EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/194331
74 EW FEATURE February 2011 Combined glaucoma and cataract surgery October 2013 Combined EX-PRESS, cataract surgery effective, useful by Erin L. Boyle EyeWorld Senior Staff Writer AT A GLANCE • Approximately 16,000 EX-PRESS devices were implanted in the U.S. last year. • The device is placed under the scleral flap and works by diverting aqueous humor through the implant to the bleb. • EX-PRESS combined with cataract surgery can lead to steadier IOP postop. The EX-PRESS implant is a valuable add-on to filtration surgery and can be performed in conjunction with cataract surgery, experts say T he EX-PRESS Glaucoma Filtration Device (Alcon, Fort Worth, Texas) is another tool in the surgeon's armamentarium to lower IOP in advanced glaucoma and can be combined with cataract surgery for good overall results. "[The EX-PRESS] has been helpful in my practice for, I like to say, a kinder, gentler trabeculectomy. It's a very useful adjunct," said Leon W. Herndon, MD, professor of ophthalmology, Duke Eye Center, Duke University, Durham, N.C. Peter A. Netland, MD, Siegal Professor of Ophthalmology, Hamilton Eye Institute, University of Tennessee Health Science Center, Memphis, was an early adopter of the technology and has published extensively on the device. He took part in the recent Comparison of Trabeculectomy Versus EX-PRESS Miniature Glaucoma Device: A Prospective Randomized Study (XVT), comparing trabeculectomy to EX-PRESS filtration surgery. Results from the study should be published soon, he said. Since the device was created by Optonol (Neve Ilan, Israel) and received U.S. Food and Drug Administration approval in 2002, it has grown in popularity. Last year, approximately 16,000 EX-PRESS devices were implanted under the scleral flap in the U.S.; worldwide, approximately 25,000 EX-PRESS devices were implanted, according to Dr. Netland. Cost remains an issue with the device, but studies such as the XVT A desirably placed EX-PRESS device following implantation surgery Source: Garry P. Condon, MD study could assist in showing that its benefits could be cost effective over trabeculectomy, including decreased hypotony, reduced tissue trauma, and lower risk of hyphema, experts say. "You'll run into some physicians who don't want to use it, but many clinicians use it and are happy with it," Dr. Netland said. "It has that nice combination of ease of use and familiarity of technique and effectiveness." Indications The EX-PRESS device has a range of uses in advanced cases, often with different indications for different surgeons, including in combined surgery. Dr. Herndon has been using the device for seven years. In that time, he has seen how most patients who need trabeculectomy are good candidates for the device. There are cases that are not indicated for the device, he said, including those with thin sclera because of potential erosion and patients with angle closure glaucoma who might need an iridectomy. But those cases, in his practice, are "few and far between." "It's very rare now that if I have a patient who needs trabeculectomy that I'm not adding an EX-PRESS device to the procedure," Dr. Herndon said. In contrast, other surgeons, including Douglas Rhee, MD, chairman, Department of Ophthalmology, Case Western Reserve University, Cleveland, and Joseph Panarelli, MD, New York Eye and Ear Infirmary, New York, said they use the EX-PRESS in specific cases. The device assists in standardizing the non-standard trabeculectomy surgery, which some surgeons find of great benefit, both physicians said. "As long as the surgeon is comfortable with how and where to place the device, the EX-PRESS device can be a helpful adjunct to trabeculectomy surgery," Dr. Panarelli said. Dr. Rhee said the very nature of how trabeculectomy is not standardized could widen the range of indications for the EX-PRESS device because surgeons might be able to use it for more cases. "One quote that I ascribe to my colleague Louis Pasquale is that 'Trabeculectomy is one of the most artisan procedures.' In other words, it's not terribly standardized. Everybody does it [his or her] own way. The EX-PRESS is just one more tool," Dr. Rhee said. "Because trabeculectomy surgery it is so artisan and so individualized, different surgeons will have different indications, ranging from none to every." Combined surgery Physicians have differing opinions on the device's use in combined surgery. Garry P. Condon, MD, associate professor, College of Medicine, Drexel University, Pittsburgh, took part in the XVT study. He said the EX-PRESS is a valuable addition to continued on page 76 The specific type of scleral flap closure needed to control the outflow with the EX-PRESS implantation procedure Source: Garry P. Condon, MD