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51 EW FEATURE May 2015 Secondary glaucoma challenges then watch as the episcleral vessels blanch, he explained. "You can see a wave of bal- anced salt solution going through the vessels and that, in our mind, is confirmation that a patient has a functioning inherent drainage system," Dr. Grover said. First-line surgical approach Dr. Grover views the procedure as another MIGS option. "A lot of the procedure was not considered a home run, there is still a 60% to 70% chance of success. In a retrospective study pub- lished in the February 2015 issue of the British Journal of Ophthalmology, a marked decrease in pressure was seen in cases involving primary con- genital glaucoma and juvenile open angle patients. The mean decrease in IOP was from 27.3 to 14.8 mm Hg with the mean number of medica- tions dropping from 2.6 to 0.86. Investigators found that 5 eyes of the 14 studied had a drop of greater than or equal to 15 mm Hg. Patients who tend to be best suited for GATT are those whose dis- tal outflow system is still intact, D . Grover said. "If you have glaucoma for 40 years and have been taking drops, your distal outflow system is likely to be atrophic," he said, add- ing that unfortunately this system cannot be imaged well. Dr. Grover said there are proxies for an intact drainage system, such as identifying mild to moderate glaucoma patients whose drainage system is likely to be healthier. He and Dr. Fellman have also described how intraoperatively, an episcleral venous wave could help to show patency of the patient's collector system. 1 After doing the GATT procedure, practitioners can irrigate balanced salt solution in the eye and EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send an online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the hundreds of physicians who take a minute a month to share their views, please send us an email and we will add your name. Email carly@eyeworld.org and put EW Pulse in the subject line. Poll size: 145 continued on page 52 B: Schlemm's canal is then cannulated with a microcatheter, using microsurgical forceps. C: One can appreciate that the catheter has already been passed 2–3 clock hours around Schlemm's canal.