorld 2013

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