Eyeworld

EW GLAUCOMA by Ellen Stodola EyeWorld Staff Writer long distances because it is not being implanted locally where they are. "People are seeking out this technology because either a friend has had it or their primary eye doctor mentioned it to them, and they want someone who's doing it," he said. Dr. Rhee said he does have patients coming in and asking for procedures like canaloplasty, Trabectome, and iStent; however, he said that a large number of patients still rely on advice for their individual situation. Other concerns Dr. Berdahl said there are other important details to ensure patients know before the iStent procedure, one particularly involving pressure. It is also important to explain to patients that if Trabectome or iStent implantation is performed, a trabe- culectomy can still be performed at a later time with the same expec- tation for success as primary trabe- culectomy. However, trabeculectomy performed after a deep sclerectomy or canaloplasty would be expected to have a worse success rate than a primary trabeculectomy or tube shunt because of the conjunctival scarring. Patients asking for the technology With more and more information and positive results coming out about the iStent, Dr. Berdahl said that he has more patients coming in and asking to have it implanted. He has even had patients come from physician's role is to present all possible options to the patient and offer guidance, he said. The 3 op- tions he presents are using the iStent or the Trabectome (NeoMedix, Tu- stin, Calif.), a canaloplasty or deep sclerectomy, or a trabeculectomy. Dr. Rhee offers every FDA- approved glaucoma device and implant, so in the preoperative discussion, it is important for him to separate these procedures into categories. Currently, the Hydrus Microstent (Ivantis, Irvine, Calif.) and CyPass Micro-Stent (Transcend Medical, Menlo Park, Calif.) are still in experimental stages, so these are not yet commonly used, he said. The iStent and Trabectome are considered MIGS procedures and offer a canal-based, intraocular approach. Trabectome is a procedure where trabecular meshwork tissue is ablated to expose the collecting channels. Initially, canaloplasty and deep sclerectomy were categorized as MIGS as well, Dr. Rhee said, but are now thought of as their own category. Additionally, there are new procedures similar to trabeculecto- my, where a hole is made in the eye. These include using the EX-PRESS Glaucoma Filtration Device (Al- con, Fort Worth, Texas) and could eventually include the XEN Gel Stent (AqueSys, Aliso Viejo, Calif.), which is still in experimental phases but will be a different way to do a transscleral procedure. "With Trabectome, it works a lot better if you do it in combina- tion with cataract surgery," he said. The iStent is currently indicated if cataract surgery is being performed. The odds of these working are not as good as trabeculectomy, but they are much safer, Dr. Rhee said. The risk of blindness and compli- cations are a lot lower. Meanwhile, deep sclerectomy or canaloplasty are intermediate approaches. There are still no options that work as well and lower pressure as much as trabeculectomy, but this procedure carries more risk and the healing process is longer than other options, Dr. Rhee said. Surgeons may want to prepare for a preoperative discussion with patients W ith popularity of the iStent (Glaukos, Laguna Hills, Calif.) and the concept of other still-unapproved MIGS devices growing, it is increas- ingly important for surgeons to counsel patients about these devices prior to surgery. John Berdahl, MD, Vance Thompson Vision, Sioux Falls, S.D.; and Douglas Rhee, MD, University Hospitals Case Medical Center, Cleveland, offered tips and spoke about what patients should be aware of before a MIGS procedure. Preoperative discussion Dr. Berdahl said that for patients with cataracts and glaucoma who are going to receive an iStent, he fi rst explains both of the conditions. He tells patients that taking the cat- aracts out will help them see better, the surgery takes only about 10–20 minutes, it is painless, and they will probably be able to see well about 48 hours after surgery. For glaucoma, he explains that this is the reason they may be on a number of medications. Too remedy this, he explains that an iStent could be placed at the time of cataract surgery. The iStent, he tells them, is "the smallest device ever implanted in humans" and is "so small that it fi ts into the ridge of a fi ngerprint." Dr. Berdahl explains that the iStent goes across the area of high resistance to outfl ow and the area of blockage and works to increase outfl ow and decrease pressure in the eye. He tells patients: "It adds a bit of time onto the surgery, but studies show that it is as safe as cataract surgery by itself. We don't have to make any new incisions, and if it were my eye and I had cataracts and glaucoma, there is no doubt that this is what I would do." Dr. Rhee explains to patients the different categories of proce- dures that they could have. The September 2014 Counseling patients about MIGS devices 77 continued on page 78

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