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EW FEATURE 46 Combined procedures for glaucoma November 2014 by Maxine Lipner EyeWorld Senior Contributing Writer procedures, the only intraocular one is ECP, Dr. Francis noted. Finally, there are the transconjunctival procedures. While traditionally this includes the use of tubes and trab- eculectomy, considered to be very extensive, the as-yet unapproved XEN Gel Stent (AqueSys, Aliso Viejo, Calif.) also fits into this category, Dr. Francis said. Candidates at the plate Determining who may be the best candidate for these in-between procedures begins with considering the condition. "The first step is to match the diagnosis and what's going on anatomically in the eye with what you want to do," Dr. Francis said. These procedures can offer patients a rapid visual recovery and overall enhanced safety profile that more extensive surgery like trabeculectomy cannot, said Nathan M. Radcliffe, MD, clinical profes- sor of ophthalmology, New York University Langone Medical Center, New York. "This does include [advantages] like enabling patients to go back to work the week after," he said. "It's not like trabeculectomy, where patients may have to take more time off work, and we are unable to predict the full course of recovery." On the other hand, these in- between procedures also differ from traditional MIGS. Technically, tradi- tional MIGS procedures are non-tis- sue destructive, Dr. Radcliffe said. "It's the concept of doing nothing to the eye but getting the pressure down," he said. As near-MIGS procedures do alter tissue, you may potentially get something for this in terms of efficacy, he said. "With an ECP you are coagulat- ing the ciliary processes, but with that comes a potential advantage in efficacy," Dr. Radcliffe said. "With the Trabectome, you're ablating or coagulating and removing the trabecular meshwork, but again potentially by doing that you could have some added efficacy if you access more collector channels." He stressed, however, that there has been no study to show that these are better than other procedures and devices. There are 4 basic groups of glaucoma treatment options to consider that target different areas, Swinging for the fences with "near-MIGS" procedures W hile many tout the microinvasive iStent (Glaukos, Laguna Hills, Calif.) on one end of the spectrum and swear by trabeculec- tomies and tubes on the other, a whole world of glaucoma procedures exists in between that can make a big difference to glaucoma patients with cataracts, according to Robert J. Noecker, MD, assistant clinical professor of ophthalmology, Yale University, New Haven, Conn. For some patients, "near-MIGS" proce- dures, which are less invasive than trabeculectomy, may provide an in- termediate answer, he thinks. Here is how some practitioners are making use of procedures such as Trabec- tome (NeoMedix, Tustin, Calif.), ECP (endoscopic cyclophotocoagula- tion, Endo Optiks, Little Silver, N.J.), canaloplasty (iScience, Menlo Park, Calif.), and more. In the intermediate glaucoma treatment ballpark AT A GLANCE • Intermediate "near-MIGS" procedures may offer enhanced safety over trabeculectomy with good pressure lowering. • Those who do not want a traditional filter but who need greater pressure reduction than the mid-teens may be good candidates. • Combining different "near-MIGS" procedures can help boost the pressure-lowering effect. The Xen Gel Stent shunts fluid from the anterior chamber to the subconjunctival space. Source: Brian A. Francis, MD "Another piece of advice would be to get a mentor who has done many implants and talk to him or her before the first case," Dr. Kahook said. "Surgeons can teach their peers pearls for practice that might be hard to learn from company reps or from reading materials." The future of MIGS With new devices and techniques in the pipeline, the iStent is the window to the future, Dr. Condon said. One promising technique is to target MIGS implantation within the anterior chamber angle. By evaluat- ing the appearance of the aqueous outflow along the limbal region, he said, a surgeon could target implantation to the area with the most available outflow channels. With MIGS devices in the early stages of development, surgeons can Combining phaco continued from page 44 play a role in their innovation, Dr. Kahook said. "MIGS will develop over time, and surgeons can be part of this improvement process to help shift surgical intervention toward earlier implementation in those with more mild disease," he said. EW Editors' note: Dr. Kahook has financial interests with Ivantis (Irvine, Calif.) and Glaukos. Dr. Condon has finan- cial interests with Alcon (Fort Worth, Texas). Dr. Rhee has financial interests with Glaukos, Ivantis, and Alcon. Contact information Condon: garrycondon@gmail.com Kahook: malik.kahook@gmail.com Rhee: dougrhee@aol.com said Brian A. Francis, MD, profes- sor of ophthalmology, Doheny Eye Institute, University of California, Los Angeles. These include the trabecular, the suprachoroidal, the decreased aqueous production, and the transconjunctival filtration. In addition to the iStent, the Trabectome and the Hydrus (Ivantis, Irvine, Calif.) are considered trabecular treatments. The Hydrus is not FDA approved and is currently in trials. No devices are currently FDA approved in the suprachoroidal group. Devices in the pipeline in that space are the SOLX Gold Shunt (SOLX, Waltham, Mass.), CyPass (Transcend Medical, Menlo Park, Calif.), and iStent Supra in trials. In decreased aqueous production