Eyeworld

EW FEATURE 52 Secondary glaucoma challenges May 2015 MIGS-based procedures are surgeries that try to enhance the patient's own drainage system," he said, add- ing that several MIGS procedures are lifestyle of a younger, more active patient without, Dr. Fellman said. Dr. Grover said that with trab- eculectomy or a tube shunt there is a relatively high rate of hypotony, choroidal detachment, and choroi- dal effusions; practitioners do not have that fear of hypotony or any hypotony-related complications with a GATT procedure. When first t ying GATT, there can be a bit of a learning process, Dr. Fellman said. "It takes a certain skill set to do a scleral flap, for example, when you're doing a trabeculec- tomy," he said, adding that it is different when you are working in the angle where other techniques are used. Dr. Grover concurred. He ad- vised that those who are interested in learning GATT become comfort- able working in the angle. "You need to know angle anatomy and be comfortable doing angle-based sur- gery, holding a gonioprism onto the eye with one hand and manipulat- ing things with the other hand," Dr. Grover said. While GATT is certainly not something anyone can learn in a day, he has found that those who are already well versed at angle sur- gery will become comfortable much more rapidly. "We've seen skilled surgeons who are comfortable in the angle, and they can pick it up in a short period of time," he said. For those practitioners who have not done angle surgery, the learning curve might ultimately be a little steeper. EW References 1. Fellman RL, Grover DS. Episcleral venous fluid w ve: Intraoperative evidence for patency of the conventional collector system. J Glau- coma. 2014 Aug;23(6):347–50. 2. Grover DS, Smith O, Fellman RL et al. Gonioscopy assisted transluminal trabeculot- omy: an ab interno circumferential trabeculo- tomy for the treatment of primary congenital glaucoma and juvenile open angle glaucoma. Br J Ophthalmol. 2015 Feb 12. (Epub ahead of print) 3. Grover DS, Godfrey DG, Smith, et al. Gonios- copy-assisted transluminal trabeculectomy, ab interno trabeculectomy: technique report and preliminary results. Ophthalmology. 2014 Apr;121(4):855–61. Editors' note: Drs. Grover and Fellman have no financial interests related to their comments. Contact information Fellman: rfellman@glaucomaassociates.com Grover: dgrover@glaucomaassociates.com Shedding light continued from page 51 D: Given the blinking red light on the distal end of the tip, one can follow the path of the catheter as it travels circumferentially around the canal. The catheter has passed 180 degrees around the canal. E: The microcatheter has come full circle around the canal. F: The distal tip of the catheter is retrieved within the anterior chamber using micro- surgical forceps. Blood reflux from S hlemm's canal is normal and usually a prognos- tic indicator of a successful outcome as well as an intact distal collector system. Source (all): Davinder Grover, MD done in conjunction with cataract surgery, which is also an option for GATT. Dr. Fellman pointed out that the beauty of microinvasive surgery today is that it allows practitioners to tailor surgery to the patient's stage of disease. "We've never had that before," he said. "In the past we did the same operation in everyone regardless of the stage of disease because that's all we had." Dr. Grover views GATT as a first line surgical approach for glaucoma. "I tell my patients that this is one of the safest, easiest, and least invasive things we can do in terms of glauco- ma surgery," he said. "The beauty of the surgery is it doesn't violate the conjunctiva, so it's an easy go-to as an initial surgical approach." He explains to patients that if they succeed with GATT, they can potentially avoid a lifelong risk of infection and avoid putting a piece of hardware in the eye that involves concerns about double vision or erosion. He considers the procedure for mild to moderate glaucoma patients who do not need particularly low pressure. "They are patients who function well with a pressure in the mid-teens," he said. "Also for patients who need cataract surgery who are on several medications, it's a great way to treat them." Patients who are not candidates GATT is not for everyone, however. "If a patient has very advanced glau- coma and I know they need a pres- sure of 10, they need a trab without question," Dr. Grover said. In addi- tion, because there is some bleeding, although transient, if a patient has a predisposition to bleeding or cannot be taken off blood thinners, Dr. Grover avoids the procedure. "Also, there's a lot of manipu- lation in the anterior chamber, so if the patient has an unstable IOL we don't want to do that because you're going to disrupt the IOL," he said. Likewise, he finds that patients who have undergone penetrating keratoplasty will most likely end up needing a tube, so his bias is to avoid GATT in these cases. Because patients need to lie on their back with their head slightly elevated for about 1 or 2 weeks postop to avoid hyphema, that is a consideration as well, Dr. Grover said. Take-home message As Dr. Fellman explained, GATT allows surgeons to tailor the procedure to the patient's stage of disease and lifestyle. It fits the

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