EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/511377
46 trabecular bypass procedures with the iStent [Glaukos, Laguna Hills, Calif.] may be less invasive and safer options," Dr. Harasymowycz said, noting that the latter surgeries have been found to be more effec- tive when combined with cataract extraction. Pigmentary glaucoma tends to get better with age, remission usual- ly beginning in the mid-40s with the onset of presbyopia, Dr. Ritch said. So, while patients with other types of glaucoma may see worsening of their symptoms in their 50s or by age 60, those with pigmentary glau- coma tend to find their condition has improved. EW Editors' note: Dr. Francis has financial interests with Allergan (Irvine, Calif.), AqueSys (Aliso Viejo, Calif.), Endo Optiks/Beaver Visitec (Waltham, Mass.), Lumenis (Yokneam, Israel), and NeoMedix. Dr. Harasymowycz has financial interests with Alcon (Fort Worth, Texas), Abbott Medical Optics (Abbott Park, Ill.), Bausch + Lomb (Bridgewater, N.J.), and Ivantis (Irvine, Calif.). Dr. Noecker has financial inte - ests with Glaukos and Endo Optiks. Dr. Ritch has financial interests with Aeon Astron (Leiden, the Netherlands), Sen- simed (Lausanne, Switzerland), iSonic Medical (Paris), Allergan, and Ocular Instruments (Bellevue, Wash.). Contact information Francis: BFrancis@doheny.org Harasymowycz: pavloh@igmtl.com Noecker: noeckerrj@gmail.com Ritch: ritchmd@earthlink.net seeing patients back sooner if the IOP is elevated, and giving oral car- bon anhydrase inhibitors if tolerat- ed. "It may not be advisable to offer selective laser trabeculoplasty (SLT) to patients with heavily pigmented trabecular meshwork, especially if they have uncontrolled IOPs and are already on multiple IOP-lowering drops," he said. Trabeculectomy and tube shunts are also an option. "With trabeculec- tomy, you have to be careful because of the risk for hypotony. That's where MIGS has a role," Dr. Francis said. "MIGS procedures where you remove or bypass the trabecular meshwork will be fairly effective." "You have to decide if MIGS will be adequate in getting the pressure down," Dr. Noecker said. "Anything working with outflow is helpful. There's a move to do more MIGS versus just doing a trabeculectomy. It's reasonable to start with SLT or a MIGS procedure that's safe to do, but it may not lower the IOP enough. Other procedures that elim- inate the trabecular meshwork may have the best indication." Some MIGS procedures may have to be used off-label if there is not a coexistent cataract, Dr. Francis said. Another consideration is whether a patient wants to con- tinue using contact lenses, which are common in these mostly myopic patients, Dr. Harasymowycz said. "Clearly, MIGS procedures such as trabeculectomy with the Trabectome [NeoMedix, Tustin, Calif.], 360-degree trabeculotomy with sutures, or the iTrack catheter [iScience, Menlo Park, Calif.], or Pearls for care continued from page 44 The treatment for pigmentary glaucoma tends to vary according to the patient and the surgeon— there is no one go-to procedure. "In general, it's somewhat more difficult to control than open angle glaucoma, but we still use the same types of medications and surgeries." –Brian A. Francis, MD