Eyeworld

EW GLAUCOMA 57 Implantation under a scleral—not conjunctival— flap leads to favorable outcomes A lthough the EX-PRESS Glaucoma Filtration De- vice (Alcon, Fort Worth, Texas) is making good headway as a glaucoma surgical treatment, it's interesting to note that the original method of im- plantation isn't being used much anymore. "The original technique of plac- ing the shunt directly under a con- junctival flap has largely been abandoned," according to a report by Marlene R. Moster, M.D., glau- coma service, Wills Eye Institute, Philadelphia. This is due to prob- lems under the conjunctival flap re- lated to flow control (like persistent hypotony and choroidal detach- ment), as well as device positioning. "The EX-PRESS glaucoma im- plant is now placed under a scleral flap in order to limit excessive aque- ous flow and to decrease adverse postoperative events," Dr. Moster re- ported. With the new technique em- ployed, the EX-PRESS is getting bet- ter results, according to Dr. Moster's study, published online in December 2010 in Clinical and Experimental Ophthalmology. "In two studies, with 4 and 11 eyes the complication rate was unac- ceptably high," Dr. Moster noted. "In both studies the shunts were in- serted without fashioning a scleral flap." But now that a scleral flap is being used, the success rate has be- come quite good, 84% among 100 previously operated eyes at 36 months follow-up. Analyzing the EX-PRESS now Success was considered complete in 60 (60%) eyes and qualified in 24 (24%). Complete success was de- fined as having an IOP of 5-21 mm Hg without need for medications, while qualified success referred to an IOP in the same range with the use of medications. Mean pre-op IOP of 27.7 mm Hg decreased to 14.02 mm Hg. Drug use declined from a mean 2.73 bot- tles to 0.72 bottles at the last follow- up. Reasons for failed surgery included uncontrolled IOP (11%), bleb needling (4%), and persistent hypotony (1%). "The probability of success in the patients with previous cataract surgery and trabeculectomy at 3 years was 60.6% and 50.9%, respec- tively," Dr. Moster noted. "In addi- tion, it has been demonstrated to be an effective and safe procedure in patients with prior vitrectomy or corneal graft." These statistics represent new- found success with the EX-PRESS, according to Dr. Moster, who consid- ers these results to be part of "inter- mediate-term experience." "Either done as a primary proce- dure or after a previously failed glaucoma surgery, the EX-PRESS miniature glaucoma implant placed under a scleral flap with adjunctive MMC provides a safe and effective February 2011 April 2011 by Matt Young EyeWorld Contributing Editor With new technique in place, EX-PRESS results looking better The creation of a scleral flap. A recent study reports that implantation of the EX-PRESS Glaucoma Filtration Device under a scleral flap has led to reduced complication rates Source: Alcon continued on page 58

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