NOV 2015

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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Even though her pressure OD was acceptable, she wanted to alleviate the strabismus and diplopia. She also had problems with ocular surface disease and sensitivity to medications. We removed the tube (Figure 1). We could have replaced the tube, but the patient did not want any sort of implant because of the diplopia problems. We resolved her issue by doing an ab interno trabeculoto- my (Trabectome, NeoMedix) and were able to control her IOP, albeit on more medical therapy than she had been previously (two medications vs. one pre- Trabectome). Her diplopia did resolve with removal of the tube shunt. Case No. 2: Primary open-angle glaucoma A 68-year-old Indian female is the wife of an ophthalmologist. She has uncontrolled POAG in her left eye (24 mm Hg) and document- ed visual field progression with significant moderate to severe nerve damage in that eye. She is on four topical medications and a low-dose oral carbonic anhydrase inhibitor. This is clearly a patient on maximal medical therapy. We elected to perform a trabeculectomy (Figure 2), as a traditional filtering surgery should give her the best possibility of decreasing or eliminating most of those medications and reaching a target IOP in the low teens. Case No. 3: Exfoliation glaucoma A 75-year-old Caucasian female with exfoliation glaucoma pre- sented with uncontrolled IOP in Figure 1. Tube shunt removal to alleviate diplopia issues Figure 3. Endoscopic cyclophotocoagulation with Trabectome implantation for exfoliation glaucoma Source: Brian Francis, MD Figure 2. Traditional trabeculectomy to help ensure intraocular pressure lowering the right eye (24 mm Hg), and moderate to severe nerve damage of C:D=0.85. She had failed a previous canaloplasty. Her left eye has had a retinal detachment and a scleral buckle. She is on two glaucoma drops (prostaglan- din and a carbonic anhydrase inhibitor) plus oral acetazolamide, which constitutes maximal thera- py for her; she has failed the other medical treatments. This patient was against a filtering surgery and wanted to explore a MIGS-type procedure. We opted for an inflow procedure (ECP) and an outflow procedure (Trabectome). Dr. Radcliffe has previously discussed a combined ECP, iStent (Glaukos), and cataract surgery; combining MIGS proce- dures is not a novel concept. Conclusions Surgery is not going to replace topical medications, and there is room for adjunctive medical ther- apy. MIGS are not curative and may not reduce the IOP enough. But when the disease cannot be managed medically, adding glau- coma surgery earlier with these newer, less invasive procedures may be able to improve compli- ance and provide better patient outcomes. For mild glaucoma, I recommend cataract surgery alone or MIGS; for mild to moderate cases, consider the newer proce- dures, and for severe cases, opt for a combined trab or tube shunt. Dr. Francis is professor of ophthal- mology, Doheny Eye Institute, Uni- versity of California, Los Angeles. He can be contacted at 323-442-6335 or bfrancis@doheny.org. Supported by unrestricted educational grants from Aerie, Alcon Laboratories, Allergan, Carl Zeiss Meditec, and Glaukos 7

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