Eyeworld

EW FEATURE 65 The advent of blebless procedures and adjuncts to trabeculectomy means more surgeons might consider surgery earlier in their management strategy G laucoma is primarily one of those chronic diseases that cannot be "cured," where the most a clinician can hope for is to stave off progression of the disease long enough to preserve a patient's sight throughout the remainder of the pa- tient's life. Surgery has been typi- cally successful for decades, and although there are risks involved, most patients can be managed with a combination of medical and laser or surgical therapies. These days, however, with the advent of numer- ous ab-interno procedures and mod- ifications to bleb-inducing procedures, surgical options may be considered not as a last resort but as part of a strategic management strat- egy. While trabeculectomy remains the gold standard for the surgical management of glaucoma, techno- logic advances in other areas are helping to make the procedure safer and helping physicians diagnose ear- lier, experts say. "Diagnostics continue to evolve," said Robert J. Noecker, M.D., vice chair, University of Pitts- burgh Medical Center Eye Center, Pittsburgh. Whereas 5 years ago, spectral-domain optical coherence tomography was state of the art, these days it's considered routine, he said, adding that the ability to image the nerve fiber layer is "helping di- agnose people earlier. We're slowly chipping away at that standard phrase that half the people with glaucoma don't know they have it." Why surgery is viable Adjuncts in trabeculectomy surgery such as the EX-PRESS Glaucoma Fil- tration Device (Alcon, Fort Worth, Texas) "standardize the non-stan- dard procedure," Dr. Noecker said. "There will be some situations in surgery where I don't want to ma- nipulate the iris," said Thomas K. Mundorf, M.D., Mundorf Eye Cen- ter, Charlotte, N.C. "Most of my sur- gical patients will need an iridec- tomy. The EX-PRESS helps speed up the surgery a bit and offers a nice al- ternative to standard trabeculec- tomy. An upside is that the post-op care is not significantly impacted." Agreed Louis B. Cantor, M.D., chairman and professor of ophthal- mology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis: "There's only so much manipulation you can do with a bleb-based proce- dure. The EX-PRESS can standardize one step in the surgery, but I haven't seen the need to assume the addi- tional expense for the most part. I think we're hitting a technological wall with filtering surgery. The inter- est is in how we can surgically con- trol glaucoma without creating a bleb. A bleb is just a ticking time bomb." When it comes to glaucoma sur- gery, "it's been a slow, arduous process to put new procedures in the hands of surgeons," said Thomas W. Samuelson, M.D., director, glau- coma service, and instructor, oph- thalmic pharmacology, Regions Hospital, St. Paul, Minn., and at- tending surgeon, Minnesota Eye Consultants, Minneapolis. He cited a patient he had just seen who had undergone trabeculectomy a few years earlier—"utilizing all the new techniques to obtain a more favor- able bleb morphology"—yet the pa- tient still presented with a bleb-related infection. "It underscores the risk of filter- ing blebs and how they're vulnera- ble to infection even years after the original surgery," he said. "As a group, we have to be looking for a better way. We simply can't be satis- fied with a procedure that leaves the patient at risk for a devastating event, such as bleb-related endoph- thalmitis, for the rest of his life." Some surgeons have "not signif- icantly changed glaucoma practice patterns over the past 5 years," said Kuldev Singh, M.D., professor of ophthalmology and director, glau- coma service, Stanford University School of Medicine, Stanford, Calif. Other than performing modern cataract surgery earlier as a means of offering better visual acuity as well as IOP lowering/reduction in glau- coma medications in patients with mild and/or well-controlled disease, his practice patterns have not changed much in recent years. The "big breakthrough in glaucoma sur- gery" has yet to come, Dr. Singh be- lieves. "There are more than 3 million cataract procedures performed each year in the United States, and an es- timated 15% of these are on patients who are receiving IOP-lowering medications for glaucoma or ocular hypertension at the time of such surgery," he said. "Cataract surgery lowers IOP, although the effect is variable, and there is generally lit- tle—if any—downside of early February 2011 February 2011 GLAUCOMA by Michelle Dalton EyeWorld Contributing Editor New strategies for glaucoma surgery An example of a failed trabeculectomy Source: Leon W. Herndon, M.D. AT A GLANCE • Newer techniques are making traditional surgery safer; trabeculectomy remains the single most commonly performed glaucoma surgery • Phacoemulsification alone and phaco-trab are being used earlier in the treatment strategy as a means of lowering IOP • Blebless surgery will continue to gain acceptance • Surgical strategies continue to differ between phakic and pseudophakic patients continued on page 68 58-81 Feature_EW February 2011-DL2_Layout 1 2/4/11 2:29 PM Page 65

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