Eyeworld

EW FEATURE 50 Complicated glaucoma surgery management • November 2016 AT A GLANCE • Glaucoma surgeons have more treatment options now than ever before. Many have incorporated newer techniques into the way they perform a trabeculectomy. • The use of trabeculectomy versus tube shunts will often depend on the severity of glaucoma and whether the patient has progressive disease. • MIGS has provided more treatment options for patients with mild to moderate glaucoma. • Surgeons are eager to learn more about newer surgical innovations such as Xen and CyPass, but they still want to see long-term efficacy and safety data. by Vanessa Caceres EyeWorld Contributing Writer Fitting in MIGS Glaucoma specialists have praised the entry of MIGS into their surgical toolbox, but that doesn't mean it's the cure-all for everyone. For exam- ple, it's a reasonable option for those with mild and moderate glaucoma, and it has reduced the number of filters and tubes used in that pa- tient population, Dr. Fellman said. "However, patients with advanced disease who require IOPs in the low teens are not the best candidates for MIGS and fare better long-term with external filtration," he said. "MIGS has definitely reduced the number of trabs/tubes I'm performing," Dr. Seibold said. "We now have MIGS options that are increasingly effective at controlling IOP when medications or lasers fail. The recovery is much easier for patients, and they do not face the vision-threatening complications or lifelong risk of infection as with external filtration procedures." On the other hand, MIGS has not changed how often Dr. Ayyala is performing trabs and tubes. "I am performing MIGS primarily in patients with mild and moderate glaucoma who need cataract sur- gery," he said. For Dr. Gedde, his work with patients who usually have advanced and/or progressive glaucoma has limited his use of MIGS. Ramesh Ayyala, MD, professor of ophthalmology, Tulane University School of Medicine, New Orleans, will use an Ahmed valve (New World Medical, Rancho Cucamonga, California) for neovascular, uveitic, and traumatic glaucoma as well as congenital glaucoma with angle abnormalities. However, he will use the Baerveldt glaucoma implant for primary open-angle glaucoma with failed trabeculectomy patients who are in need of an IOP of 15 mm Hg or lower. "I prefer the Baerveldt with a Vicryl tie and revise the failed trabeculectomy with mitomycin-C to control the IOP in the immediate postop period," he said. Glaucoma surgeons must care- fully consider when they perform external drainage procedures. For Dr. Fellman, his preference is in patients who are not good candidates for MIGS or filtration surgery. Dr. Ayyala considers this approach in advanced primary open-angle glaucoma pa- tients who need an IOP in the low teens. The need for external drainage procedures is becoming less and less common with the increase in safer MIGS options, Dr. Seibold said. However, he still uses them in patients with moderate to severe glaucoma who require low IOP and have failed other options. • a change from a bridle to corneal traction suture • a change from a limbal- to fornix- based conjunctival incision as well as a significant posterior dissection that preserves Tenon's capsule • the use of mitomycin-C and its proper application • the incorporation of Tenon's cap- sule into the wound closure • meticulous conjunctival wound closure • the use of stronger postop steroids to inhibit fibrosis • intense postop vigilance to preserve the bleb with timely suture-lysis and overall wound management For H. George Tanaka, MD, clinical instructor, California Pacific Medical Center, San Francisco, trabeculectomy entails a retrobulbar block, a subconjunctival mitomycin- C injection in the OR after giving the block and before scrubbing, a fornix-based incision, a half-thick- ness trapezoidal flap, a sclerotomy and iridectomy, two or three flap sutures, and conjunctival closure with a running 8-0 Vicryl suture on a vascular needle. Trabs versus tubes The mix of trabeculectomies versus tube shunts varies by specialist. For Leonard Seibold, MD, assistant pro- fessor, University of Colorado School of Medicine, the mix is 60% tubes and 40% trabeculectomies, as he often sees patients who have had at least one trabeculectomy performed by an outside physician. Steven Gedde, MD, professor of ophthalmology, Bascom Palmer Eye Institute, Miami, also performs more tube shunt procedures for similar reasons. "But I still favor trabeculec- tomy as an initial procedure in low- risk eyes, such as primary open-an- gle glaucoma or other lower risk glaucomas with no prior surgery," he said. The tube shunt technique used also depends on the typical patient seen. Dr. Tanaka uses a supra-Ten- on's approach as most of his tube patients are at a high risk for failure due to plate encapsulation. "I use a Baerveldt [Abbott Medical Optics, Abbott Park, Illinois] 250 sq mm with a 3-0 Prolene ripcord and 7-0 Vicryl ligation suture around the rip- cord to prevent hypotony," he said. Specialists weigh in on their preferred techniques W hen Ronald Fellman, MD, Glaucoma Asso- ciates of Texas, Dallas, was a glaucoma fellow in the early 1980s, filtration surgery was the go-to procedure for all patients, he said— regardless of their disease stage. If it failed, it was repeated up to three times. After that, cyclocryotherapy was used. Glaucoma surgeons today have more options than Dr. Fellman and his colleagues once did. "The ability to tailor modern-day glaucoma surgery to the immediate and long- term needs of the patient, either by enhancing natural drainage path- ways or creating a new drainage system, is a milestone in the care of glaucoma patients of all ages," Dr. Fellman said. So what preferred surgical tech- niques are glaucoma specialists using for trabeculectomies, tube shunts, microinvasive glaucoma surgery (MIGS), and newer innovations? EyeWorld spoke with a few leading surgeons for their perspectives. Trabeculectomy approach There have been advances in both surgical options and approaches. Dr. Fellman has incorporated seven major changes in filtration surgery over the past 30 years into his trabeculectomy approach, he said. These include: Trabs, tubes, and newer glaucoma treatments Using a fornix-based approach for his trabeculectomies, Dr. Tanaka creates a trapezoidal flap, which he closes with two to three 10-0 nylon sutures. Source: H. George Tanaka, MD continued on page 51

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