Eyeworld

EW FEATURE 60 Complicated glaucoma surgery management • November 2016 somewhat difficult," Dr. Sarkisian said. "For some surgeons it has been a struggle for them to convert to canal surgery." Dr. Sheybani also thinks the CyPass is one of the technically easier MIGS procedures. He thinks it has the potential to lower pressure more than the devices targeting the trabecular meshwork because the suprachoroidal space has less resis- tance to outflow than the episcleral venous pathway. "The other interesting thing will be if you have a tube or [trabeculec- tomy] patient who is now failed," Dr. Sheybani said. "I don't think it would be reasonable to go back and in that case do an iStent or angle surgery because a lot of the collec- tor system, just from surgery alone, might be damaged. But CyPass would give an alternative pathway. It might have a place in refractory glaucomas, whereas before we might have been doing diode [cyclophoto- coagulation]." Other options and combination therapies Dr. Sarkisian said the waters have become "a little bit muddier"—in a good way—in that there are a variety of MIGS procedures surgeons can perform in combination with cataract surgery. "I'll combine iStent with [endo- scopic cyclophotocoagulation] in a lot of cases," Dr. Sarkisian said. Ab interno canaloplasty or an ab interno trabeculotomy or goniot- omy can be combined with cataract surgery or performed as standalone procedures. He named the Trab360 (Sight Sciences, Menlo Park, Califor- nia), iTRACK Microcatheter (Ellex, Adelaide, Australia), Trabectome (NeoMedix, Tustin, California), Kahook Dual Blade (New World Medical, Rancho Cucamonga, Cal- ifornia), and GATT (gonioscopy-as- sisted transluminal trabeculotomy) as examples of devices that could perform these procedures. In his hands, however, Dr. Sarkisian said he performs iStent, endoscopic cy- clophotocoagulation, and Trab360, doing a combination of these pro- cedures depending on the desired outcome with cataract surgery. "I think that all of these have positions in our arsenal, but my go-to right now is an iStent," Dr. Bacharach said of his current pre- ferred MIGS procedure. Dr. Okeke said her predominant MIGS procedure is Trabectome. "It was the first MIGS procedure I trained to do, and I continue to utilize it because I think it's useful for all stages of glaucoma from mild to moderate to even severe disease," she said, adding that she will also perform goniotomy procedures with Trabectome and has used the Kahook Dual Blade and Trab360. "I have used the Kahook more frequently as the next procedure and then the Trab360 … but I have found that my Trabectome out- comes are better." Dr. Sheybani said he doesn't perform one MIGS procedure more than the others, considering them spread pretty evenly. Different MIGS procedures suit different patients. "So much of it depends on their comorbidities," he said, explaining that being on blood thinners, for example, can be a contraindication for some MIGS procedures because of the risk for hyphema. The physicians interviewed said they think each of the MIGS options—those that stent, ablate, or otherwise improve aqueous outflow —have a role. "Having been in glaucoma for more than 30 years, I think it's nice that we have a broader base of pro- cedures to attack this problem," Dr. Lewis said. "There is a lot of glaucoma, and there will be a need for interesting and innovative ways to treat the ag- ing population that will have glau- coma as the number … is going to increase dramatically over the next few decades," Dr. Okeke said. EW Reference 1. Berdahl JP. Cataract surgery to lower intra- ocular pressure. Middle East Afr J Ophthalmol. 2009;16:119–122. Editors' note: Dr. Bacharach has financial interests with Alcon, Allergan (Dublin), and Glaukos. Dr. Lewis has financial interests with Aerie Pharma- ceuticals (Irvine, California), Alcon, Allergan, CenterVue (Fremont, Cali- fornia), Glaukos, and Ivantis (Irvine, California). Dr. Okeke has financial interests with Glaukos, NeoMedix, and New World Medical. Dr. Sarkisian has financial interests with Aeon Astron (Leiden, Netherlands), Alcon, Allergan, Beaver-Visitec International (Waltham, Massachusetts), Glaukos, InnFocus (Miami), Katena (Denville, New Jersey), New World Medical, and Sight Scienc- es. Dr. Sheybani has financial interests with Allergan. Contact information Bacharach: jbacharach@northbayeye.com Lewis: rlewiseyemd@icloud.com Okeke: iglaucoma@gmail.com Sarkisian: Steven-Sarkisian@dmei.org Sheybani: sheybaniar@wustl.edu reduced chance of corneal folds, which could impede visualization of angle structures. New kid in the MIGS market A new stent—the CyPass Micro-Stent (Alcon, Fort Worth, Texas)—recent- ly received FDA approval. CyPass, like the iStent, is meant to improve outflow through the eye's natural drainage system, but unlike the iStent, it is inserted into the su- prachoroidal space. Will the two stents be in compe- tition with each other? The physi- cians interviewed don't think about it that way, but rather view the ad- dition of CyPass as giving specialists another tool to better treat a broad spectrum of glaucoma patients. "I think CyPass will be a nice addition, and I think it's going to broaden the indication for MIGS and glaucoma surgery in general," Dr. Lewis said. Dr. Bacharach said he doesn't consider the iStent and suprachoroi- dal stents mutually exclusive. "I think it will expand the opportunity and marketplace for surgeons to use the devices in a greater patient platform," he said. "For example, in people with more significant IOP reduction needs, it might be that a CyPass is beneficial. For those patients in whom you've placed an iStent and need additional IOP reduction, you can surely place a suprachoroidal stent, and there have been some early studies that demonstrate that they might work well together." Dr. Sarkisian said the CyPass might be attractive to surgeons who don't feel comfortable with the iStent. "There are surgeons for whom implanting the iStent can be Cataract continued from page 59 Readjusting the iStent in Schlemm's canal Source: Arsham Sheybani, MD Inserting iStent into the canal has a bit of a learning curve.

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