Eyeworld

EW GLAUCOMA by Michelle Dalton EyeWorld Contributing Writer Laguna Hills, Calif.], which speaks to the severity of the disease that's out there," he said. "Unfortunately I still see a lot of patients in whom their next amount of progression could be loss of fi xation." For Dr. Ahmed, the quickest way to lower pressure is with a trab—in secondary glaucomas or where a patient has failed a trab, he will "very quickly" go to a tube shunt. Trabeculectomy and tube shunts remain "the most effi cacious procedure for lowering pressure," Dr. Gedde said. "But there are well- known signifi cant risks associated with them." He reserves invasive surgery for patients who cannot be controlled medically or through noninvasive procedures like laser. "Anyone who needs a profound pressure lowering or can't tolerate medication undergoes trabeculecto- my or tube shunts. Of course, failed MIGS or failed previous surgeries are candidates as well," Dr. Ahmed said. Dr. Samuelson said he tends to use the EX-PRESS device "for most of my incisional fi ltration glaucoma procedures now" and the Baerveldt for tube shunt procedures, but acknowledged other surgeons are equally adamant about using Ahmed implants. Still, the decision to perform incisional surgery must remain individualized to the particular patient, Dr. Gedde said. "It really is a judgment call on when to pull the trigger and recommend incisional surgery," he said. What the evidence shows Advances in ocular imaging mean glaucoma specialists are "increas- ingly more capable of detecting structural changes," Dr. Gedde said, and as soon as he has evidence of progression, he escalates therapy. "Some patients have such advanced disease that if they progress further, even by a small amount, it may have a very mean- ingful impact on their functional- ity," Dr. Samuelson said. "Trabe- culectomy and aqueous drainage devices have excellent effi cacy, and for those patients with advanced disease they remain the 'go-to' procedures. Even so, while there are exceptions, I don't believe trabeculectomy and tube shunts are safe enough to be used as the fi rst For patients with moderate to advanced glaucoma that is still progressing, traditional procedures remain necessary T raditional glaucoma surgery—trabeculectomy or tube shunts—will continue to have a place in the treat- ment paradigm, experts say. The advent of microincisional glaucoma surgery (MIGS) is gaining worldwide acceptance, but will not likely replace traditional devices— including the Ahmed valve (New World Medical, Rancho Cucamonga, Calif.), Baerveldt Glaucoma Implant (Abbott Medical Optics, AMO, Santa Ana, Calif.), Molteno drainage device (Molteno, Dunedin, New Zealand), or trabeculectomy with or without the EX-PRESS Glaucoma Filtration Device (Alcon, Fort Worth, Texas)—any time soon, said Iqbal "Ike" K. Ahmed, MD, as- sistant professor of ophthalmology, University of Toronto, Canada, and clinical assistant professor, University of Utah, Salt Lake City. "We still perform a lot of these traditional surgeries," he said, "be- cause those are still the gold stan- dard and the most powerful pres- sure-lowering procedures we have." Trying to manage patients with medical therapy and laser treatment before incisional surgery is still gen- erally the preferred approach, said Steven J. Gedde, MD, professor of ophthalmology, Bascom Palmer Eye Institute, Miami. "Traditional glau- coma surgery is usually reserved for patients who don't have adequate pressure control despite maximum medical therapy and appropriate laser treatment and are having pro- gressive disease or have a pressure elevation to a level where you think progression is likely to occur at a visually signifi cant rate." The newer surgical techniques/ devices involved in MIGS are not going to change that defi nition, at least not any time soon, said Thomas W. Samuelson, MD, attending surgeon and co-founder of Minnesota Eye Consultants, Minneapolis. "I perform as many fi ltration procedures as I do iStents [Glaukos, Traditional glaucoma surgical devices still play vital role 75 September 2014 A Baerveldt implant and Ahmed valve implanted inferiorly, at varying degrees of magnifi cation Source: Leon W. Herndon, MD continued on page 76 Device focus incisional procedure for those with early to moderate disease, especially phakic eyes." With "multiple, well-designed, randomized control trial" results now published, Dr. Ahmed said "there's still a lot of evidence coming out in this area," and these procedures "will continue to have a big role." With the safety of less invasive methods "now fairly well estab- lished," Dr. Samuelson saves the "more aggressive transscleral pro- cedures for patients that are on the more advanced end of the disease." The XEN Gel Stent (AqueSys, Aliso Viejo, Calif.) procedure— dubbed "MIGS plus" by Dr. Ahmed —"seems to have a bit more power than our traditional MIGS proce- dures," but does create a bleb, and its effi cacy is "approachi ng what trab can achieve," he said. "Most studies" have shown the EX-PRESS and trabeculectomy "have similar results," Dr. Ahmed said, although the former can eliminate the need for iridectomy. Dr. Samuelson, however, "has become pretty bullish on devices for surgery. There are those that believe the EX-PRESS adds unnec- essary expense, but I use it for most of my fi ltration procedures because I've grown fond of the additional precision that it allows." The device "augments a trabeculectomy," Dr. Gedde said. "It eliminates the need to remove a small piece of limbal tissue under- neath your trabeculectomy fl ap, and an iridectomy is not performed. There have been studies that sug- gest there's a faster visual recovery than trabeculectomy alone." He also cited the potentially lower risk of hypotony-related complications,

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