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EW FEATURE 72 February 2011 GLAUCOMA February 2011 Shaarawy said. Two of them are al- ready available in the market. They include the iStent (Glaukos, Laguna Hills, Calif.) and the CyPass (Tran- scend Medical, Menlo Park, Calif.), which both have an ab interno ap- proach, he said. "The difference between the two is that the iStent in its commercial version basically targets the conven- tional outflow pathway, so it is sup- posed to be inserted into the Schlemm's canal. The CyPass is an implant that is supposed to be put in the suprachoroidal space, so it is targeting the uveoscleral outflow pathway," Dr. Shaarawy explained. It is difficult to say how these new devices fit into the European glaucoma treatment paradigm, Dr. Shaarawy said, as there aren't any long-term results. However, they do come with a new set of advantages— they are not dependent on the health of the conjunctiva and they are fast procedures. Nevertheless, they come with specific challenges— anchor surgery and gonioscopy have to be well mastered before approach- ing these kinds of procedures, he said. Other experimental work on stents is ongoing but to his knowl- edge is not close to getting approval, Dr. Sharaawy said. So far, it's not clear whether there will be a real breakthrough with these implants, Dr. Pfeiffer said. "My impression is that the stent im- plants have not reached a sizeable market share, which would be a sign of appreciation by a large number of glaucoma surgeons." Where there is real competition is with glaucoma drainage implants, colloquially known as tubes, Dr. Pfeiffer said. There are a few around, like the Baerveldt Glaucoma Implant (Ab- bott Medical Optics, Santa Ana, Calif.), the Molteno implant (Molteno Ophthalmic Ltd., Dunedin, New Zealand), and the Ahmed Glaucoma Valve (New World Medical, Rancho Cucamonga, Calif.) that are helpful in the more severe cases of glaucoma, Dr. Pfeiffer said. In an ongoing study comparing the Baerveldt implant to trabeculec- tomy, the two were found to have similar efficacy and side effects, he said. There are, however, some argu- ments for using a tube first, at least for certain forms of glaucoma, for instance with iridocorneal endothe- lial syndrome, Dr. Pfeiffer said. One other device worth men- tioning is the EX-PRESS Glaucoma Filtration Device (Alcon, Fort Worth, Texas), which facilitates trabeculec- tomy in the sense that it avoids doing an iridectomy, Dr. Shaarawy said. It seems (although evidence is not conclusive) to offer fewer com- plications related to hypotony in the immediate post-op period, he said. "Obviously, with a device like the EX-PRESS, there are issues that need to be resolved as well, includ- ing the effect on the endothelial cell count of the cornea and its cost ef- fectiveness from an economic stand- point," Dr. Shaarawy said. The present and future of glaucoma treatment in Europe According to Dr. Pfeiffer, while reim- bursements for glaucoma surgery vary across Europe, they are so low in some countries that patients can barely pay for any of it. "Therefore, it appears that the development of glaucoma surgery is hampered by reimbursement sys- tems that do not allow the use of anything else but what has been used for the last 40 years and proba- bly is cheaper than [newer tech- niques]," he said. Still, glaucoma treatment meth- ods today have never been more in- teresting, Dr. Shaarawy said. Multinational companies have shown interest in glaucoma surgery, and with that comes a new enthusi- asm in research and development, as well as enough economic muscle to change the face of glaucoma surgery in the coming few years, he said. Surgeons now have a better un- derstanding of the higher quality of IOP reduction with glaucoma sur- gery as compared to that of glau- coma medications, Dr. Shaarawy said. Despite the fact that glaucoma medications lower IOP efficiently in most cases, they are unable to flat- ten the curve of IOP throughout 24 hours. Glaucoma medications are as- sociated with a certain degree of IOP fluctuation that is significantly higher than that of glaucoma sur- gery as evidenced from scientific work comparing the two treatment methods, he explained. Glaucoma specialists are starting to realize that the quality of IOP re- duction could be just as important as the quantity of reduction, Dr. Shaarawy said. EW Editors' note: Dr. Pfeiffer has financial interests with Alcon (Fort Worth, Texas), Novartis (Basel, Switzerland), and Pfizer (New York), among other companies. Dr. Shaarawy has no finan- cial interests related to his comments. Contact information Pfeiffer: +49 6131 177085, norbert.pfeiffer@unimedizin-mainz.de Shaarawy: +41 22 3828 400, Tarek.Shaarawy@hcuge.ch European continued from P. 71 The ASCRS•ASOA Electronic Preview Program Is Now Available Online www.ascrs.org/11am/previewprogram/ With our online program, you can "turn the pages" to browse the entire program or use the search engine to go directly to a specific section. Registration infor- mation and forms for the ASCRS Symposium, ASOA Congress, Technicians & Nurses Program, Cornea Day and ASCRS Glaucoma Day can be downloaded. Be sure to read the Welcome Letter and Special Events pages to note the highlights of the meetings. See what we have to offer... Then Register! www.ascrs.org • www.asoa.org Preview Program Friday, March 25, 2011 2 Special 1-Day Programs ASCRS Symposium on Cataract, IOL and Refractive Surgery March 25–29, 2011 ASOA Congress on Ophthalmic Practice Management March 25–29, 2011 Technicians & Nurses Program March 26–28, 2011 Simply the Best Meeting in Ophthalmology for Ophthalmologists, Practice Managers and Nurses & Technicians Come early and attend our 2 Special One-Day Meetings... Cornea Day and ASCRS Glaucoma Day Friday, March 25, 2011 58-81 Feature_EW February 2011-DL2_Layout 1 2/4/11 2:30 PM Page 72

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