EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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EW GLAUCOMA 38 December 2014 by Tony Realini, MD Glaucoma device for difficult cases Trabectome versus tubes Studies evaluating the Trabectome have demonstrated IOP reductions that are consistent with those expected from aqueous tube shunt surgery, according to Sushma Kola, a medical student at the Universi- ty of Pittsburgh. "Trabectome has not been compared in head-to- head trials with either the Ahmed valve [New World Medical, Rancho technique is performed through a paracentesis and easily paired with cataract surgery. As with many of the MIGS procedures, Trabectome's place in the glaucoma treatment paradigm is not entirely clear. Recently, several studies have explored the role of Trabectome surgery in eyes with ad- vanced and/or complex glaucomas. Tustin, Calif.), an electrocautery device that performs trabecular ablation. The procedure is similar to the goniotomy procedure usually reserved for congenital glaucoma, the key difference being that in goniotomy the meshwork is incised with a blade without ablation, and in trabecular ablation the electrocau- tery handpiece is used to physically remove a strip of meshwork. The T he holy grail of glaucoma surgery is a safe and effec- tive procedure for lowering IOP without the creation of a bleb, thus avoiding the life-long risks of bleb leaks and potential infections. Several micro- invasive glaucoma surgeries (MIGS) have been developed in recent years to address this unmet need. Among them is the Trabectome (NeoMedix, In this non-randomized study of patients, Trabectome (T), Baerveldt glaucoma implant (BGI), and Ahmed glaucoma implant (AGI) had similar final IOPs and reduction of glaucoma medications at 6 and 12 months. Reoperation rate for IOP control was similar in all 3 groups. In contrast to BGI and AGI, in patients who underwent trabecular meshwork ablation with the Trabectome, a plasma-surgical modality that is fundamentally different from the coagulative effect of cautery, no serious complications were observed. Source: Sushma Kola should be monitored. "You have to warn people that they may experience some redness," he said. Eye drop math Dr. Robin said practitioners should keep in mind that with all of the combination medicines, there is not as much of an additive effect for the second medication in the bottle. "In Cosopt or in Combigan, timo- lol is the major component, and in Simbrinza it's brimonidine," he said. "I think it's important for most oph- thalmologists to start out with just a major component, and if that isn't enough don't expect much more." He urges practitioners to expect only 1 or 2 mm more of pressure lowering from adding the second agent. Dr. Brown agrees. He refers to this as "eye drop math." "When you add 1 drop to another you do not get the full impact of the second drop—you get a fraction of what that drop does by itself," Dr. Brown said. "Then if you use a third drop, you get a fraction of that." Dr. Robin said it is an offshoot of this principle that has kept Xalacom (latanoprost and timolol, Pfizer), a combination of a prosta- glandin and a beta blocker, out of the U.S. market. "It's available in almost every other country except the U.S. and Japan," Dr. Robin said. The Food and Drug Administration The latest continued from page 36 requires at least 2 mm of mean pressure difference at all time points between the combination and the single agent, something that was not attained with the prostaglandin timolol combination, he said. A new combination still in the pipeline that Dr. Robin thinks shows promise is Rhoclatan (Aerie Pharmaceuticals, Bedminster, N.J.), which combines the Rho-kinase in- hibitor Rhopressa with latanoprost. "The combination of a Rho-kinase inhibitor with a prostaglandin seems to be helpful," he said. Overall, Dr. Brown views combination agents as an import- ant, patient-centered innovation. "The more we can put in 1 bottle, the better," he said. "Once a person is needing more than 1 drop a day, combinations make so much sense." EW Editors' note: Dr. Brown has no finan- cial interests related to his comments. Dr. Noecker has financial interests with Alcon and Allergan. Dr. Robin has financial interests with Aerie Pharma- ceuticals, Akorn Pharmaceuticals, and Teva Pharmaceutical Industries (Petah Tikvah, Israel). Contact information Brown: reaymary@comcast.net Noecker: noeckerrj@gmail.com Robin: arobin@glaucomaexpert.com