Eyeworld

EW FEATURE 70 February 2011 GLAUCOMA February 2011 Glaucoma Treatment Study." Despite the study results show- ing tube superiority, Dr. Singh con- tinues to perform a second trabeculectomy in certain circum- stances, especially given his increas- ing comfort with inferonasal Baerveldt (Abbott Medical Optics, AMO, Santa Ana, Calif.) seton im- plantation over the past decade. In the past, the inferior conjunctiva was not a desirable location for a glaucoma operation, and most sur- geons were less likely to try multiple trabeculectomy procedures superi- orly with the concern that subse- quent tube implantation would be made more difficult due to the scar- ring associated with prior failed pro- cedures, he said. "The inferior tube option, which is technically not difficult and remarkably well tolerated, gives one more flexibility in performing a second trabeculectomy superiorly in patients where this is the best option for a variety of reasons," Dr. Singh said. Surgical treatments at status quo "I will once again make the predic- tion that in 5 years, trabeculectomy, with or without the EX-PRESS, will still be the most commonly per- formed stand-alone glaucoma surgi- cal procedure," Dr. Singh said. While he does not believe trabeculectomy will be the most commonly per- formed combined procedure with cataract surgery in 5 years, he is un- willing to bet on which such com- bined procedure will emerge as the treatment of choice and said there are presently many promising tech- niques at various stages. "The ideal profile of such a pro- cedure is ab interno to preserve con- junctiva, preferably performed through a temporal cataract incision and without an adverse impact on visual recovery following cataract surgery," he said. The reason for these qualifiers, he said, is that as cataract surgery lowers IOP on its own, the addition of significant risk or use of valuable superior conjunc- tiva with a concomitant glaucoma operation will not be accepted in the overwhelming majority of patients taking IOP-lowering medications who come to cataract surgery. For Dr. Cantor, the more ad- vanced the glaucoma, the "more I lean toward trabeculectomy. The milder it is, the more I'll perform canaloplasty." In younger patients especially "you have to take the bleb into consideration, but in really ad- vanced disease, trab is still on aver- age going to give you the greatest odds of getting to lower IOPs." If (or when) medication therapy is no longer effective, and patients trend toward the higher end of the normal range, "those patients are likely going to have a Trabectome, iStent, or something in the family of less invasive procedures," Dr. Noecker said. "If patients have pres- sures in the mid-teens and appear to be progressing," depending on what additional surgery the eye has un- dergone, he may try the EX-PRESS, an Ahmed Glaucoma Valve (New World Medical, Rancho Cucamonga, Calif.), or Baerveldt tube shunt. He will also use Avastin "for really bad neovascular patients," although he added they comprise a minority of his patients. Dr. Mundorf's go-to surgery is still trabeculectomy. "If I perform a trab, I view the EX-PRESS device as a modification," he said. "In some cases, I'll use it in place of a trab." Once the iStent is approved, Dr. Mundorf may try that before a trab; "if that doesn't work, I can always look at filters. If the iStent can get us into the mid-teen and then the dis- ease progresses, we can still perform a trab." Dr. Samuelson prefers canalo- plasty over trabeculectomy "in pha- kic eyes that don't have enough disease severity to warrant a tra- beculectomy. It's less risky, less inva- sive, and retains the eye's physiologic outflow." In pseudophakic cases or more advanced disease, "trabeculec- tomy or an aqueous drainage device is preferred. In early-to-moderate dis- ease, I think it's just a matter of time before something dethrones trab as the standard. EW This is part one of a two-part series. Next month: What generic prostaglandins will mean for glau- coma specialists and their patients. Editors' note: Dr. Cantor has financial interests with AMO, Alcon, Allergan (Irvine, Calif.), and Pfizer (New York). Dr. Mundorf has financial interests with Allergan. Dr. Noecker has finan- cial intersts with Alcon, Allergan, and Endo Optiks (Little Silver, N.J.). Dr. Samuelson has financial interests with AMO, AcuMems (Menlo Park, Calif.), Alcon, Allergan, AqueSys (Irvine, Calif.), Endo Optiks, Glaukos, iScience (Menlo Park, Calif.), Ivantis (Irvine, Calif.), Pfizer, QLT (Menlo Park, Calif.), and Santen (Napa, Calif.). Dr. Singh has financial interests with Alcon, Allergan, Bausch & Lomb (Rochester, N.Y.), iScience, Ivantis, and Transcend Medical (Menlo Park, Calif.). Contact information Cantor: 317-274-8485, lcantor@iupui.edu Mundorf: 704-334-3222, tommundorf@aol.com Noecker: 412-526-1757, noeckerrj@upmc.edu Samuelson: 612-813-3628, twsamuelson@mneye.com Singh: 650-575-8849, kuldev@yahoo.com New continued from P. 69 58-81 Feature_EW February 2011-DL2_Layout 1 2/4/11 2:30 PM Page 70

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